The Effect of Cemented Implants Placed During Initial TKA on Surgical Time and Expenses in Revision TKA.

INTRODUCTION: Revision total knee arthroplasty (rTKA) is a complex procedure that often requires the removal of previous implants. There is little information evaluating the difference between removing cemented or noncemented knee prostheses in revision surgeries. The purpose of this study was to determine whether removing cemented or noncemented implants would affect surgical time and expenses incurred during revision procedures. METHODS: This retrospective cohort study used a single-institution database to identify 300 patients who underwent femoral and tibial implant rTKA from 2016 to 2022 because of mechanical complications (infection cases excluded). Radiographs and surgical reports were used to confirm whether the fixation technique was cemented (N = 243) or noncemented (N = 57). The primary outcomes were surgical time and surgery costs. Secondary outcomes included readmission rates, revision implants used, stem usage, and insurance type. RESULTS: The average surgical time was 121 minutes for noncemented and 128 minutes for cemented procedures (P = 0.118). The 90-day readmission rates for each group were similar at 7.00% for the cemented cohort and 8.77% for the noncemented cohort (P = 0.643). For patients with Medicare Advantage, the respective surgery costs were $1,966 for noncemented and $1,968 for cemented TKA (P = 0.988). For patients with commercial insurance, the respective surgery costs were $4,854 for noncemented and $5,660 for cemented TKA (P = 0.330). CONCLUSION: Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both-implant revision knee surgery indicated for mechanical complications.

How to Estimate Femoral Stem Anteversion During Direct Anterior Approach Total Hip Arthroplasty.

Background: There are various traditional landmarks used to estimate the femoral component version, yet none are widely accepted by direct anterior surgeons. The purpose of this study was to compare bony landmarks easily accessible to direct anterior surgeons and to estimate which one provides the best estimate of femoral component anteversion. Methods: A computed tomography database was used to identify 736 left entire-femur computed tomography scans. Seven visible anatomic landmarks were identified using a computer model in which a 45° virtual neck resection was made at 10 mm above the lesser trochanter. Thirteen axes, to reference the femoral stem position, were created between the 7 landmarks. Means and standard deviations (SDs) of angles between each axis and the transepicondylar axis (TEA) were compared for their precision. Results: The traditional lesser trochanter predicted anteversion from the TEA was 34.1° (SD 9.7°). Predicted anteversion from the TEA was 3.3° (SD 8.1°) when aligned from the center of the canal to the middle of the medial calcar; 14.0° (SD 8.1°) from the center of the canal to the anterior 1/3 of the medial calcar; and 24.8° (SD 8.5°) from the center of the canal to the most anterior point on the medial calcar. Conclusions: Compared to the lesser trochanter, 7 axes were more precise (lower SD) when predicting the version. Estimating the femoral component position, via simulated data, using 3 points along the medial calcar is a relatively precise and easily accessible tool for surgeons.

A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care.

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

BACKGROUND: Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. QUESTIONS/PURPOSES: (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? METHODS: Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. RESULTS: Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. CONCLUSION: Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution.

BACKGROUND: Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA. RESULTS: Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001). CONCLUSION: The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

BACKGROUND: Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS: Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS: When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION: We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Early Infection Trends for Primary Total Knee Arthroplasty: A 5-Year Review.

The aim of this study was to track the annual rates and trends of overall, deep, and superficial surgical site infections (SSIs) following total knee arthroplasty using the most recent results from a large and nationwide database. A total of 197,192 cases were performed between 2012 and 2016 from a nationwide database stratified into years and based on superficial and/or deep SSIs. Cohorts were analyzed individually and then combined to evaluate overall SSI rates. The infection incidence for each year was calculated. After a 6-year correlation and trends analysis, univariate analyses were performed to compare the most recent year, 2016, with each of the preceding 4 years. Overall, there was a downward trend in overall SSI rates over the study period (2012-2016, with the lowest rate occurring in the most recent year, 2016 [0.11%]). Additionally, there was a decreasing trend for superficial SSI, with the lowest superficial SSI incidence occurring in 2016 (0.47%) and the greatest incidence occurring in 2012 (0.53%). An overall trend of decreasing SSI rates was observed nationwide over the 5-year period evaluated. A similar decreasing trend was also noted specifically for deep SSI rates, which can be potentially more complicated to manage, and result in decreased implant survivorship. The down trending SSI rates observed give potential credence to the value for newer and developing SSI preventative therapies as well as improved medical and surgical patient management. Nevertheless, there is still room for improvement, and continued efforts are needed to further lower SSIs after total knee arthroplasty.

Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal. METHODS: PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism. RESULTS: A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms). CONCLUSIONS: Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.

Psoriasis and Post-Surgical Infections in Primary Total Knee Arthroplasty: An Analysis of 10,727 Patients.

BACKGROUND: Psoriasis is a dermatologic condition characterized by erythematous plaques that may increase wound complications and deep infections following total knee arthroplasty (TKA). There is a paucity of evidence concerning the association of this disease and complications after TKA. This study aimed to determine if patients who have psoriasis vs non-psoriatic patients have differences in demographics and various comorbidities as well as post-operative infections, specifically the following: (1) wound complications; (2) cellulitic episodes; and (3) deep surgical site infections (SSIs). METHODS: We identified 10,727 patients undergoing primary TKA utilizing an institutional database between January 1, 2017 and April 1, 2019. A total of 133 patients who had psoriasis (1.2%) were identified using International Classification of Diseases, Tenth Revision codes and compared to non-psoriatic patients. The rate of wound complications, cellulitic episodes, and deep SSIs were determined. After controlling for age and various comorbidities, multivariate analyses were performed to identify the associated risks for post-operative infections. RESULTS: Psoriasis patients showed an increased associated risk of deep SSIs (3.8%) compared to non-psoriasis patients (1.2%, P = .023). Multivariate analyses demonstrated a significant associated risk of deep SSIs (odds ratio 7.04, 95% confidence interval 2.38-20.9, P < .001) and wound complications (odds ratio 4.44, 95% confidence interval 1.02-19.2, P = .047). CONCLUSION: Psoriasis is an inflammatory dermatologic condition that warrants increased pre-operative counseling, shared decision-making, and infectious precautions in the TKA population given the increased risk of wound complications and deep SSIs. Increased vigilance is required given the coexistence of certain comorbidities with this population, including depression, substance use disorder, smoking history, gastroesophageal reflux disease, and inflammatory bowel disease.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program.

BACKGROUND: Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A). METHODS: We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions. RESULTS: Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224). CONCLUSIONS: Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Orthopaedic Surgeons Have a High Prevalence of Burnout, Depression, and Suicide: Review of Factors Which Contribute or Reduce Further Harm.

Orthopaedic surgeons have the highest prevalence of death by suicide among all surgical subspecialties, comprising 28.2% of surgeon suicides from 2003 to 2017. There is a continuum of burnout, depression, and other mental health illnesses likely contributing to these numbers in our profession. Stigmatization in terms of medical licensing and professional development are currently barriers to seeking mental health treatment. Education on the risk and treatment of burnout, depression, and suicidal ideations should begin early in a surgeon's career. This review documents the issue of physician burnout and depression and makes recommendations regarding necessary changes to counteract mental illness in orthopaedic surgeons.

Identifying and Creating Value for Employed Arthroplasty Surgeons in an Era of Decreasing Reimbursement.

Recent regulatory changes made by the Center for Medicare and Medicaid Services (CMS) will result in a 9% decrease in reimbursement for hip and knee replacements by the end of 2022. Combining this with CMS's recent removal of total knee and total hip arthroplasty from the inpatient-only list has begun to take effect on the bottom line for hospital systems, which now employ around 50% of the arthroplasty community. Employed joint replacement surgeons should continue to innovate and be leaders within their hospital systems in the outpatient and ambulatory surgery space to recoup lost value, increase autonomy, and should be compensated for this work. Employed arthroplasty surgeon leaders can better align goals with and control the narrative in the C-suite to redefine their value as the most consistent, dependable, and transparent department within a larger health system or corporate medical group.

Does Time Spent in the Post-Anesthesia Care Unit Affect Hospital Lengths of Stay following Primary Total Knee Arthroplasty?

Given the current healthcare economic environment, substantial efforts have been made to help streamline the in-hospital care for total knee arthroplasty (TKA) patients. While potential cost-reducing factors have been identified in the literature, analyses specifically considering post-anesthesia care unit (PACU) lengths of stay (LOS) are lacking. Therefore, the purpose of this study was to identify factors associated with (1) longer PACU LOS as well as (2) longer Hospital LOS. Prospectively collected TKA data from seven participating hospitals within a large health system were evaluated for patient demographics, body mass indices, Charlson Comorbidity Indices (CCI), surgeon volumes/training, admission types, anesthesia types, PACU LOS, and overall hospital LOS. Complete data was available for 1,690 patients (1,082 females, mean age: 67 years). Univariate and multivariate analytical models were constructed to identify which factors were predictive of longer PACU and overall hospital LOS. Same-day admissions, higher volume surgeons (≥ 100 cases per year), fellowship-trained arthroplasty surgeons, and longer operative times were associated with longer PACU LOS (p < 0.05). Multivariate analyses found age more than or equal to 65 years (ß= 0.124) and CCI more than or equal to 3 (ß= 0.088) to be associated with longer hospital LOS (p < 0.001). Operative times, PACU LOS, and procedure times (operative time plus PACU LOS) were not associated with longer hospital LOS (p > 0.05). These data identify associative factors for PACU LOS, as well as the influence of time spent in the PACU on overall hospital LOS. Interestingly, this analysis revealed that patients of arthroplasty fellowship-trained and higher-volume surgeons had longer PACU LOS; however, this could be explained by the observation that these particular surgeons tend to perform more complex deformity cases. Also of importance, increased PACU LOS, meaning the patient spent more time in a high-monitored setting immediately after surgery, did not necessarily confer a longer overall hospital LOS. Based on these data, it may be more beneficial to identify alternate sources than time spent in the operating room or PACU to potentially help reduce overall hospital LOS. LEVEL OF EVIDENCE: II, prospective cohort.

Generalizability of Homeopathic Prognostic Factor Research Outcome in COVID-19 Treatment: Comparison of Data.

BACKGROUND/OBJECTIVE: During the coronavirus disease 2019 (COVID-19) pandemic, several homeopathic prognostic factor research (PFR) projects have been undertaken. We found two projects with comparable outcomes to assess consistency and possible flaws. METHODS: Two comparisons were made. (1) Outcome of a PFR data collection from the Liga Medicorum Homoeopathica Internationalis (LMHI) by about 100 doctors with 541 cases was compared with a previous analysis of 161 cases in the same database. (2) The updated LMHI database was also compared with a data collection carried out in India by four doctors with a total of 1,445 cases. Differences that resulted in conflicting outcomes (indication in one, contraindication in the other) were examined for possible causes. RESULTS: There was only a single outcome in the updated LMHI database that conflicted with the previous dataset, and this could have been due to statistical variation. The Indian data contained many cases, from few doctors, while the LMHI database had few cases per doctor, but many doctors. The overlap between the projects (individual cases entered in both) was between zero and 22%. In 72 comparisons we found six (8.3%) conflicting outcomes. Possible causes were statistical error due to small numbers of cases and/or observers, confirmation bias, and keynote prescribing if this resulted in symptoms being inadequately checked. CONCLUSION: There was little conflict between the outcomes of the two versions of one project and between the two different PFR projects. Differences could mostly be explained by causes that can be managed. This consistency should primarily be interpreted as showing a strong overall consensus between homeopathic practitioners worldwide, but with variation of consensus between small groups of practitioners.

Management of Refractory Pain After Total Joint Replacement.

PURPOSE OF REVIEW: Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. RECENT FINDINGS: The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

Does Structured Postgraduate Training Affect the Learning Curve in Direct Anterior Total Hip Arthroplasty? A Single Surgeon's First 200 Cases.

BACKGROUND: The direct anterior approach (DAA) used for primary total hip arthroplasty has been shown to improve early postoperative outcomes, but prior studies have identified a marked learning curve for surgeons transitioning to this approach. However, these studies do not capture surgeons with postgraduate fellowship training in DAA. Therefore, the purpose of this study was to evaluate the learning curve by comparing perioperative outcomes for the first 100 to latter 100 cases and first 50 to final 50 cases. METHODS: The first 200 consecutive primary total hip arthroplasties performed by a single surgeon were prospectively followed up for up to 2 years postoperatively. Data on demographic and perioperative factors, 90-day readmissions, and short- and long-term complications were collected. Radiographic outcomes included acetabular cup anteversion and abduction measurements. Logistic regressions were used to calculate odds ratios and confidence intervals for surgical time greater than 2 hours. RESULTS: The first 100 and second 100 cases had significant differences in operative times (118.1 vs 110.4 minutes, P = .009), acetabular abduction (38.3 vs 35.5 degrees, P = .001) and anteversion (13.5 vs 15.1 degrees, P = .009), and incidence of neuropraxia (41 vs 9%, P < .001). Estimated blood loss, transfusions, discharge disposition, length of stay, readmission, and other complications had no statistical significance between the first and second 100 cases. The first 50 cases had higher odds of surgical time greater than 2 hours (odds ratio = 5.2, 95% confidence interval = 1.84-14.75, P = .002) than the final 50 cases. CONCLUSIONS: When compared with the existing literature, incorporation of DAA into fellowship training can lead to reduction in fractures and reoperation rates.

Data Collection during the COVID-19 Pandemic: Learning from Experience, Resulting in a Bayesian Repertory.

BACKGROUND: A novel pandemic disease offered the opportunity to create new, disease-specific, symptom rubrics for the homeopathic repertory. OBJECTIVE: The aim of this study was to discover the relationship between specific symptoms and specific medicines, especially of symptoms occurring frequently in this disease. MATERIALS AND METHODS: Worldwide collection of data in all possible formats by various parties was coordinated by the Liga Medicorum Homeopathica Internationalis. As the data came in, more symptoms were assessed prospectively. Frequent analysis and feedback by electronic newsletters were used to improve the quality of the data. Likelihood ratios (LRs) of symptoms were calculated. An algorithm for combining symptom LRs was programmed and published in the form of an app. The app was tested against 18 well-described successful cases from Hong Kong. RESULTS: LRs of common symptoms such as 'Fatigue' and 'Headache' provided better differentiation between medicines than did existing repertory entries, which are based only on the narrow presence or absence of symptoms. A mini-repertory for COVID-19 symptoms was published and supported by a web-based algorithm. With a choice of 20 common symptoms, this algorithm produced the same outcome as a full homeopathic analysis based upon a larger number of symptoms, including some that are traditionally considered more specific to particular medicines. CONCLUSION: A repertory based on clinical data and LRs can differentiate between homeopathic medicines using a limited number of frequently occurring epidemic symptoms. A Bayesian computer algorithm to combine symptoms can complement a full homeopathic analysis of cases.

Annual Nationwide Infection Trends for Revision Total Knee Arthroplasty.

Several recent intraoperative and wound management techniques have been developed and implemented in the United States over the past decade; however, it is unclear what the effects of these newer modalities have on reducing surgical site infection (SSI) rates. Therefore, the purpose of this study was to track the annual rate and trends of (1) overall, (2) deep, and (3) superficial SSIs following revision total knee arthroplasty (TKA). The National Surgical Quality Improvement Program database was queried for all revision TKA cases performed between 2011 and 2016, which yielded 9,887 cases. Cases with superficial and/or deep SSIs were analyzed separately and then combined to evaluate overall SSI rates. After an overall 6-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 5 years. Correlation coefficients and chi-square tests were used to determine correlation and statistical significance. No significant correlations between combined, deep, and/or superficial SSI rates and year were noted (p > 0.05). The lowest overall SSI incidence was in 2012 (1.16%), while the greatest incidence was in 2014 (1.76%). The deep SSI incidence over the 6 years was 0.67% (66 out of 9,887 cases). Deep SSI rate decreased by 10% in 2016 compared with 2011 (0.50 vs. 0.56%, p > 0.05). In this 6-year period, 94 cases out of 9,887 were complicated by a superficial SSI, an incidence of 0.95%. The lowest superficial SSI incidence occurred in 2015 (n = 17, 0.77%). Overall, the incidence of SSIs in revision TKA has remained fairly low with some annual variance, indicating room for improvement. These variations likely as revision surgeries can be more complex and have several associated confounding factors influencing outcomes, when compared with primary cases. Further research is needed to identify revision-specific strategies to reduce the risk of surgical site infections.