5-Factor Modified Frailty Index as a Predictor of Outcomes After Hemiarthroplasty or Total Hip Arthroplasty for Femoral Neck Fracture.

INTRODUCTION: Although the 5-factor modified frailty index (mFI-5) has been shown to be an independent predictor of complications after primary total hip arthroplasty (THA), its predictive value has not been evaluated in the setting of hip fracture. We therefore assessed the utility of mFI-5 score as an independent predictor of morbidity and mortality in patients who underwent THA or hemiarthroplasty for femoral neck fracture. METHODS: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients with femoral neck fractures treated with THA or hemiarthroplasty between 2006 and 2020. A multivariate logistic regression analysis was done using mFI-5 as a predictor while controlling for baseline demographic and clinical variables. RESULTS: In total, 45,185 patients (hemiarthroplasty: 37,645; THA: 7,540) were identified. For hemiarthroplasty patients, the mFI-5 strongly predicted risk of any complication (OR, 1.1; 95% CI, 1.1 to 1.2; P < 0.001), bleeding (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001), and readmission (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001). For THA patients, the mFI-5 was a strong predictor of any complication (OR, 1.2; 95% CI, 1.0 to 1.3; P = 0.023), pneumonia (OR, 1.4; 95% CI, 1.0 to 2.0; P = 0.047), and readmission (OR, 1.3; 95% CI, 1.1 to 1.6; P = 0.004). DISCUSSION: The mFI-5 is an independent predictor of morbidity and complications after hemiarthroplasty and THA for femoral neck fracture. Importantly, readmission risk was predicted by the mFI-5. The mFI-5 may present a valuable clinical tool for assessment of high-risk patients who might require additional resources and specialized care after femoral neck fracture.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis.

BACKGROUND: As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort. METHODS: A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission. RESULTS: A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001). CONCLUSION: There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

Trends in prevalence and complications for smokers who underwent total hip arthroplasty from 2011 to 2019: an analysis of 243,163 patients.

BACKGROUND: Smoking is an established risk factor for postoperative complications after total hip arthroplasty (THA). It is unknown if the decreasing prevalence of adult smoking in the United States is reflected in the elective THA patient population. We aimed to investigate recent trends in: (1) the prevalence of smoking pre-THA, stratified by patient demographics; and (2) rates of 30-day complications and increased healthcare utilisation post-THA in smokers versus non-smokers. METHODS: Patients who underwent primary elective THA (2011-2019) were identified using the National Surgical Quality Improvement Program database. A total of 243,163 cases (Smokers: n = 30,536; Non-smokers: n = 212,627) were included. Trends analyses were performed for smoking prevalence across the study period. Smokers were propensity score-matched (1:1) to a cohort of non-smokers (n = 29,628, each), and rates of 30-day complications, readmission, and non-home discharge were compared. RESULTS: The rate of preoperative smoking significantly decreased from 14.0% in 2011 to 11.6% in 2019 (p-trend = 0.0286). When stratified, a significant decreasing trend in smoking was found for males and all races; within races, American-Indian/Alaska-Native race had the sharpest decline (2011:36.3% vs. 2019:23.2%). No significant change in 30-day complication rates among smokers or non-smokers was observed (p-trend > 0.05), but non-home discharge significantly decreased for both smokers (p-trend = 0.001) and non-smokers (p-trend < 0.001). After matching, higher rates of superficial surgical site infections (SSI) (0.9% vs. 0.5%; p < 0.001), deep SSI (0.5% vs. 0.3%; p < 0.001), wound disruption (0.2% vs. 0.1%; p = 0.006), and readmission (4.2% vs. 3.1%; p = <0.001) were found in smokers versus non-smokers. CONCLUSIONS: The present study is encouraging that national efforts to reduce the prevalence of smoking may be successful within the THA population, but there is a persistently elevated risk of postoperative complications in smokers after THA.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

BACKGROUND: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. RESULTS: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. DISCUSSION: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Single-level posterior cervical foraminotomy associated with increased incidence of early postoperative wound infection rates relative to anterior cervical discectomy with fusion and cervical disc arthroplasty.

Background: To date, there are no studies comparing perioperative outcomes of cervical radiculopathy patients managed by anterior cervical discectomy with fusion (ACDF), cervical disc arthroplasty (CDA), or posterior cervical foraminotomy (PCF). To assess if there were differences in perioperative outcomes between cervical radiculopathy patients who can be appropriately treated with ACDF, CDA, or PCF. Methods: Patients diagnosed with cervical radiculopathy who underwent a single-level ACDF, CDA, or PCF between 2012 and 2019 were retrospectively identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology (CPT) codes. Patients were subsequently stratified into those who underwent ACDF, CDA, or PCF, and propensity score-matched to adjust for differences in patient demographics/characteristics. Differences were assessed in terms of operative time, healthcare utilization metrics (reoperations, readmissions, lengths-of-stay), as well as medical and surgical complications. Results: A total of 18,614 cervical radiculopathy patients undergoing surgery were identified (ACDF: n=15,862; CDA: n=1,731; PCF: n=1,021). After 1:1 propensity score matching (n=535 each), there were no differences in characteristics in patients undergoing ACDF, CDA, or PCF (P>0.05). PCF patients had statistically higher rates of reoperation (2.1%) than ACDF (0.4%), CDA (0.6%) patients (P=0.010). PCF patients also experienced higher rates of superficial infection (P=0.001), and deep infection (P=0.007), relative to ACDF and CDA patients. There were no other significant differences in medical/surgical complications between the ACDF, CDA, or PCF patients. Conclusions: Cervical radiculopathy patients undergoing PCF are associated with higher rates of perioperative infection and overall reoperation than ACDF or CDA. Further research is required to elucidate the mechanism behind this association.

Is High Body Mass Index Protective or Detrimental in Surgical Fixation of Hip Fractures?: A Spline Regression Analysis of 22,388 Patients.

OBJECTIVE: We aimed to characterize the association between BMI as a continuous variable and 30-day postoperative outcomes following hip fracture surgery through (1) 30-day readmission and reoperation; (2) local wound-related; and (3) systemic complications. METHODS: The National Surgical Quality Improvement Program database (January 2016-December 2019) was queried for patients undergoing hip fracture open reduction and internal fixation. Baseline patient demographics, comorbidities, and patient outcomes were recorded. Multivariable regression models accounted for baseline demographics, comorbidities, and fracture patterns. Significant associations were analyzed using spline regression models to evaluate the continuous association between BMI and the aforementioned outcomes. RESULTS: Spline models demonstrated a U-shaped curve for the odds of 30-day readmission and 30-day reoperation with nadirs at the BMI of 27.5 and 22.0 kg/m 2 . The odd ratios of superficial infection, deep infection, any wound complication, and inability to weight bear on POD 1 rose progressively starting at a BMI of 25.6, 35.5, 25.6, and 32.7 kg/m 2 respectively. Odds of 30-day mortality, transfusion, pneumonia, and delirium were greatest at the lowest recorded BMI (11.9 kg/m 2 ). CONCLUSION: BMI has a U-shaped association with 30-day readmission and reoperation. Conversely, the highest risk of mortality and systemic complications (transfusion, pneumonia, and delirium) were within the lower BMI range, with diminishing risk as BMI increased. Local wound complications and systemic sepsis exhibited a third unique pattern with progressive rise in odds as BMI increased. The odds of any complications demonstrated a U-shaped pattern with a nadir in the overweight to obese I categories, suggesting that patients may be at lowest risk within this range. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures.

INTRODUCTION: Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS: The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R 2 values were calculated. RESULTS: A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION: Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.

Preoperative Veteran RAND-12 Mental Composite Score of >60 Associated With Increased Likelihood of Patient Satisfaction After Total Hip Arthroplasty.

BACKGROUND: The present study aimed to determine the distribution of Veterans RAND 12-Item health survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher health care utilizations and 1-year patient-reported outcome measures (PROMs). METHODS: A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (nonhome discharge, prolonged length of stay [LOS](ie, ≥3 days), all-cause readmission), attainment of patient acceptable symptom state (PASS) at 1-year postoperative and substantial clinical benefit (SCB) in the hip disability osteoarthritis outcome score (HOOS)-pain and HOOS-physical short form. RESULTS: Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all P < .001). Preoperative VR-12 MCS<20 was associated with more than twice the odds of nonhome discharge (odds ratio [OR]:2.31) and prolonged LOS (OR: 3.46). VR-12 MCS >60 was associated with higher odds of achieving PASS (OR: 2.00) and SCB in HOOS-joint related (JR) (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes. CONCLUSION: Low preoperative VR-12 MCS, specifically less than 40, may predict increased health care utilization. Furthermore, preoperative VR-12 MCS>60 predicts greater satisfaction at 1 year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared decision-making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA. LEVEL OF EVIDENCE: II.

Opioid and Sedative NarxCare Scores Greater Than 300 Are Associated With Adverse Outcomes After Nonemergent Spine Surgery.

STUDY DESIGN: This was a prospectively captured cohort study. OBJECTIVE: To explore associations between the preoperative opioid-specific NarxCare Scores (NCS) (NCS-opioids) as well as sedative-specific NCS (NCS-sedatives) as measures of patients' prescription drug use and (1) 90-day postoperative readmission; (2) ED visits; (3) reoperation; (4) prolonged (>2 d) hospital length of stay (LOS); and (5) nonhome discharge. In addition, we sought to evaluate the previously suggested 300+ threshold as a cutoff for moderate/high-risk designation. BACKGROUND: The association between preoperative opioids and sedative use and healthcare utilization after nonemergent spine surgery is not well quantified. The NCS is a weighted scalar measure of opioids and sedatives that accounts for the number of prescribing providers, dispensing pharmacies, milligram equivalence doses, and overlapping prescription days. METHODS: A total of 4680 nonemergent spine surgery cases were included. Preoperative NCS-opioids/sedatives were captured. Bivariate and multivariable regression models were constructed to analyze associations between NCS-opioids/sedatives ranges and outcomes while accounting for baseline differences. Spline regression and propensity score matching (PSM) analyses were also implemented. RESULTS: For NCS-opioid, multivariable regression demonstrated higher odds of prolonged LOS starting in the 400 to 499 NCS-opioids category [odds ratio (OR): 1.44; 95% confidence interval (CI): 1.05-1.97; P =0.026] going into the 500+ category (OR: 1.94; 95% CI: 1.29-2.93; P =0.002]. The 500+ categories exhibited higher odds of 90-day readmission (OR: 1.77; 95% CI: 1.01-3.09; P =0.045). PSM comparison demonstrated that patients within the 300+ category had higher incidence of prolonged LOS [n=455 (44%) vs . n=537 (52%); P <0.001], 90-day readmission [n=118 (11%) vs . n=155 (15%); P =0.019] and 90-day reoperation [n=51 (4.9%) vs . n=74 (7.2%); P =0.042]. For NCS-sedative; there was higher odds of prolonged LOS (OR: 1.73; 95% CI: 1.14-2.63; P =0.010) and nonhome discharge(OR: 2.09; 95%CI: 1.22-3.63; P =0.008) within the 400 to 499 NCS-sedatives category. PSM comparison demonstrated significantly higher rates of prolonged LOS within the 300+ NCS-sedative cohort ( vs . scores <300), [n=277 (44%) vs. 319 (50%); P =0.021]. CONCLUSION: Spine surgery continues to advance toward patient-specific care. Higher NCS-opioids/sedatives values may predict up to a twofold increase in postoperative healthcare utilization. High values should prompt an interdisciplinary approach to mitigate deleterious prescription drug use.

Factors Affecting 30-Day Mortality following Primary Elective Total Knee Arthroplasty: A Database Study of 326,157 Patients.

Despite its rarity, the risk of mortality following primary elective total knee arthroplasty (TKA) is a critical component of surgical decision-making and patient counseling. The purpose of our study was to (1) determine the overall 30-day mortality rate for unilateral primary elective TKA patients, (2) determine the 30-day mortality rates when stratified by age, comorbidities, and preoperative diagnosis, and (3) identify the distribution of (i) patient demographics, (ii) baseline comorbidities, and (iii) preoperative diagnoses between mortality and mortality-free cohorts. A total of 326,157 patients underwent primary elective TKA (2011-2018) were identified through retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into 30-day mortality (n = 320) and mortality-free (n = 325,837) cohorts. Patient demographics, preoperative comorbidities, and preoperative diagnoses were compared. Age group, American Society of Anesthesiology (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis. The overall mortality rate was 0.098%. Older age (p < 0.001) and male gender (p < 0.001) were associated with increased mortality. There was no association between mortality and race (p = 0.346) or body mass index (BMI) class (p = 0.722). All reported comorbidities except smoking status were significantly greater in the mortality cohort (p < 0.05). For ASA scores of I, II, III, and IV, the number of deaths per 1,000 were 0.16, 0.47, 1.4, and 4.4, respectively. For CCI scores of 0, 1, 2, 3, 4, and 6, mortality rates per 1,000 were 0.76, 2.1, 7.0, 11, 29, and 7.6, respectively. Mortality rates for a preoperative diagnosis of osteoarthritis (OA) versus non-OA were, respectively, 0.096% and 0.19% (p < 0.001). Increased age, male gender, increased comorbidity burden, and non-OA preoperative diagnoses are associated with higher rates of 30-day postoperative mortality. There were no significant associations between BMI or race and 30-day mortality. These findings aid in identifying of higher-risk patients, who can then receive appropriate counseling or preoperative interventions to reduce the risk of perioperative mortality.

Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients.

BACKGROUND: Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address. QUESTIONS/PURPOSES: The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes. METHODS: Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI. RESULTS: In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 [95% confidence interval (CI) 0.31 to 0.59]; p < 0.001) and nonhome discharge (OR 0.39 [95% CI 0.27 to 0.56]; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 [95% CI -0.063 to -0.026]; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 [95% CI 0.024 to 0.059]; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 [95% CI -0.13 to -0.024]; p = 0.004; nonhome discharge: 0.060 [95% CI 0.016 to 0.11]; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 [95% CI 0.32 to 0.54]; p < 0.001), nonhome discharge (OR 0.44 [95% CI 0.33 to 0.60]; p < 0.001), 90-day readmission (OR 0.54 [95% CI 0.39 to 0.77]; p < 0.001), and 90-day ED admission (OR 0.60 [95% CI 0.45 to 0.79]; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 [95% CI -0.035 to -0.007]; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 [95% CI -0.016 to 0.040]; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 [95% CI -0.13 to -0.049]; p < 0.001; nonhome discharge: 0.046 [95% CI 0.014 to 0.078]; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group. CONCLUSION: Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage. LEVEL OF EVIDENCE: Level III, therapeutic study.

Identifying Trends and Quantifying Growth for Technological Innovation in Knee Arthroplasty: An Analysis of a Patent Database (1990 to 2020).

Technological innovation is the key for surgical progress in knee arthroplasty and improvement in patient outcomes. Exploring patented technologies can help elucidate trends and growth for numerous innovative technologies. However, patent databases, which contain millions of patents, remain underused in arthroplasty research. Therefore, the present study aimed to: (1) quantify patent activity; (2) group patents related to similar technologies into well-defined clusters; and (3) compare growth between technologies in the field of knee arthroplasty over a 30-year period. An open-source international patent database was queried from January 1990 to January 2020 for all patents related to knee arthroplasty A search strategy identified 70,154 patents, of which 24,425 were unique and included analysis. Patents were grouped into 14 independent technology clusters using Cooperative Patent Classification (CPC) codes. Patent activity was normalized via a validated formula adjusting for exponential growth. Compound annual growth rates (CAGR) were calculated (5-year, 10-year, and 30-year CAGR) and compared for each cluster. Overall yearly patent activity increased by 2,023%, from 104 patents in 1990 to 2,208 patents in 2020. The largest technology clusters were "drugs" (n = 5,347; 23.8%), "components" (n = 4,343; 19.0%), "instruments" (n = 3,130; 13.7%), and "materials" (n = 2,378; 10.4%). The fastest growing technologies with their 5-year CAGR were: "user interfaces for surgical systems" (58.1%); "robotics" (28.6%); "modularity" (21.1%); "navigation" (15.7%); and "computer modeling" (12.5%). Since 1990, overall patent growth rate has been greatest for "computer modeling" (8.4%), "robotics" (8.0%), "navigation" (7.9%), and "patient-specific instrumentation" (6.4%). Most patents in knee arthroplasty for the last 30 years have focused on drugs, components, instruments, and materials. Recent exponential growth was mainly observed for user interfaces for surgical systems, robotics, modularity, navigation, and computer-assisted technologies. Innovation theory would suggest that these rapidly growing technologies are experiencing high innovation output, increased resource investments, growing adoption by providers, and significant clinical impact. Periodic monitoring of technological innovation via patent databases can be useful to establish trends and future directions in the field of knee arthroplasty.

Have all races experienced reductions in complication rates following total hip arthroplasty? A NSQIP analysis between 2011 and 2019.

INTRODUCTION: Despite numerous articles in the orthopedic literature evaluating racial and ethnic disparities, inequalities in total joint arthroplasty outcomes remain. While the National Surgical Quality Improvement (NSQIP) database has been previously utilized to highlight these disparities, no previous analysis has evaluated how the rate of various perioperative complications has changed over recent years when segregating by patient race. Specifically, we evaluated if all races have experienced decreases in (1) medical complications, (2) wound complications, (3) venous thromboembolism (VTE), and (4) readmission/reoperation rates following total hip arthroplasty (THA) over recent years? METHODS: Current Procedural Terminology (CPT) code 27,130 (total hip arthroplasty) was utilized to identify all THA procedures conducted between 2011 and 2019. Patients were segregated according to race and various demographics were collected. Linear regression was utilized to evaluate changes in each complication rate between 2011 and 2019. A multivariate regression was then conducted for each complication to evaluate whether race independently was associated with each outcome. RESULTS: Our analysis included a total of 212,091 patients undergoing primary THA. This included 182,681 (85.76%) White, 19,267 (9.04%) Black, 5928 (2.78%) Hispanic, and 4215 (1.98%) Asian patients. We found that for urinary tract infection (UTI), acute renal failure, superficial SSI, and readmission rates, White patients experienced significant reductions between 2011 and 2019. However, this was not consistent across all races. Black race was associated with a significantly increased risk of acute renal failure (OR: 2.03, 95% CI: 1.17-3.34; p = 0.008), renal insufficiency (OR: 2.33, 95% CI: 1.62-3.28; p < 0.001), deep vein thrombosis (DVT) (OR: 1.34, 95% CI: 1.07-1.66; p = 0.01), and pulmonary embolism (PE) (OR: 1.76, 95% CIL: 1.36-2.24; p < 0.001). CONCLUSION: Our analysis highlights specific complications for which further interventions are necessary to reduce inequalities across races. These include medical optimization, increased patient education, and continued efforts at understanding how social factors may impact-related care inequalities. Future study is needed to evaluate specific interventions that can be applied at the health systems level to ensure all patients undergoing THA receive the highest quality of care regardless of race.

Perioperative outcomes of cervical disc arthroplasty: no difference between orthopaedic and neurologic surgeons.

Background: Given differences in residency training background, there has been increasing interest in characterizing differential outcomes between orthopaedic surgeons (OS) and neurosurgeons (NS) with regards to outcomes after cervical disc arthroplasty (CDA). This study aimed to assess if there were differences in perioperative outcomes of CDA between OS and NS. Methods: Patients who underwent a single-level CDA between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology codes. The patients were subsequently stratified into those who underwent CDA with OS versus NS, and propensity score-matched to adjust for differences in patient characteristics. Differences were assessed in medical and surgical complications, as well as operative time and healthcare utilization parameters [reoperations, readmissions, and lengths-of-stay (LOS)]. Results: A total of 2,148 patients were identified (NS: n=1,395; OS: n=753). After 1:1 propensity score matching (n=741 each), there were no differences in characteristics between patients who underwent CDA by OS versus NS (P>0.05). There were no significant differences in any of the medical or surgical complications between the two groups (P>0.05 for each). There was a significant difference in the operative time between NS and OS (103.7±36.18 vs. 98.75±36.69 minutes; P=0.009). There were no significant differences in readmissions, reoperations, or LOS between the two groups (P>0.05 for each). Conclusions: There were no differences in medical or surgical complications, as well as in reoperations, readmissions, and LOS in patients who underwent a single-level CDA between OS and NS. There was a statistically significant shorter operative time of four minutes for OS as compared to NS, which is unlikely to have clinical relevance.

The association between perioperative blood transfusions and venous thromboembolism risk following surgical management of hip fractures.

Introduction: Despite high rates of transfusion reported among hip fracture patients in the perioperative period, the relationship between perioperative transfusions and VTE has not been thoroughly explored. Therefore, we used a national database to evaluate how perioperative transfusions among patients undergoing surgical management of hip fractures impacted 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE) risk. Methods: The Targeted Hip Fracture Database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients undergoing surgical management of hip fractures from 2016 to 2019. A multivariate logistic regression was conducted using various patient-specific variables to identify risk factors for DVT and PE. A nearest-neighbor propensity score matched (PSM) comparison between patients receiving and not receiving perioperative blood transfusions (1:1) was additionally conducted. Results: Prior to our PSM, preoperative transfusions were not associated with DVT incidence (OR: 1.48, 95% CI: 0.80-2.50; p = 0.2). However, intra-operative/post-operative transfusions (OR: 1.26, 95% CI: 1.02-1.56; p = 0.00.30) as well as the receipt of both transfusion types (OR: 1.81, 95% CI: 1.10-2.81; p = 0.012) were associated with an increased risk of DVT. The latter of these findings remained significant following PSM (OR: 1.73, 95% CI: 1.04-2.73; p = 0.025). No relationship was demonstrated between PE risk and perioperative transfusion receipt. Conclusion: Our findings emphasize the importance of perioperative blood management strategies among patients undergoing surgical repair of hip fracture. Specifically, orthopaedic surgeons should aim to optimize hip fracture patients prior to surgical intervention as well as intra-operatively to reduce transfusion incidence.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases.

Background The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p = 0.002). There was no association between operative time and 30-day readmission ( p > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Cooled and traditional thermal radiofrequency ablation of genicular nerves in patients with chronic knee pain: a comparative outcomes analysis.

INTRODUCTION: Genicular nerve radiofrequency ablation (GNRFA) is a minimally invasive intervention for patients with chronic knee pain (CKP) not responding to conservative treatments. Few investigations have compared treatment outcomes of cooled-RFA (c-RFA) and thermal-RFA (t-RFA), two common approaches of GNRFA. This study aims to investigate and compare outcomes, including probability of treatment success, between c-RFA and t-RFA in patients with CKP. METHODS: This retrospective cohort study analyzed a total of 208 propensity score matched patients, including 104 patients who received c-RFA and 104 patients who received t-RFA. The primary outcome was probability of pain relief after the procedure, defined as reduction in Numeric Rating Scale (NRS) pain score of 2 or greater. The secondary outcomes were degree of NRS pain score reductions, duration of relief, and the probability of patients receiving TKA within 1 year of treatment. RESULTS: T-RFA was associated with a higher probability of pain relief within 1, 3, and 6 months after procedure when compared with c-RFA. Probabilities of pain relief from t-RFA and c-RFA were 62% (95% CI 51% to 71%) and 43% (95% CI 34% to 53%; p=0.01) within 1 month, 78% (95% CI 68% to 85%) and 55% (95% CI 45% to 64%; p<0.001) within 3 months, and 79% (95% CI 70% to 86%) and 59% (95% CI 49% to 68%; p<0.01) within 6 months, respectively. t-RFA was also associated with greater mean NRS pain score reduction at 1 month after procedure: -4.71 (95% CI -5.3 to -4.1) when compared with -3.59 (95% CI -4.3 to -2.9; p=0.02) from c-RFA. T-RFA and c-RFA were comparable in pain score reduction at 3, 6, 9 and 12 months after procedure. Both groups demonstrated comparable duration of relief and probability of patients receiving TKA within 1 year. DISCUSSION: Both t-RFA and c-RFA effectively reduced NRS pain scores in most patients with CKP within the 1 year follow-up period. Genicular nerve t-RFA was associated with a higher probability of treatment success and a greater degree of pain relief at 1 month after the procedure when compared with c-RFA in propensity score matched patients with CKP.

Hyaluronic Acid Injections for Knee Osteoarthritis: Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?

BACKGROUND: The utilization of hyaluronic acid (HA) for the management of knee osteoarthritis (OA) remains controversial, and more information is needed regarding how its utilization and financial burden have changed over recent years. The purpose of our analysis was to evaluate changes in overall utilization and health-care costs associated with HA injections among Medicare beneficiaries over a contemporary time frame. METHODS: The 2012 to 2018 Medicare Fee-for-Service Provider Utilization and Payment Public Use Files (PUFs) were utilized for our analysis. Organized by Healthcare Common Procedure Coding System (HCPCS) codes, these files capture 100% of Medicare Part B claims. Payment and utilization data were collected for all HCPCS codes corresponding to injection of an HA formulation. The number of services involving HA as well as the total cost of HA administration in 2020 U.S. dollars were tabulated. Mann-Kendall trend tests were used to evaluate trends in utilization for providers nationally and when segregated by specialty. RESULTS: Total HA utilization increased significantly from 2012 (n = 1,090,503) through 2018 (n = 1,209,489; p = 0.04). Although orthopaedic surgeons did not demonstrate significant changes in total utilization rates (p = 0.23), the average number of services per orthopaedic surgeon increased significantly (p = 0.02). Reflecting a substantial growth in the number of advanced practice providers (APPs) providing injections, there was a significant increase in utilization and associated costs among physician assistants (p < 0.01) and nurse practitioners (p < 0.01). Total costs associated with HA services increased significantly from $290.10 million to $325.02 million (p < 0.01). CONCLUSIONS: Despite the 2013 American Academy of Orthopaedic Surgeons clinical practice guideline recommending against the clinical utility of these injections, HA services continued to be widely implemented among Medicare beneficiaries. Although there were variations across specialties when evaluating overall utilization rates as well as rates per provider, APPs largely contributed to the increase seen in the U.S. over this study period. More data are needed to support continued implementation and spending on this low-value care.

Neighborhood Socioeconomic Disadvantage Associated With Increased Healthcare Utilization After Total Hip Arthroplasty.

BACKGROUND: The multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions. METHODS: Two thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (>3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios. RESULTS: In the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P < .001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001). CONCLUSIONS: Higher ADI is associated with an increased healthcare utilization within 90 days of THA.

Preoperative Veterans Rand-12 Mental Composite Score of < 40 Leads to Increased Healthcare Utilization and Diminished Improvement After Primary Knee Arthroplasty.

BACKGROUND: Adverse outcomes after total knee arthroplasty (TKA) have been associated with preoperative psychological disorders and poor mental health. We aimed to investigate and quantify the association between preoperative mental health and 1) postoperative 90-day health care utilization; and 2) 1-year patient-reported outcomes after primary TKA. METHODS: Retrospective review of prospectively collected data of patients who underwent primary elective TKA (n = 7,476) was performed. Preoperative mental health was evaluated using Veterans Rand-12 Mental Composite Scores (VR-12 MCS). Outcomes included prolonged length of stay (>2-days), nonhome discharge, 90-day readmissions, emergency department visits, and reoperation. Improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) and Patient Acceptable Symptom State (PASS) achievement were evaluated at 1-year. Multivariable regression was implemented to explore associations between preoperative VR-12 MCS and outcomes of interest. RESULTS: A total of 5,402 (72.3%) completed 1-year follow-up. Lower preoperative VR-12 MCS was associated with higher odds of prolonged length of stay (MCS 20-39: odds ratio (OR): 1.46;P < .001), and nonhome discharge disposition (MCS 20-39: OR: 1.92;P < .001), but not 90-day readmission or reoperation (MCS20-39; P = .12 and P = .64). At 1-year, patients with a lower MCS were less likely to attain a substantial clinical benefit in KOOS-pain (MCS 0-19; OR: 0.25; P < .001) and less likely to achieve PASS (MCS20-39; OR: 0.74; P = .002). Patients with an MCS >60 were more likely to be discharged home (OR: 1.42; P = .008), achieve substantial clinical benefit in their KOOS-JR (OR: 1.16; P = .027),-Pain (OR: 1.220; P = .007) and PASS at 1-year (OR: 1.28; P = .008). CONCLUSIONS: Lower VR-12 MCS is associated with increased postoperative health care utilization and worse patient-reported outcome measures at 1-year post-TKA. These findings suggest that a VR-12 MCS ≤40 could be used to designate increased risk, guide the preoperative discussion and potential interventions.