Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a rare, yet devastating complication with high mortality rates, unpredictable treatment outcomes, and high costs. The purpose of this study was to determine 90-day and 1-year mortality rates at a specialized PJI center, assess the impact of delayed referral to a PJI center on outcomes, and determine the cost of PJI treatment prior to referral to a PJI center. METHODS: A review of our institution's PJI registry was performed to identify patients who had a chronic PJI treated with a 2-stage exchange arthroplasty at our PJI Center from 2017 to 2021. Patients not referred from an external location were excluded. Mortality at 90 days and 1 year was collected. The date of infection diagnosis until the date of referral was recorded. Outcomes were documented as failure of treatment at the final clinical follow-up. The number and type of prior infection treatments were documented for each patient. The estimated cost was calculated using established PJI literature. RESULTS: There were 172 patients (182 joints) who met inclusion criteria during this timeframe. The 90-day and 1-year mortality rates were 0 and 3.9%, respectively. There was a higher failure rate in patients referred >90 days after the diagnosis of chronic PJI (23 versus 11%, P = 0.031). The total cost of PJI treatment prior to referral for this group of patients was $6.9 million. CONCLUSIONS: Implementation of a specialized PJI referral center leads to lower mortality rates, improved outcomes, and decreased cost for the health-care system.

Precision or Pitfall? Evaluating the Accuracy of ICD-10 Coding for Cemented Total Hip Arthroplasty: A Multicenter Study.

BACKGROUND: The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Procedure Coding System (ICD-10-PCS) was adopted in the U.S. in 2015. Proponents of the ICD-10-PCS have stated that its granularity allows for a more accurate representation of the types of procedures performed by including laterality, joint designation, and more detailed procedural data. However, other researchers have expressed concern that the increased number of codes adds further complexity that leads to inaccurate and inconsistent coding, rendering registry and research data based on ICD-10-PCS codes invalid and inaccurate. We aimed to determine the accuracy of the ICD-10-PCS for identifying cemented fixation in primary total hip arthroplasty (THA). METHODS: We retrospectively reviewed all cemented primary THAs performed at 4 geographically diverse, academic medical centers between October 2015 and October 2020. Cemented fixation was identified from the ICD-10-PCS coding for each procedure. The accuracy of an ICD-10-PCS code relative to the surgical record was determined by postoperative radiograph and chart review, and cross-referencing with institution-level coding published by the American Joint Replacement Registry (AJRR) was also performed. RESULTS: A total of 552 cemented THA cases were identified within the study period, of which 452 (81.9%) were correctly coded as cemented with the ICD-10-PCS. The proportion of cases that were correctly coded was 187 of 260 (72%) at Institution A, 158 of 185 (85%) at Institution B, 35 of 35 (100%) at Institution C, and 72 of 72 (100%) at Institution D. Of the 480 identified cemented THA cases at 3 of the 4 institutions, 403 (84%) were correctly reported as cemented to the AJRR (Institution A, 185 of 260 cases [71%]; Institution B, 185 of 185 [100%]; and Institution C, 33 of 35 [94%]). Lastly, of these 480 identified cemented THA cases, 317 (66%) were both correctly coded with the ICD-10-PCS and correctly reported as cemented to the AJRR. CONCLUSIONS: Our findings revealed existing discrepancies within multiple institutional data sets, which may lead to inaccurate reporting by the AJRR and other registries that rely on ICD-10-PCS coding. Caution should be exercised when utilizing ICD-10 procedural data to evaluate specific details from administrative claims databases as these inaccuracies present inherent challenges to data validity and interpretation.

Size and morphology of the coracoid and glenoid in pediatric and adolescent patients: implications for Latarjet procedure.

Background: Glenohumeral instability is a challenging problem in children and adolescents. For patients with anterior glenoid bone loss, the Latarjet procedure is an effective treatment option. However, concerns about coracoid size and morphology may limit its utilization within this patient population. The purpose of this study was to establish normative data on coracoid and glenoid size and morphology among a large cohort of adolescent patients and describe the anatomic relationships with demographic factors. Methods: This is a retrospective cross-sectional study of a consecutive series of 584 patients aged 12-21 years after a chest computed tomography scan for non-shoulder related trauma at a single level I trauma center. Demographic characteristics were collected from the electronic medical record, and the following coracoid anatomic measurements were obtained from computed tomography scans: coracoid length, coracoid thickness, coracoid width, glenoid height, and glenoid width. The ratio of coracoid thickness to glenoid width was calculated to estimate the percent bone loss that could be addressed with a traditional Latarjet coracoid transfer. To ensure reliability among 3 reviewers, all measured the same 25 scans and inter-rater reliability was excellent with all Kappa coefficients >0.81. The remaining scans were divided equally and assessed separately by these reviewers. Correlation coefficients were used to quantify the relationships between all anatomic measures and the age, weight, and height of individuals. Growth curves for each measurement were modeled using quantile regression with height and height∗height as predictors. Additionally, we stratified the growth curves by sex, when significant. Of the 584 subjects, 55% were male, and average age was 19 years (range 12, 21). Results: All growth curves illustrated increase anatomic size across the height range of 145-190 cm. The growth curve including all patients (Fig. 1) illustrated that the 50% percentile of median coracoid length increased from approximately 28 to 32 mm. In addition to height, sex was a significant predictor for coracoid width and glenoid width. The median coracoid width increased from approximately 9.5 to 10.2 mm for females compared to an increased width from approximately 10 to 11 mm for males. The median glenoid width for females increased from approximately 21 to 25 mm and for males the median glenoid width increased from just under 22 to 25.5 mm. Conclusions: Among children and adolescents, coracoid and glenoid size are correlated with patient height. These data can help guide patient selection for the Latarjet procedure.

An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty.

The prevalence of obesity in the United States is at a record high of 42%. In 1999, the Centers for Disease Control and Prevention recognized the obesity epidemic as a national problem, spurring the first generation of interventions for obesity prevention and control. Despite billions of dollars in funding, legislative changes, and public health initiatives, the trajectory of American obesity has not waivered. Obesity is also strongly associated with the development of osteoarthritis. The growing population of young, obese, and sick patients presents a unique dilemma for orthopedic surgeons performing joint replacement, as obesity levels and the demand for joint replacement are only expected to rise further.

Laceration of the Sciatic Nerve After Closed Reduction of a Dislocated Total Hip Arthroplasty.

Sciatic nerve injury after closed reduction of a dislocated total hip arthroplasty (THA) is an exceedingly rare but tremendously devastating complication. Closed reduction is the standard of care and is typically associated with a low complication rate. There have only been seven sciatic nerve injuries after closed reduction of a dislocated THA reported in the literature, and none were secondary to nerve laceration. We report a case of sciatic nerve laceration after attempted closed reduction of a dislocated THA. This resulted in complete loss of sensory and motor sciatic nerve function. This case highlights the importance of a detailed neurologic examination before and after closed reduction of a dislocated total hip, the importance of using careful reduction maneuvers, and transitioning to open reduction when necessary.

Resident Education and Wellness: A Strategy for Future Pandemics.

The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the "Inpatient-Team" delivered direct care, the "Back-up Team" and "Quarantine-Team" managed the telemedicine virtual clinic and education-wellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150-154, 2022).

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway.

BACKGROUND: Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty. METHODS: This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed. RESULTS: Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P = .003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P < .001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P = .006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium. CONCLUSION: A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

Prediction of tibial nonunion at the 6-week time point.

INTRODUCTION: Intramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST). METHODS: A retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study. RESULTS: Infection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratio > or < 1.0; p < 0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6-9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST <6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion. CONCLUSION: Three variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients.