In Vivo Intra-Articular Antibiotic Concentrations at 24 Hours After TKA Fall Below the Minimum Inhibitory Concentration for Most Bacteria: A Randomized Study of Commercially Available Bone Cement.

BACKGROUND: The use of antibiotic-loaded bone cement (ALBC) to help reduce the risk of infection after primary total knee arthroplasty (TKA) is controversial. There is a paucity of in vivo data on the elution characteristics of ALBC. We aimed to determine whether the antibiotic concentrations of 2 commercially available ALBCs met the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) for common infecting organisms. METHODS: Forty-five patients undergoing TKA were randomized to receive 1 of the following: bone cement without antibiotic (the negative control; n = 5), a commercially available formulation containing 1 g of tobramycin (n = 20), or a commercially available formulation containing 0.5 g of gentamicin (n = 20). Intra-articular drains were placed, and fluid was collected at 4 and 24 hours postoperatively. An automated immunoassay measuring antibiotic concentration was performed, and the results were compared against published MIC and MBEC thresholds. RESULTS: The ALBC treatment groups were predominantly of White (65%) or Black (32.5%) race and were 57.5% female and 42.4% male. The mean age (and standard deviation) was 72.6 ± 7.2 years in the gentamicin group and 67.6 ± 7.4 years in the tobramycin group. The mean antibiotic concentration in the tobramycin group was 55.1 ± 37.7 µg/mL at 4 hours and 19.5 ± 13.0 µg/mL at 24 hours, and the mean concentration in the gentamicin group was 38.4 ± 25.4 µg/mL at 4 hours and 17.7 ± 15.4 µg/mL at 24 hours. Time and antibiotic concentration had a negative linear correlation coefficient (r = -0.501). Most of the reference MIC levels were reached at 4 hours. However, at 24 hours, a considerable percentage of patients had concentrations below the MIC for many common pathogens, including Staphylococcus epidermidis (gentamicin: 65% to 100% of patients; tobramycin: 50% to 85%), methicillin-sensitive Staphylococcus aureus (gentamicin: 5% to 90%; tobramycin: 5% to 50%), methicillin-resistant S . aureus (gentamicin: 5% to 65%; tobramycin: 50%), Streptococcus species (gentamicin: 10% to 100%), and Cutibacterium acnes (gentamicin: 10% to 65%; tobramycin: 100%). The aforementioned ranges reflect variation in the MIC among different strains of each organism. Gentamicin concentrations reached MBEC threshold values at 4 hours only for the least virulent strains of S . aureus and Escherichia coli. Tobramycin concentrations did not reach the MBEC threshold for any of the bacteria at either time point. CONCLUSIONS: The elution of antibiotics from commercially available ALBC decreased rapidly following TKA, and only at 4 hours postoperatively did the mean antibiotic concentrations exceed the MIC for most of the pathogens. Use of commercially available ALBC may not provide substantial antimicrobial coverage following TKA. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Incidence, Risk Factors, and Subsequent Complications of Postoperative Hematomas Requiring Reoperation After Primary Total Hip Arthroplasty.

Background: Studies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA. Methods: Study population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation. Results: Among the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023). Conclusions: Surgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

Analyses of Orthopaedic Surgery Residency Interviews.

Interviews are a critical component of orthopaedic surgery residency selection for both the applicant and the program. Some institutions no longer report Alpha Omega Alpha (AOA) designation or class rank, and US Medical Licensing Examination (USMLE) Step 1 recently switched to pass/fail scoring. During the coronavirus disease 2019 (COVID-19) pandemic, all Accreditation Council for Graduate Medical Education programs conducted virtual interviews and subinternship rotations were restricted. These changes offer significant challenges to the residency match process. The purpose of this study was to examine the residency applicant interview and ranking process at a large urban academic university setting. We hypothesized that large variability exists among evaluations submitted by faculty interviewers and also that applicant academic factors (i.e., USMLE Step 1 score) would show association with final ranking. Methods: We retrospectively reviewed the 2020-2021 and 2021-2022 residency interview cycles, both conducted virtually due to the COVID-19 pandemic. Residency application (i.e., applicant demographic and academic backgrounds) and interview data (i.e., faculty interviewer scores) were recorded. Interobserver reliability among faculty interviewers was calculated. Statistical analysis was performed to determine factors associated with ranking of applicants. Results: There were 195 included applicants from the 2020 and 2021 interview cycles. There was no true agreement of interviewers' scoring of shared applicants (kappa intraclass coefficient range 0-0.2). Applicant factors associated with being ranked include applying to the match for the first time, USMLE Step 1 and 2 scores, educational break (vs. consecutive completion of college and medical school in 4 years each), higher class rank, and greater interviewer scores. Factors associated with better rank included additional degrees (i.e., PhD or MBA), couples match, AOA designation, educational break, underrepresented minority status, and notable attributes (i.e., collegiate athletics or Eagle Scout participation). Factors associated with worse rank included male sex, international medical graduate, prior match history, science major, extended research (i.e., >1 year spent in a research role), and home medical school students. Conclusions: There was significant variability and no reliability at our institution among faculty interviewers' applicant ratings. Being ranked was based more on academic record and interview performance while final rank number seemed based on applicant qualities. The removal of merit-based objective applicant measurements offers challenges to optimal residency applicant and program match. Level of Evidence: III (retrospective cohort study).

Evaluating Outcomes of Spinopelvic Fixation for Patients Undergoing Long Segment Thoracolumbar Fusion with a Prior Total Hip Arthroplasty.

INTRODUCTION: Understanding the relationship between spinal fusion and its effects on relative spinopelvic alignment in patients with prior total hip arthroplasty (THA) is critical. However, limited data exist on the effects of long spinal fusions on hip alignment in patients with a prior THA. Our objective was to compare clinical outcomes and changes in hip alignment between patients undergoing long fusion to the sacrum versus to the pelvis in the setting of prior THA. METHODS: Patients with a prior THA who underwent elective thoracolumbar spinal fusion starting at L2 or above were retrospectively identified. Patients were placed into one of two groups: fusion to the sacrum or pelvis. Preoperative, six-month postoperative, one-year postoperative, and delta spinopelvic and acetabular measurements were measured from standing lumbar radiographs. RESULTS: A total of 112 patients (55 sacral fusions, 57 pelvic fusions) were included. Patients who underwent fusion to the pelvis experienced longer length of stay (LOS) (8.31 vs. 4.21, P < 0.001) and less frequent home discharges (30.8% vs. 61.9%, P = 0.010), but fewer spinal revisions (12.3% vs. 30.9%, P = 0.030). No difference was observed in hip dislocation rates (3.51% vs. 1.82%, P = 1.000) or hip revisions (5.26% vs. 3.64%, P = 1.000) based on fusion construct. Fusion to the sacrum alone was an independent predictor of an increased spine revision rate (odds ratio: 3.56, P = 0.023). Patients in the pelvic fusion group had lower baseline lumbar lordosis (LL) (29.2 vs. 42.9, P < 0.001), six-month postoperative LL (38.7 vs. 47.3, P = 0.038), and greater 1-year ∆ pelvic incidence-lumbar lordosis (-7.98 vs. 0.21, P = 0.032). CONCLUSION: Patients with prior THA undergoing long fusion to the pelvis experienced longer LOS, more surgical complications, and lower rate of spinal revisions. Patients with instrumentation to the pelvis had lower LL preoperatively with greater changes in LL and pelvic incidence-lumbar lordosis postoperatively. No differences were observed in acetabular positioning, hip dislocations, or THA revision rates between groups.

New Evaluation and Management Code Level Selection Trends in Hip and Knee Osteoarthritis Patients.

BACKGROUND: On January 1, 2021, the American Medical Association implemented changes regarding the outpatient Evaluation and Management (E/M) criteria dictating Current Procedural Terminology code level selection to help diminish administrative burden and emphasize medical decision-making as the primary determinant in E/M level of service (EML). The goal of this study was to describe EML coding trends in outpatient visits for hip and knee osteoarthritis after the 2021 Centers for Medicare and Medicaid Services changes to the E/M system. METHODS: All outpatient visits for primary hip and knee osteoarthritis within the divisions of Joint Replacement, Operative Sports Medicine, and Nonoperative Sports Medicine at a single orthopaedic practice were retrospectively analyzed during 2 separate 10-month timeframes in 2019 and 2021. The primary endpoint was the visit EML (1 through 5) based on Current Procedural Terminology E/M codes. RESULTS: In 2019, 7.8% of all visits were billed as level 2, 85.8% of all visits were billed as level 3, and 6.3% of all visits were billed as level 4. In 2021, 2.8% of visits were billed as level 2, 54% of visits were billed as level 3, and 41.3% of visits were billed as level 4. Level 1 and Level 5 visits did not exceed 2% in either year. Across all 3 divisions, level 2 and 3 visits decreased significantly (P < .05), while level 4 visits increased significantly (P < .05). CONCLUSION: Since the E/M coding criteria overhaul in 2021, there has been a significant trend towards higher level of service code selection across multiple divisions in our orthopaedic practice.

Melatonin Does Not Improve Sleep Quality in a Randomized Placebo-controlled Trial After Primary Total Joint Arthroplasty.

INTRODUCTION: Sleep disturbance is a common concern among patients who have undergone total joint arthroplasty (TJA). Poor sleep during the postoperative period affect quality of life directly and may influence pain recovery after TJA. The purpose of this prospective study was to investigate whether the daily use of exogenous melatonin for 6 weeks after TJA can mitigate the effects of TJA on sleep. METHODS: A cohort of 118 patients undergoing primary total hip arthroplasty or total knee arthroplasty from 2018 to 2020 were randomized to melatonin (6 mg) or placebo for 42 days after surgery. Inclusion criterion was patients undergoing unilateral primary TJA. Patients who underwent bilateral TJA and revision TJA, with a history of sleep disturbance, and on opioid medication or sleep aids preoperatively were excluded. Sleep quality was assessed at baseline and at 2 and 6 weeks postoperatively using the validated self-administered questionnaire, Pittsburgh Sleep Quality Index (PSQI). Continuous and categorical variables were analyzed using Student t-test and chi-square analysis, respectively. Multivariate linear regression analysis was also conducted. RESULTS: Patients in both groups exhibited higher PSQI scores, representing lower sleep quality, at both 2 and 6 weeks postoperatively compared with that at baseline. Overall, global PSQI scores were 6.8, 9.8, and 8.8 at baseline, week 2, and week 6, respectively. No significant differences were noted between melatonin and placebo groups at baseline (6.8 versus 6.8, P = 0.988), week 2 (10.2 versus 9.3, P = 0.309), or week 6 (8.8 versus 8.7, P = 0.928). In multivariable regression, the only significant predictors of increased PSQI scores were an elevated baseline PSQI score (at both time points), a decreased length of stay (at week 2 only), and patients undergoing total hip arthroplasty versus total knee arthroplasty (at week 6 only). CONCLUSION: Patients undergoing TJA had poor sleep quality both preoperatively and postoperatively. The use of exogenous melatonin did not demonstrate any notable effect on sleep quality.

Predictors of Success in an Orthopaedic Residency.

¼: Orthopaedic surgery is one of the most competitive residencies to match into. Meanwhile, the average applicant's United States Medical Licensing Examination (USMLE) test scores, research involvement, and number of clinical honors increase every year. ¼: Measures such as USMLE scores, productivity in research, Alpha Omega Alpha (AΩA) honor society status, number of clinical honors, and performance on away rotations have all been cited as factors contributing to program directors choosing applicants for interviews and ranking them for their program. However, questions remain as to whether these measures translate to success on board examinations, high faculty evaluations, and designation as chief resident during orthopaedic residency. ¼: USMLE scores have been shown to correlate with Orthopaedic In-Training Examination (OITE) and American Board of Orthopaedic Surgery (ABOS) scores, while clinical grades and AΩA status correlate with faculty evaluations. Participating in research as a medical student was predictive of research productivity in residency but did not correlate with standardized testing scores or faculty evaluations. ¼: The literature has suggested ways in which measures such as personality and grit may be used in the application process and how these factors may contribute to predictors of success. However, additional research is needed to measure and define personality and grit during the application evaluation process.

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty.

BACKGROUND: Development of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including discharge to facilities and mortality. Few studies have identified modifiable risk factors or strategies that the surgeon may use to reduce this risk. METHODS: We identified all patients undergoing primary TJA at a single hospital from 2005 to 2017, and collected patient demographics, comorbidities, short-term outcomes, as well as perioperative laboratory results. We defined AKI as an increase in creatinine levels by 50% or 0.3 points. We compared demographics, comorbidities, and outcomes between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. A stochastic gradient boosting model was constructed to predict AKI. RESULTS: In total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (95% confidence interval [CI] 0.14-0.38, P < .001), in-hospital complication risk (odds ratio = 1.73, 95% CI 1.45-2.07, P < .001), and discharge to facility risk (odds ratio = 1.26, 95% CI 1.05-1.53, P = .012). Forty-one predictive variables were included in the predictive model, with important potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered. The final predictive model demonstrated excellent performance with a c-statistic of 0.967. CONCLUSION: Our results confirm that AKI has adverse effects on outcome metrics including length of stay, discharge, and complications. Although many risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss, such as through the use of tranexamic acid, may aid in mitigating this risk.

Return to Work After Total Joint Arthroplasty: A Predictive Model.

Returning to work after surgery is a primary concern of patients who are contemplating total joint arthroplasty (TJA). The ability to return to work has enormous influence on the patient's independence, financial well-being, and daily activities. The goal of this study was to determine the independent patient variables that predict return to work as well as to create a predictive model. From June 2017 to December 2017, a total of 391 patients who underwent primary TJA (243 hips, 148 knees) were prospectively enrolled in the study to obtain information on return to work after surgery. Patients were sent a series of questions in a biweekly survey. Information was collected on the physical demands of their occupation, the number of hours spent standing, the limitations to return to work, and the use of assistive devices. Bivariate analysis was performed, and a multiple linear regression model was created. Most (89.6%) patients returned to work within 12 weeks of surgery. Patients who underwent total hip arthroplasty returned to work earlier than those who underwent total knee arthroplasty (5.56 vs 7.79 weeks, respectively). Analysis showed the following independent predictors for faster return to work: self-employment, availability of light-duty work, male sex, and higher income. Predictors for slower return to work included a physically demanding occupation (at least 50% physical duties), knee arthroplasty, longer length of stay, and a job requiring more hours spent standing. This model reported an adjusted R2 of 0.332. The findings provide an objective predictive model of the patient- and procedure-specific characteristics that affect postoperative return to work. Surgeons should consider these factors when counseling patients on their postoperative expectations. [Orthopedics. 2020;43(5):e415-e420.].

Patient Complications after Total Joint Arthroplasty: Does Surgeon Gender Matter?

INTRODUCTION: Recent studies in general surgery and internal medicine have shown that female physicians may have improved morbidity and mortality compared with their male counterparts. In the field of orthopaedic surgery, little is known about the influence of surgeon gender on patient complications. This study investigates patient complications after hip and knee arthroplasty based on the gender of the treating surgeon. METHODS: Using a risk-adjusted outcomes database of 100% Medicare data from a third party, an analysis of outcomes after primary hip and knee arthroplasty based on surgeon gender was performed. This data set, which provided risk-adjusted complication rates for each surgeon performing at least 20 primary knee or hip arthroplasties from 2009 to 2013, was matched with publically available Medicare data sets to determine surgeon gender, year of graduation, area of practice, and surgical volume. Confounding variables were controlled for in multivariate analysis. RESULTS: Of the 8,965 surgeons with identified gender, 187 (2.0%; 187 of 8,965) were identified as women and performed 21,216 arthroplasties (1.4%; 21,216 of 1,518,419). Overall, female surgeons averaged fewer arthroplasties (total knee arthroplasty: 87.0 versus 124.9 [P < 0.001]; total hip arthroplasty [THA]: 62.8 versus 78.8 [P = 0.02]) and were earlier in their practice (20.6 versus 25.0 years; P < 0.001) compared with their male counterparts. Male and female surgeons had similar adjusted complication rates for THA (2.78% versus 2.84%) and total knee arthroplasty (2.24% versus 2.26%). Multivariate analysis found that the predictors of increased complications were decreased surgeon volume, THA, increased surgeons' years in practice, and geographic region. DISCUSSION: Overall, female orthopaedic surgeons performed fewer arthroplasties and were earlier in their career. This, however, did not a have a negative impact on their surgical outcomes. Rather, complication rates were dependent on surgeon volume, surgeon experience, and region. LEVEL OF EVIDENCE: Level III-prognostic retrospective case-control study.

What is the Geographic Distribution of Women Orthopaedic Surgeons Throughout the United States?

BACKGROUND: Orthopaedic surgery has a shortage of women surgeons. An even geographic distribution of women orthopaedic surgeons may provide more uniform care to patients. However, little is known about the geographical distribution of women orthopaedic surgeons. QUESTIONS/PURPOSES: (1) Is there substantial geographic variation in the distribution of orthopaedic surgeons who are women? (2) How does the geographic distribution of women orthopaedic surgeons compare with that of other physicians? (3) What are the variables associated with increased region-based proportions of orthopaedic surgeons who are women? METHODS: To obtain a national snapshot of orthopaedic providers, two Medicare databases were used (Medicare Provider Utilization and Payment Data and Medicare's current and archived Physician Compare Data). These databases were used to identify physicians with self-reported specialties of "Orthopedic Surgeon," "Hand Surgeon," or "Sports Medicine" with at least 11 Medicare claims in 1 year for a single procedure type between 2012 and 2014. These databases are the only databases known to specifically report surgeon gender on a national scale and include physician demographics and education. The Dartmouth Atlas's hospital referral regions and United States Census Bureau divisions were used to group physicians by geographic region. The Gini coefficient, a measure of statistical dispersion, was used to quantify the regional distribution of orthopaedic surgeons. This was compared with the dispersion of non-orthopaedic physicians within the same Medicare databases. Surgeon and regional characteristics were correlated with the proportion of women orthopaedic surgeons in the region. RESULTS: There is substantial geographic variation in the distribution of orthopaedic surgeons who are women, ranging from 0% to 15%. There was a greater prevalence of women orthopaedic surgeons in New England (7.3%, 107 of 1469 surgeons) and the Pacific region (6.5%, 208 of 3196 surgeons) than in the South Atlantic (4.5%, 210 of 4618 surgeons) and East South Central regions (3.5%, 50 of 1442 surgeons). This represents a greater level of variation (Gini coefficient = 0.37) compared with other specialties (0.30 and 0.37) and compared with men orthopaedic surgeons (0.16). Variables independently associated with an increased prevalence of women orthopaedic surgeons based on hospital referral region were an increased proportion of currently practicing women physicians who graduated from medical schools in that region (beta = 0.03; p = 0.01), increased proportion of Medicaid-eligible patients (beta = 0.12; p = 0.002), increased proportion of regional population is black (beta = -0.06; p = 0.03), and increased regional supply of women physicians (beta = 0.26; p < 0.0001). CONCLUSIONS: Despite the recent increase in women orthopaedic surgeons nationally, gains have not been equally distributed throughout the United States. CLINICAL RELEVANCE: In other medical fields, gender diversity has been proven to be beneficial for patients. If this holds true in the field of orthopaedic surgery, we should be mindful of the geographic distribution of women orthopaedic surgeons as the percentage of these surgeons increases.

Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?

BACKGROUND: Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities. METHODS: A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course. RESULTS: Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively. DISCUSSION: This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

A Step in the Right Direction: Body Location Determines Activity Tracking Device Accuracy in Total Knee and Hip Arthroplasty Patients.

INTRODUCTION: Step counts measured by activity monitoring devices (AMDs) and smartphones (SPs) can objectively measure a patient's activity levels after total hip and knee arthroplasty (total joint arthroplasty [TJA]). This study investigated the use and optimal body location of AMDs and SPs to measure step counts in the postoperative period. METHODS: This was a two-armed, prospective, observational study of TJA inpatients (n = 24) and 2-week status after TJA (n = 25) completing a 100-ft walk. Observer-counted steps were compared with those measured by AMDs (wrist and ankle) and SPs (hip and neck). Acceptable error was defined as <30%. Error rates were treated as both dichotomous and continuous variables. RESULTS: AMD and SP step counts had overall unacceptable error in TJA inpatients. AMDs on the contralateral ankle and SPs on the contralateral hip had error rates less than 30% at 2 weeks postoperatively. Two-week postoperative patients required lower levels of assist (11/25 walker; 4/25 no assist), and significant improvements in stride length (total hip arthroplasty 1.27 versus 1.83 ft/step; total knee arthroplasty 1.42 versus 1.83 ft/step) and cadence (total hip arthroplasty 74.6 versus 166.0 steps/min; total knee arthroplasty 73.5 versus 144.4 steps/min) were seen between inpatient and postoperative patients. Regression analysis found that increases in postoperative day and cadence led to a decrease in device error. CONCLUSION: In inpatients with TJA, AMDs and SPs have unacceptable variability and limited utility for step counting when using a walker. As gait normalizes and the level of ambulatory assist decreases, AMDs on the contralateral ankle and SPs on the contralateral hip demonstrated low error rates. These devices offer a novel method for measurement of objective outcomes and potential for remote monitoring of patient progress after TJA. LEVEL OF EVIDENCE: Level II, prospective, three-armed study, prognostic study.

Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial.

BACKGROUND: The use of a tourniquet during total knee arthroplasty (TKA) is controversial. Pain and return to function are believed, by some, to be influenced by the use of a tourniquet. The hypothesis of this study was that use of a tourniquet would delay postoperative functional recovery and increase pain as compared with no tourniquet use. METHODS: Two hundred patients were recruited for this prospective, double-blinded, randomized controlled trial. Patients were randomized to undergo TKA either with a tourniquet (100 patients) or without one (100 patients) and blinded to group allocation. Primary outcome measures were functional assessment testing using the Timed Up & Go (TUG) test and visual analog scale (VAS) pain scores. Secondary outcome measures included the stair-climb test, blood loss, surgical field visualization, and range of motion. Outcome measures were completed preoperatively, in the hospital, and postoperatively at a first and a second follow-up. The minimal detectable change, Student t test, Fisher exact test, and nonasymptotic chi-square analysis with an alpha of p < 0.05 were used to determine significance. RESULTS: The no-tourniquet group had more calculated blood loss (1,148.02 mL compared with 966.64 mL; p < 0.001) and more difficulty with surgical field visualization (p < 0.0001). The tourniquet group had greater knee extension at the first follow-up (-7° compared with -9°; p = 0.044). CONCLUSIONS: Tourniquet use during TKA significantly decreases blood loss and does not adversely affect early postoperative outcomes. Tourniquet use during routine TKA is safe and effective, and concerns about deleterious effects on function and pain may not be justified. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Does Prior Anterior Cruciate Ligament Reconstruction Affect Outcomes of Subsequent Total Knee Arthroplasty? A Systematic Review.

BACKGROUND: Anterior cruciate ligament injury may accelerate knee osteoarthritis, and patients with a history of anterior cruciate ligament reconstruction (ACLR) tend to undergo total knee arthroplasty (TKA) at a greater rate than patients without a history of ACLR. PURPOSE: To compare clinical outcomes of TKA in patients with and without a history of ACLR through a systematic review. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A comprehensive search of the PubMed (MEDLINE), Cochrane Central, and SPORTDiscus databases from inception through November 2018 was performed to identify studies directly comparing outcomes of TKA between patients with and without a history of ipsilateral ACLR. Eligible studies were included in this review if they reported at least 1 outcome measure. RESULTS: Included for review were 5 retrospective case-control studies collectively evaluating TKA outcomes in 318 patients (176 males, 142 females) with a history of ACLR and 455 matched controls. The mean age in the ACLR and control groups was 58.5 years and 60.9 years, respectively. The mean follow-up period after arthroplasty was 3.4 years in the ACLR group and 3.3 years in the control group. The mean time between ACLR and arthroplasty was 21.8 years. Three studies noted greater operative time in the ACLR group than in the control group. No differences in intraoperative blood loss were reported. Greater preoperative extension deficits were noted in the ACLR group in 2 studies. Two studies reported increased preoperative Knee Society Score function scores in the ACLR group, but no differences in postoperative subjective outcome scores were noted in any of the studies. One study reported increased incidence of periprosthetic joint infection and a higher total reoperation rate in the ACLR group, and another study reported an increased incidence of manipulation under anesthesia in the ACLR group. CONCLUSION: Short- and midterm subjective scores and functional outcomes of TKA appear to be comparable in patients with and without a history of ACLR, although the risk for reoperation after TKA may be greater in patients with prior ACLR. Surgeons should anticipate increased operative time in patients with a history of ACLR. However, the findings of this review must be interpreted within the context of its limitations.

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change.

BACKGROUND: The need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change. METHODS: A single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program. RESULTS: Overall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP. CONCLUSION: Comparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.

Perioperative Telephone Encounters Should Be Included in the Relative Value Scale Update Committee Review of Time Spent on Total Hip and Knee Arthroplasty.

BACKGROUND: Providing care for patients undergoing hip and knee arthroplasty requires substantial effort beyond the actual replacement surgery to ensure a safe, clinical, and economically effective outcome. Recently, the Centers for Medicare and Medicaid Services has stated that the procedural codes for total hip (THA) and total knee arthroplasty (TKA) are potentially misvalued and has asked for a review by the Relative Value Scale Update Committee (RUC). The purpose of this study is to quantify one of the additional work efforts associated with telephone encounters during the perioperative episode of care. METHODS: We retrospectively reviewed all 47,841 telephone calls from patients to our office from 2015 to 2017 in a consecutive series of 3309 patients who underwent TKA and 3651 patients who underwent THA. We recorded reasons for communication, amount of communication, and the caller identity for both 30 days preoperatively and 90 days postoperatively. We then used the RUC Building Block Method to calculate the preservice and postservice work included in a review of the time and intensity of the codes for THA and TKA. RESULTS: The average number of preoperative patient calls per patient was 2.31 for TKA and 2.44 for THA, and the average number of postoperative calls was 5.01 for TKA and 4.00 for THA. The most common reasons for patient calls were perioperative care instructions, medications, medical clearance, paperwork/insurance, and complications. Using the RUC-approved work relative value units (wRVUs) assigned to each telephone encounter, an additional 1.83 wRVUs for perioperative telephone encounters for TKA and 1.61 for THA should be assigned. CONCLUSIONS: Providing patients with appropriate support during the arthroplasty episode of care requires substantial telephonic support, which should be acknowledged. As the RUC considers reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA, they should consider appropriately documenting the amount of work required for telephone communication.