The Impact of Diagnosed Chronic Sleep Disorders on Outcomes Following Total Knee Arthroplasty.

BACKGROUND: Up to 20% of patients undergoing total knee arthroplasty (TKA) remain dissatisfied with their outcome, leading to the identification of risk factors for poor outcomes. The purpose of this study was to analyze the effect of chronic sleep disorders on patient-reported outcomes after primary TKA. METHODS: A retrospective review of patients undergoing primary TKA was conducted using a prospectively collected database of patients from a single institution between 2018 and 2022. The cohort was split based on the presence of documented chronic sleep disorders, identified preoperatively from the electronic medical record using current procedural terminology codes. The sample was further restricted to include all patients who have sleep disorders (SDs), as well as a 3:1 propensity-matched (on age, sex, body mass index, and American Society of Anesthesiologists class) cohort of patients who had no documented SDs (NSDs) prior to surgery. The final sample included 172 patients (SD: 43; NSD: 129). Repeated-measures linear mixed model analysis was used to analyze the progression of Knee Injury and Osteoarthritis Outcome Score (KOOS) through time between groups. RESULTS: Those who had SDs had a lower preoperative mean total KOOS score (40.2) than the NSD group (44.1); however, this was not significantly different (P = .108). At 1 year postoperatively, those who had an SD had a significantly higher mean total KOOS score (87.2) than the NSD group (80.4), P = .005. When comparing total KOOS scores by group, over each time period, the SD group showed a better progression when compared to the NSD group, P = .001. CONCLUSIONS: Compared to patients who did not have documented chronic sleep disorders, patients who had a prior history of chronic sleep disorders reported significantly greater improvements in most KOOS domains in the 12-month period following TKA.

Effects of pubertal growth variation on knee mechanics during walking in female and male adolescents.

INTRODUCTION: Puberty substantially alters the body's mechanical properties, neuromuscular control, and sex differences therein, likely contributing to increased, sex-biased knee injury risk during adolescence. Female adolescents have higher risk for knee injuries than male adolescents of similar age engaging in similar physical activities, and much research has investigated sex differences in mechanical risk factors. However, few studies address the considerable variation in pubertal growth (timing, pace), knee mechanics, and injury susceptibility within sexes, or the impact of such growth variation on mechanical injury risk. OBJECTIVES: The present study tested for effects of variation in pubertal growth on established mechanical knee injury risk factors, examining relationships between and within sexes. METHODS: Pubertal growth indices describing variation in the timing and rate of pubertal growth were developed using principal component analysis and auxological data from serial stature measurements. Linear mixed models were applied to evaluate relationships between these indices and knee mechanics during walking in a sample of adolescents. RESULTS: Later developing female adolescents with slower pubertal growth had higher extension moments throughout stance, whereas earlier developers had higher valgus knee angles and moments. In male adolescents, faster and later growth were related to higher extension moments throughout gait. In both sexes, faster growers had higher internal rotation moments at foot-strike. CONCLUSIONS: Pubertal growth variation has important effects on mechanical knee injury risk in adolescence, affecting females and males differently. Earlier developing females exhibit greater injury risk via frontal plane factors, whereas later/faster developing males have elevated risk via sagittal plane mechanisms.

Accuracy of self-reported opioid use in orthopaedic trauma patients.

PURPOSE: Opioids have long been a mainstay of treatment for pain in patients with orthopaedic injuries, but little is known about the accuracy of self-reported narcotic usage in orthopaedic trauma. The purpose of this study is to evaluate the accuracy of self-reported opioid usage in orthopaedic trauma patients. METHODS: A retrospective review of all new patients presenting to the orthopaedic trauma clinic of a level 1 trauma centre with a chief complaint of recent orthopaedic-related injury over a 2-year time frame was conducted. Participants were administered a survey inquiring about narcotic usage within the prior 3 months. Responses were cross-referenced against a query of a statewide prescription drug monitoring program system. RESULTS: The study comprised 241 participants; 206 (85.5%) were accurate reporters, while 35 (14.5%) were inaccurate reporters. Significantly increased accuracy was associated with hospital admission prior to clinic visit (ß = - 1.33; χ2 = 10.68, P < 0.01; OR: 0.07, 95% CI 0.01-0.62). Decreased accuracy was associated with higher pre-visit total morphine equivalent dose (MED) (ß = 0.002; χ2 = 11.30, P < 0.01), with accurate reporters having significantly lower pre-index visit MED levels compared to underreporters (89.2 ± 208.7 mg vs. 249.6 ± 509.3 mg; P = 0.04). An Emergency Department (ED) visit prior to the index visit significantly predicted underreporting (ß = 0.424; χ2 = 4.28, P = 0.04; OR: 2.34, 95% CI 1.01-5.38). CONCLUSION: This study suggests that most new patients presenting to an orthopaedic trauma clinic with acute injury will accurately report their narcotic usage within the preceding 3 months. Prior hospital admissions increased the likelihood of accurate reporting while higher MEDs or an ED visit prior to the initial visit increased the likelihood of underreporting.

Screw Thread Configuration Has No Effect on Outcomes of In Situ Fixation for Stable Slipped Capital Femoral Epiphysis.

BACKGROUND: No consensus exists regarding the optimal surgical management of slipped capital femoral epiphysis (SCFE). Treatment goals include avoiding slip progression and sequelae such as avascular necrosis (AVN). Factors associated with surgical implants merit further research. This study investigates the effect of screw thread configuration and the number of screws on surgical outcomes. METHODS: A total of 152 patients undergoing cannulated, stainless steel, in situ screw fixation of SCFE between January 2005 and April 2018 were included. Procedure laterality, screw number and thread configuration (partially threaded/fully threaded), bilateral diagnosis, Loder classification, final follow-up, patient demographics, and endocrinopathy history were analyzed. Primary outcomes were return to the operating room (ROR), AVN, hardware failure/removal, and femoroacetabular impingement (FAI). RESULTS: Most patients received a single (86.2%), partially threaded (81.6%) screw; most were unilateral (67.8%) and stable (79.6%). Mean follow-up was 2.0±2.7 years, with a 15.8% rate of ROR, 5.3% exhibiting AVN, 6.6% exhibiting FAI, and 9.2% experiencing hardware failure/removal. Number of screws was the sole predictor of ROR [odds ratio (OR)=3.35, 95% confidence interval (CI): 1.18-9.49]. Unstable SCFE increased the odds of AVN (OR=38.44; 95% CI: 4.35-339.50) as did older age (OR=1.43, 95% CI: 1.01-2.03). Female sex increased risk for FAI (OR=4.87, 95% CI: 1.20-19.70), and bilateral SCFE elevated risk for hardware failure/removal versus unilateral SCFE (OR=4.41, 95% CI: 1.39-14.00). Screw thread configuration had no significant effect on any outcome (for each, P ≥0.159). CONCLUSIONS: Rates of ROR, AVN, FAI, and hardware failure/removal did not differ between patients treated with partially threaded or fully threaded screws. The use of 2 screws was associated with an increased likelihood of ROR. These findings suggest that screw thread configuration has no impact on complication rates, whereas screw number may be an important consideration in SCFE fixation. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population.

BACKGROUND: Improved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1. METHODS: A retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05). RESULTS: Of those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]). CONCLUSION: Most patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.

Biomechanical Comparison of Tape Versus Suture in Simulated Achilles Tendon Midsubstance Rupture.

As sutures have progressed in strength, increasing evidence supports the suture tendon interface as the site where most tendon repairs fail. We hypothesized that suture tape would have a higher load to failure versus polyblend suture due to its larger surface area. Eleven matched pairs of cadaveric Achilles tendons were sutured with 2 mm wide braided ultrahigh molecular weight polyethylene tape (Tape) or 2 mm wide braided ultrahigh molecular weight polyethylene suture (Suture) using a Krackow repair method. All Achilles repair constructs were cyclically loaded, after which they were loaded to failure. Change in suture footprint height, clinical and ultimate load to failure, and location of failure was recorded. Clinical loads to failure for Tape and Suture were 290.4 ± 74.8 and 231.7 ± 70.4 Newtons, respectively (p= .01). Ultimate loads to failure for Tape and Suture were 352.9 ± 108.1 and 289.8 ± 53.7 Newtons, respectively (p = .11). Cyclic testing resulted in significant changes in footprint height for both Tape and Suture, but the 2 sutures did not differ in terms of the magnitude of change in footprint height (p = .52). The suture tendon interface was the most common site of failure for both Tape and Suture. Our results suggest that Tape may provide added repair strength in vivo for Achilles midsubstance rupture.

Effects of the Ohio Opioid Prescribing Guidelines on Total Joint Arthroplasty Postsurgical Prescribing and Refilling Behavior of Surgeons and Patients.

BACKGROUND: The opioid epidemic has been declared a public health crisis, with thousands of Americans dying from overdoses each year. In 2017, Ohio passed the Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. The present study sought to evaluate the effects of OPG on the prescribing behavior of orthopedists following total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: An institutional database was queried to compare morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) pre-OPG and post-OPG. Cases were identified over a 2-year period starting 1 year before OPG implementation. RESULTS: Nine orthopedic surgeons performed 1160 TKAs (692 pre-OPG, 468 post-OPG) and 834 THAs (530 pre-OPG, 304 post-OPG). Total MED for TKA and THA dropped post-OPG (1602.6 ± 54.3 vs 1145.8 ± 66.1, P < .01; 1302.3 ± 47.0 vs 878.3 ± 62.2, P < .01). Much of the total MED decrease was accounted for by the decrease in discharge MED, which was the largest in magnitude (904.8 ± 16.4 vs 606.2 ± 20.0, P < .01; 948.4 ± 19.6 vs 630.6 ± 25.9, P < .01). Seven of the 9 surgeons statistically reduced mean MED prescribed at discharge following OPG. The percentage of patients receiving new narcotic scripts at acute follow-up increased post-OPG for both TKA (41.5% vs 47.2%, P = .05) and THA (18.3% vs 25.7%, P = .01). CONCLUSION: Orthopedists reduced total MED prescribed after TKA and THA following the onset of OPG. The majority of this decrease is explained by decreased MED at discharge. Conversely, the post-OPG period saw slightly more new narcotic scripts written during acute follow-up.

Physical activity and time budgets of Hadza forager children: Implications for self-provisioning and the ontogeny of the sexual division of labor.

OBJECTIVES: To determine the effects of age and sex on physical activity and time budgets of Hadza children and juveniles, 5-14 years old, including both in-camp and out-of-camp activities. METHODS: Behavioral data were derived from ~15 000 hourly in-camp scan observations of 76 individuals and 13 out-of-camp focal follows on nine individuals. The data were used to estimate energy expended and percentage of time engaged in a variety of routine activities, including food collection, childcare, making and repairing tools, and household maintenance. RESULTS: Our results suggest that (1) older children spend more time in economic activities; (2) females spend more time engaged in work-related and economic activities in camp, whereas males spend more time engaged in economic activities out of camp; and (3) foraging by both sexes tends to net caloric gains despite being energetically costly. CONCLUSIONS: These results show that, among the Hadza, a sexual division of labor begins to emerge in middle childhood and is well in place by adolescence. Furthermore, foraging tends to provide net caloric gains, suggesting that children are capable of reducing at least some of the energetic burden they place upon their parents or alloparents. The findings are relevant to our understanding of the ways in which young foragers allocate their time, the development of sex-specific behavior patterns, and the capacity of children's work efforts to offset the cost of their own care in a cooperative breeding environment.

Hospital Discharge Within 1 Day After Total Joint Arthroplasty From a Veterans Affairs Hospital Does Not Increase Complication and Readmission Rates.

BACKGROUND: Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits. METHODS: After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05. RESULTS: Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901). CONCLUSION: Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications.

Factors Predicting Length of Hospital Stay and Extended Care Facility Admission After Hindfoot Arthrodesis Procedures.

Delayed identification of patients requiring admission to extended care facilities (ECFs) can lead to greater healthcare costs through an increased length of hospital stay (LOHS). Previous studies of hip and knee arthroplasty identified factors associated with a likely discharge to an ECF. These issues have not been extensively studied for major hindfoot procedures. We conducted a retrospective review of 198 cases treated during a 3-year period to identify the risk factors for an extended LOHS and ECF admission after ankle arthrodesis, triple arthrodesis, pantalar arthrodesis, and subtalar arthrodesis. The primary outcomes were LOHS and ECF admission. The independent predictors included age, sex, body mass index, housing status, American Society of Anesthesiologists class, diabetes and/or diabetic neuropathy, health insurance, fixation type, and perioperative infection. Stepwise multiple regression analysis was used to determine which variables were related to a longer LOHS. Nonparametric discriminant function analysis was used to identify the preoperative factors that best predicted ECF admission. A longer LOHS was significantly related to postoperative ECF admission, Centers for Medicare and Medicaid Services (CMS) insurance, diabetic neuropathy, external fixation, and infection. ECF admission was required for 34 of 198 patients (17.2%). Discriminant analysis found that older age, living alone, external fixation, and CMS insurance predicted a greater probability of ECF admission. The function accurately classified 94% of ECF admissions and 80% of non-ECF admission patients. ECF admission and CMS insurance extended the LOHS, likely owing to the administrative process of arranging an ECF discharge. If externally validated, the function we have derived could provide preoperative identification of likely ECF discharge candidates and reduce costs by shortening the LOHS.