Randomized Controlled Trials Comparing Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction Surgery Are Statistically Fragile: A Systematic Review.

PURPOSE: To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction. METHODS: The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size. RESULTS: We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI. CONCLUSIONS: There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions. CLINICAL RELEVANCE: We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT.

The Impact of Obesity on Total Hip Arthroplasty Outcomes When Performed by High-Volume Surgeons-A Propensity Matched Analysis From a High-Volume Urban Center.

BACKGROUND: Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons. METHODS: A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases. RESULTS: The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056). CONCLUSIONS: Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons. LEVEL OF EVIDENCE: III.

Socioeconomic Disparities in Online Patient Portal Utilization Among Total Knee Arthroplasty Recipients.

BACKGROUND: Since 2021, the Centers for Medicare and Medicaid Services have mandated that patients have open access to their medical records. Many institutions use online portals, which allow patients to access their health information and communicate with care teams. Our research aimed to evaluate demographic patterns for online patient portal utilization in patients undergoing total knee arthroplasty (TKA). Further, we assessed if and how portal engagement contributes to perioperative outcomes. METHODS: This study retrospectively reviewed primary and elective TKA from 2017 to 2022 at a single academic institution. Patients were stratified into 2 groups based on their online portal status: activated (A) or not-activated (NA). Baseline characteristics and postoperative outcomes were collected from the electronic medical record and compared. RESULTS: In total, 10,995 patients were included: 8,330 (75.8%) were A and 2,625 (24.2%) were NA. The NA group was significantly older (P < .001); more likely to be Black (P < .001), women (P < .001), single/divorced/widowed (P < .001), non-English speaking (P < .001), and Medicare or Medicaid insured (P < .001); from zip codes with median incomes below $50,000 (P < .001), and more likely to be American Society of Anesthesiologists class III or IV (P < .001). Patient-reported outcome measure completion rates were significantly lower in the NA group (15.3 versus 47.7%, P < .001). Lengths of stay (LOS) were significantly higher in the NA group (2.7 versus 2.1 days, P < .001). The NA group was significantly more likely to be discharged to skilled nursing facilities (P < .001). Comparable rates of 90-day emergency department visits, readmissions, as well as 90-day and 2-year revisions, were observed across groups. CONCLUSIONS: There are significant disparities in online portal activation status based on patient demographics. Patients who have A portals had significantly higher Patient-reported outcome measure completion rates, shorter LOS, and higher rates of home discharge. Further research should determine which other factors may affect patient portal utilization and inform interventions to improve portal utilization among minority populations.

Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty From 2013 to 2022-An Analysis From an Urban Orthopaedic Hospital.

BACKGROUND: As worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. METHODS: A retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients' age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients' ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. RESULTS: In the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients' race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. CONCLUSIONS: Over the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. LEVEL OF EVIDENCE: IV.

The Financial Feasibility of Bilateral Total Knee Arthroplasty: A Matched Cohort Analyses of Revenue and Contribution Margin Between Simultaneous and Staged Procedures.

BACKGROUND: Financial analyses of simultaneous bilateral total knee arthroplasty versus staged bilateral total knee arthroplasty (simBTKA and staBTKA, respectively) have shown improved cost-effectiveness of simBTKA, though revenue and contribution margin (CM) for these procedures have not been investigated. Our analyses compared surgical outcomes, revenues, and CMs between simBTKA and staBTKA. METHODS: We retrospectively reviewed all patients who underwent simBTKA (both procedures done on the same day) and staBTKA (procedures done on a different day within one year) between 2012 and 2021. Patients were 1:1 propensity matched based on baseline characteristics. Surgical outcomes, as well as revenue, cost, and CM of the inpatient episode were compared between groups. Of the 2,357 patients evaluated (n = 595 simBTKA, n = 1,762 staBTKA), 410 were included in final matched analyses (205 per group). RESULTS: Total (P < .001) and direct (P < .001) costs were significantly lower for simBTKA procedures compared to overall costs of both staBTKA procedures. Significantly lower revenue for simBTKA procedures (P < .001), resulted in comparable CM between groups (P = .477). Postoperative complications including 90-day readmission (P = 1.000), 90-day revision (P = 1.000) and all-cause revision at latest follow-up (P = .083) were similar between groups. CONCLUSIONS: In our propensity-matched cohort, lower costs for simBTKA compared to staBTKA were matched by lower revenues, with a resulting similar CM between procedures. Given that postoperative complication rates were similar, both procedures had comparable cost-effectiveness. Future research is needed to identify patients for whom simBTKA may represent a better surgical intervention compared to staBTKA with respect to clinical and patient reported outcomes.

Does Melatonin Improve Sleep Following Primary Total Knee Arthroplasty? A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Sleep impairment following total knee arthroplasty (TKA) is common and may decrease patient satisfaction and recovery. Standardized postoperative recommendations for sleep disturbances have not been established. We aimed to assess whether melatonin use could promote healthy sleep and reduce sleep disturbance in the acute period following TKA. METHODS: Patients undergoing primary, elective TKA between July 19, 2021 and January 4, 2024 were prospectively enrolled and randomized to receive either 5 mg of melatonin nightly or placebo for 14 days postoperatively. Participants recorded their nightly pain on the visual analog scale, the number of hours slept, and the number of night-time awakenings in a sleep diary starting the night of surgery (postoperative day [POD] 0). Sleep disturbance was assessed preoperatively and on POD 14 using the patient-reported outcome measurement information system sleep disturbance form. Epworth Sleepiness Scores were collected on POD 14 to assess sleep quality. RESULTS: Of the 138 patients enrolled, 128 patients successfully completed the study protocol, with 64 patients in each group. Melatonin patients trended toward more hours of sleep on POD 2 (placebo: 5.0 ± 2.4, melatonin: 5.8 ± 2.0, P = .084), POD 3 (placebo: 5.6 ± 2.2, melatonin: 6.3 ± 2.0, P = .075), and averaged over POD 1 to 3 (placebo: 4.9 ± 2.0, melatonin: 5.6 ± 1.8, P = .073), although no differences were observed on POD 4 or after. Fewer night-time awakenings in the melatonin group were observed on POD 1 (placebo: 4.4 ± 3.9, melatonin: 3.6 ± 2.4, P = .197), although this was not statistically significant. Preoperative and postoperative Patient-Reported Outcomes Measurement Information System Sleep Disturbance score increases were comparable for both groups (placebo: 4.0 ± 8.4, melatonin: 4.6 ± 8.2, P = .894). The melatonin (65.4%) and placebo (65%) groups demonstrated similar rates of increased sleep disturbance. CONCLUSIONS: Melatonin may promote longer sleep in the immediate postoperative period after TKA, although these benefits wane after POD 3. Disturbances in sleep should be expected for most patients, although melatonin may have an attenuating effect. Melatonin is safe and can be considered for TKA patients experiencing early sleep disturbances postoperatively.

Indications, Clinical Outcomes, and Re-Revisions Following Revision Total Hip Arthroplasty - Does Age Matter?

BACKGROUND: Younger age is associated with increased revision incidence following primary total hip arthroplasty, though the association between age and repeat revision following revision total hip arthroplasty (rTHA) has not been described. This study aimed to describe the incidences and indications for subsequent revision (re-revision) following rTHA based on age. METHODS: Patients undergoing aseptic rTHA from 2011 to 2021 with minimum 1-year follow-up were retrospectively reviewed. Patients were stratified into 3 groups based on age at the time of index rTHA (ie, <55 years, 55 to 74 years, and >74 years). Perioperative characteristics, complications, and re-revisions were compared between groups. RESULTS: Of 694 included rTHAs, those in the >74 age group were more likely to undergo rTHA for periprosthetic fracture (P < .001) while those in the <55 age group were more likely to undergo rTHA for metallosis/taper corrosion (P = .028). Readmissions (P = .759) and emergency department visits (P = .498) within 90 days were comparable across ages. Rates of re-revision were comparable at 90 days (P = .495), 1 year (P = .443), and 2 years (P = .204). Kaplan-Meier analysis of all-cause re-revision at latest follow-up showed a nonstatistically significant trend toward increasing re-revisions in the <55 and 55 to 74 age groups. Using logistic regressions, smoking and index rTHA for instability were independently associated with re-revision, while age at index surgery was not. CONCLUSIONS: While indications for rTHA differ across age groups, rates of 2-year re-revision are statistically comparable between groups. Further studies are warranted to understand the association between age, activity, and re-revision rates after 5 years postoperatively.

Does Surgical Approach Affect Dislocation Rate After Total Hip Arthroplasty in Patients Who Have Prior Lumbar Spinal Fusion? A Retrospective Analysis of 16,223 Cases.

BACKGROUND: Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF. METHODS: We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk. RESULTS: There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095). CONCLUSIONS: The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.

The influence of body mass index on patient-reported outcome measures following total hip arthroplasty: a retrospective study of 3,903 Cases.

BACKGROUND: The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification. METHODS: Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99 kg/m2), overweight (25-29.99 kg/m2), obese (30-39.99 kg/m2), and morbidly obese (> 40 kg/m2). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders. RESULTS: We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR. CONCLUSIONS: Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.

Increased patient body mass index is associated with increased surgeon physiologic stress during total hip arthroplasty.

INTRODUCTION: While increased body mass index (BMI) in patients undergoing total hip arthroplasty (THA) increases surgical complexity, there is a paucity of objective studies assessing the impact of patient BMI on the cardiovascular stress experienced by surgeons during THA. The aim of this study was to assess the impact of patient BMI on surgeon cardiovascular strain during THA. METHODS: We prospectively evaluated three fellowship-trained arthroplasty surgeons performing a total of 115 THAs. A smart-vest worn by the surgeons recorded mean heart rate, stress index (correlate of sympathetic activation), respiratory rate, minute ventilation, and energy expenditure throughout the procedures. Patient demographics as well as perioperative data including surgical approach, surgery duration, number of assistants, and the timing of the surgery during the day were collected. Linear regression was utilized to assess the impact of patient characteristics and perioperative data on cardiorespiratory metrics. RESULTS: Average surgeon heart rate, energy expenditure, and stress index during surgery were 98.50 beats/min, 309.49 cal/h, and 14.10, respectively. Higher patient BMI was significantly associated with increased hourly energy expenditure (P = 0.027), mean heart rate (P = 0.037), and stress index (P = 0.027) independent of surgical approach. Respiratory rate and minute ventilation were not associated with patient BMI. The number of assistants and time of surgery during the day did not impact cardiorespiratory strain on the surgeon. CONCLUSION: The physiologic burden on surgeons during primary THA significantly increases as patient BMI increases. This study suggests that healthcare systems should consider adjusting reimbursement models to account for increased surgeon workload due to obesity. Further surgeons should adopt strategies in operative planning and case scheduling to handle this added physical strain. LEVEL OF EVIDENCE: III.

Return to athletics after total knee arthroplasty: a survey study of 784 recreational athletes across 12 sports.

BACKGROUND: Postoperative return to recreational activity is a common concern among the increasingly active total knee arthroplasty (TKA) patient population, though there is a paucity of research characterizing sport-specific return and function. This study aimed to assess participation level, postoperative return to activity, sport function, and limitations for recreational athletes undergoing TKA. METHODS: A survey of recreational sports participation among primary, elective TKA patients from a single academic center between June 2011 and January 2022 was conducted. Of the 10,777 surveys administered, responses were received from 1,063 (9.9%) patients, among whom 784 indicated being active in cycling (273 [34.8%]), running (33 [4.2%]), jogging (68 [8.7%]), swimming (228 [29.1%]), tennis (63 [8.0%]), skiing (55 [7.0%]), or high-impact team sports (64 [8.2%]) between two years preoperatively and time of survey administration, and were included for analyses. RESULTS: Cycling (62.3% at two years preoperatively vs. 59.0% at latest follow-up) and swimming (62.7% at two years preoperatively vs. 63.6% at latest follow-up) demonstrated the most favorable participation rate changes, while running (84.0% at two years preoperatively vs. 48.5% at latest follow-up) and skiing (72.7% at two years preoperatively vs. 45.5% at latest follow-up) demonstrated the least favorable participation rate changes. The majority of respondents were "satisfied" or "very satisfied" with their return across all sports, though dissatisfaction was highest among runners and joggers. For cycling, running, jogging, and swimming, respondents most commonly reported no change in speed or distance capacity, though among these cyclists reported the highest rates of improved speed and distance. The majority of returning skiers reported improved balance, form, and ability to put on skis. CONCLUSION: Return to sport is feasible following TKA with high satisfaction. Swimming and cycling represent manageable postoperative activities with high return-rates, while runners and joggers face increased difficulty returning to equal or better activity levels. Patients should receive individualized, sports-specific counseling regarding their expected postoperative course based on their goals of treatment.

The Fragility of Tourniquet Use in Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Physicians utilize P-values to interpret clinical trial data and guide patient-care decisions. Fragility analysis assesses the stability of statistical findings in relation to outcome event reversals. This study assessed the statistical fragility of recent randomized controlled trials (RCTs) investigating tourniquet use in total knee arthroplasty (TKA). METHODS: We queried PubMed, EMBASE, and MEDLINE for RCTs comparing outcomes in TKA based on tourniquet use. Fragility index (FI) and reverse fragility index (reverse FI) were calculated - for significant and nonsignificant outcomes, respectively - as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) was calculated by dividing the FI or reverse FI by the sample size. Median overall FI and FQ were calculated for all included outcomes, and sub-analyses were performed by reported significance. The literature search yielded 23 studies reporting 91 total dichotomous outcomes. RESULTS: Overall median FI was 4 with an interquartile range (IQR) of 3 to 6. Overall median FQ was 0.0476 (IQR 0.0291 to 0.0867). A total of 11 outcomes were statistically significant with a median FI and FQ of 2 (IQR 1.5 to 5) and 0.0200 (IQR 0.0148 to 0.0484), respectively. There were 80 outcomes that were nonsignificant with a median reverse FI of 4 (IQR 3 to 6). Loss to follow-up was greater than the median FI in 17.6% of outcomes. CONCLUSION: Altering a small number of outcomes is often sufficient to reverse findings in RCTs evaluating tourniquet use in TKA. We recommend including fragility analyses to increase reliability in the interpretation of study conclusions.

Non-English Speakers and Socioeconomic Minorities are Significantly Less Likely to Complete Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty: Analysis of 16,119 Cases.

BACKGROUND: The Comprehensive Care for Joint Replacement requires patient-reported outcome measure (PROM) completion for total knee/hip arthroplasty (TKA/THA) patients. A 90% completion rate to avoid penalties was planned for 2023 but has been delayed. Our analysis compares TKA/THA PROM completion and results across demographics. We hypothesized that minority groups would be less likely to complete PROMs. METHODS: A retrospective review was performed from 2018 to 2021 of 16,119 patients who underwent primary elective TKA or THA at a single institution. Pairwise chi-squared tests, t-tests, analysis of variance, and multiple logistic regression analyses were used to compare PROM completion rates and scores across demographics and surgery type (TKA/THA). RESULTS: Comparing patients who had (N = 7,664) and did not have (N = 8,455) documented PROMs, completion rates were significantly lower in patients who were women, Black, Hispanic, less educated, used Medicaid insurance, lived in lower income neighborhoods, spoke non-English languages, required an interpreter, and underwent TKA versus THA. After regression analyses, odds ratios for PROM completion remained significantly lower in non-English speakers, Hispanic and Medicaid patients, lower income groups, and patients undergoing TKA. For the 31.8% of patients who completed both preoperative/postoperative PROMs, women, Black, and non-English speaking patients had significantly lower PROM scores for most measures preoperatively and postoperatively despite similar or better improvements after surgery. CONCLUSION: Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PROMs. Strategies to create, validate, and collect PROMs for these populations are needed to avoid exacerbation of healthcare disparities.

Positive Preoperative Colonization With Methicillin Resistant Staphylococcus Aureus Is Associated With Inferior Postoperative Outcomes in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status. METHODS: We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group). RESULTS: The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately. CONCLUSION: Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA.

The Benefit in Patient-Reported Outcomes After Total Knee Arthroplasty was Comparable Across Income Quartiles.

BACKGROUND: Few studies have assessed how socioeconomic status (SES) influences patient-reported outcomes (PROMs) after total knee arthroplasty (TKA). This study evaluated the impact of patient median ZIP code income levels on PROMs after TKA. METHODS: We retrospectively reviewed patients at our institution undergoing primary, unilateral TKA from 2017 to 2020. Patients who did not have one-year postoperative PROMs were excluded. Patients were stratified based on the quartile of their home ZIP code median income from United States Census Bureau data. There were 1,267 patients included: 98 in quartile 1 (median income ≤ $46,308) (7.7%); 126 in quartile 2 (median income $46,309-$57,848) (10.0%); 194 in quartile 3 (median income $57,849-$74,011) (15.7%); and 849 in quartile 4 (median income ≥ $74,012) (66.4%). We collected baseline demographic data, 2-year outcomes, and PROMs preoperatively, as well as at 12 weeks and one year, postoperatively. RESULTS: The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was significantly higher in quartile 4 preoperatively (P < .001), 12 weeks postoperatively (P < .001), and one year postoperatively (P < .001). There were no significant differences in delta improvements of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement from preoperative to 12 weeks or one year postoperatively. There were no significant differences in lengths of stay, discharge dispositions, readmissions, or revisions. CONCLUSION: Patients from lower income areas have slightly worse knee function preoperatively and worse outcomes following TKA. However, improvements in PROMs throughout the first year postoperatively are similar across income quartiles, suggesting that patients from lower income quartiles achieve comparable therapeutic benefits from TKA. LEVEL III EVIDENCE: Retrospective Cohort Study.

Does Obesity Impact Outcomes of Total Knee Arthroplasty When Treated by High-Volume Surgeons? A Propensity-Matched Analysis From a High-Volume Urban Center.

BACKGROUND: The impact of morbid obesity (MO) on outcomes following total knee arthroplasty (TKA) when performed by high-volume (HV) surgeons has not been investigated. This study aimed to assess complication rates and implant survivorship in MO patients operated on by HV surgeons. METHODS: Patients undergoing primary, elective TKA between June 2011 and May 2022 with a HV surgeon (top 25% surgeons by the number of primary TKAs per year) were retrospectively reviewed. Patients were stratified by body mass index (BMI) into 3 groups: BMI ≥40 (MO), 30≤ BMI <40 (non-morbidly obese), and BMI <30 (nonobese) and 1:1:1 propensity matched based on baseline characteristics. Of the 12,132 patients evaluated, 1,158 were included in final matched analyses (386 per group). The HV surgeons performed a median of 104 TKAs annually (range, 90-173). RESULTS: The MO patients had significantly longer surgery duration (P = .006) and hospital lengths of stay (P < .001). The 90-day postoperative complications (P = .38) and readmission rates (P = .39) were comparable between groups. Rates of all-cause, septic and aseptic revision were similar between groups at two-year (P = .30, P = .15, and P = .26, respectively) and the latest follow-up (P = .36, P = .52, and P = .38, respectively). Improvement in Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores at 6 months (P = .049) and one year (P = .015) was significantly higher in MO patients. CONCLUSION: Clinical outcomes and complication rates following TKA by HV surgeons are comparable regardless of obesity status. The MO patients may benefit from referral to experienced surgeons to minimize procedural risks and improve outcomes. LEVEL OF EVIDENCE: III.

Opioid Use During Hospitalization Following Total Knee Arthroplasty: Trends in Consumption From 2016 to 2021.

BACKGROUND: In response to physician and patient concerns, many institutions have adopted protocols aimed at reducing postoperative opioid consumption after total knee arthroplasty (TKA). Thus, this study sought to examine how consumption of opioids has changed following TKA in the past 6 years. METHODS: We conducted a retrospective review of all 10,072 patients who received primary TKA at our institution from January 2016 to April 2021. We collected baseline demographic data including patient age, sex, race, body mass index (BMI), American Society of Anesthesiologist (ASA) classification, as well as dosage and type of opioid medication prescribed on each postoperative day while the patient was hospitalized following TKA. This data was converted to milligram morphine equivalents (MME) per day hospitalized to compare rates of opioid use over time. RESULTS: Our analysis found the greatest daily opioid use was in 2016 (43.2 ± 68.6 MME/day) and the least was in 2021 (15.0 ± 29.2 MME/day). Linear regression analyses found a significant linear downward trend in postoperative opioid consumption over time, with a decrease of 5.55 MME per day per year (Adjusted R-squared: 0.982, P < .001). The highest visual analog scale (VAS) score was 4.45 in 2016 and the lowest was 3.79 in 2021 (P < .001). CONCLUSION: Opioid reducing protocols have been implemented for patients recovering from primary TKA in an effort to decrease reliance on opioids for postoperative pain control. The results of this study demonstrate that such protocols have been successful in reducing overall opioid use during hospitalization following TKA. LEVEL III EVIDENCE: Retrospective Cohort.

Comparison of canal fill and radiolucent line formation between two fully coated, hydroxyapatite tapered stems: a 2-year follow-up after total hip arthroplasty.

INTRODUCTION: Comparison between fully hydroxyapatite (HA)-coated stems with differing geometry are lacking in the total hip arthroplasty (THA) literature. This study aimed to compare femoral canal fill, radiolucency formation, and 2-year implant survivorship between two commonly used, HA-coated stems. METHODS: All primary THAs performed with two fully HA-coated stems (Polar stem, Smith&Nephew, Memphis, TN and Corail stem, DePuy-Synthes, Warsaw, IN) with a minimum 2-year radiographic follow-up were identified. Radiographic measures of proximal femoral morphology based on the Dorr classification and femoral canal fill were analyzed. Radiolucent lines were identified by Gruen zone. Perioperative characteristics and 2-year survivorship were compared between stem types. RESULTS: A total of 233 patients were identified with 132 (56.7%) receiving the Polar stem (P) and 101 (43.3%) receiving the Corail stem (C). No differences were observed with respect to proximal femoral morphology. Femoral stem canal fill at the middle third of the stem was greater for P stem patients than for C stem patients (P stem; 0.80 ± 0.08 vs. C stem; 0.77 ± 0.08, p = 0.002), while femoral stem canal fill at the distal third of the stem and presence of subsidence were comparable between groups. A total of six and nine radiolucencies were observed in P stem and C stem patients, respectively. Revision rate at 2-year (P stem; 1.5% vs C stem; 0.0%, p = 0.51) and latest follow-up (P stem; 1.5% vs C stem; 1.0%, p = 0.72) did not differ between groups. CONCLUSION: Greater canal fill at the middle third of the stem was observed for the P stem compared to the C stem, however, both stems demonstrated robust and comparable freedom from revision at 2-year and latest follow-up, with low incidences of radiolucent line formation. Mid-term clinical and radiographic outcomes for these commonly used, fully HA-coated stems remain equally promising in THA despite variations in canal fill.

Characterizing patient factors, perioperative interventions, and outcomes associated with inpatients falls after total knee arthroplasty.

INTRODUCTION: Mechanical falls represent a potential adverse event after total knee arthroplasty (TKA) and may introduce further injury and delay postoperative recovery. This study aimed to identify patient characteristics associated with inpatient falls, to determine the impact of inpatient falls on surgical outcomes following TKA, and to describe the relationship between tourniquet and/or adductor canal block (ACB) use and fall rates. METHODS: Patients undergoing primary, elective TKA at a single institution between 2018 and 2022 were retrospectively analyzed. Patients were stratified into groups based on whether they sustained a postoperative inpatient fall or not. Perioperative characteristics, lengths of stay (LOS), rates of 90-day readmissions, and revisions were compared, and fall characteristics were described. Subanalysis was conducted comparing fall incidence based on tourniquet and/or ACB use. RESULTS: In total 6472 patients were included with 39 (0.6%) sustaining falls. Falls most commonly occurred on postoperative days one (43.6%) and two (30.8%), and were most commonly due to loss of balance (41.9%) or buckling (35.5%). Six (15.4%) fall patients sustained minor injuries, and one (2.6%) sustained major injury (malleolar fracture requiring non-operative orthopaedic management). The LOS (3.0 ± 1.5 vs 2.3 ± 1.5 days, p = 0.002) and all-cause revision rates at latest follow-up (10.3% vs. 2.0%, p = 0.008) were significantly higher in the fall group. Falls were comparable across subgroups based on tourniquet and/or ACB use (p = 0.429). CONCLUSION: Patients who fell had a longer LOS and higher revision rate postoperatively. Rates of inpatient falls were comparable regardless of tourniquet and/or ACB use. Concern for inpatient falls should not influence surgeons when considering the use of tourniquets and/or ACBs, though well-designed, large-volume, prospective randomized studies are warranted to better understand this relationship.

Patient-reported outcome differences for navigated and robot-assisted total hip arthroplasty frequently do not achieve clinically important differences: a systematic review.

INTRODUCTION: Total hip arthroplasty (THA) using computer-assisted navigation (N-THA) and robot-assisted surgery (RA-THA) has been increasingly adopted to improve implant positioning and offset/leg-length restoration. Whether clinically meaningful differences in patient-reported outcomes (PROMs) compared to conventional THA (C-THA) are achieved with intraoperative technology has not been established. This systematic review aimed to assess whether published relative PROM improvements with technology use in THA achieved minimal clinically important differences (MCIDs). METHODS: PubMed/MEDLINE/Cochrane Library were systematically reviewed for studies comparing PROMs for primary N-THA or RA-THA with C-THA as the control group. Relative improvement differences between groups were compared to established MCID values. Reported clinical and radiographic differences were assessed. Review of N-THA and RA-THA literature yielded 6 (n = 2580) and 10 (n = 2786) studies, respectively, for analyses. RESULTS: Statistically significant improvements in postoperative PROM scores were reported in 2/6 (33.3%) studies comparing N-THA with C-THA, though only 1 (16.7%) reported clinically significant relative improvements. Statistically significant improvements in postoperative PROMs were reported in 6/10 (60.0%) studies comparing RA-THA and C-THA, though none reported clinically significant relative improvements. Improved radiographic outcomes for N-THA and RA-THA were reported in 83.3% and 70.0% of studies, respectively. Only 1 study reported a significant improvement in revision rates with RA-THA as compared to C-THA. CONCLUSIONS: Reported PROM scores in studies comparing N-THA or RA-THA to C-THA often do not achieve clinically significant relative improvements. Future studies reporting PROMs should be interpreted in the context of validated MCID values to accurately establish the clinical impact of intraoperative technology.