Corticosteroid Injections within 2 weeks Following Knee Arthroscopy is Associated with Increased Infection Risk.

PURPOSE: We quantified the risk of 90-day postoperative infection following arthroscopy, stratified by specific time intervals of corticosteroid injection (CSI) postoperatively (0-2 weeks, 2-4 weeks, 4-6 weeks, and 6-8 weeks). METHODS: A national, all-payer database was queried. In the primary and secondary analyses, the main outcome was infection at 90-days. Infection was defined by documentation of a septic knee or surgical-site infection according to International Classification of Disease (ICD) Ninth Revision (9) and Tenth Revision (10) codes, and Current Procedure Terminology (CPT) codes. RESULTS: In the multivariable regression, the odds ratio (OR) of postoperative infection at 90-days was greater in the CSI injections within 0-<2 weeks (OR 3.31, 95% CI 1.85-5.92, P<0.001) and 2-<4 weeks (OR 2.72 95% CI 1.57-4.71, P=0.003) cohorts in comparison to the control group. When comparing CSI administered within 0-2 weeks to CSI administered within 2-4 weeks, there was a greater odds of postoperative infection (OR 2.50) at 90-days following arthroscopy. CONCLUSION: CSI given within 2 weeks following knee arthroscopy increases the risk of postoperative infection the greatest whereas CSI given with 4 weeks increases the risk but to a lesser degree.

How-To Create an Orthopaedic Systematic Review: A Step-by-step Guide Part II: Study Execution.

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

INTRODUCTION: The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. METHODS: A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). RESULTS: The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). CONCLUSION: Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total knee arthroplasty: a propensity score matched analysis.

INTRODUCTION: Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited. METHODS: A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years. RESULTS: The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years. CONCLUSION: Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group.

The effect of fixation type on periprosthetic fractures in high-risk patients who have osteoporosis undergoing total joint arthroplasty.

Introduction: Minimizing the burden of periprosthetic fractures (PFF) following total joint arthroplasty (TJA) with regard to morbidity and mortality remains an outcome of interest. Patient and surgical risk factors, including osteoporosis and fixation type, have not truly been optimized in patients undergoing TJA as a means to reduce the risk of PFF. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA? Methods: We queried an all-payer, national database from April 1, 2016 to December 31, 2021, to identify high-risk and low-risk patients who underwent TJA with a cementless or cemented fixation. High-risk patients met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years old who have the following: tobacco use, alcohol abuse, body mass index <18.5, prior fragility fracture, chronic systemic corticosteroids, or genetic condition affecting sex hormones or bone mineral density. Exclusion criteria were a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and a minimum follow-up of less than 2 years. Results: There were 384,783 patients (67.1 %) who underwent cementless TKA and 67,774 patients (11.8 %) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9 %) who underwent cemented THA and 58,667 patients (10.2 %) who underwent cementless THA and were considered high risk. The cementless cohort had a 5-year periprosthetic fracture risk following TKA of 7.8 % (95 % CI, 5.56 to 10.98) in comparison to 4.30 % in the cemented cohort (85 % CI, 3.98 to 4.65), P < 0.0001. The high-risk cementless cohort had a 5-year periprosthetic fracture risk following THA of 7.9 % (95 % confidence interval (CI), 6.87 to 9.19) in comparison to 7.78 % in the cemented cohort (85 % CI, 6.77 to 8.94), P < 0.0001. Conclusion: There is an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but no clinically meaningful difference between the two groups. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate patients for TJA based on bone quality and fracture risk can help expedite the process of improving the current state of practice.

Assessing social disparities in inpatient vs. outpatient arthroplasty: a in-state database analysis.

INTRODUCTION: Given the growing emphasis on patient outcomes, including postoperative complications, in total joint arthroplasty (TJA), investigating the rise of outpatient arthroplasty is warranted. Concerns exist over the safety of discharging patients home on the same day due to increased readmission and complication rates. However, psychological benefits and lower costs provide an incentive for outpatient arthroplasty. The influence of social determinants of health disparities on outpatient arthroplasty remains unexplored. One metric that assesses social disparities, including the following individual components: socioeconomic status, household composition, minority status, and housing and transportation, is the Social Vulnerability Index (SVI). As such, we aimed to compare: (1) mean overall SVI and mean SVI for each component and (2) risk factors for total complications between patients undergoing inpatient and outpatient arthroplasty. METHODS: Patients who underwent TJA between January 1, 2022 and December 31, 2022 were identified. Data were drawn from the Maryland State Inpatient Database (SID). A total of 7817 patients had TJA within this time period. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). The mean SVI was compared between inpatient and outpatient procedures for each themed score. The SVI identifies communities that may need support cause by external stresses on human health based on four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. The SVI uses the United States Census data to rank census tracts for each individual theme, as well as an overall social vulnerability score. The higher the SVI, the more social vulnerability, or resources needed to thrive in that area. Multivariate logistic regression analyses were performed to identify independent risk factors for total complications following TJA after controlling for risk factors and patient comorbidities. Total complications included: infection, aseptic loosening, dislocation, arthrofibrosis, mechanical complication, pain, and periprosthetic fracture. RESULTS: Patients who had inpatient arthroplasty had higher overall SVI scores (0.45 vs. 0.42, P < 0.001). The SVI scores were higher for patients who had inpatient arthroplasty for socioeconomic status (0.36 vs. 0.32, P < 0.001), minority status and language (0.76 vs. 0.74, P < 0.001), and housing and transportation (0.53 vs. 0.50, P < 0.001) compared to outpatient arthroplasty, respectively. There was no difference between inpatient and outpatient arthroplasty for household composition and disability (0.41 vs. 0.41, P = 0.99). When controlling for comorbidities, inpatient arthroplasty [Odds Ratio (OR) 1.91, 95% Confidence Interval (CI) 1.23-2.95, P = 0.004], hypertension (OR 2.11, 95% CI 1.23-3.62, P = 0.007), and housing and transportation (OR 2.00, 95% CI 1.17-3.42, P = 0.012) were independent risk factors for total complications. CONCLUSION: Inpatient arthroplasty was associated with increased social disparities across several components of deprivation as well as an independent risk factor total complications following TJA. To the best of our knowledge, this study is the first to examine the negative repercussions of inpatient arthroplasty through the lens of social disparities and can target specific areas for intervention.

Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty.

INTRODUCTION: Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications. METHODS: A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors. RESULTS: After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05). CONCLUSION: Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.

A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis. METHODS: Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM. RESULTS: The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision. CONCLUSIONS: The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

The Utility of the Area Deprivation Index in Assessing Complications After Total Joint Arthroplasty.

Background: Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year. Methods: A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128). Results: Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications. Conclusions: Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cemented is not superior to cementless total knee arthroplasty for complications: a propensity score matched analysis.

INTRODUCTION: There is continued debate regarding the survivorship and revision rate of cementless versus cemented total knee arthroplasty (TKA) prostheses. This includes the assessment of early revision surgery due to aseptic loosenings and periprosthetic joint infections (PJIs). Studies have not always taken into account the impact of comorbidities, such as diabetes, obesity, and tobacco. Therefore, we compared revisions in a large population of patients undergoing cemented or cementless TKAs at 90 days, 1 year, and 2 years. METHODS: A review of an administrative claims database was used to identify patients undergoing primary TKA, either cementless (n = 8,890) or cemented (n = 215,460), from October 1, 2015 to October 31, 2020. Revision surgery for PJI and aseptic loosening were identified with diagnosis and associated procedural codes at 90 days, 1 year, and 2 years and then compared between groups. A propensity matched-analysis was performed for age, sex, Charles Comorbidity Index (CCI) > 3, alcohol abuse, tobacco use, obesity, and diabetes. Chi square tests assessed statistical significance of differences in the matched cohorts using odds ratios (ORs) with 95% confidence intervals (CIs). A P < 0.05 was defined as statistically significant. RESULTS: Cementless TKA was associated with similar revisions rates due to PJIs at 90 days (OR, 1.04, 95% CI 0.79-1.38, p = 0.83), 1 year (OR, 0.93, 95% CI 0.75-1.14, p = 0.53, and 2 years (OR, 0.87, 95% CI 0.73-1.05, p = 0.17) in comparison to the cemented TKA cohort. The odds ratio of revision due to aseptic loosening was similar as well at 90 days (OR, 0.67, 95% CI 0.34-1.31, 0.31), 1 year (OR, 1.09, 95% CI 0.73-1.61, p = 0.76), and 2 years (OR, 1.00, 95% CI 0.73-1.61, p = 0.99). CONCLUSIONS: This study found a comparable risk of PJI and aseptic loosening in cementless and cemented TKA when controlling for several comorbidities, such as tobacco, diabetes, and alcohol. Therefore, with proper patient selection, cementless TKAs can be performed with expectation of low risks of infections and aseptic loosenings.

Antibiotic prophylaxis prior to colonoscopy with biopsy does not decrease risk of prosthetic joint infection in total knee arthroplasty recipients.

Introduction: Prosthetic joint infection (PJI) risk continues to receive much attention given its associated morbidity and costs to patients and healthcare systems. It has been hypothesized that invasive colonoscopies may increase the risk of PJI. However, the decision to administer antibiotic prophylaxis lacks clinical guidance. In this study we aimed to compare PJI rates in patients undergoing colonoscopies with and without antibiotic prophylaxis against a control group, analyzing PJI occurrences at 90 days, 6 months, 9 months, and 1-year post-procedure and (2) assess the impact of antibiotic prophylaxis on PJI rates to inform clinical guidelines. Methods: We queried a national, all-payer database to identify all primary total knee arthroplasty procedures without prior history of PJI between January 2010 and October 2020 (n = 1.9 million). All patients who had a diagnosis of PJI within one year of index procedure were excluded. There were three cohorts identified: colonoscopy with biopsy without antibiotic prophylaxis; colonoscopy with biopsy with antibiotic prophylaxis; and a control of no prior colonoscopy. Both colonoscopy cohorts were slightly younger and had higher comorbidities than the controls. The PJI diagnoses were identified at four separate time intervals within one-year after colonoscopy: 90-days; 6-months; 9-months; and 1-year. Chi-square analyses with odds ratios (ORs) and 95% confidence intervals were conducted for PJI rates between groups at all time-points. Results: Among all cohorts, no significant differences in PJI rates were found at 90-days (P = 0.459), 6-months (P = 0.608), 9-months (P = 0.598), and 1-year (P = 0.330). Similarly, direct comparison of both colonoscopy groups, with and without antibiotic prophylaxis, demonstrated no PJI rate differences at 90-day (P = 0.540), 6-months (P = 0.812), 9-months (P = 0.958), and 1-year (P = 0.207). Ranges of ORs between the colonoscopy cohorts were 1.07-1.43. Conclusion: Invasive colonoscopy does not increase the risk of PJI in patients who have pre-existing knee implants. Furthermore, antibiotic prophylaxis may not be warranted in patients undergoing colonoscopy who have a planned biopsy.

Risk Factors Portending a Total Hip Arthroplasty for Patients Who Have Osteonecrosis of the Femoral Head.

INTRODUCTION: Osteonecrosis of the femoral head (ONFH) poses a substantial burden to orthopaedic surgeons. However, the exact risk attributed by each specific patient factor for those who end up receiving a total hip arthroplasty (THA) are not well known. We assessed: (1) patient demographics (age and sex); (2) blood cell dyscrasias (sickle-cell disease and hypercoagulable states); and (3) substance use (oral corticosteroid use, tobacco use, and alcohol abuse). MATERIALS AND METHODS: A retrospective search examined all patients who had a primary THA (n=715,100) between January 1, 2010 and April 30, 2020 using a national, all-payer database. Risk factors studied included age, sex, sickle-cell, hypercoagulable state, oral corticosteroid use, tobacco use, and alcohol abuse. RESULTS: Several risk factors were found to be significantly predictive for ONFH requiring THA: age <55 years (odds ratio [OR] 1.02, 95% confidence interval [CI] of 1.01 to 1.02, p<0.001), men (OR 1.07, 95% CI of 1.04 to 1.10, p<0.001), oral corticosteroid use (OR 1.21, 95% CI of 1.17 to 1.25, p<0.001), tobacco use (OR 1.15, 95% CI of 1.11 to 1.18, p<0.001), and alcohol abuse (OR 1.05, 95% CI of 1.01 to 1.08, p=0.009). CONCLUSIONS: Based on the results of this study, young age, men, oral corticosteroid use, tobacco use, and alcohol abuse are risk factors for patients who have ONFH and had a THA. The degree of risk from greatest to least were: oral corticosteroid use, tobacco use, men, alcohol abuse, and age <55 years old.

Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021.

BACKGROUND: In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin. METHODS: Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA. RESULTS: From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days. CONCLUSIONS: An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older.

BACKGROUND: Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older. METHODS: We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance. RESULTS: The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries. CONCLUSIONS: This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

Spinal fusion and total hip arthroplasty: why timing is important.

BACKGROUND: There is increasing debate among orthopaedic surgeons over the temporal relationship between lumbar spinal fusion (LSF) and total hip arthroplasty (THA) for patients with hip-spine syndrome. Few large studies have directly compared the results of patients who undergo LSF prior to THA (LSF-THA) to those who undergo LSF after THA (THA-LSF). The current study matched THA patients with a prior LSF to patients who underwent LSF after THA to assess: 90-day and 1-year (1) medical/surgical complications; and (2) revisions. METHODS: We queried a national, all-payer database to identify all patients undergoing THA between 2010 and 2018 (n = 716,084). The LSF-THA patients and THA-LSF patients were then matched 1:1 on age, sex, Charleson Comorbidity Index, and obesity. Medical/surgical complications and revisions at 90 days and 1 year were recorded. Categorical and continuous variables were analysed utilising t-tests and chi-square, respectively. RESULTS: LSF-THA patients experienced significantly more postoperative dislocations at 90 days and 1 year compared to THA-LSF patients (p = 0.048 and p < 0.001). There were a similar number of revisions performed for LSF-THA and THA-LSF patients at both 90 days and 1 year (p = 0.183 and p = 0.426). Furthermore, at 1 year, LSF-THA patients experienced more pneumonia (p = 0.005) and joint infection (p = 0.020). CONCLUSIONS: Prior LSF has been demonstrated to increase the risk of postoperative dislocation in patients undergoing THA. The results of the present study demonstrate increased dislocations with LSF-THA compared to THA-LSF. For "hip spine syndrome" patients requiring both LSF and THA, it may be more beneficial to undergo THA prior to LSF. Arthroplasty surgeons may wish to collaborate with spinal surgeons to ensure optimal outcomes for this group of patients.

C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications.

A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA (n = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA (n = 6,027) and those experiencing CDIs ≤ 6 months before TKA (n = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION: CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection.

The Current Epidemiology of Revision Total Knee Arthroplasty in the United States From 2016 to 2022.

BACKGROUND: The number of revision total knee arthroplasties (TKAs) is projected to reach 268,200 cases annually by 2030 in the United States. The growing demand for revision TKA can be attributed to the successes of primary TKAs combined with an aging population, patient desires to remain active, as well as expanded indications for younger patients. Given the evolving nature of revision TKAs, an epidemiological analysis of: (1) etiologies; (2) demographics, including age and region; as well as (3) lengths of stay (LOS) offers a way to minimize the gap between appropriate understanding and effective intervention. METHODS: From 2016 to 2022, a national, all-payer database was queried. Incidences and indications were analyzed for a total of 135,983 patients who had revision TKA procedures. RESULTS: The most common etiologies for revision TKA procedures were infection (19.3%) and aseptic loosening (12.8%), followed by mechanical complications (7.9%). The largest age group was 65 to 74 years (34.9%) followed by 55 to 64 years (32.2%), then age >75 years (20.5%). The South had the largest total procedure cohort (39.8%), followed by the Midwest (28.6%), then the Northeast (18.6%), and the West (13.0%). The mean length of stay was 3.86 days (range, 1.0 to 15.0). CONCLUSIONS: Our study details the current status of revision TKA through 2022. While infection and aseptic loosening remain leading causes, we found a low aseptic loosening rate of 12.8%.

Biologic Disease-Modifying Antirheumatic Drugs Do Not Increase Risk for Prosthetic Joint Infection in Setting of Total Knee Arthroplasty.

Over 25% of patients with rheumatoid arthritis (RA) are expected to undergo a joint replacement during their lifetime. Current practice guidelines recommend withholding biologic therapy 1 week prior to total hip arthroplasty, given its immunosuppressive effects. Most patients are on a regimen including biologic and nonbiologic therapy; however, the individual influences of these therapies are not well understood in the setting of total knee arthroplasty (TKA). Therefore, we sought to compare biologic, nonbiologic, and recipients of both types of therapy in patients with RA undergoing TKA. We specifically assessed (1) medical complications at 90 days; (2) surgical complications up to 1 year; and (3) independent risk factors for prosthetic joint infections (PJIs).A retrospective review was conducted using a national, all-payer database for patients undergoing primary TKA from January 2010 to April 2020 (n = 1.97 million). Patients diagnosed with RA were then separated into at least 1-year users of biologic (n = 3,092), nonbiologic (28,299), or dual (n = 10,949) therapy. Bivariate analyses were utilized to assess for 90-day medical and up to 1-year surgical outcomes. Additionally, multivariate regression models were utilized to assess for independent risk factors.The incidence and odds ratio for medical/surgical outcomes were equivocal among the biologic, nonbiologic, and recipients receiving both types of therapy (p > 0.061). No differences were observed between the type of therapy as additional risk factors for infection (p > 0.505). However, glucocorticoids at 90 days and alcohol abuse, diabetes mellitus, obesity, as well as tobacco use were identified as additional risk factors for PJI(p < 0.036).No appreciable differences in medical or surgical outcomes were associated with the independent use of biologic, nonbiologic, or recipients of both types of therapy in patients with RA. Additionally, alcohol abuse, diabetes mellitus, glucocorticoids, obesity, and tobacco use conferred an increased risk of PJI. These results can serve as an adjunct to current practice guidelines.