What is the long-term survivorship, complication profile, and patient reported outcomes after Birmingham hip resurfacing?

Introduction: When indicated, Birmingham Hip Resurfacing (BHR) presents a viable alternative to total hip arthroplasty (THA), but there remain questions about the long-term outcomes of BHR. Therefore, we asked: 1) what are the long-term patient-reported outcomes and 2) survivorship rates following BHR; 3) what are the causes for revision surgery after BHR? and 4) how have these outcomes compared to THA at long-term follow-up. Methods: A query of PubMed, MEDLINE, Scopus, and Cochrane in September 2023 was performed. Articles were included if they reported BHR survivorship rates at ≥10 years. Survivorship was defined as an all-cause revision of any BHR component. This review encompasses 26 articles, totaling 13,103 hips. Mean follow-up ranged from 6.0 to 20.9 years, but each study had at least a subgroup analysis for ≥10-year follow-up. Results: Five studies compared preoperative and postoperative PROs for BHR, with four reporting improvement in at least one PRO after 10-year follow-up. Overall, survivorship rates ranged from 83% to 100% across diverse long-term timeframes, with 25 of 26 studies reporting 10-year survivorship rates greater than 87%. The primary reasons for revisions were implant loosening (22%), adverse reactions to metal debris (21.2%), and fractures of any kind (17.2%). In the six studies that compared BHR to THA, long-term survivorship was similar while BHR exhibited slightly superior activity levels. Conclusion: The findings from this study suggested favorable long-term survivorship and postoperative outcomes of BHR. In studies comparing long-term BHR and THA, survivorship was comparable, with BHR potentially providing enhanced postoperative activity levels.

Low-Dose Aspirin Is the Safest Prophylaxis for Prevention of Venous Thromboembolism After Total Knee Arthroplasty Across All Patient Risk Profiles.

BACKGROUND: The International Consensus Meeting on Venous Thromboembolism (ICM-VTE) in 2022 proclaimed low-dose aspirin as the most effective agent in patients across all risk profiles undergoing joint arthroplasty. However, data on large patient populations assessing trends in chemoprophylactic choices and related outcomes following total knee arthroplasty (TKA) remain scant. The present study was designed to characterize the clinical use of various chemoprophylactic agents in patients undergoing TKA and to determine the efficacy of aspirin compared with other agents in patient groups stratified by VTE risk profiles. METHODS: This study utilized a national database to determine the proportion of patients undergoing TKA who received low-dose aspirin versus other chemoprophylaxis between 2012 and 2022. VTE risk profiles were determined on the basis of comorbidities established in the ICM-VTE. The odds ratios (ORs) and 95% confidence intervals (CIs) between various classes of thromboprophylaxis in patients with high and low risk of VTE were calculated. The odds of deep-vein thrombosis (DVT), pulmonary embolus (PE), bleeding events, infections, mortality, and hospitalizations were also assessed in the 90-day postoperative period for propensity-matched cohorts receiving low-dose (81 mg) aspirin only versus other prophylaxis, segregating patients by VTE risk profile. RESULTS: A total of 126,692 patients undergoing TKA across 60 health-care organizations were included. The proportion of patients receiving low-dose aspirin increased from 7.65% to 55.29% between 2012 and 2022, whereas the proportion of patients receiving other chemoprophylaxis decreased from 96.25% to 42.98%. Low-dose-aspirin-only use increased to approximately 50% in both high-risk and low-risk populations but was more likely in low-risk populations (OR, 1.17; 95% CI, 1.15 to 1.20) relative to high-risk populations. Both low-risk and high-risk patients in the low-dose-aspirin-only cohorts had decreased odds of DVT, PE, bleeding, infections, and hospitalizations compared with other prophylaxis regimens. CONCLUSIONS: The findings of the present study on a very large population of patients undergoing TKA support the recent ICM-VTE statement by showing that low-dose aspirin is a safe and effective method of prophylaxis in patients across various risk profiles. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies.

Robotic assisted (RA) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting novel platforms challenging. Therefore, we conducted a systematic review to assess the learning curve associated with RA-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA). PubMed, MEDLINE, EBSCOhost, and Google Scholar were searched on June 16, 2023, to identify studies published between January 1, 2000 and June 16, 2023 (PROSPERO registration: CRD42023437339). The query yielded 655 unique articles, which were screened for eligibility. The final analysis included 11 articles, evaluating 1351 THA procedures. Risk of bias was assessed via the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 21.3 ± 0.9. RA-THA provided immediate improvements in acetabular component placement accuracy and radiographic outcomes compared to M-THA, with little to no experience required to achieve peak proficiency. A modest learning curve (12-17 cases) was associated with operative time, which was elevated compared to M-THA (+ 9-13 min). RA-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes. Surgeons should expect to experience increased operative times, which become less pronounced or equivalent to M-THA after a modest caseload.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis.

BACKGROUND: As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort. METHODS: A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission. RESULTS: A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001). CONCLUSION: There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

Are robotic-assisted and computer-navigated total hip arthroplasty associated with superior outcomes in patients who have hip dysplasia?

Introduction: Robotic-assisted (RA) and computer-navigated (CN) total hip arthroplasty (THA) have been demonstrated to improve component placement accuracy compared to manual THA (mTHA) for primary osteoarthritis. As hip dysplasia presents several additional challenges in component placement accuracy and leg length discrepancy (LLD) correction during THA, a systematic review was conducted to evaluate whether utilizing these platforms may be associated with superior outcomes over mTHA in patients who have hip dysplasia. Methods: PubMed, Medline, EBSCOhost, and Google Scholar were searched on September 13, 2023 to identify comparative studies published after January 1, 2000 that evaluated outcomes of RA-THA or CN-THA in patients who have hip dysplasia. The query yielded 197 unique articles, which were screened for alignment with the study aims. After screening, 10 studies fulfilled all inclusion criteria, comprising 946 patients. Risk of bias was evaluated via the Methodological Index for Nonrandomized Studies tool, and the mean score was 21.2 ± 1.5. Results: Both RA-THA and CN-THA were not associated with improved acetabular anteversion and inclination when evaluating Crowe I-IV types altogether compared to mTHA, but studies reported improved accuracy for each Crowe I and II cases when assessed individually. While studies reporting acetabular cup placement within the Lewinnek and Callanan safe zones consistently found higher odds of accurate positioning for RA-THA versus mTHA, accuracy in achieving targeted center of rotation was mixed. Also, studies reported no difference in LLD restoration for RA-THA and CN-THA compared to mTHA. While operative time may be increased when utilizing these platforms, they may also expedite specific sequences, offsetting most of the increase in operative time. Conclusion: This review highlights the advantages of RA-THA and CN-THA for patients who have DDH, particularly when treating Crowe I and II types as superior radiographic outcomes were achieved with these intraoperative technologies. However, there remains a need for studies to investigate whether this results in patient-reported outcome measures.

Automated digital templating of component sizing is accurate in robotic total hip arthroplasty when compared to predicate software.

Accurate pre-operative templating of prosthesis components is an essential factor in successful total hip arthroplasty (THA), including robotically-assisted THA (RA-THA) techniques. We sought to validate the accuracy of a novel, robotic-optimized THA planning software compared to a predicate THA planner for component sizing. We analyzed a series of 199 patients who received manual THA (mTHA) and fluoroscopy-based RA-THA at a single institution. All cases were templated using a predicate pre-operative templating software. For RA-THA cases, the novel robotic-optimized pre-operative planner software was also used for templating. The differences between templated and implanted acetabular cup, femoral head, and stem component sizes were compared based on matching within 1, 2, and ≥3 sizes. Differences in templated and implanted femoral stem implant geometry were also compared. The robot-optimized pre-operative RA-THA plans demonstrated equivalent accuracy to that of predicate pre-operative plans for both RA-THA and mTHA cases. Templated acetabular cups (90.4 vs. 86.8 vs. 82.8; p = 0.421), femoral stems (76.0 vs. 65.1 vs. 67.7; p = 0.096), and femoral heads (91.3 vs. 96.2 vs. 88.2; p = 0.302) were within +/-1 size of implanted components. No significant differences were detected in the proportion of matching templated and implanted stem geometry across the study cohorts.

Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance.

BACKGROUND: While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated. METHODS: This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores. RESULTS: No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468). CONCLUSION: Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.

Cost-effectiveness of a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system: A Markov analysis.

BACKGROUND: The purpose of this study was to assess the cost-effectiveness of a novel, fluoroscopy-based robotic-assisted total hip arthroplasty (RA-THA) system compared to a manual unassisted technique (mTHA) up to 5 years post-operatively. METHODS: A Markov model was constructed to compare the cost-effectiveness of RA-THA and mTHA. Cost-effectiveness was defined as an Incremental Cost-Effectiveness Ratio (ICER) <$50 000 or $100 000 per Quality Adjusted Life Year (QALY). RESULTS: RA-THA patients experienced lower costs compared to mTHA patients at 1 year ($20 865.12 ± 9897.52 vs. $21 660.86 ± 9909.15; p < 0.001) and 5 years ($23 124.57 ± 10 045.48 vs. $25 756.42 ± 10 091.84; p < 0.001) post-operatively. RA-THA patients also accrued more QALYs (1-year: 0.901 ± 0.117 vs. 0.888 ± 0.114; p < 0.001; 5-years: 4.455 ± 0.563 vs. 4.384 ± 0.537 p < 0.001). Overall, RA-THA was cost-effective (1-year ICER: $-61 210.77; 5-year ICER: $-37 068.31). CONCLUSIONS: The novel, fluoroscopy-based RA-THA system demonstrated cost-effectiveness when compared to manual unassisted THA.

Total Hip Arthroplasty Outcomes in Patients Who Have a History of Prior Radiation.

BACKGROUND: The purpose of this study was to assess the odds of developing medical and surgical adverse events following total hip arthroplasty (THA) in patients who have a history of radiation therapy (RT) for cancer. METHODS: A retrospective cohort study was conducted using a national database to identify patients who underwent primary THA (Current Procedural Terminology code 27130) from 2002 to 2022. Patients who had a prior RT were identified by International Classification of Diseases, Tenth Revision, Clinical Modification codes Z51.0 (encounter for antineoplastic RT), Z92.3 (personal history of irradiation), or Current Procedural Terminology code 101843 (radiation oncology treatment). One-to-one propensity score matching was conducted to generate 3 pairs of cohorts: 1) THA with/without a history of RT; 2) THA with/without a history of cancer; and 3) THA patients who have a history of cancer treated with/without RT. Surgical and medical complications were assessed at the 30-day, 90-day, and 1-year postoperative periods. RESULTS: Patients who have a history of RT had higher odds of developing anemia, deep vein thrombosis, pneumonia, pulmonary embolism, and prosthetic joint infection at all intervals. When controlling for a history of cancer, RT was associated with an increased risk of pulmonary embolism, heterotrophic ossification, prosthetic joint infection, and periprosthetic fracture at all postoperative time points. There was additionally an increased risk of aseptic loosening at 1 year (odds ratio: 2.0, 95% confidence interval: 1.2 to 3.1). CONCLUSION: These findings suggest that patients who have a history of antineoplastic RT are at an increased risk of developing various surgical and medical complications following THA.

What Factors Are Associated with Clinical Trial Discontinuation in Orthopaedic Surgery: An Analysis of Clinical Trials Between 2007 and 2022.

BACKGROUND: Clinical trials play a crucial role in advancing medical knowledge and have the potential to change standards of care. The present study evaluated the prevalence of discontinued clinical trials in orthopaedic surgery. Additionally, we sought to identify the study characteristics associated with and the rationale behind trial discontinuation. METHODS: A cross-sectional survey of orthopaedic clinical trials using the ClinicalTrials.gov registry and results database was performed for trials between October 1, 2007, and October 7, 2022. Interventional trials listed as "completed," "terminated," "withdrawn," or "suspended" were included. Study characteristics were collected and clinical trial abstracts were reviewed in order to assign the appropriate subspecialty category. A univariate linear regression analysis was performed to determine whether the percentage of discontinued trials changed between 2008 and 2021. Univariate and multivariable hazard ratios (HRs) were calculated to identify factors associated with trial discontinuation. RESULTS: A total of 8,603 clinical trials were included in the final analysis, of which 1,369 (16%) were discontinued, with the highest rates of discontinuation found in oncology (25%) and trauma (23%). The most common rationales for discontinuation were insufficient patient accrual (29%), technical or logistical issues (9%), business decision (9%), and lack of funding or resources (9%). Industry-funded studies were more likely than government-funded studies to be discontinued (HR: 1.81; p < 0.001). There was no change in the percentage of discontinued trials for each orthopaedic subspecialty between 2008 and 2021 (p = 0.21). As shown on multivariable regression analysis, trials for devices (HR: 1.63 [95% confidence interval, 1.20 to 2.21]; p = 0.002) and drugs (HR: 1.48 [1.10 to 2.02]; p = 0.013) as well as Phase-2 trials (HR: 1.35 [1.09 to 1.69]; p = 0.010), Phase-3 trials (HR: 1.39 [1.09 to 1.78]; p = 0.010), and Phase-4 trials (HR: 1.44 [1.14 to 1.81]; p = 0.010) had a higher likelihood of early discontinuation. However, pediatric trials were less likely to be discontinued (HR: 0.58 [0.40 to 0.86]; p = 0.007). CONCLUSIONS: The results of the present study suggest the need for continued efforts to ensure the completion of orthopaedic clinical trials in order to limit publication bias and to employ resources and patient contributions more efficiently for research. CLINICAL RELEVANCE: Discontinued trials contribute to publication bias, which limits the comprehensiveness of the literature available to support evidence-based patient care interventions. Therefore, identifying the factors associated with and the prevalence of orthopaedic trial discontinuation encourages orthopaedic surgeons to design future trials to be more resistant to early discontinuation.

Improved accuracy of a novel fluoroscopy-based robotically assisted THA system compared to manual THA.

Accurate acetabular cup position remains a persistent challenge in total hip arthroplasty (THA). Studies investigating the early outcomes of robotic-assisted THA (RA-THA) systems have shown improved cup placement compared to manual THA (mTHA) approaches, however, contemporary robotic platforms are reliant on pre-operative CT imaging. The goal of this study was to analyze the accuracy of a novel, fluoroscopy-based RA-THA system compared to an unassisted mTHA approach and determine the effect of the robotic system on operative time. We performed a retrospective cohort analysis on a consecutive series of 198 patients who received mTHA and RA-THA between March 2021 and July 2022. The primary outcome of interest was the accuracy of acetabular component placement, defined by average cup inclination and anteversion. Secondary outcomes included the proportion of acetabular cups positioned within the Lewinnek safe zone, operative time, and overall room time. The RA-THA group demonstrated significantly higher accuracy of acetabular anteversion to target compared to the manual group (18.5 vs. 21.7˚; p < 0.001), and had a significantly greater proportion of acetabular cups placed within the Lewinnek safe zone (81.6 vs. 59.0%; p < 0.001). The RA-THA cohort had longer operative times compared to mTHA group (39.0 vs. 35.3 min; p = 0.003), but no difference was seen in total operating room time (101.2 vs. 101.2 min; p = 0.982). This study demonstrates that the use of a novel, fluoroscopy-based, pin-less THA robotic platform increased the accuracy of acetabular cup placement, including a 22.6% improvement in safe zone placement, compared to mTHA approach, with no increase in overall case time.

The learning curve for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system.

BACKGROUND: Adoption of robotic-assisted total hip arthroplasty (RA-THA) systems can improve the accuracy of acetabular cup placement, but no group has reported the learning curve of novel, fluoroscopy-based RA-THA systems. METHODS: A learning-curve cumulative summation (LC-CUSUM) analysis was performed on a consecutive series of the first 100 patients who received fluoroscopy-based RA-THA by the study surgeon. Operative times and specific robotic timepoints were compared between learning and proficiency phases. RESULTS: Implementation of fluoroscopy-based RA-THA was associated with a learning curve of 12 cases. A 6-min increase in operative time was seen during the learning phase compared to the proficiency phase (44.3 ± 4.4 vs. 38.0 ± 7.1 min; p < 0.001), with a 3-min longer robotic cup impaction sequence during the learning phase (7.8 ± 1.9 vs. 4.8 ± 1.3 min; p < 0.001). CONCLUSION: Adoption of fluoroscopy-based RA-THA is associated with a brief learning curve of 12 cases, with the most significant improvements in surgical efficiency realised during acetabular cup placement.

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty.

BACKGROUND: Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions. METHODS: A large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons. RESULTS: For knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures. CONCLUSION: The MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.

Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review.

BACKGROUND: To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity. QUESTIONS/PURPOSES: We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)? METHODS: A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively. RESULTS: Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles. CONCLUSION: These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment. LEVEL OF EVIDENCE: Level III, therapeutic study.

Have all races experienced reductions in complication rates following total hip arthroplasty? A NSQIP analysis between 2011 and 2019.

INTRODUCTION: Despite numerous articles in the orthopedic literature evaluating racial and ethnic disparities, inequalities in total joint arthroplasty outcomes remain. While the National Surgical Quality Improvement (NSQIP) database has been previously utilized to highlight these disparities, no previous analysis has evaluated how the rate of various perioperative complications has changed over recent years when segregating by patient race. Specifically, we evaluated if all races have experienced decreases in (1) medical complications, (2) wound complications, (3) venous thromboembolism (VTE), and (4) readmission/reoperation rates following total hip arthroplasty (THA) over recent years? METHODS: Current Procedural Terminology (CPT) code 27,130 (total hip arthroplasty) was utilized to identify all THA procedures conducted between 2011 and 2019. Patients were segregated according to race and various demographics were collected. Linear regression was utilized to evaluate changes in each complication rate between 2011 and 2019. A multivariate regression was then conducted for each complication to evaluate whether race independently was associated with each outcome. RESULTS: Our analysis included a total of 212,091 patients undergoing primary THA. This included 182,681 (85.76%) White, 19,267 (9.04%) Black, 5928 (2.78%) Hispanic, and 4215 (1.98%) Asian patients. We found that for urinary tract infection (UTI), acute renal failure, superficial SSI, and readmission rates, White patients experienced significant reductions between 2011 and 2019. However, this was not consistent across all races. Black race was associated with a significantly increased risk of acute renal failure (OR: 2.03, 95% CI: 1.17-3.34; p = 0.008), renal insufficiency (OR: 2.33, 95% CI: 1.62-3.28; p < 0.001), deep vein thrombosis (DVT) (OR: 1.34, 95% CI: 1.07-1.66; p = 0.01), and pulmonary embolism (PE) (OR: 1.76, 95% CIL: 1.36-2.24; p < 0.001). CONCLUSION: Our analysis highlights specific complications for which further interventions are necessary to reduce inequalities across races. These include medical optimization, increased patient education, and continued efforts at understanding how social factors may impact-related care inequalities. Future study is needed to evaluate specific interventions that can be applied at the health systems level to ensure all patients undergoing THA receive the highest quality of care regardless of race.

Less Than One-third of Hospitals Provide Compliant Price Transparency Information for Total Joint Arthroplasty Procedures.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) recently implemented price transparency legislation. As total joint arthroplasty (TJA) procedures are widely used, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures are a proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, cost estimates for TJA procedures represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population. QUESTIONS/PURPOSES: We asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes? METHODS: Our cross-sectional retrospective analysis used the CMS's Hospital Compare database. This database includes information for 5326 Medicare hospitals nationally. We excluded children's, psychiatric, Veterans Affairs, and active military base hospitals as well as hospitals performing fewer than 100 TJAs annually. A total of 1719 hospitals remained after this selection process. Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 facilities for our final analysis. Included hospitals were located predominately in urban areas (79% [317 of 400]) and were mostly medium-sized facilities (43% [171 of 400]). Most hospitals were classified as acute care (98% [392 of 400]) versus critical access. Three reviewers thoroughly searched each hospital website for a machine-readable file providing the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals with any gross price information pseudocompliant. The consumer-friendliness of the website was assessed based on the following criteria: (1) languages other than English were offered, (2) it took less than 15 minutes to locate pricing information, (3) a phone number or email address was provided for questions, and (4) there was a description of procedure in common terms. Pricing information was recorded and compared for CPT codes 27447 and 27130 and DRG codes 469 and 470. Data were sourced from December 1 through 20, 2021, to assess compliance in the first year since the legislation was implemented. RESULTS: Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing. When segregating by individual procedures, 21% (84 of 400), 18% (72 of 400), 18% (71 of 400), and 19% (74 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130 and DRG codes 469 and 470, respectively. For each code, rates of pseudocompliance were 36% (143 of 400), 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400) for the included codes, respectively. Most included hospitals provided at least some of their pricing data in a user-friendly format. Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code. CONCLUSION: Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures. CLINICAL RELEVANCE: Given the potential influence compliance and price sharing may have on empowering patients' healthcare decisions and reducing healthcare expenditures, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available to their patients. In addition to ensuring that all six CMS mandates are met, this should include providing information in easy-to-understand formats and making related services identifiable across all levels of health literacy. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest.