Outcomes After Successful Debridement, Antibiotic, and Implant Retention Therapy for Periprosthetic Joint Infection in Total Knee Arthroplasty.

BACKGROUND: Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable with little investigation of functional outcomes. METHODS: We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed. RESULTS: Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5. CONCLUSION: Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years. LEVEL OF EVIDENCE: Level III.

Altered Ulnar Variance With Full-Body Weight-bearing During Handstands With Upper Extremity Weight-bearing CT.

PURPOSE: Ulnar variance (UV) is a radiographic measurement relating the articular surface heights of the distal radius and ulna. Abnormal UV increases the risk for wrist pathology; however, it only provides a static measurement of an inherently dynamic bony relationship that changes with wrist position and loading. The purpose of this study was to investigate how full-body weight-bearing affects UV using weight-bearing computed tomography (WBCT). METHODS: Ten gymnasts completed two 45-second scans inside a WBCT machine while performing a handstand on a flat platform (H) and parallettes (P). A non-weight-bearing CT scan was collected to match clinical practice (N). Differences in UV between weight-bearing conditions were evaluated separately for dominant and nondominant sides, and then, UV was compared between weight-bearing conditions on pooled dominant/nondominant data. RESULTS: Pooled analyses comparing weight-bearing conditions revealed a significant increase in UV for H versus N (0.58 mm) and P versus N (1.00 mm), but no significant change in UV for H versus P (0.43 mm). Significant differences in UV were detected for H versus N, P versus N, and H versus P for dominant and nondominant extremities. The change from N to H was significantly greater in the dominant versus nondominant side, but greater in the nondominant side from N to P. CONCLUSIONS: Ulnar variance changed with the application of load and position of the wrist. Differences in UV were found between dominant and nondominant extremities. CLINICAL RELEVANCE: Upper extremity loading patterns are affected by hand dominance as defined by a cartwheel and suggest skeletal consequences from repetitive load on a dominantly used wrist. Although statistically significant, subtle changes detected in this investigational study do not necessarily bear clinical significance. Future WBCT research can lead to improved diagnostic measures for wrist pathologies affected by active loading and rotational wrist behavior.

Cam Morphology Is Associated With Increased Femoral Version: Findings From a Collection of 1,321 Cadaveric Femurs.

BACKGROUND: To evaluate the relationship between femoral version (FV) and α angle (AA) in a large osteological collection of human femurs. METHODS: The University of Iowa-Stanford osteological collection was used to evaluate the research aims. To measure FV and AA, axial photographs of the proximal femurs were taken, referenced from the posterior condylar axis. FV and AA measurements were obtained using ImageJ software, and the relationship between FV and AA was assessed with repeated-measures analysis of variance and generalized linear models. A P value of <.05 was considered statistically significant. RESULTS: A total of 1321 cadaveric femurs (666 left and 655 right) in 721 cadavers were examined. The average AA for all femurs was 47.8° ± 10.9°, and the average FV for all femurs was 8.53° ± 8.09°. Overall, 191 femurs (14.5%) exhibited cam morphology (AA ≥ 60°). Of the 721 cadavers, 600 had both femurs available for side-to-side comparison. The average FV of femurs with cam morphology was significantly higher than that of femurs without cam morphology (11.70° ± 8.82° vs. 7.99° ± 8.82°, P < .001). Linear regression analysis demonstrated that increased AA was significantly correlated with increased FV (ß ± standard error of the mean = 0.21 ± 0.02, P < .0001). CONCLUSION: In a large osteological collection of human femurs, a significant positive relationship between AA and increasing FV was identified. CLINICAL RELEVANCE: FAI and hip impingement morphology are more complex than cam or pincer morphology. Cam morphology with high femoral anteversion may allow for normal or near-normal hip mechanics without impingement, and this may partially explain the high rates of asymptomatic cam-type femoroacetabular impingement (FAI) morphology in active and general populations. Given the multiple morphological factors implicated in the development of FAI syndrome, these findings warrant further investigation.

Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). METHODS: A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated. RESULTS: There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P = .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P =.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P = .118). Matched subanalysis (LIA and ACB; n = 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P = .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P = .520). CONCLUSION: The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery. LEVEL OF EVIDENCE: III, retrospective comparison study.

Comparison of Patient-Reported Outcomes and Functional Assessment Using a Marker-Less Image Capture System in End-Stage Knee Arthritis.

BACKGROUND: Patient self-assessment of knee function in end-stage osteoarthritis (OA) and following total knee arthroplasty (TKA) using patient-reported outcome measures (PROMs) has become standard for defining disability. The relationship of PROMs to functional performance requires a continued investigation. The purpose of this study was to determine correlations between patient demographics, PROMs, and functional performances using a marker-less image capture system (MICS). METHODS: Patients indicated for elective TKA completed the Knee Injury and Osteoarthritis Score for Joint Replacement (KOOS-JR) and an office-based functional assessment using a MICS. Patient age, body mass index (BMI), and gender were collected. A total of 112 patients were enrolled. Their mean age was 65.0 (±9.7) years, mean BMI was 32.5 (±6.6) kg/m2, and mean KOOS-JR was 14.5 (±5.7). The relationships between patient characteristics, KOOS-JR, MICS Alignment (coronal), MICS Mobility (flexion), and composite Total Joint scores were described using Spearman's correlation coefficients. RESULTS: BMI was weakly correlated with KOOS-JR (ρ = -0.22, P = .024), whereas age was not. Age and BMI were not correlated with performance scores. There were weak to no correlations between KOOS-JR and MICS Alignment (ρ = -0.01, P = .951), Mobility (ρ = 0.33, P < .001), and Total Joint scores (ρ = 0.06, P = .504). CONCLUSION: This study found no strong correlation between KOOS-JR and functional performance using a validated MICS for patients with end-stage knee OA. Further study is warranted in determining the relationship between PROMs and performance to optimize outcomes of patients undergoing nonoperative or surgical interventions for knee OA. The use of high-fidelity functional assessment tools that can be integrated into clinical workflow, such as the MICS used in this study, should permit PROM/functional performance comparisons in large populations.

Outcomes Vary Significantly Using a Tiered Approach to Define Success After Total Knee Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROM) allow assessment of clinical outcomes following primary total knee arthroplasty (TKA). The purpose of this study is to use progressively more stringent definitions of success to examine clinical outcomes of primary TKA at 1 year postoperatively and to determine which demographic variables were associated with achieving clinical success. METHODS: The American Joint Replacement Registry was queried from 2012 to 2020 for primary TKA. Patients who completed the following PROMs preoperatively and 1 year postoperatively were included: Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and KOOS for Joint Replacement (KOOS JR). Mean PROM scores were determined for each visit and between-visit changes were evaluated using paired t-tests. Rates of achievement of minimal clinically important difference (MCID) by distribution-based and anchor-based criteria, Patient Acceptable Symptom State, and substantial clinical benefit were calculated. Logistic regression was used to evaluate the association between demographic variables and odds of clinical success. RESULTS: In total, 12,341 TKAs were included. Mean improvement in PROM scores were as follows: KOOS JR, 29; WOMAC-Pain, 33; and WOMAC-Function, 31 (P < .0001 for all). Rates of achievement of each metric were the following: distribution-based MCID, 84%-87%; anchor-based MCID, 46%-79%; Patient Acceptable Symptom State, 54%-82%; and substantial clinical benefit, 68%-81%. Patient age and gender were the most influential demographic factors on achievement of clinical success. CONCLUSION: Clinical outcomes at 1 year following TKA vary significantly when using a tiered approach to define success. A tiered approach to interpretation of PROMs should be considered for future research and clinical assessment.

Projected Prevalence of Obesity in Primary Total Knee Arthroplasty: How Big Will the Problem Get?

BACKGROUND: Obesity is a well-established risk factor for complications following primary total knee arthroplasty (TKA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary TKA patients in the United States through 2029. METHODS: Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27447 was used to identify primary TKA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS: A total of 8,372,221 individuals were included (7,986,414 BRFSS, 385,807 NSQIP TKA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary TKA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary TKA from 60% to 64%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 69% of primary TKA will be obese/morbidly obese. CONCLUSION: By 2029, we estimate ≥69% of primary TKA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Not all Total Hip and Knee Arthroplasties Are the Same: What Are the Implications in Large Database Studies?

BACKGROUND: The use of claims databases for research after total hip and knee arthroplasty (THA, TKA) has increased exponentially. These studies rely on accurate coding, and inadvertent inclusion of patients with nonroutine indications may influence results. The purpose of this study was to evaluate the complexity of THA and TKA captured by CPT code and determine if complication rates vary based on the indication. METHODS: The NSQIP database was queried using CPT codes 21730 and 27447 to identify patients undergoing THA and TKA from 2018 to 2019. The surgical indication was classified based on the ICD-10 diagnosis code as routine primary, complex primary, inflammatory, fracture, oncologic, revision, infection, or indeterminant. Patient factors and 30-day complications, readmission, reoperation, and wound complications were compared. RESULTS: A total of 86,009 THA patients had 703 ICD-10 diagnosis codes and 91.4% were routine primary indications. Complication rates were: routine primary 7.4%, complex primary 11.3%, inflammatory 12.5%, fracture 23.9%, oncologic 32.4%, revision 26.9%, infection 38.7%, and indeterminant 10.3% (P < .0001). 137,500 TKA patients had 552 ICD-10 diagnosis codes and 96.1% were routine primary cases. Complication rates were: routine primary 5.9%, complex primary 8.0%, inflammatory 7.2%, fracture 38.9%, oncologic 32.7%, revision 13.3%, infection 37.7%, and indeterminant 9.6% (P < .0001). Routine primary arthroplasty had significantly lower rates of reoperation, readmission, and wound complications. CONCLUSION: Using CPT code alone captures 10% of THA and 4% of TKA patients with procedures for nonroutine primary indications. It is essential to recognize identification of patients simply by CPT code has the potential to inadvertently introduce bias, and surgeons should critically assess methods used to define the study populations.

What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications?

BACKGROUND: Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA. METHODS: Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI. RESULTS: A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m2, of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m2 as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed. CONCLUSION: Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.

Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get?

BACKGROUND: Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029. METHODS: Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS: A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese. CONCLUSION: By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?

BACKGROUND: Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data. RESULTS: Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis. CONCLUSION: Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.

Are Morbidly Obese Patients Equally Benefitting From Care Improvements in Total Hip Arthroplasty?

BACKGROUND: Morbidly obese patients have increased rates of complications following primary total hip arthroplasty (THA) and it is not clear whether improvements in THA care pathways are equally benefitting these patients. The purpose of this study is to assess if reductions in complications have similarly improved for both morbidly obese and non-morbidly obese patients after THA. METHODS: Patients undergoing primary THA between 2011 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 and ≥40 kg/m2. Thirty-day rates of infectious complications, readmissions, reoperation, and any complication were assessed. Trends in complications were compared utilizing odds ratios and multivariate analyses. RESULTS: In total, 234,334 patients underwent THA and 16,979 (7.8%) had BMI ≥40 kg/m2. Patients with BMI ≥40 kg/m2 were at significantly higher odds for readmission, reoperation, and infectious complications. Odds for any complication were lower for morbidly obese patients in 2011, not different from 2012 to 2014, and higher from 2015 to 2019 compared to lower BMI patients. Odds for any non-transfusion complication were higher for morbidly obese patients and there was no improvement for either group over the study period. There were improvements in rates of readmission and reoperation for patients with BMI <40 kg/m2 and readmission for BMI >40 kg/m2. CONCLUSION: Odds for readmission and reoperation for non-morbidly obese patients and readmission for morbidly obese patients improved from 2011 to 2019. Reductions in transfusions are largely responsible for improvements in overall complication rates. Although morbidly obese patients remain at higher risk for complications, there does not appear to be a growing disparity in outcomes between morbidly obese and non-morbidly obese patients.

What is the Impact of Body Mass Index Cutoffs on Total Knee Arthroplasty Complications?

BACKGROUND: Body mass index (BMI) cutoffs are commonly used to decide whether to offer obese patients elective total knee arthroplasty (TKA). However, weight loss goals may be unachievable for many patients who are consequentially denied complication-free surgery. The purpose of this study was to assess the impact of different BMI cutoffs on the rates of complication-free surgery after TKA. METHODS: Patients undergoing elective, primary TKA from 2015 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27447. The BMI and rates of any thirty-day complication were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if TKA would have been allowed or denied based on the BMI. RESULTS: A total of 314,719 patients underwent TKA, and 46,386 (14.7%) had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 268,333 (85.3%) patients would have undergone TKA. A total of 282,552 (94.8%) would experience complication-free surgery, and 17.3% of all complications would be prevented. TKA would proceed for 309,479 (98.3%) patients at a BMI cutoff of 50 kg/m2. A total of 293,108 (94.7%) would not experience a complication, and 2.8% of complications would be prevented. A BMI cutoff of 35 kg/m2 would prevent 36.6% of all complications while allowing 94.8% of complication-free surgeries to proceed. CONCLUSION: Lower BMI cutoffs can reduce complications, but will limit access to complication-free TKA for many patients. These data do not indicate TKA should be performed without consideration of risks from obesity; however, a holistic assessment and shared decision-making may be more valuable when deciding on appropriate goal weight reduction.

Hip Arthroscopy With and Without A Perineal Post: A Comparison of Early Postoperative Pain.

PURPOSE: To compare postoperative pain and early recovery after hip arthroscopy with and without a perineal post for joint distraction. METHODS: We retrospectively reviewed a consecutive series of patients who underwent hip arthroscopy before and after the adoption of a postless technique. Patients who underwent concurrent periacetabular or femoral osteotomy were excluded. Demographic information, procedure variables, and visual analog scale (VAS) pain scores were recorded. Analgesic medications given were converted to morphine milligram equivalents (MME) for comparison. Uni- and multivariate analyses were conducted to compare total MME, postoperative pain, and time to discharge between groups. RESULTS: One hundred patients were in each group. The overall age (mean ± standard deviation) was 26.5 ± 9.9 years (Post [P]: 57 females; No Post [NP]: 68 females). Total operative time (P 100.4 ± 17.9 minutes vs NP 89.1 ± 25.5 minutes, P = .0004), traction time (P 45.8 ± 10.3 minutes vs NP 40.9 ± 11.1 minutes, P = .0017), and operating room time (P 148.8 ± 19.3 minutes vs NP 137.3 ± 25.8 minutes, P = .0005) were found to be shorter in the NP group. Total MME, and final VAS pain scores in the PACU were similar between both groups (MME, P = .1620; VAS, P = .2139). Time to discharge was significantly shorter in the NP group (P 207.2 ± 58.8 vs NP 167.5 ± 47.9, P < .0001). Patient age (≥25 years) (65.2 ± 18.1 vs 59.8 ± 15.7 [MME], P = .0269) and elevated body mass index (≥25) (65.1 ± 17.1 vs 59.3 ± 16.4 [MME], P = .0164) were factors associated with greater total MME consumption. Female sex was associated with higher postoperative VAS pain scores (FM 4.1 ± 1.6 vs M 3.4 ± 1.8 P = .0027). CONCLUSIONS: Adoption of the postless technique did not result in prolonged operating room or operative time. Overall, both groups had similar postoperative pain, however, the time from surgery to hospital discharge was shorter in the postless group. LEVEL OF EVIDENCE: III, retrospective comparison study.

Dental Screening in Elective Total Joint Arthroplasty: Risk Factors for Failure.

BACKGROUND: Active dental infection at the time of total joint arthroplasty (TJA) or in the acute postoperative period following TJA is thought to increase the risk of periprosthetic joint infection (PJI). Many surgeons recommend preoperative dental screening. This study aimed to identify how many elective TJA patients failed preoperative dental screening and what patient risk factors were associated with failure. METHODS: A consecutive series of elective, primary TJA was reviewed from 8/1/2016 to 8/1/2017. We studied 511 operations in 511 patients. All patients were referred for preoperative dental screening per protocol. Dental screening failure was defined as required dental intervention by the dentist. Screening failure rate was calculated for and logistic regression was used to evaluate the relationship between odds of screening failure and patient demographic data. RESULTS: In 94 of the 511 total cases (18.5%), patients failed dental screening and required dental procedures prior to TJA. Reasons for failure included tooth extractions, root canals, abscess drainage, and carious lesions requiring filling. Patient characteristics associated with failed dental screening included male gender (odds ratio 1.56, 95% confidence interval 1.0006-2.468, P = .047) and current smoker (odds ratio 3.6, 95% confidence interval 1.650-7.927, P = .001). CONCLUSION: Universal dental screening prior to primary TJA resulted in 18.5% of patients needing an invasive dental intervention. Universal dental screening results in extra cost and time for patients and providers. Although male gender and active smoking were associated with increased odds of requiring an invasive dental procedure, more work is needed to develop targeted screening to improve perioperative workflow and limit unnecessary dental evaluations for patients.

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases.

BACKGROUND: There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA. METHODS: Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed. RESULTS: In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases. CONCLUSION: Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

More Patients Are Being Discharged Home After Total Knee Arthroplasty, However Rates Vary Between Large Databases.

BACKGROUND: There have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications. METHODS: Patients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed. RESULTS: In total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001). CONCLUSION: Patients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.

Do Extended Oral Postoperative Antibiotics Prevent Early Periprosthetic Joint Infection in Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty?

BACKGROUND: Extended oral antibiotic prophylaxis after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) in patients with body mass index (BMI) ≥40 kg/m2 may reduce the rate of early periprosthetic joint infection (PJI); however, existing data are limited. The purpose of this study was to examine rates of wound complications and PJI in patients with BMI ≥40 kg/m2 treated with and without extended oral antibiotic prophylaxis after surgery. METHODS: We retrospectively identified all primary THA and TKA performed since 2015 in patients with a BMI ≥40 kg/m2 at a single institution. Extended oral antibiotic prophylaxis for 7-14 days after surgery was prescribed at the discretion of each surgeon. Wound complications and PJI were examined at 90 days postoperatively. RESULTS: In total, 650 cases (205 THA and 445 TKA) were analyzed. Mean age was 58 years and 62% were women. Mean BMI was 44 kg/m2. Extended oral antibiotic prophylaxis was prescribed in 177 cases (27%). At 90 days, there was no difference between prophylaxis and nonprophylaxis groups in rate of wound complications (11% vs 8%; P = .41) or PJI (1.7% vs 0.6%; P = .35). The univariate analysis demonstrated increased operative time (odds ratio (OR) 1.01; 95% confidence interval (95% CI) 1.01-1.02) and diabetes mellitus (OR 1.88; 95% CI 1.03-3.46) to be associated with increased risk of 90-day wound complications. No patient factors were associated with increased risk of PJI at 90 days postoperatively. CONCLUSION: Extended oral antibiotic prophylaxis after primary THA and TKA did not reduce rates of wound complications or early PJI in a morbidly obese patient population.

Total Ankle Arthroplasty and Ankle Arthrodesis Use: An American Board of Orthopaedic Surgery Part II Database Study.

Total ankle arthroplasty (TAA) use has increased during the past 20 years, whereas ankle arthrodesis (AAD) use has remained constant. The purpose of this study was to examine trends in TAA and AAD use in American Board of Orthopedic Surgery Part II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis. The American Board of Orthopedic Surgery Part II database was queried to identify all candidates who performed ≥1 TAA or AAD from examination years 2009 through 2018. Candidates were categorized by examination year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in use of TAA and AAD were examined by using log-modified regression analyses. From 2009through 2018, there was no significant change in TAA or AAD use among all candidates (p = .92, p = .20). Candidates reporting a foot and ankle fellowship trended toward increased use of TAA relative to AAD compared with non-foot and ankle fellowship candidates, but this failed to reach statistical significance (p = .06). The use of arthroscopic AAD increased over time (p < .01) among all candidates. TAA and AAD use did not change over the study period. Volume of TAA and AAD performed by early-career surgeons remains low. The findings in this study should serve as an important reference for orthopedic trainees, early-career surgeons, and orthopedic educators interested in optimizing training curriculum for surgical management of end-stage ankle arthritis.

Trends in Hip Arthroscopic Labral Repair: An American Board of Orthopaedic Surgery Database Study.

PURPOSE: The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy. METHODS: Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05. RESULTS: During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072). CONCLUSIONS: Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.