High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA.

BACKGROUND: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it. QUESTIONS/PURPOSES: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms? METHODS: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs. RESULTS: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]). CONCLUSION: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Predictive Modeling of Medical- and Orthopaedic-Related 90-Day Readmissions Following Primary Total Hip Arthroplasty.

BACKGROUND: The rate of unplanned hospital readmissions following total hip arthroplasty (THA) varies from 3 to 10%, representing a major economic burden. However, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to: (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate; and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following THA. METHODS: A prospective cohort of primary unilateral THAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 8,893 patients) using a validated institutional data collection system. Orthopaedic-related readmissions were specific complications affecting the prosthesis, joint, and surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently. RESULTS: Overall, the rate of 90-day readmissions was 5.6%. Medical readmissions (4.2%) were found to be more prevalent than orthopaedic-related readmissions (1.4%). The area under the curve for the 90-day readmission model was 0.71 (95% confidence interval: 0.69 to 0.74). Factors significantly associated with medical-related readmissions were advanced age, Black race, education, Charlson Comorbidity Index, surgical approach, opioid overdose risk score, and nonhome discharge. In contrast, risk factors linked to orthopaedic-related readmissions encompassed body mass index, patient-reported outcome measure phenotype, nonosteoarthritis indication, opioid overdose risk, and nonhome discharge. CONCLUSIONS: Of the overall 90-day readmissions following primary THA, 75% were due to medical-related complications. Our successful predictive model for complication-specific 90-day readmissions highlights how different risk factors may disproportionately influence medical versus orthopaedic-related readmissions, suggesting that patient-specific, tailored preventive measures could reduce postoperative readmissions in the current value-based health care setting.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty.

BACKGROUND: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider. METHODS: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio. RESULTS: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187). CONCLUSIONS: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Patient satisfaction and patient-reported outcomes do not vary by BMI class in total hip arthroplasty.

PURPOSE: Obesity has been identified as a risk factor for postoperative complications in patients undergoing total hip arthroplasty (THA). This study aimed to investigate patient-reported outcomes, pain, and satisfaction as a function of body mass index (BMI) class in patients undergoing THA. METHODS: 1736 patients within a prospective observational study were categorized into BMI classes. Pre- and postoperative Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), satisfaction, and pain scores were compared by BMI class using one-way ANOVA. RESULTS: Healthy weight patients reported the highest preoperative HOOS JR (56.66 ± 13.35) compared to 45.51 ± 14.45 in Class III subjects. Healthy weight and Class III patients reported the lowest (5.65 ± 2.01) and highest (7.06 ± 1.98, p < 0.0001) preoperative pain, respectively. Changes in HOOS JR scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported an increase of 33.7 ± 15.6 points at 90 days compared to 26.1 ± 17.1 in healthy weight individuals (p = 0.002). Fewer healthy weight patients achieved the minimal clinically important difference (87.4%) for HOOS JR compared to Class II (96.5%) and III (94.7%) obesity groups at 90 days postoperatively. Changes in satisfaction and pain scores were largest in the Class III patients. Overall, no functional outcomes varied by BMI class postoperatively. CONCLUSION: Patients of higher BMI class reported greater improvements following THA. While risk/benefit shared decision-making remains a personalized requirement of THA, this study highlights that utilization of BMI cutoff may not be warranted based on pain and functional improvement.

What Drives the Material Costs of Total Knee Arthroplasty in the Operating Room?

INTRODUCTION: Approximately one-third of US healthcare spending is related to surgical care. Optimizing operating room (OR) spending is crucial, specifically for high-volume procedures like total knee arthroplasty (TKA). Therefore, the primary objective was to identify leading material drivers of cost for TKA procedures within the OR. MATERIALS AND METHODS: Patients who underwent a primary, elective TKA from 2018 to 2019 were included (n=8,672). Intraoperative cost details for each TKA patient were captured from the Vizient Clinical Database Resource Manager (CDB/RM) data. Each cost type was categorized into (1) implant, (2) disposables, (3) wound care, and (4) miscellaneous. RESULTS: 7,124 patients undergoing primary TKA were included. Implant-related costs accounted for 87.3% of cost, disposable materials covered 10.7%, and wound care products took 2%. The leading subcategories of implant costs were primary prosthetics (85.1%), revision prosthetics (9.9%), cement (2.8%), and implant instruments (1.7%). Within disposables, surgical products accounted for 81.3% of the cost, patient care products for 8.9%, medical apparel for 7.9%, and electrolytes for 1.8%. For an average individual TKA procedure, 86.4% (±4.4) of total cost went towards the implant, 10.7% (±3.4) towards disposable materials, and 1.6% (±1.4) to wound care products. Within the implant category, 92.5% (± 12.8) of costs were associated with primary implants, 13.3% (± 6.9) with instruments, and 2.5% (± 2.8) with cement. CONCLUSIONS: The primary operative material expense category was costs associated with the TKA prosthesis and its fixation followed by disposable materials. A large amount of variation exists in the percent of the total cost for a given TKA procedure that can be attributed to each category.

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis.

BACKGROUND: There is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population. METHODS: A systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4). RESULTS: A total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively). CONCLUSION: Liver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.

Periprosthetic Tibial Fractures After Total Knee Arthroplasty: Early and Long-Term Clinical Outcomes.

BACKGROUND: Although periprosthetic fractures are increasing in prevalence, evidence-based guidelines for the optimal treatment of periprosthetic tibial fractures (PTx) are lacking. Thus, the purpose of this study is to assess the clinical outcomes in PTx after a total knee arthroplasty (TKA) which were treated with different treatment options. METHODS: A retrospective review was performed on a consecutive series of 34 nontumor patients treated at 2 academic institutions who experienced a PTx after TKA (2008-2016). Felix classification was used to classify fractures (Felix = I-II-III; subgroup = A-B-C) which were treated by closed reduction, open reduction/internal fixation, revision TKA, or proximal tibial replacement. Patient demographics and surgical characteristics were collected. Failure of treatment was defined as any revision or reoperation. Independent t-tests, one-way analysis of variance, chi-squared analyses, and Fisher's exact tests were conducted. RESULTS: Patients with Felix I had more nonsurgical complications when compared to Felix III patients (P = .006). Felix I group developed more postoperative anemia requiring transfusion than Felix III group (P = .009). All fracture types had >30% revision and >50% readmission rate with infection being the most common cause. These did not differ between Felix fracture types. Patients who underwent proximal tibial replacement had higher rate of postoperative infection (P = .030), revision surgery (P = .046), and required more flap reconstructions (P = .005). CONCLUSION: PTx after a TKA is associated with high revision and readmission rates. Patients with Felix type I fractures are at higher risk of postoperative nonsurgical complications and anemia requiring transfusion. Fractures treated with proximal tibial replacement are more likely to develop postoperative infections and undergo revision surgery.

Sarcopenia as a Risk Factor for Prosthetic Infection After Total Hip or Knee Arthroplasty.

BACKGROUND: Sarcopenia, an age-related loss of muscle mass and function, has been previously linked to an increased risk of morbidity, mortality, and infection after a variety of surgical procedures. This study is the first to evaluate the impact of the psoas-lumbar vertebral index (PLVI), a validated marker for central sarcopenia, on determining post-arthroplasty infection status. METHODS: This is a case-control, retrospective review of 30 patients with prosthetic joint infection (PJI) diagnosed by the Musculoskeletal Infection Society criteria compared to 69 control patients who underwent a total hip or knee arthroplasty. All patients had a recent computed tomography scan of the abdomen/pelvis to calculate the PLVI. PLVI was evaluated alongside age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, and smoking status to determine the predictive value for infection. RESULTS: Notably, the infected group had a large, significant difference in their average PLVI (0.736 vs 0.963, P < .001). The patient's PLVI was a predictor of infection status, with a higher PLVI being protective against infection (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.109-0.715, P = .008). Additional predictors of infection status were higher American Society of Anesthesiologists score (OR 10.634, 95% CI 3.112-36.345, P < .001) and Charlson Comorbidity Index (OR 1.438, 95% CI 1.155-1.791, P = .001). Multivariate, binary logistic regression analysis confirmed that PLVI was a significant independent predictor of infection status (B = -0.685, P = .039). CONCLUSION: PLVI, a marker for central sarcopenia, was demonstrated to be a risk factor for PJI. Further research and consideration of sarcopenia as a screening and optimizable risk factor for total joint arthroplasty must be explored.

Biological and Chemical Removal of Primary Cilia Affects Mechanical Activation of Chondrogenesis Markers in Chondroprogenitors and Hypertrophic Chondrocytes.

Chondroprogenitors and hypertrophic chondrocytes, which are the first and last stages of the chondrocyte differentiation process, respectively, are sensitive to mechanical signals. We hypothesize that the mechanical sensitivity of these cells depends on the cell surface primary cilia. To test this hypothesis, we removed the primary cilia by biological means with transfection with intraflagellar transport protein 88 (IFT88) siRNA or by chemical means with chloral hydrate treatment. Transfection of IFT88 siRNA significantly reduced the percentage of ciliated cells in both chondroprogenitor ATDC5 cells as well as primary hypertrophic chondrocytes. Cyclic loading (1 Hz, 10% matrix deformation) of ATDC5 cells in three-dimensional (3D) culture stimulates the mRNA levels of chondrogenesis marker Type II collagen (Col II), hypertrophic chondrocyte marker Type X collagen (Col X), and a molecular regulator of chondrogenesis and chondrocyte hypertrophy bone morphogenetic protein 2 (BMP-2). The reduction of ciliated chondroprogenitors abolishes mechanical stimulation of Col II, Col X, and BMP-2. In contrast, cyclic loading stimulates Col X mRNA levels in hypertrophic chondrocytes, but not those of Col II and BMP-2. Both biological and chemical reduction of ciliated hypertrophic chondrocytes reduced but failed to abolish mechanical stimulation of Col X mRNA levels. Thus, primary cilia play a major role in mechanical stimulation of chondrogenesis and chondrocyte hypertrophy in chondroprogenitor cells and at least a partial role in hypertrophic chondrocytes.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature.

BACKGROUND: While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior. METHODS: A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material. RESULTS: This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables. CONCLUSION: Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft. LEVEL OF EVIDENCE: Level IV.

Initial management of ankle fractures in the overweight and obese: the providence pinch.

BACKGROUND: Obese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. DISCUSSION: A novel technique, described herein by the authors, may be useful in obtaining a suitable reduction of the ankle in the initial management of unstable ankle fractures in the overweight and obese. CONCLUSIONS: Obese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.

Are Femoral Stems in Primary Total Knee Arthroplasty Cost Effective in High Fracture Risk Patients? A Risk Model and Cost Analysis.

Femoral stemmed total knee arthroplasty (FS TKA) may be used in patients deemed higher risk for periprosthetic fracture (PPF) to reduce PPF risk. However, the cost effectiveness of FS TKA has not been defined. Using a risk modeling analysis, we investigate the cost effectiveness of FS in primary TKA compared with the implant cost of revision to distal femoral replacement (DFR) following PPF. A model of risk categories was created representing patients at increasing fracture risk, ranging from 2.5 to 30%. The number needed to treat (NNT) was calculated for each risk category, which was multiplied by the increased cost of FS TKA and compared with the cost of DFR. The 50th percentile implant pricing data for primary TKA, FS TKA, and DFR were identified and used for the analysis. FS TKA resulted in an increased cost of $2,717.83, compared with the increased implant cost of DFR of $27,222.29. At 50% relative risk reduction with FS TKA, the NNT for risk categories of 2.5, 10, 20, and 30% were 80, 20, 10, and 6.67, respectively. At 20% risk, FS TKA times NNT equaled $27,178.30. A 10% absolute risk reduction in fracture risk obtained with FS TKA is needed to achieve cost neutrality with DFR. FS TKA is not cost effective for low fracture risk patients but may be cost effective for patients with fracture risk more than 20%. Further study is needed to better define the quantifiable risk reduction achieved in using FS TKA and identify high-risk PPF patients.

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons.

INTRODUCTION: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics. METHODS: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted. RESULTS: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance (P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons. CONCLUSION: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon. STUDY DESCRIPTION: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

Enabling Personalized Medicine in Orthopaedic Surgery Through Artificial Intelligence: A Critical Analysis Review.

¼ The application of artificial intelligence (AI) in the field of orthopaedic surgery holds potential for revolutionizing health care delivery across 3 crucial domains: (I) personalized prediction of clinical outcomes and adverse events, which may optimize patient selection, surgical planning, and enhance patient safety and outcomes; (II) diagnostic automated and semiautomated imaging analyses, which may reduce time burden and facilitate precise and timely diagnoses; and (III) forecasting of resource utilization, which may reduce health care costs and increase value for patients and institutions.¼ Computer vision is one of the most highly studied areas of AI within orthopaedics, with applications pertaining to fracture classification, identification of the manufacturer and model of prosthetic implants, and surveillance of prosthesis loosening and failure.¼ Prognostic applications of AI within orthopaedics include identifying patients who will likely benefit from a specified treatment, predicting prosthetic implant size, postoperative length of stay, discharge disposition, and surgical complications. Not only may these applications be beneficial to patients but also to institutions and payors because they may inform potential cost expenditure, improve overall hospital efficiency, and help anticipate resource utilization.¼ AI infrastructure development requires institutional financial commitment and a team of clinicians and data scientists with expertise in AI that can complement skill sets and knowledge. Once a team is established and a goal is determined, teams (1) obtain, curate, and label data; (2) establish a reference standard; (3) develop an AI model; (4) evaluate the performance of the AI model; (5) externally validate the model, and (6) reinforce, improve, and evaluate the model's performance until clinical implementation is possible.¼ Understanding the implications of AI in orthopaedics may eventually lead to wide-ranging improvements in patient care. However, AI, while holding tremendous promise, is not without methodological and ethical limitations that are essential to address. First, it is important to ensure external validity of programs before their use in a clinical setting. Investigators should maintain high quality data records and registry surveillance, exercise caution when evaluating others' reported AI applications, and increase transparency of the methodological conduct of current models to improve external validity and avoid propagating bias. By addressing these challenges and responsibly embracing the potential of AI, the medical field may eventually be able to harness its power to improve patient care and outcomes.

Preoperative and Postoperative Weight Change has Minimal Influence on Health Care Utilization and Patient-Reported Outcomes Following Total Knee Arthroplasty.

As obesity becomes more prevalent, more patients are at risk of lower extremity osteoarthritis and subsequent total knee arthroplasty (TKA). This study aimed to test (1) the association of preoperative weight change with health care utilization and (2) the association of pre- and postoperative weight changes with failure to achieve satisfaction and minimal clinically important difference (MCID) in Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and function (KOOS-PS) 1 year after TKA. Prospectively collected monocentric data on patients who underwent primary TKA were retrospectively reviewed. Multivariable logistic regression assessed the influence of BMI and weight change on outcomes while controlling for confounding variables. Outcomes included prolonged length of stay (LOS >3 days), nonhome discharge, 90-day readmission rate, satisfaction, and achievement of MCID for KOOS-Pain and KOOS-PS. Preoperative weight change had no impact on prolonged LOS (gain, p = 0.173; loss, p = 0.599). Preoperative weight loss was associated with increased risk of nonhome discharge (odds ratio [OR]: 1.47, p = 0.003). There was also increased risk of 90-day readmission with preoperative weight gain (OR: 1.27, p = 0.047) and decreased risk with weight loss (OR: 0.73, p = 0.033). There was increased risk of nonhome discharge with obesity class II (OR: 1.6, p = 0.016) and III (OR: 2.21, p < 0.001). Weight change was not associated with failure to achieve satisfaction, MCID in KOOS-Pain, or MCID in KOOS-PS. Obesity class III patients had decreased risk of failure to reach MCID in KOOS-Pain (OR: 0.43, p = 0.005) and KOOS-PS (OR: 0.7, p = 0.007). Overall, pre- and postoperative weight change has little impact on the achievement of satisfaction and clinically relevant differences in pain and function at 1 year. However, preoperative weight gain was associated with a higher risk of 90-day readmissions after TKA. Furthermore, patients categorized in Class III obesity were at increased risk of nonhome discharge but experienced a greater likelihood of achieving MCID in KOOS-Pain and KOOS-PS. Our results raise awareness of the dangers of using weight changes and BMI alone as a measure of TKA eligibility.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

Acetabular Component Removal Systems.

¼: As primary total hip arthroplasty procedures continue to rise, acetabular revision surgery will be in increasing demand. ¼: Treatment of acetabular component failure and associated bone defects depends on patient characteristics, the degree and location of bone loss, the ability of the columns to support biologic fixation, and the presence of pelvic discontinuity. ¼: In revision total hip arthroplasty, technological advances have been made to address limitations of acetabular cup removal while preserving host bone stock. ¼: The goal of acetabular revision reconstruction should be to obtain stable fixation and restore the hip center. The various acetabular cup removal systems are discussed.

Diagnosis, Treatment, and Outcomes of Crystalline Arthropathy in the Setting of Total Knee Arthroplasty: A Critical Analysis Review.

¼ Emerging evidence suggests the prevalence of crystalline arthropathy (CA) in the setting of total knee arthroplasty (TKA) is increasing, and diagnosis of CA is often intricate because of symptom overlap with other common postoperative complications such as periprosthetic joint infection (PJI). Consequently, an accurate and timely diagnosis becomes pivotal in guiding the choice of treatment.¼ CA includes gout and calcium pyrophosphate deposition (CPPD) disease, and accurate diagnosis in patients with prior TKA requires a multifaceted approach. The diagnosis algorithm plays a critical role in determining the appropriate treatment approach.¼ Management of CA typically involves a conservative strategy, encompassing the administration of nonsteroidal anti-inflammatory drugs, colchicine, and steroids, regardless of whether patients have undergone prior TKA.¼ There is conflicting evidence on the effect CA has on the surgical outcomes in postoperative TKA patients. While these patients may expect excellent functional outcomes and pain relief, they may be at a higher risk of complications such as infections, medical complications, and revision procedures.¼ Additional research is required to fully comprehend the impact of CA on postoperative TKA outcomes and to establish effective strategies for enhancing patient care and optimizing long-term joint function.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review.

¼ Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.¼ The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.¼ Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.¼ Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

Robotic-Assisted Conversion of a Failed Medial Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty: A Case Report.

CASE: An 81-year-old man with a history of left medial unicompartmental knee arthroplasty (mUKA) 8 years prior presented to the outpatient clinic with gradually increasing medial left knee pain of 6 years of duration. He underwent left conversion robotic-assisted total knee arthroplasty (RA TKA). At 1-year follow-up, the patient reported satisfactory clinical outcomes and excellent component alignment on x-rays. CONCLUSION: This case highlights using RA TKA for failed mUKA as a viable and promising conversion arthroplasty alternative technique that may improve surgical outcomes by enhancing implant alignment and positioning, protecting the soft tissues, and preserving bone stock.