Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

BACKGROUND: Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. QUESTIONS/PURPOSES: (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? METHODS: Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. RESULTS: Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. CONCLUSION: Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care.

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

BACKGROUND: Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS: Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS: When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION: We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Identifying and Creating Value for Employed Arthroplasty Surgeons in an Era of Decreasing Reimbursement.

Recent regulatory changes made by the Center for Medicare and Medicaid Services (CMS) will result in a 9% decrease in reimbursement for hip and knee replacements by the end of 2022. Combining this with CMS's recent removal of total knee and total hip arthroplasty from the inpatient-only list has begun to take effect on the bottom line for hospital systems, which now employ around 50% of the arthroplasty community. Employed joint replacement surgeons should continue to innovate and be leaders within their hospital systems in the outpatient and ambulatory surgery space to recoup lost value, increase autonomy, and should be compensated for this work. Employed arthroplasty surgeon leaders can better align goals with and control the narrative in the C-suite to redefine their value as the most consistent, dependable, and transparent department within a larger health system or corporate medical group.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program.

BACKGROUND: Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A). METHODS: We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions. RESULTS: Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224). CONCLUSIONS: Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Psoriasis and Post-Surgical Infections in Primary Total Knee Arthroplasty: An Analysis of 10,727 Patients.

BACKGROUND: Psoriasis is a dermatologic condition characterized by erythematous plaques that may increase wound complications and deep infections following total knee arthroplasty (TKA). There is a paucity of evidence concerning the association of this disease and complications after TKA. This study aimed to determine if patients who have psoriasis vs non-psoriatic patients have differences in demographics and various comorbidities as well as post-operative infections, specifically the following: (1) wound complications; (2) cellulitic episodes; and (3) deep surgical site infections (SSIs). METHODS: We identified 10,727 patients undergoing primary TKA utilizing an institutional database between January 1, 2017 and April 1, 2019. A total of 133 patients who had psoriasis (1.2%) were identified using International Classification of Diseases, Tenth Revision codes and compared to non-psoriatic patients. The rate of wound complications, cellulitic episodes, and deep SSIs were determined. After controlling for age and various comorbidities, multivariate analyses were performed to identify the associated risks for post-operative infections. RESULTS: Psoriasis patients showed an increased associated risk of deep SSIs (3.8%) compared to non-psoriasis patients (1.2%, P = .023). Multivariate analyses demonstrated a significant associated risk of deep SSIs (odds ratio 7.04, 95% confidence interval 2.38-20.9, P < .001) and wound complications (odds ratio 4.44, 95% confidence interval 1.02-19.2, P = .047). CONCLUSION: Psoriasis is an inflammatory dermatologic condition that warrants increased pre-operative counseling, shared decision-making, and infectious precautions in the TKA population given the increased risk of wound complications and deep SSIs. Increased vigilance is required given the coexistence of certain comorbidities with this population, including depression, substance use disorder, smoking history, gastroesophageal reflux disease, and inflammatory bowel disease.

Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal. METHODS: PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism. RESULTS: A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms). CONCLUSIONS: Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.

Generalizability of Homeopathic Prognostic Factor Research Outcome in COVID-19 Treatment: Comparison of Data.

BACKGROUND/OBJECTIVE: During the coronavirus disease 2019 (COVID-19) pandemic, several homeopathic prognostic factor research (PFR) projects have been undertaken. We found two projects with comparable outcomes to assess consistency and possible flaws. METHODS: Two comparisons were made. (1) Outcome of a PFR data collection from the Liga Medicorum Homoeopathica Internationalis (LMHI) by about 100 doctors with 541 cases was compared with a previous analysis of 161 cases in the same database. (2) The updated LMHI database was also compared with a data collection carried out in India by four doctors with a total of 1,445 cases. Differences that resulted in conflicting outcomes (indication in one, contraindication in the other) were examined for possible causes. RESULTS: There was only a single outcome in the updated LMHI database that conflicted with the previous dataset, and this could have been due to statistical variation. The Indian data contained many cases, from few doctors, while the LMHI database had few cases per doctor, but many doctors. The overlap between the projects (individual cases entered in both) was between zero and 22%. In 72 comparisons we found six (8.3%) conflicting outcomes. Possible causes were statistical error due to small numbers of cases and/or observers, confirmation bias, and keynote prescribing if this resulted in symptoms being inadequately checked. CONCLUSION: There was little conflict between the outcomes of the two versions of one project and between the two different PFR projects. Differences could mostly be explained by causes that can be managed. This consistency should primarily be interpreted as showing a strong overall consensus between homeopathic practitioners worldwide, but with variation of consensus between small groups of practitioners.

Management of Refractory Pain After Total Joint Replacement.

PURPOSE OF REVIEW: Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. RECENT FINDINGS: The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

Data Collection during the COVID-19 Pandemic: Learning from Experience, Resulting in a Bayesian Repertory.

BACKGROUND: A novel pandemic disease offered the opportunity to create new, disease-specific, symptom rubrics for the homeopathic repertory. OBJECTIVE: The aim of this study was to discover the relationship between specific symptoms and specific medicines, especially of symptoms occurring frequently in this disease. MATERIALS AND METHODS: Worldwide collection of data in all possible formats by various parties was coordinated by the Liga Medicorum Homeopathica Internationalis. As the data came in, more symptoms were assessed prospectively. Frequent analysis and feedback by electronic newsletters were used to improve the quality of the data. Likelihood ratios (LRs) of symptoms were calculated. An algorithm for combining symptom LRs was programmed and published in the form of an app. The app was tested against 18 well-described successful cases from Hong Kong. RESULTS: LRs of common symptoms such as 'Fatigue' and 'Headache' provided better differentiation between medicines than did existing repertory entries, which are based only on the narrow presence or absence of symptoms. A mini-repertory for COVID-19 symptoms was published and supported by a web-based algorithm. With a choice of 20 common symptoms, this algorithm produced the same outcome as a full homeopathic analysis based upon a larger number of symptoms, including some that are traditionally considered more specific to particular medicines. CONCLUSION: A repertory based on clinical data and LRs can differentiate between homeopathic medicines using a limited number of frequently occurring epidemic symptoms. A Bayesian computer algorithm to combine symptoms can complement a full homeopathic analysis of cases.

Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study.

BACKGROUND: Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES: Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS: All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS: Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS: After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

BACKGROUND: Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA. QUESTIONS/PURPOSES: In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA. METHODS: All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant. RESULTS: For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort. CONCLUSIONS: These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Effect of Bladder Catheterization on Ambulation and Venous Thromboembolism Following Total Knee Arthroplasty: An Institutional Analysis.

BACKGROUND: Although intermittent catheters are immediately removed, indwelling catheterization may lead to decreased ambulation and participation in physical therapy, critical components to post-total knee arthroplasty (TKA) management. Therefore, this study aimed to compare the effect of catheterization treatments on (1) postoperative ambulation distances, (2) deep vein thromboses (DVTs), and (3) pulmonary emboli (PEs) following TKA. METHODS: A total of 9123 prospectively collected primary TKA patients were assessed based on postoperative catheter status. Patient demographics, Charlson Comorbidity Indices, body mass indices, DVT prophylaxes, first ambulation distances, DVTs, and PEs were collected at approximately mean 12 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models in order to compare catheterization techniques. RESULTS: There were 1193 patients who had urinary retention and treated with either indwelling only (62%, n = 734), both indwelling and intermittent catheterizations (13%, n = 160), or intermittent only (25%, n = 299). Multivariate analyses found that indwelling catheter-only use had an 11% decrease in ambulation distance (P < .001). Additionally, the indwelling catheterization-only group was found to be at increased risk of DVTs (odds ratio 2.605, P < .001), even after controlling for DVT prophylaxes (odds ratio 2.807, P < .001). CONCLUSION: This study showed that the use of an indwelling catheter for treatment of urinary retention significantly decreased TKA patient ambulation distance and subsequently increased the risk for DVTs. This information is important as we would recommend the treatment with intermittent catheterization rather than indwelling catheters to decrease the risk of immobilization and postoperative DVTs.

Does Intermittent Catheterization Compared to Indwelling Catheterization Decrease the Risk of Periprosthetic Joint Infection Following Total Knee Arthroplasty?

BACKGROUND: Catheterization for the prophylaxis against or treatment for urinary retention commonly occurs after total knee arthroplasty (TKA). Recent studies have questioned the use of the indwelling catheterization, especially in its potential role as a nidus for infection. We are still unsure of its downstream effects on periprosthetic joint infections (PJIs). Therefore, this study aimed to compare the risks of postoperative PJI following intermittent vs indwelling catheterization after TKA. METHODS: Between 2017 and 2019, 15 hospitals in a large health system collected data on patients undergoing TKA. Patient treatments with indwelling catheter only, intermittent straight catheter only, and both indwelling and intermittent straight catheterizations were recorded. Patient demographics, comorbidities, body mass indices, and PJIs were collected from time of surgery to time of data collection at mean 14 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models to compare catheterization treatment types. RESULTS: A total of 9123 TKAs were performed, with patients receiving indwelling catheter only (62%, n = 734), intermittent straight catheter only (25%, n = 299), or both indwelling and intermittent catheterizations (13%, n = 160). Univariate analyses showed that PJIs occurred in 1.1% of no-catheter patients and 2.3% of patients treated with bladder catheterization (P = .002). Using multivariate analyses, indwelling catheter use (odds ratio [OR] 2.647, P < .001), diabetes (OR 1.837, P = .005), and peripheral vascular disease (OR 2.372, P = .046) were found to have a statistically significant increased risk for PJIs. The use of intermittent straight catheterization (OR 1.249, P = .668) or both indwelling and intermittent (OR 1.171, P = .828) did not increase the risk for PJIs. CONCLUSION: Urinary bladder catheterization is commonly required for prophylaxis against or treatment for urinary retention following TKA. The use of a urinary catheter can provide a potential nidus for infection in these patients. This study found that indwelling catheterization, but not intermittent catheterization, was associated with an increased risk for PJI. Surgeons should therefore limit the duration of catheterization in an effort to decrease the risk for PJI.

The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty.

BACKGROUND: Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA. METHODS: A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications. RESULTS: We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively. CONCLUSIONS: Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty.

BACKGROUND: Urinary bladder catheters are potential sources of infection after total hip arthroplasty (THA). Therefore, the goal of this study was to determine if intermittent catheterization provides a decreased risk of postoperative urinary tract infections (UTIs) compared with indwelling catheterization in THA patients. METHODS: Patients undergoing THA at 15 hospitals within a large health system were prospectively collected between 2017 and 2019 and then stratified based on catheterization technique: no-catheter; indwelling catheter-only; intermittent catheter-only; and both intermittent and indwelling catheter. Patient demographics, medical comorbidities, anesthesia types, and postoperative UTIs were assessed. Independent Student t-tests were used to perform univariate analyses for the catheterization groups. Multiple linear regression models were used to compare the different groups while controlling for confounding variables. RESULTS: There were a total of 7306 THA patients recorded with 5513 (75%) no-catheter, 1181 (16%) indwelling catheter-only, 285 (3.9%) intermittent catheter-only, and 327 (4.5%) indwelling and intermittent catheterization patients. A total of 580 patients experienced postoperative UTI. Urinary bladder catheterization increased the risk of postoperative UTIs (P < .001) in univariate analyses. Multiple linear regression models showed that indwelling catheter-only (OR: 2.178, P < .001), intermittent catheterization (OR: 1.975, P = .003), and both indwelling and intermittent (OR: 2.372, P = .002) were more likely to experience UTIs compared with no catheters. CONCLUSION: This study found that patients treated with indwelling catheterization, with or without preceding intermittent catheterization, were significantly more likely to experience UTIs. Therefore, in an effort to decrease the risk of UTIs, THA patients experiencing postoperative urinary retention should be treated with intermittent catheterization.

The Case for Cementless Total Knee Arthroplasty.

The demographics of total knee arthroplasty (TKA) patients are changing. Individuals are more active, younger, and more obese. These changing demographics and a higher demand for longevity creates a new challenge for reliable and long-term implant fixation. Historically, cemented fixation has remained the gold standard, as cementless design and techniques from the 1980s and 1990s did not obtain long-term positive outcomes due to a failure of ingrowth onto the implants. Advances in the modern-day cementless TKA designs appear to have overcome their initial challenges, indicating the dependence of cementless TKA on implant design. However, there remains the perception that cementless total knee arthroplasty are inferior to cemented TKA. This review discusses the longer-term survivorship data for recent systems, which has shown the potential advantages of cementless fixation.

Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment.

PURPOSE OF REVIEW: Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain. Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%. RECENT FINDINGS: Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology. Etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery. In chronic back pain patients, a multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches. Low back pain is a difficult condition to effectively treat and continues to affect millions of Americans every year. In the current investigation, we present a comprehensive review of low back pain and discuss associated pathophysiology, diagnosis, and treatment.

Have We Actually Reduced Our 30-Day Short-Term Surgical Site Infection Rates in Primary Total Hip Arthroplasty in the United States?

BACKGROUND: The purpose of this study is to track the 30-day postoperative annual rates and trends of (1) overall, (2) deep, and (3) superficial surgical site infections (SSIs) following total hip arthroplasty (THA) using a large nationwide database. METHODS: The National Surgical Quality Improvement Program database was queried for all THA cases performed between 2012 and 2016. After an overall 5-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 4 years. Correlation coefficients and chi-squared tests were used to determine correlation and statistical significance. RESULTS: The lowest incidence of SSIs was in the most recent year, 2016 (0.81%), while the greatest incidence was in the earliest year, 2012 (1.12%), marking a 31% decrease (P < .01). The lowest rate was in the most recent year, 2016 (0.23%), marking a 26% decrease from 2012. The lowest superficial SSI incidence occurred in the most recent year, 2016 (0.58%), while greatest incidence was in 2012 (0.83%), marking a 31% decrease over time (P < .05). There was an inverse correlation among overall, deep, and superficial SSI rates with operative year. CONCLUSION: The findings from this study suggest a decreasing trend in SSIs within 30 days following THA. Furthermore, deep SSIs, which can pose substantial threats to implant survivorship, have also decreased throughout the years. These results highlight that potentially through improved medical and surgical techniques, we are winning the fight against short-term infections, but that more can still be done.

Operative Times Can Predict and Are Correlated With Lengths-of-Stay in Primary Total Knee Arthroplasty: A Nationwide Database Study.

BACKGROUND: The specific influence of operative times on lengths-of-stay (LOS) has not been well assessed and is therefore an important topic of evaluation for multiple reasons, including potential economic implication. The purpose of this study is to (1) identify predictors of longer operative times; (2) identify predictors of longer LOS; and (3) evaluate the effects of operative times on LOS in primary total knee arthroplasty (TKA). METHODS: The National Surgical Quality Improvement Program database was queried for primary TKAs performed between 2008 and 2016, yielding 225,344 cases. Multivariate analysis was performed to determine the effect of operative times on LOS after adjusting for patient factors. Univariate analyses were performed with 1-way analysis of variance (ANOVA), linear regression, and independent sample t-tests where appropriate. Multivariate analysis was performed with a multiple linear regression model adjusted for patient age, sex, and body mass index (BMI). RESULTS: The mean operative time was 93 ± 35 minutes and the mean LOS was 3 ± 3 days. Young age, male sex, and obesity were predictors of longer operative times (P < .001). Similarly, there were significant associations of age, sex, and BMI with LOS (P < .001). Increasing 30-minute operative time intervals were associated with increasing LOS (P < .001). Longer operative times had significant associations with longer LOS even after adjusting for patient factors (ß = 0.076, SE < 0.001, P value < .001). Out of all study covariates, operative times had the greatest effect on LOS. CONCLUSION: This study provides unique insight by directly correlating operative times to LOS in over 200,000 TKAs. The results from this study indicate that there is a strong correlation between operative times and LOS, so that operative time had a greater association than age, sex, and BMI with postoperative TKA LOS.