Tranexamic Acid Led to Improved Safety of Total Knee Arthroplasty in Jehovah's Witness Patients: A Multicentered Matched Study.

BACKGROUND: This study aimed to evaluate the safety of total knee arthroplasty (TKA) in Jehovah's Witness patients compared to non-Jehovah's Witness patients using standard perioperative TKA protocols and assess the role of tranexamic acid (TXA) in managing blood loss in this population. METHODS: Patients undergoing TKA between 2011 and 2021 at 2 tertiary academic centers were retrospectively reviewed. Patient demographics, preoperative and postoperative hematologic laboratory values, intraoperative TXA use, 90-day postoperative complications, and subsequent revisions were collected. These variables were then compared between propensity score-matched cohorts at a 2:1 ratio of those who did not identify as Jehovah's Witness to those who did. Regression analysis was used to determine the effect of intraoperative TXA on hemoglobin (hgb) shift. RESULTS: After applying exclusion criteria and matching, the TKA outcomes of 316 non-Jehovah's Witness patients and 152 Jehovah's Witness patients were analyzed. Univariate analysis suggested that non-Jehovah's Witness patients and Jehovah's Witness patients had similar preoperative and postoperative hgb, hgb shift, and hematocrit. Only 1 (0.8%) Jehovah's Witness patient reached an hgb < 8.0 mg/dL postoperatively. Multivariate logistic regression suggested that Jehovah's Witness patients did not have increased odds of reaching an hgb < 8.0 mg/dL (odds ratio = 0.99 [0.96, 1.02]; P = 0.42). Multivariate linear regression suggested that intraoperative TXA was positively correlated with hgb shift and thus a smaller decrease in hgb from pre-TKA to post-TKA (ß = 0.38 [0.06, 0.69]; P = 0.02). Additionally, Jehovah's Witness patients had excellent revision-free (95% [91, 99]) and infection-free (98% [95, 100]) survival at 8 years. CONCLUSIONS: Standard perioperative TKA protocols are safe for Jehovah's Witness patients who do not have the need for transfusion, especially with appropriate preoperative hgb levels and the use of intraoperative TXA. Furthermore, these patients have excellent survivorship at 5 and 8 years of follow-up. LEVEL OF EVIDENCE: Level III.

Same Day Discharge Total Knee Arthroplasty: Hospital Demonstrates Similar Outcomes to Ambulatory Surgery Center in a More Complex Patient Population.

BACKGROUND: The purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting. METHODS: A single tertiary academic center's institutional database was reviewed for patients who underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least 1 year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures, emergency department visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria. RESULTS: Patients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (P < 0.001), Elixhauser comorbidity index (P < 0.001), proportion of patients who had an American Society of Anesthesiologists classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0.422) scores as well as similar rates of achieving minimum clinically important difference for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of emergency department visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years CONCLUSIONS: Although ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting.

Native Joint Septic Arthritis.

Native joint septic arthritis (NJSA) is a severe and rapidly progressing joint infection, predominantly bacterial but also potentially fungal or viral, characterized by synovial membrane inflammation and joint damage, necessitating urgent and multidisciplinary management to prevent permanent joint damage and systemic sepsis. Common in large joints like knees, hips, shoulders, and elbows, NJSA's incidence is elevated in individuals with conditions like rheumatoid arthritis, diabetes, immunosuppression, joint replacement history, or intravenous drug use. This review provides a comprehensive overview of NJSA, encompassing its diagnosis, treatment, antibiotic therapy duration, and surgical interventions, as well as the comparison between arthroscopic and open debridement approaches. Additionally, it explores the unique challenges of managing NJSA in patients who have undergone graft anterior cruciate ligament (ACL) reconstruction. The epidemiology, risk factors, pathogenesis, microbiology, clinical manifestations, diagnosis, differential diagnosis, antibiotic treatment, surgical intervention, prevention, and prophylaxis of NJSA are discussed, highlighting the need for prompt diagnosis, aggressive treatment, and ongoing research to enhance patient outcomes.

Comparison of Two Previously Validated Risk Assessment and Prediction Tool Models in Extended Length of Stay Patients Following total Hip Arthroplasty.

INTRODUCTION: Previous studies have attempted to validate the risk assessment and prediction tool (RAPT) in primary total hip arthroplasty (THA) patients. The purpose of this study was to: (1) identify patients who had an extended length of stay (LOS) following THA; and (2) compare the accuracy of 2 previously validated RAPT models. METHODS: We retrospectively reviewed all primary THA patients from 2014 to 2021 who had a completed RAPT score. Youden's J computational analysis was used to determine the LOS where facility discharge was statistically more likely. Based on the cut-offs proposed by Oldmeadow and Dibra, patients were separated into high- (O: 1 to 5 versus D: 1 to 3), medium- (O: 6 to 9 versus D: 4 to 7), and low- (O: 10 to 12 versus D: 8 to 12) risk groups. RESULTS: We determined that an LOS of greater than 2 days resulted in a higher chance of facility discharge. In these patients (n = 717), the overall predictive accuracy (PA) of the RAPT was 79.8%. The Dibra model had a higher PA in the high-risk group (D: 68.2 versus O: 61.2% facility discharge). The Oldmeadow model had a higher PA in the medium-risk (O: 78.7 versus D: 61.4% home discharge) and low-risk (O: 97.0 versus D. 92.5% home discharge) groups. CONCLUSIONS: As institutions continue to optimize LOS, the RAPT may need to be defined in the context of a patient's hospital stay. In patients requiring an LOS of greater than 2 days, the originally established RAPT cut-offs may be more accurate in predicting discharge disposition. LEVEL OF EVIDENCE: III Retrospective Cohort Study.

Opioid Consumption and Mobilization in Staged Bilateral Total Joint Arthroplasty: Did We Learn Our Lesson the First Time?

BACKGROUND: In patients who require bilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA), staged procedures are a reasonable option for treatment of bilateral osteoarthritis. We sought to determine whether perioperative outcomes differed between first and second total joint arthroplasty (TJA). METHODS: This was a retrospective review of all patients who underwent staged, bilateral THA or TKA between January 30, 2017, and April 8, 2021. All patients who were included underwent their second procedure within 1 year of the first. Patients were separated based on whether both their procedures took place before or subsequently after an institution-wide opioid-sparing protocol that was implemented on October 1, 2018. A total of 961 patients who underwent 1,922 procedures met the inclusion criteria for this study. For THA, 388 unique patients comprised 776 procedures, while 573 unique patients comprised 1,146 TKAs. Opioid prescriptions were prospectively documented on nursing opioid administration flowsheets and converted to morphine milligram equivalents (MME) for comparison. Activity measure scores for postacute care (AM-PAC) were used as a measurement of physical therapy progression. RESULTS: Hospital stays, home discharges, perioperative opioid usages, pain scores, and AM-PAC scores were not significantly different for the second THA or TKA compared to first procedure, regardless of timing in relation to the opioid-sparing protocol. CONCLUSION: Patients experienced similar outcomes following their first versus their second TJA. Limited opioid prescriptions following TJA do not negatively impact pain and functional outcomes. These protocols can safely be instituted to help mitigate the opioid epidemic. LEVEL III EVIDENCE: Retrospective Cohort Study.

Vaping Trends and Outcomes in Primary Total Joint Arthroplasty Patients: An Analysis of 21,341 Patients.

INTRODUCTION: The effect of vaping on outcomes after total joint arthroplasty (TJA) and its prevalence in this patient population remain unclear. The purpose of this study was twofold: (1) to investigate the trends of vaping in TJA patients compared with patients who underwent routine physical examination and (2) to examine the influence vaping has on outcomes after TJA. METHODS: Patients were classified as never vaped, former vape users, or whether they reported current vaping (CV). TJA patients were further classified based on whether they had no exposure to tobacco or vaping (NTNV), tobacco only (TO), both tobacco and vaping (BTV), or vaping only (VO). RESULTS: The TJA group exhibited a steady trend of patients with CV status (P = 0.540) while patients in the routine physical examination cohort demonstrated a significant upward trend in CV status (P = 0.015). Subanalysis of TJA patients revealed that those in the VO category had significantly higher mean surgical time (P < 0.001), length of stay (P = 0.01), and rates of readmission (P = 0.001) compared with all other subgroups. CONCLUSION: We found steady or increasing trends of electronic cigarette exposure in both groups over time. Additional efforts should be made to document electronic cigarette exposure for all patients.

The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Short-term outcomes of thin highly cross-linked polyethylene liners in primary total hip arthroplasty.

INTRODUCTION: The use of thin highly cross-linked polyethylene (HXLPE) liners in total hip arthroplasty (THA) allows utilisation of larger femoral heads. However, concern surrounding postoperative complications remains. This study aims to investigate rates of revision and re-admission associated with thin HXLPE liners at short-term follow-up. METHODS: We retrospectively reviewed 3047 patients who underwent THA with a cementless modular acetabular implant with a 36-mm femoral head, and different thicknesses of HXPLE liners from 2011 to 2021. We identified 723 patients (23.7%) with a minimum 2-year follow-up and 206 patients (6.8%) with a minimum 5-year follow-up. Patients in the thin group (TG, n = 1020) received <5.1-mm liners with 52-mm size cups while patients in the non-thin group (NTG, n = 2027) received >5.1-mm liners with >52-mm size cups. Outcomes were compared using multi-variable logistic regressions while controlling for all significant demographic differences. RESULTS: We found no significant differences in re-admission (3.9% vs. 4.3%, OR 0.97; 95% CI, 0.63-1.49; p = 0.874) and revision (2.5% vs. 3.2%, OR 0.72; 95% CI, 0.41-1.26; p = 0.246) rates between groups. The difference in fracture rate between groups was not significant, but the 1 recorded acetabular fracture (5%) occurred in the NTG. Although the rate of liner exchange was lower in the TG (1.1%) compared to the NTG (2.3%), the difference was not statistically significant (OR 0.51; 95% CI, 0.24-1.05; p = 0.068). Liners were exchanged for liner wear in 1 hip (1%), aseptic reasons in 38 hips (66%), and peri-prosthetic joint infection in 19 hips (33%). CONCLUSIONS: Patients undergoing THA with a thin liner were not significantly predisposed to higher rates of revision surgery or poorer clinical outcomes at short-term follow-up when compared to those who received a thicker liner. Consequently, further long-term studies regarding the utility of thin HXLPE implants in reducing complications should be pursued.

Intra-articular Distal Humerus Fractures: Parallel Versus Orthogonal Plating.

Background: Dual-plating osteosynthesis is the standard treatment for Orthopedic Trauma Association (OTA)-type 13-C distal humerus fractures. However, optimal plate position is debated. Purpose: The purpose of this study was to evaluate dual-plate positioning following intra-articular distal humerus fracture repair by comparing outcomes between patients plated in parallel and those plated orthogonally following open-reduction, internal-fixation (ORIF) of intra-articular distal humerus fractures. Methods: All OTA-type 13-C intra-articular distal humerus fractures treated operatively at our institution over a 10-year period were reviewed. Clinical outcomes and complications were compared between those plated in parallel and those plated orthogonally. Data were analyzed using independent-samples t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests. Results: A total of 69 patients met inclusion criteria. Mean follow-up among this cohort was 19.3 months; 45 (64.8%) patients had orthogonal dual plating, and 24 (35.2%) had parallel plating. Groups did not differ with respect to demographics or duration of follow-up. Clinically, there were no significant differences in time to union, elbow arc of motion at any time point, or patient Mayo Elbow Performance Index (MEPI) scores at final follow-up. Furthermore, there were no differences in complications. Conclusion: Parallel and orthogonal plating following ORIF of distal humerus fractures with modern, contoured locking compression plates had similar outcomes in this study. This study represents the largest comparative series in the literature at the time of its writing. Both techniques may be considered when deciding on dual-plating technique for treating intra-articular distal humerus fractures.

Dual Mobility in Total Hip Arthroplasty.

Dual mobility designs in total arthroplasty allow for increased range of motion prior to impingement and dislocation. While valuable for reducing dislocation, dual mobility has its own unique complication profile that includes intraprosthetic dislocation, corrosion, and femoral notching. Despite these relatively rare complications, dual mobility articulations are valuable options for patients at higher risk of dislocation-both early and contemporary reports on dual mobility in total hip arthroplasty suggest that it can reduce the risk of dislocation without leading to unacceptable rates of complication or early revision. Cost analyses and longer follow-up studies on newer dual mobility designs will help determine the future of dual mobility in total hip arthroplasty.

Self-Reported Feelings of Disability Following Lower Extremity Orthopaedic Trauma.

BACKGROUND: Nearly 20% of Americans consider themselves disabled. A common cause of disability is unexpected orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma, is the following: to assess the prevalence of self-reported feelings of disability following these injuries, to determine if self-reported feelings of disability impact functional outcomes, and to understand patient characteristics associated with self-reported feelings of disability. METHODS: The functional statuses of patients with tibial plateau fractures and ankle fractures were prospectively assessed. Patient reported feelings of disability (acquired from validated functional outcome surveys), which were compared with overall patient-reported functional outcome and emotional status at each follow-up visit. Additionally, patient demographics were analyzed, to assess associations with feelings of disability. RESULTS: A total of 710 patients were included in our analysis. At short-term follow-up (3 months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.744, P < 0.001). At long-term follow-up (12-months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.741, P < 0.001). Self-reported feelings of disability were associated with increased age at both short-term (P = 0.015) and long-term (P = 0.003) follow-ups. At short-term follow-up, 41% of males and 59% of females self-reported feelings of disability (P < 0.001) No significant differences existed between genders at long-term follow-up (P = 0.252). Self-reported feelings of disability declined at each follow-up visit, from 48.1% at short-term follow-up to 22.1% at long-term follow-up. CONCLUSION: Self-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes. LEVEL OF EVIDENCE: III.

Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty.

BACKGROUND: As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA. METHODS: A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress. RESULTS: A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p < 0.01) and have lower BMIs (28.92 kg/m2 vs 32.52 kg/m2; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA. CONCLUSION: THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.

Effect of Marital Status on Outcomes Following Total Joint Arthroplasty.

INTRODUCTION: The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences. RESULTS: This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort. CONCLUSION: Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Presence of back pain prior total knee arthroplasty and its effects on short-term patient-reported outcome measures.

PURPOSE: Back pain may both decrease patient satisfaction after TKA and confound outcome assessment in satisfied patients. Our primary objective was to determine whether preoperative back pain is associated with differences in postoperative patient-reported outcome measures (PROMs). METHODS: We retrospectively reviewed 234 primary TKA patients who completed PROMs preoperatively and 12 weeks postoperatively, which included a back pain questionnaire, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the Forgotten Joint Score-12 (FJS-12). Cohorts were defined based on the severity of preoperative back pain (none, mild, moderate and severe) and compared. Demographics were compared using ANOVA and Chi-square analysis. Univariate ANCOVA analysis was utilized to compare PROMs while accounting for significant demographic differences. RESULTS: Both preoperative KOOS JR scores (none: 47.90, mild: 47.61, moderate: 44.61 and severe: 38.70; p = 0.013) and 12-week postoperative KOOS JR scores (none: 61.24, mild: 64.94, moderate: 57.48 and severe: 57.01; p = 0.012) had a statistically significant inverse relationship with regard to the intensity of preoperative back pain. Although FJS-12 scores at the 12-week postoperative period trended lower with increasing levels of preoperative back pain (p = 0.362), it did not reach statistical significance. Patients who reported severe back pain preoperatively achieved the largest delta improvement from baseline compared to those with lesser pain intensity (p = 0.003). Patients who had a 2-grade improvement in their back pain achieved significantly higher KOOS JR scores 12 weeks postoperatively compared to patients with either 1-grade or no improvement (63.53 vs. 55.98; p = 0.042). Both preoperative (47.99 vs. 41.11; p = 0.003) and 12-week postoperative (64.06 vs. 55.73; p < 0.001) KOOS JR scores were statistically higher for those who reported mild or no back pain pre-and postoperatively than those who reported moderate or severe back pain pre-and postoperatively. CONCLUSION: Knee pain and back pain both exert negative effects on outcome instruments designed to measure pain and function. Although mean improvement from pre- to postoperative KOOS JR scores for patients with severe pre-existing back pain was higher than their counterparts, this statistical difference is likely not clinically significant. This implies that all patients may experience similar benefits from TKA despite the presence or absence of back pain. Attempts to measure TKA outcomes using PROMs should seek to control for lumbago and other sources of body pain. Level of Evidence IIIRetrospective Cohort Study.

Does racial background influence outcomes following total joint arthroplasty?

BACKGROUND: The purpose of this study is to assess whether racial differences influence patient-reported outcome measures (PROMs) following primary total hip (THA) and knee (TKA) arthroplasty. METHODS: We retrospectively reviewed patients who underwent primary THA or TKA from 2016 to 2020 with available PROMs. Both THA and TKA patients were separated into three groups based on their ethnicity: Caucasian, African-American, and other races. Patient demographics, clinical data, and PROMs at various time-periods were collected and compared. Demographic differences were assessed using chi-square and ANOVA. Univariate ANCOVA was utilized to compare outcomes and PROMs while accounting for demographic differences. RESULTS: This study included 1999 THA patients and 1375 TKA patients. In the THA cohort, 1636 (82%) were Caucasian, 177 (9%) were African-American, and 186 (9%) were of other races. In the TKA cohort, 864 (63%) were Caucasian, 236 (17%) were African-American, and 275 (20%) were of other races. Surgical-time significantly differed between the groups that underwent THA (88.4vs.100.5vs.96.1; p < 0.001) with African-Americans requiring the longest operative time. Length-of-stay significantly differed in both THA (1.5vs.1.9vs.1.8; p < 0.001) and TKA (2.1vs.2.5vs.2.3; p < 0.001) cohorts, with African-Americans having the longest stay. Caucasians reported significantly higher PROM scores compared to non-Caucasians in both cohorts. All-cause emergency-department (ED) visits, 90-day postoperative events (readmissions&revisions), and discharge-disposition did not statistically differ in both cohorts. CONCLUSION: Non-Caucasian patients demonstrated lower PROM scores when compared to Caucasian patients following TJA although the differences may not be clinically relevant. LOS was significantly longer for African-Americans in both THA and TKA cohorts. Further investigation identifying racial disparity interventions is warranted. LEVEL OF EVIDENCE: Prognostic Level III.

A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list. This has created significant confusion regarding which patients qualify for an inpatient designation. The purpose of this study is to develop and validate a novel predictive tool for preoperatively objectively determining "outpatient" vs "inpatient" status for THA in the Medicare population. METHODS: A cohort of Medicare patients undergoing primary THA between January 2017 and September 2019 was retrospectively reviewed. A machine learning model was trained using 80% of the THA patients, and the remaining 20% was used for testing the model performance in terms of accuracy and the average area under the receiver operating characteristic curve. Feature importance was obtained for each feature used in the model. RESULTS: One thousand ninety-one patients had outpatient stays, and 318 qualified for inpatient designation. Significant associations were demonstrated between inpatient designations and the following: higher BMI, increased patient age, better preoperative functional scores, higher American Society of Anesthesiologist Physical Status Classification, higher Modified Frailty Index, higher Charlson Comorbidity Index, female gender, and numerous comorbidities. The XGBoost model for predicting an inpatient or outpatient stay was 78.7% accurate with the area under the receiver operating characteristic curve to be 81.5%. CONCLUSIONS: Using readily available key baseline characteristics, functional scores and comorbidities, this machine-learning model accurately predicts an "outpatient" or "inpatient" stay after THA in the Medicare population. BMI, age, functional scores, and American Society of Anesthesiologist Physical Status Classification had the highest influence on this predictive model.

Impact of Preoperative Opioid Use on Patient Outcomes Following Primary Total Hip Arthroplasty.

The purpose of this study was to investigate whether preoperative opioid use had any effect on clinical outcomes and patient-reported outcome measures (PROMs) before and after primary, elective total hip arthroplasty (THA). The authors retrospectively reviewed 793 patients who underwent primary THA from November 2018 to March 2020 with available PROMs. Patients were stratified into two groups based on whether or not they were taking opioids preoperatively. Demographics, clinical data, and PROMs (Forgotten Joint Score-12 [FJS-12], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Veterans RAND 12 [VR-12] Physical Component Score [PCS] and Mental Component Score [MCS]) were collected at various time periods. Demographic differences were assessed with chi-square and independent sample t tests. Clinical data and PROMs were compared using multilinear regressions. Seventy-five (10%) patients were preoperative opioid users and 718 (90%) were not. Preoperative opioid users had a longer stay (1.37 vs 1.07 days; P=.030), a longer surgical time (102.44 vs 90.20 minutes; P=.001), and higher all-cause postoperative emergency department visits (6.7% vs 2.1%; P=.033) compared with patients not taking opioids preoperatively. Preoperative HOOS, JR (46.63 vs 51.26; P=.009), VR-12 PCS (27.79 vs 31.53; P<.001), and VR-12 MCS (46.24 vs 49.33; P=.044) were significantly lower for preoperative opioid users, but 3-month and 1-year postoperative scores were not statistically different. At 3 months and 1 year, FJS-12 scores did not differ significantly. Mean improvement preoperatively to 1 year in HOOS, JR values exceeded the minimal clinically important difference, with preoperative opioid users experiencing a greater improvement (36.50 vs 33.11; P=.008). Preoperative opioid users had a longer stay, a longer surgical time, and higher all-cause emergency department visits compared with preoperatively opioid naïve patients. Although preoperative opioid users reported significantly lower preoperative PROMs, they did not statistically differ postoperatively, which indicates a larger delta improvement and similar benefits following THA. [Orthopedics. 2021;44(2):77-84.].

Comparing the Efficacy of Articulating Spacer Constructs for Knee Periprosthetic Joint Infection Eradication: All-Cement vs Real-Component Spacers.

BACKGROUND: The most common treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a 2-stage revision. Few studies have compared different articulating spacer constructs. This study compares the outcomes of real-component and all-cement articulating spacers for TKA PJI treatment. METHODS: This retrospective observational study examined the arthroplasty database at 3 academic hospitals for articulating spacers placed for TKA PJIs between April 2011 and August 2020. Patients were categorized as receiving a real-component or an all-cement articulating spacer. Data on demographics, surgical information, and outcomes were collected. RESULTS: One-hundred sixty-four spacers were identified: 72 all-cement and 92 real-component spacers. Patients who received real-component spacers were older (67 ± 10 vs 63 ± 12 years; P = .04) and more likely to be former smokers (50.0% vs 28.6%; P = .02). Real-component spacers had greater range of motion (ROM) after Stage 1 (84° ± 28° vs 58° ± 28°; P < .01) and shorter hospital stays after Stage 1 (5.8 ± 4.3 vs 8.4 ± 6.8 days; P < .01). There was no difference in time to reimplantation, change in ROM from pre-Stage 1 to most recent follow-up, or reinfection. Real-component spacers had shorter hospital stays (3.3 ± 1.7 vs 5.4 ± 4.9 days; P < .01) and operative times during Stage 2 (162.2 ± 47.5 vs 188.0 ± 66.0 minutes; P = .01). CONCLUSION: Real-component spacers had improved ROM after Stage 1 and lower blood loss, shorter operative time, and shorter hospital stays after Stage 2 compared to all-cement articulating spacers. The 2 spacer constructs had the same ultimate change in ROM and no difference in reinfection rates, indicating that both articulating spacer types may be safe and effective options for 2-stage revision TKA. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Declining Medicare Reimbursement in Orthopaedic Trauma Surgery: 2000-2020.

OBJECTIVES: To evaluate monetary trends in government (Medicare) reimbursement rates for 20 commonly used orthopedic trauma surgical procedures over a 20-year period. METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the 20 common Current Procedural Terminology (CPT) codes in orthopaedic trauma, and reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars (USD) using changes to the US Consumer Price Index. Both the average annual and the total percentage change in reimbursement and in Relative Value Units were calculated for all included procedures. RESULTS: After adjusting for inflation, the average reimbursement for all procedures decreased by 30.0% from 2000 to 2020. Total Relative Value Units during this time increased by 4.4% on average. Procedures about the foot and ankle demonstrated the greatest decrease in the mean adjusted reimbursement at -42.6%, whereas procedures about the shoulder and upper extremity demonstrated the smallest mean decrease at 23.7% during the study period. From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 1.5% each year. CONCLUSION: To the best of our knowledge, this is the first study to comprehensively evaluate trends in procedural Medicare reimbursement for orthopaedic trauma. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2020. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons to assure continued access to meaningful surgical orthopaedic trauma care in the United States.

Olecranon Osteotomy Fixation Following Distal Humerus Open Reduction and Internal Fixation: Clinical Results of Plate and Screws Versus Tension Band Wiring.

Olecranon osteotomy allows for improved visualization of the distal humeral articular surface. This study compared the clinical outcomes of 2 methods of olecranon repair following olecranon osteotomy as part of distal humerus fracture repair. This was a retrospective review of distal humerus fractures treated via a transolecranon approach during a 9-year period. In each case, the olecranon osteotomy was fixed with either tension band wiring (TBW) or plate fixation (PF). Patient demographics, injury information, and surgical management were recorded. Measured outcomes included elbow motion, time to osteotomy union, and postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. Forty-eight patients were included. All patients had intra-articular AO type 13-C2 or 13-C3 distal humerus fractures and underwent open reduction and internal fixation (ORIF) with olecranon osteotomy. Mean documented follow-up was 20.5 months. Twenty-seven patients had fixation of the olecranon osteotomy with TBW, and 21 with PF. Clinically, there were no differences in osteotomy time to union, elbow motion, or MEPI score at final follow-up. However, patients fixed with TBW had greater elbow extension at both 6-month and final follow-up. Complication rates did not differ. Patients undergoing TBW or PF for repair of an olecranon osteotomy following ORIF of intra-articular distal humerus fractures have similar outcomes. Patients undergoing osteotomy PF may experience less terminal elbow extension when compared with those fixed with TBW. Given their similar clinical outcomes, either modality may be considered when selecting a construct for olecranon osteotomy repair as part of comminuted distal humerus fracture repair. [Orthopedics. 2021;44(1):e107-e113.].