Precision soft tissue balancing: grid-assisted pie-crusting in total knee arthroplasty.

Introduction: The varus and valgus knee deformities result from imbalance in tension between medial and lateral soft tissue compartments. These conditions need to be addressed during total knee arthroplasty (TKA). However, there is no consensus on optimal soft-tissue release techniques for correcting varus and valgus deformities during TKA. We assessed the efficacy of a novel grid-based pie-crusting technique on soft-tissue release. Methods: Cadaver knees were dissected, leaving only the femur and tibia connected by an isolated MCL or the femur and fibula connected by an isolated LCL. Bone cuts were made as performed during primary TKA. Mechanical testing was performed using an MTS machine. A 3D-printed 12-hole grid was placed directly over the MCL and LCL. Using an 18-gauge needle, horizontal in-out perforations were made 3 mm apart. Deformation and stiffness of the ligaments were collected after every 2 perforations. Means were calculated, and regression analyses were performed. Results: A total of 7 MCL and 6 LCL knees were included in our analysis. The mean medial femorotibial (MFT) space increased from 6.018 ± 1.4 mm-7.078 ± 1.414 mm (R2 = 0.937) following 12 perforations. The mean MCL stiffness decreased from 32.15 N/mm-26.57 N/mm (R2 = 0.965). For the LCL group, the mean gap between the femur and fibula increased from 4.287 mm-4.550 mm following 8 perforations. The mean LCL stiffness decreased from 29.955 N/mm-25.851 N/mm. LCL stiffness displayed a strong inverse relationship with the number of holes performed (R2 = 0.988). Discussion: Our results suggest that using this novel grid for pie-crusting of the MCL and LCL allows for gradual lengthening of the ligaments without sacrificing their structural integrity. Our proposed technique may serve as a valuable piece in the soft-tissue release toolkit for orthopaedic surgeons performing TKA in varus and valgus deformed knees.

Outpatient Total Joint Arthroplasty: Are We Closing the Racial Disparities Gap?

INTRODUCTION: As ne arly half of all total joint arthroplasty (TJA) procedures are projected to be performed in the outpatient setting by 2026, the impact of this trend on health disparities remains to be explored. This study investigated the racial/ethnic differences in the proportion of TJA performed as outpatient as well as the impact of outpatient surgery on 30-day complication and readmission rates. METHODS: The ACS National Surgical Quality Improvement Program was retrospectively reviewed for all patients who underwent primary, elective total hip and knee arthroplasty (THA, TKA) between 2011 and 2018. The proportion of TJA performed as an outpatient, 30-day complications, and 30-day readmission among African American, Hispanic, Asian, Native American/Alaskan, and Hawaiian/Pacific Islander patients were each compared to White patients (control group). Analyses were performed for each racial/ethnic group separately. A general linear model (GLM) was used to calculate the odds ratios for receiving TJA in an outpatient vs. inpatient setting while adjusting for age, gender, body mass index (BMI), functional status, and comorbidities. RESULTS: In total, 170,722 THAs and 285,920 TKAs were analyzed. Compared to White patients, non-White patients had higher likelihood of THA or TKA performed as an outpatient (OR 1.31 and 1.24 respectively for African American patients, OR 1.65 and 1.76 respectively for Hispanic patients, and OR 1.66 and 1.59 respectively for Asian patients, p < 0.001). Outpatient surgery did not lead to increased complications in any of the study groups compared to inpatient surgery (p > 0.05). However, readmission rates were significantly higher for outpatient TKA in all the study groups compared to inpatient TKA (OR range 2.47-10.15, p < 0.001). Complication and readmission rates were similar between inpatient and outpatient THA for all the study groups. CONCLUSION: While this study demonstrated higher proportion of TJA performed as an outpatient among most non-White racial/ethnic groups, this observation should be tempered with the increased readmission rates observed in outpatient TKA, which could further the disparities gap in health outcomes.

Role of Depression in Total Knee Arthroplasty: A Retrospective Analysis of Perioperative Outcomes in Patients in the United States.

We evaluate the patient demographics, perioperative outcomes, in-hospital complications, and assess recent national trends in clinically depressed and non-depressed patients undergoing primary total knee arthroplasty (TKA). Using the National Hospital Discharge Survey from 2001 and 2010, patients undergoing primary TKA in the United States were identified based upon the diagnosis of depression. Differences in gender, patient-demographics, comorbidities, complications, length of stay, and discharge disposition were analyzed. A total of 32,761 TKA patients were identified, consisting of 1,880 patients with a diagnosis of depression and 30,881 patients without. The depression group had an average age significantly younger than the non-depression cohort (p < 0.01). The depression group contained a significantly greater percentage of females when compared to the non-depression group. The non-depression group had a significantly greater percentage of African-Americans (p < 0.01), and a significantly smaller percentage of Caucasians (p < 0.01). Our findings contribute to the literature on the role of depression on perioperative outcomes of TKA. (Journal of Surgical Orthopaedic Advances 30(1):007-009, 2021).

A novel method for predicting superior gluteal nerve safe zones in the lateral approach to the hip.

INTRODUCTION: The superior gluteal nerve (SGN) is at risk for laceration during lateral approach total hip arthroplasty (THA). The purpose of this study is to assess the accuracy of the trochanter-to-iliac crest distance (TCD) and the nerve-to-trochanter distance (NTD) ratio in determining a reproducible safe zone around the SGN independent of height. MATERIALS AND METHODS: Eighteen hemipelvises were dissected and the SGNs were exposed. The distance (NTD) from greater trochanter (GT) to the most inferior branch of the SGN encountered in each of the three approaches (Bauer et al., 1979) was measured. A reference distance (TCD) was measured from the GT to the highest point on the iliac crest. The NTD was divided by the TCD to generate standardized ratios. Coefficient of variation CV = (SD/mean) × 100 was calculated for each distance and ratio to measure relative variability. RESULTS: The standardized ratios (and CV) were determined for the nerve branches in three different surgical approaches: Hardinge 0.464 (0.9%), Bauer 0.406 (1.7%), and Frndak 0.338 (4.1%). There was a strong correlation of the individual NTDs with the TCD: NTD for Hardinge (r = 0.996, p < .001), NTD for Bauer (r = 0.984, p < .001), and NTD for Frndak (r = 0.932, p < .001). CONCLUSION: By measuring the TCD preoperatively and using the respective standardized ratios, surgeons can accurately predict the NTD and how proximal to the GT each SGN branch can be expected to be encountered during lateral approach to the hip. This will allow surgeons to work with a more precise safe zone around the SGN and minimize the possibility for a nerve injury.

Urinary Tract Infection after Total Hip Arthroplasty: A Retrospective Cohort Study.

Perioperative urinary tract infections (UTI) are a relatively common occurrence after total hip arthroplasty (THA). The purpose of this study was to assess demographics, outcomes and trends in the development of UTI's after THA using the National Hospital Discharge Survey (NHDS). All patients undergoing THA were divided based on whether or not they developed a UTI, and data regarding demographics, outcome and complications were gathered and analyzed. No significant trend in rate of UTI after THA was found. Patients who developed a UTI were more likely to be female, have more comorbidities and receive a transfusion. They had a longer hospitalization, lower rate of discharge directly home and an increased rate of discharge to a rehabilitation facility. Orthopaedists should identify those patients at increased risk who according to this study appear to be older, female patients with multiple co-morbidities who received a blood transfusion. (Journal of Surgical Orthopaedic Advances 29(3):162-164, 2020).

Mechanical Properties of the Human Tibial and Peroneal Nerves Following Stretch With Histological Correlations.

Despite the extensive literature regarding peripheral nerve stretch injuries, there are few studies that compare the nerve histology with the mechanical properties in humans. There is clinical evidence suggesting that the peroneal nerve is at greater risk for injury compared to the tibial nerve following total hip arthroplasty and hip trauma. We examined the two nerves from fresh human cadavers with or without controlled stretch. The mechanical properties, stiffness, and strain were compared with light microscopic preparations in longitudinal sections stained by the trichrome method for collagen and showing the effects of structural deformation. The tibial nerve had an average failure load 1.7× that for the peroneal nerve (P = 0.0001). Although the corresponding average stiffness showed a trend toward being larger (4.39 vs. 3.81 N/mm), the difference was not significant (P = 0.126). Histologically, the perineurium along with the underlying nerve fascicle was undulated in the control specimens and straightened out in the stretched specimens. Peroneal nerves went on to failure at lower loads and exhibited a wavy pattern on pathologic slides after failure, which shows that peroneal nerves fail mechanically before they can unfold. The tibial nerve has a biomechanical and histological advantage compared to the peroneal nerve during tensile testing, which could be the reason why it is less commonly damaged. We conclude that the perineurium is especially protective against deformation changes in human nerves relative to the respective nerve size and number of fascicles. Anat Rec, 302:2030-2039, 2019. © 2019 American Association for Anatomy.

Hand Infections in the Immunocompromised Patient: An Update.

Physicians are increasingly caring for immunocompromised individuals owing, in part, to the improved treatments and the increased life expectancy in these patients. Presentation of a patient with hand infection can vary greatly depending on the patient's underlying immune status. It is important to recognize and treat the infections quickly and effectively owing to the higher morbidity and mortality that may result from ineffective or delayed treatment in this patient population. The purpose of this article is to provide an outline of the most common and some of the more exotic organisms causing hand infections in patients with human immunodeficiency virus/acquired immunodeficiency syndrome, diabetes, and patients on immunosuppressive treatment. We discuss presentation, clinical picture, evidence-based approaches in treatment, and possible complications. It is important to inform surgeons of the atypical presentation of hand infections and systemic infections with hand manifestation in immunocompromised patients in order to shorten time to accurate diagnosis and effective treatment.

Mutant SOD1 prevents normal functional recovery through enhanced glial activation and loss of motor neuron innervation after peripheral nerve injury.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is poorly understood with no effective therapeutics. One long entertained observation is that ALS may be precipitated focally by nerve injury. Many patients with ALS are athletes or veterans, and some have suffered nerve injuries at the site where ALS first presents. Here we explore how a genetic SOD1 mutation alters the inflammatory response and affects functional recovery after an environmental insult in a rat model. METHODS: Unilateral sciatic nerve crush injuries were performed in SOD1 G93A rats prior to disease symptom onset. Functional recovery was compared between injured wild-type littermates and uninjured SOD1 rats. Spinal cord tissues were analyzed quantitatively for SOD1 expression, glial reactivity, and motor neuron synaptic integrity. RESULTS: Injured SOD1 rats failed to recover and showed hastened functional decline with decreased survival. Injury induced extracellular SOD1 expression was associated with heightened, prolonged microglial and astrogial activation in the ventral horn. This inflammatory response spread to uninjured motor neuron pools and was associated with increased motor neuron synaptic loss. DISCUSSION: This study identified a relationship between genetic and environmental contributions to disease onset and progression in ALS. The findings suggest that injury induced SOD1 mutant protein induces a heightened and prolonged inflammatory response resulting in motor neuron degeneration through synaptic loss. Once initiated, this process spreads to adjacent motor neurons leading to contiguous spread of the disease. Treatments that suppress this heightened glial response could slow disease progression in ALS patients with focal sites of disease onset. SIGNIFICANCE STATEMENT: The contribution of environmental factors such as peripheral nerve insults in ALS is not well understood. Here we examined the effect of a single sciatic nerve injury in SOD1 (G93A) rats to explore the contribution of this environmental insult on disease onset and progression. After the injury, SOD1 animals failed to recover and had a more rapid functional decline. Histopathologically, SOD1 animals had heightened SOD1 expression, microglial and astroglial responses, and a reduction of motor neuron innervation. Taken together, these results provide a plausible mechanism of how the SOD1 mutated protein promotes an abnormal response to injury that leads to neurodegenerative changes in an ALS model that is amenable to therapeutic testing.

Knee Arthrodesis Outcomes After Infected Total Knee Arthroplasty and Failure of Two-stage Revision With an Antibiotic Cement Spacer.

BACKGROUND: Reinfected total knee arthroplasty can be managed with a second two-stage exchange or a knee arthrodesis procedure. METHODS: Twenty-three patients with knee arthrodesis after failed exchange arthroplasty for infection were reviewed. Patients were managed with a staged protocol of implant extraction, débridement, and implantation of an antibiotic spacer, with subsequent arthrodesis. Follow-up averaged 40.4 months, with a minimum of 1 year. RESULTS: Bony union with eradication of infection was achieved in 20/23 knees. Sixteen of the 20 patients were able to ambulate with minimal pain. The average time to union was 11.3 months, and the average leg length discrepancy was 4.85 cm. The average Knee Society Score after arthrodesis was 44, and the average visual analog scale pain score was 1.73. Three patients underwent above-knee amputation. DISCUSSION: Knee arthrodesis performed for persistent periprosthetic infection allowed for eradication of infection and union in 87% of the patients, creating a stable knee fusion.

Septic Arthritis of the Shoulder: A Comparison of Treatment Methods.

INTRODUCTION: In-hospital outcomes were compared among patients with shoulder septic arthritis treated with arthrocentesis, open irrigation and débridement, or arthroscopic irrigation and débridement. METHODS: The Nationwide Inpatient Sample database was queried for all cases of native shoulder septic arthritis between 2002 and 2011. Patient demographics, comorbidities, and hospitalization complications were compared for the shoulder arthrocentesis (nonsurgical) and open or arthroscopic irrigation and débridement (surgical) groups. RESULTS: Data for 7,145 patients were analyzed. Medical comorbidities and complications were more common in the nonsurgical group than in the open surgical group (septicemia, 36.7% versus 23.6%, P < 0.001; death, 6.5% versus 2.5%, P < 0.001; pneumonia, 11.3% versus 6.2%, P < 0.001; septic shock, 4% versus 2.2%, P < 0.001; and urinary tract infection, 15.5% versus 10.2%, P < 0.001). The mean length of stay was longer in the nonsurgical group compared with the open surgical group (11.5 days versus 10.5 days, respectively; P = 0.002) and the percentage of patients discharged to home was lower (55.1% versus 64.0%, respectively; P < 0.001). Compared with the open surgical group, the arthroscopic surgical group had higher incidences of perioperative septicemia and urinary tract infection and similar average length of stay, hospital charges, and blood transfusion rates, but a lower incidence of osteomyelitis (P < 0.001). In a subgroup of patients with septicemia, Staphylococcus aureus was the most frequently cultured causative organism. DISCUSSION: Septic arthritis in the shoulder is challenging to manage, and patients often have medical comorbidities and complications. In this study, the nonsurgically treated patients had substantially more preexisting comorbidities and in-hospital complications than the surgically treated patients had, which likely contributed to the longer average length of stay and lower discharge percentage in the nonsurgical group. CONCLUSION: Patients with septic arthritis of the shoulder frequently experience substantial systemic complications regardless of the treatment method. Septicemia was a common complication among all treatment groups, with cultures most frequently indicating Staphylococcus aureus as the causative organism. LEVEL OF EVIDENCE: Therapeutic level III.

Biomechanical evaluation of distal biceps tendon repair using tension slide technique and knotless fixation technique.

BACKGROUND: Acute distal biceps tendon ruptures are uncommon injuries that often affect young active males, typically resulting from an eccentric load on their dominant extremity. The purpose of this study was to compare pullout strength and tendon gapping in the tension slide technique (TST) versus a knotless fixation technique (KFT). METHODS: Two sets of experiments were performed using cadaveric elbow specimens. In the first experiment, eight elbows from different cadavers were tested to compare TST with a standard locking whipstitch with KFT, four elbows in each group, using a standard locking whipstitch. In the second experiment, 12 elbows were used to study the differences between TST with a standard locking whipstitch with KFT using suture tape reinforced whipstitch (RKFT), using the TST data from the first and second experiment. Each experiment evaluated gapping after cyclic loading and the second experiment also tested the construct to load to failure. RESULTS: Gapping for KFT with a standard locking whipstitch was 10.64 mm versus 2.69 mm for the TST after 1000 cycles (P = 0.016). A reinforced whipstitch significantly improved the failure to gap on the KFT with no significant difference in gapping when compared to TST after 3000 cycles (P = 0.36). The resultant gapping for TST and KST was 2.08 mm and 2.99 mm (P = 0.91), respectively. Load to failure for TST and KFT were 282 Nm and 328 Nm (P = 0.20), respectively. CONCLUSION: Bone-tendon gap resistance of a KFT repair of a torn distal biceps tendon is limited by suture technique. Using a tape reinforced locking whipstitch, the repair is as strong as TST repair. LEVELS OF EVIDENCE: Basic Science.

Humeral head sizing using extra-articular landmarks on conventional radiographs.

PURPOSE: Proper humeral head (HH) sizing is critical to success in anatomic shoulder replacement for management of glenohumeral arthritis. In this study, we evaluate the accuracy and reliability of using non-articular landmarks on conventional radiographs for HH templating. METHODS: Anatomic HH replacement was performed on five non-arthritic shoulders, from fresh adult cadavers. Pre-operative and post-operative radiographs and 3-D CT scans were obtained. Humeral head size was determined using the articular surface and three extra-articular landmarks (inner aspect of the lateral cortex, the medial footprint of the rotator cuff, and the medial calcar). Two independent observers performed each measurement twice to evaluate reliability. The accuracy was assessed by subtracting the mean values from both the 3D-CT and the implanted HH size measurements. RESULTS: Intraclass correlation coefficient for Observer 1 and 2 for the three-point method showed excellent test-retest reliability 0.996 (95% CI 0.994-0.998) and 0.997 (95% CI 0.995-0.998), respectively. Inter-observer ICC for the three-point method was 0.996 (95% CI 0.994-0.997) showing high level of precision. The three-point method was overestimating the size of the HH (to 3D-CT) with 0.46 ± 0.61 mm on average. The three-point method predicted the size of the HH within 1 mm of the implanted head size showing very high accuracy. The center of rotation (COR) for the three-point method was within 1.34 mm of the (COR) of the articular surface. CONCLUSION: The three-point measuring technique using conventional radiographs may be useful to predict the HH size using extra-articular landmarks within a small margin of error. This method is simple, cost effective and has high level of precision. LEVEL OF EVIDENCE: Basic Science Study; Anatomic and Imaging Study.

Blood Transfusion After Primary Total Hip Arthroplasty: National Trends and Perioperative Outcomes.

The purpose of this study was to quantify the changes in transfusion rates, both allogeneic blood transfusion (ALBT) and autogenic blood transfusion (ATBT) on a national scale, and determine patient factors associated with transfusions. The National Hospital Discharge Survey was evaluated between 2001 and 2010 for primary total hip arthroplasty (THA) patients and categorized on the basis of transfusion necessity, type, and comorbidity burden. A logistic regression comparison of ALBT, ATBT, and nontransfused patients was performed with respect to patient demographics and in-hospital complications. The proportion of patients requiring any transfusion decreased from an average rate of 22.8% between 2001 and 2005 to 21.2% between 2006 and 2010 (p = .01). ATBT rates decreased (r = -.99) from 11.0% in 2001 to 2.8% in 2010. ALBT rates increased (r = .66) from 14% in 2001 to 16.6% in 2010. The number of patients requiring a blood transfusion after THA decreased in the United States with a trend shifting from ATBT to ALBT. (Journal of Surgical Orthopaedic Advances 26(4):216-222, 2017).

Gender Role in Total Knee Arthroplasty: A Retrospective Analysis of Perioperative Outcomes in US Patients.

BACKGROUND: Women present later than men for total knee arthroplasty (TKA) with more severe osteoarthritic disease but achieve comparable functional improvement and implant survival and also lower rates of revision. Despite these findings, there is significant underutilization of the procedure for women compared to men. METHODS: We conducted a retrospective study to address the lack of information in the literature concerning the immediate and short-term perioperative outcomes between genders. The National Hospital Discharge Survey was evaluated between 2001 and 2010 for men and women undergoing primary TKA in the United States. Differences in gender, patient demographics, comorbidities, complications, length of stay, and discharge disposition were analyzed and identified. RESULTS: The growth in TKA was 145% for men and 131% for women over the 10-year period. Women presented with significantly higher rates of obesity, morbid obesity, postoperative transfusion rate, and length of stay. In contrast, men showed a greater proportion of diabetes, postoperative wound infections, and increased mortality rates. Males were also more likely to be discharged to home, whereas females were more likely to be discharged to rehabilitation facilities. CONCLUSION: Our findings provide important insight into the perioperative outcomes that may be influencing gender disparity in TKA.

Total Knee Arthroplasty in Obesity: In-Hospital Outcomes and National Trends.

BACKGROUND: Both the prevalence of obesity and the utilization rate of total knee arthroplasty are increasing. The rate and proportion of total knee arthroplasty (TKA) performed in the setting of obesity/morbid obesity is increasing significantly over time. METHODS: Using International Classification of Diseases-Ninth Revision codes, we searched the National Hospitals Discharge Survey national database for patients admitted for primary TKA between 2001 and 2010. We then used International Classification of Diseases-Ninth Revision codes for obesity (body mass index = 30-40 kg/m2) and morbid obesity (body mass index, ≥ 40 kg/m2) to select the obese cohorts. RESULTS: We found 29,694 nonobese, 2645 obese, and 1150 morbidly obese patients. There was an increase in each group over time. The rate of obesity/morbid obesity was strongly correlated with time. Obese and morbidly obese patients were more likely to be younger, female, diabetic, and have Medicaid than nonobese patients. Obese and morbidly obese patients had shorter hospital stays and higher home discharge rates than nonobese patients. Obese and morbidly obese patients had lower transfusion rates, shorter hospital stays, and no increase in inpatient wound infection or venous thromboembolic complications than nonobese patients. The Midwest region saw a greater burden of obese TKA patients. CONCLUSION: With the right measures and precautions, satisfactory inhospital outcomes are possible in the obese patient after primary TKA. A limitation of this study is short inhospital stay of the index procedure as complications may present later after discharge.

Glenoid version and size: does gender, ethnicity, or body size play a role?

INTRODUCTION: Variations in glenoid morphology among patients of different gender, body habitus, and ethnicity have been of interest for surgeons. Understanding these anatomical variations is a critical step in restoring normal glenohumeral structure during shoulder reconstruction surgery. METHODS: Retrospective review of 108 patient shoulder CT scans was performed and glenoid version, AP diameter and height were measured. Statistical multiple regression models were used to investigate the ability of gender and ethnicity to predict glenoid AP diameter, height, and version independently of patient weight and height. RESULTS: The mean glenoid AP diameter was 24.7 ± 3.5, the mean glenoid height was 31.7 ± 3.7, and the mean glenoid version was 0.05 ± 9.05. According to our regression models, males would be expected to exhibit 8.4° more glenoid retroversion than females (p = 0.003) and have 2.9 mm larger glenoid height compared to females (p = 0.002). The predicted male glenoid AP diameter was 3.4 mm higher than that in females (p < 0.001). Hispanics demonstrated 6.4° more glenoid anteversion compared to African-Americans (p = 0.04). Asians exhibited 4.1 mm smaller glenoid AP diameters than African-Americans (p = 0.002). An increase of 25 kg in patient weight resulted in 1 mm increase in AP diameter (p = 0.01). CONCLUSIONS: Gender is the strongest independent predictor of glenoid size and version. Males exhibited a larger size and more retroverted glenoid. Patient height was found to be predictive of glenoid size only in patients of the same gender. Although variations in glenoid size and version are observed among ethnicities, larger sample size ethnic groups will be necessary to explore the precise relations. Surgeons should consider gender and ethnic variations in the pre-operative planning and surgical restoration of the native glenohumeral relationship. LEVEL OF EVIDENCE: Anatomic Study.

Revision total hip arthroplasty in the United States: national trends and in-hospital outcomes.

PURPOSE: With the increasing number of primary total hip arthroplasties (THA) being performed, the frequency of revision surgery is also expected to increase. We analysed the immediate in-hospital complications and epidemiologic data of 3,469 revision and 18,186 primary THA cases. METHODS: The National Hospital Discharge Survey (NHDS) was evaluated between 2001 and 2010 for patients who underwent revision and primary THA. Patients were identified and included in our retrospective study based on ICD-9 procedure codes. RESULTS: The number of primary and revision THAs increased steadily from 2001 to 2010. The revision burden decreased for the same studied period (r = -0.92) to reach 13.9 % in 2010. The South region had higher revision burden of 17.4 % (p < 0.001). The primary THA group was more likely to be obese, morbidly obese, and have hypertension (p < 0.001). The revision THA group had an increased rate of blood transfusions (p < 0.001), deep venous thrombosis (p = 0.008), post-operative sepsis (p < 0.001), and wound complications (p < 0.001). The in-hospital mortality rate was also higher for the revision THA group (0.6 % versus 0.2 %, p < 0.001). CONCLUSIONS: The revision burden has undergone a steady decrease over the ten years studied and the reason for this is likely multifactorial. The South region had a significantly higher revision burden when compared to the rest of the United States. Larger hospitals tend to perform relatively more revisions. Revision THA patients are associated with longer hospital stay, higher complications rate, and higher in-hospital mortality rate.