Perceptions of Preference Signaling in Orthopaedic Surgery: A Survey of Applicants and Program Directors.

INTRODUCTION: To improve transparency between candidates and training programs, a preference signaling program (PSP) was implemented before the 2022 to 2023 orthopaedic surgery match. The PSP allows applicants to 'signal' up to 30 programs, informing the program of the applicant's particular interest in interviewing for their available position(s). This study reports the perspectives of orthopaedic surgery residency applicants and program directors (PDs) on the effects of preference signaling on the orthopaedic match. METHODS: Electronic surveys were distributed to PDs and applicants. RESULTS: Almost all programs participated in the PSP (90%), and most of the applicants (97.6%) used 25 to 30 of their allotted preference signals. Most of the applicants (67.2%) thought that their likelihood of obtaining an interview was improved at 'signaled' programs but decreased at programs without a 'signal' designation (85.3%). Both applicants and PDs considered preference signaling to be one of the three most important factors for interview selection, along with Step 2 CK score and letters of recommendation. The applicants did not think that their likelihood of matching would improve with fewer allotted signaling tokens (35.2%), and 55.2% of PDs believed 21 to 30 tokens were optimal. CONCLUSION: Preference signaling is highly regarded by applicants and PDs. Signaling a program will likely improve an applicant's chance to interview. The optimal number of signaling tokens remains unknown, although both groups favored a larger allotment of tokens than has been seen in other specialties. Universal guidelines and recommendations for applicants and PDs would improve the utility of preference signaling.

Radiographic Measurements Correlate to Isolated Posterolateral Corner (PLC) Injury in a Novel Cadaveric Model.

INTRODUCTION:  Injury to the posterolateral corner (PLC) of the knee often requires surgical reconstruction. There remains no consensus on treatment for PLC injury, and, therefore, it is imperative to have a reproducible injury model to improve the general knowledge of PLC injuries. A novel cadaveric model of isolated PLC injury is proposed and evaluated using radiographic parameters as well as gross dissection. MATERIAL AND METHODS:  All protocols were reviewed by the Human Investigation and Research Committee of the home institution and were approved. Translational force in a defined posterior and lateral direction was applied to cadaveric native knees to induce PLC injury. Varus and recurvatum stress fluoroscopic imaging was obtained of each specimen before and after the injury model. Lateral joint distance and recurvatum angle after stress was measured on each image via picture archiving and communication software (PACS) imaging software. After the injury model, injured structures were assessed via saline loading and gross dissection. Any specimens found to be fractured were excluded from the analysis of stress radiography. RESULTS:  A total of 12 knees underwent testing and 6/12 successfully induced PLC injury without fracture. The lateral capsule was torn in every specimen. The popliteofibular ligament (PFL) was torn in 83% of specimens and the fibular collateral ligament (FCL) in 66.7% of specimens. The median lateral gapping after injury under varus stress radiography was 5.39 mm and the median recurvatum angle after injury was 14.25°. Radiographic parameters had a direct relationship with a number of structures injured. CONCLUSIONS:  This is the first successful cadaver model of PLC injury. The lateral capsule was injured in every specimen emphasizing the importance of this structure to the PLC.

Funding has no effect on studies evaluating viscosupplementation for knee osteoarthritis: A systematic review of bibliometrics and conflicts of interest.

Background: Viscosupplementation for knee osteoarthritis (OA) may raise concerns regarding conflicts of interest (COI). Evidence of inconclusive study results and publication bias in previous studies has led to concern that financial COI have influenced viscosupplementation outcomes. It is critical to ensure that clinical practice is guided by informed decision making and evidence-based medicine. Methods: A systematic review was conducted following PRISMA guidelines. PubMed, MEDLINE, and Web of Science databases were searched for articles pertaining to hyaluronic acid (or similarly derived) injections to native knees with primary OA only. Bibliometric data, financial COI, and study outcomes were assessed. Results: 67 studies met inclusion criteria for analysis, 53 of which (79.1%) presented Level I evidence, and 21 of which (31.3%) reported at least one author with COI. All studies reporting COI also disclosed industry funding. There were no relationships between reported COI and study outcomes (Χ 2  = 0.31, P = 0.577), levels of evidence (Χ 2  = 3.48, P = 0.176), or relative citation ratio (RCR) (S = 743, P = 0.591). Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors (IF) (reporting COI: IF = 3.5 ± 2.0; no COI: IF = 1.8 ± 1.1; S = 950, P < 0.001). Study outcomes were not related to the probability of being published in an open access journal (Χ 2  = 0.01, P = 0.960), nor to level of evidence (Χ 2  = 2.67, P = 0.263), RCR (S = 618, P = 0.835), or IF (S = 563, P = 0.655). Conclusions: Investigator COIs (and commercial funding of studies) have not significantly influenced the frequency of favorable outcomes or study level of evidence regarding contemporary viscosupplementation for the treatment of knee OA. Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors. Results overwhelmingly supported using viscosupplementation to treat knee OA. Level of evidence: Level V Systematic Review.

The statistical fragility of intramedullary reaming in tibial nail fixation: a systematic review.

PURPOSE: To report the statistical stability of prospective clinical trials evaluating the effect of intramedullary reaming on rates of non-union in tibial fractures through calculation of the fragility metrics for non-union rates and all other dichotomous outcomes. METHODS: Literature search was conducted for prospective clinical trials evaluating the effect of intramedullary reaming on non-union rates in tibial nailing. All dichotomous outcomes were extracted from the manuscripts. The fragility index (FI) and reverse fragility index (RFI) were calculated by determining the number of event reversals required for a statistically significant outcome to lose significance and vice-versa. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI or RFI by the sample size, respectively. Outcomes were defined as "fragile" if the FI or RFI was found to be less than or equal to the number of patients lost to follow-up. RESULTS: Literature search identified 579 results which produced ten studies meeting the criteria for review. There were 111 outcomes identified for analysis, of which 89 (80%) exhibited statistical fragility. For reported outcomes across the studies the median and mean FI was 2, the median FQ was 0.019, the mean FQ was 0.030, the median RFI was 4, the mean RFI was 3.95, the median RFQ was 0.045, and the mean RFQ was 0.030. Four studies reported outcomes which were found to have an FI of 0. CONCLUSIONS: The studies evaluating the effect of intramedullary reaming on tibial nail fixation demonstrate considerable fragility. On average, two event reversals for significant findings, and four event reversals for insignificant findings are sufficient to alter statistical significance. LEVEL OF EVIDENCE: Level II, systematic review of Level I and Level II studies.

Trends and epidemiology of knee extensor mechanism injuries presenting to United States emergency departments from 2001 to 2020.

OBJECTIVES: Injuries to the native extensor mechanism (EM) of the knee are potentially disabling and often require surgical treatment. Large-scale, updated epidemiological data on these injuries is lacking. The objective of the current study was to examine recent trends in EM injuries presenting to United States (US) Emergency Departments (EDs) over the last 20 years using a nationally representative sample. METHODS: This study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of EM injuries (defined as either a quadriceps tendon rupture, a patella fracture, or a patellar tendon rupture) presenting to EDs in the US from 2001 to 2020. RESULTS: During the study period, an estimated 214,817 EM injuries occurred in an at-risk population of 6,183,899,410 person-years for an overall incidence rate of 3.47 per 100,000 person-years. Patella fractures (PFs) were the most common injury type, representing 77.5% of all EM injuries (overall incidence rate: 2.69), followed by patellar tendon ruptures (PTRs; 13.5%; incidence: 0.48) and quadriceps tendon ruptures (QTRs; 9%; incidence: 0.31). Demographic characteristics and mechanisms of injury differed between injury types. Annual incidence rates increased significantly during the study period for all EM injury types, with PTRs demonstrating the largest relative increase (average annual percent increase: PF, 2.8%; PTR, 7.2%; QTR, 5.3%). Accounting for population growth yielded an increasing incidence of all EM injuries combined from 3.65 in 2001 to 4.9 in 2020. The largest relative increases in incidence rates were observed in older age groups. CONCLUSION: Extensor mechanism injuries of the knee are increasing in the US, which likely reflects an aging and more active population. These types of injuries are associated with substantial functional impairment and recent increases in incidence rates highlight the need for injury prevention and management strategies.

Epidemiology of patellar dislocations in the United States from 2001 to 2020: results of a national emergency department database.

OBJECTIVES: Recent studies have shown an increasing incidence of patellar dislocations among children and adolescents. Updated, population-based studies of all patellar dislocations in the United States (US), however, are lacking. This study investigated recent trends in injury rates and demographics among patients sustaining patellar dislocations in the US from 2001 to 2020. METHODS: This descriptive epidemiologic study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of acute patellar dislocations presenting to US Emergency Departments (EDs) from 2001 to 2020. Annual, overall, and age-adjusted incidence rates (IRs, expressed per 100,000 at-risk person-years) and additional patient/injury characteristics were analyzed. Average annual percent change (AAPC) estimates are presented to indicate the magnitude/direction of trends in annual injury rates. RESULTS: An estimated total of 159,529 patellar dislocations occurred over the study period for an overall IR of 2.58 (95% CI = 2.04-3.12). Accounting for population growth, the overall annual incidence increased significantly from 2.61 in 2001 to 3.0 in 2020 (AAPC = 2.8, p < 0.0001). When considering sex and age, statistically significant increases in annual IRs were observed among males aged 10-19 years (AAPC = 3.8, p < 0.0001), females aged 10-19 years (AAPC = 5.3, p < 0.0001), and females aged 20-29 years (AAPC = 3.5, p = 0.0152), while no significant changes were observed in any other age groups. Two-thirds of patellar dislocations involved sports-related injury mechanisms. The annual incidence of both sports-related and non-sports-related injuries increased significantly over the study period (sports-related: AAPC = 2.6, p = 0.0001; non-sports-related: AAPC = 3.4, p = 0.0001). Athletic patellar dislocations occurred most commonly in basketball and dance. CONCLUSION: The number of patients sustaining patellar dislocations is increasing in the US. Similar increasing trends were observed in both males and females aged 10-19 years, whereas injury rates increased in the third decade only among females. A large percentage of injuries occur during athletic activity, but both sports- and non-sports-related patellar dislocations are on the rise.

Funding has no effect on clinical outcomes of total joint arthroplasty emerging technologies: a systematic review of bibliometrics and conflicts of interest.

BACKGROUND: The use of new total joint arthroplasty technologies, including patient-specific implants/instrumentation (PSI), computer-assisted (CA), and robotic-assisted (RA) techniques, is increasing. There is an ongoing debate regarding the value provided and potential concerns about conflicts of interest (COI). METHODS: PRISMA guidelines were followed. PubMed, MEDLINE, and Web of Science databases were searched for total hip and knee arthroplasties, unicompartmental knee arthroplasties (UKA), PSI, CA, and RA. Bibliometric data, financial COI, clinical/functional scores, and patient-reported outcomes were assessed. RESULTS: Eighty-seven studies were evaluated, with 35 (40.2%) including at least one author reporting COI, and 13 (14.9%) disclosing industry funding. COI and industry funding had no significant effects on outcomes (P = 0.682, P = 0.447), and there were no significant effects of conflicts or funding on level of evidence (P = 0.508, P = 0.826). Studies in which author(s) disclosed COI had significantly higher relative citation ratio (RCR) and impact factor (IF) than those without (P < 0.001, P = 0.032). Subanalysis demonstrated RA and PSI studies were more likely to report COI or industry funding (P = 0.045). RA (OR = 6.31, 95% CI: 1.61-24.68) and UKA (OR = 9.14, 95% CI: 1.43-58.53) had higher odds of reporting favorable outcomes than PSI. CONCLUSIONS: Author COIs (about 40%) may be lower than previously reported in orthopedic technologies/techniques reviews. Studies utilizing RA and PSI were more likely to report COI, while RA and UKA studies were more likely to report favorable outcomes than PSI. No statistically significant association between the presence of COIs and/or industry funding and the frequency of favorable outcomes or study level of evidence was found. LEVEL OF EVIDENCE: Level V Systematic Review.

Effects of veterans' mental health service-connections on patient-reported outcomes following total joint arthroplasty.

Background: Studies report poor outcomes of elective orthopaedic surgeries among civilian patients receiving Workers' Compensation (WC). However, little is known about surgical outcomes in veterans receiving similar benefits through the Veterans Affairs (VA) service-connected (SC) disability compensation program. Methods: Veterans undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a VA Medical Center between 07/2019-12/2021 were analyzed by SC status. Outcomes were evaluated using Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores collected preoperatively and at 2- and 12-months postoperatively. Repeated measures mixed models were used to test for the effect of SC on HOOS-JR/KOOS-JR scores, controlling for baseline age, sex, and Charlson Comorbidity Index (CCI). SC and baseline joint function (stratified into quartiles using baseline HOOS-JR/KOOS-JR scores) were analyzed for effects on achieving substantial clinical benefit (SCB) at 12-month follow-up. Results: The analysis included 67 hips and 142 knees. SC and non-SC (NSC) veterans had similar baseline HOOS-JR/KOOS-JR and CCI. HOOS-JR remained similar between groups through 12 months (79.9 ± 19.2 vs. 82.7 ± 18.8) as did KOOS-JR (70.4 ± 15.6 vs. 74.6 ± 15.3). The designation of any SC and mental health SC reached significance for KOOS-JR (P = 0.034 and P = 0.032, respectively). For HOOS-JR and KOOS-JR, baseline function score quartile significantly influenced final score (P < 0.001), with patients in the lowest quartiles (i.e., worst baseline function) exhibiting significantly greater improvements than patients in higher quartiles. Conclusions: Mental health SC and high preoperative functional status are variables that may have unfavorable influences on self-reported outcomes of TKA in veteran patients. SC status does not appear to influence the outcomes of THA or the likelihood of achieving SCB after either THA or TKA. Regardless of SC status, most veterans can expect significant clinical improvements after total joint arthroplasty.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty.

BACKGROUND: Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research. CONCLUSION: Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.

Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates.

INTRODUCTION: Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients. HYPOTHESIS: We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty. MATERIALS AND METHODS: An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty. RESULTS: Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039). DISCUSSION: IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities. LEVEL OF EVIDENCE: III; retrospective cohort study.

Preoperative Emergency Department Visits Are Predictive of 90-Day Postoperative Emergency Department Visits and Discharge Disposition in Total Knee Arthroplasty Patients.

The increasing number of patients undergoing total knee arthroplasty (TKA) has resulted in efforts to better understand patient utilization of healthcare services in the 90-day postoperative period. The primary purpose of this study was to examine whether emergency department (ED) visits in the year prior to elective TKA were predictive of postoperative ED visits in the 90-day global period following surgery. A retrospective chart review was performed for all patients undergoing TKA from June 1, 2011 to December 31, 2015 at a Veterans Affairs hospital. Total number of ED visits in the year prior to surgery and 90 days following surgery were tabulated. Binary and ordinal logistic regression analyses were utilized to determine if preoperative ED visits were predictive of postoperative ED visits. The significance level was set to α = 0.05. Overall, 611 eligible TKA procedures were performed. The logistic regression model for postoperative ED visits was significant (p < 0.001), with the number of preoperative ED visits (1 vs. 0: p < 0.001; 2 vs. 1: p = 0.012) and presence of diabetes (p = 0.007) both predicting the likelihood of a postoperative ED visit. Healthcare changes that are redefining the concept of quality of care to include the postoperative care episode, coupled with an increasingly aging population in need of TKA, will continue to challenge orthopaedic surgeons to provide safe, competent, and cost-effective care to patients. The results of this study demonstrate that a patient's propensity to visit the ED prior to TKA is predictive of a tendency to do so postoperatively and is of use to surgeons when evaluating and counselling patients who will be undergoing a TKA.

Synopsis of the 2020 US Department of Veterans Affairs/US Department of Defense Clinical Practice Guideline: The Non-Surgical Management of Hip and Knee Osteoarthritis.

In July 2020, the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) approved a new joint clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. This synopsis highlights some of the recommendations. In February 2019, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched (ie, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE PreMEDLINE, PubMed, and the Agency for Healthcare Research and Quality website) and evaluated the literature, created a simple 1-page algorithm, and advanced 19 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. This synopsis summarizes key recommendations in all 6 topics covered in the guideline. These topics are diagnosis, self-management, physical therapy, pharmacotherapy, orthobiologics, and complementary and integrative health.

Virtual Interviews in the Era of COVID-19: Expectations and Perceptions of Orthopaedic Surgery Residency Candidates and Program Directors.

Orthopaedic surgery residency program directors (PDs) and candidates consider interviews to be central to the application process. In-person interviews are typical, but virtual interviews present a potentially appealing alternative. Candidate and PD expectations and perceptions of virtual interviews during the 2020/2021 orthopaedic surgery application cycle were assessed. METHODS: Candidates and PDs were surveyed electronically. Questions covered pre-virtual-interview and post-virtual-interview expectations and perceptions, and past in-person experiences (PDs and reapplicants) on the relative importance of application components, ability to assess fit, interview costs, and preferred interview mode. Identical questions allowed between-group comparisons. RESULTS: Responses included n = 29 PDs and n = 99 candidates. PDs reported diminished ability to assess candidate fit; social, clinical, and surgical skills; and genuine interest in the virtual context (each p ≤ 0.01). They placed greater importance on research and less on the interview in the virtual vs. in-person context (each p = 0.02). Most candidates (78%) reported fair/good ability to demonstrate potential and were better able to assess research opportunities than expected (p < 0.01). Candidates expected virtual interviews to increase the importance of research, transcripts, and recommendations (for each, p ≤ 0.02) and decrease the importance of the interview itself (p < 0.01). Compared with PDs, candidates overvalued research, United States Medical Licensing Examination scores, transcripts, and recommendations (each p ≤ 0.02) and may have slightly undervalued the virtual interview (p = 0.08). Most candidates (81%) and PDs (79%) preferred in-person interviews, despite both groups reporting monetary savings. CONCLUSIONS: Despite cost savings associated with virtual interviews, orthopaedic surgery residency PDs and candidates identified reduced abilities to assess candidate or program fit and displayed a preference for in-person interviews.

Multimodal Pain Management With Adductor Canal Block Decreases Opioid Consumption Following Total Knee Arthroplasty.

BACKGROUND: Ease of access to opioids in the perioperative period is a risk factor for subsequent opioid misuse. The purpose of this study was to quantify a decrease in opioid consumption following implementation of a new analgesic protocol after total knee arthroplasty (TKA). METHODS: A retrospective cohort study was performed analyzing patients who underwent TKA at a US Department of Veterans Affairs medical center. Patients were divided into 2 groups by multimodal analgesic regimen: Analgesia with intraoperative general anesthesia, a patient-controlled analgesia pump, and oral opioids (control group) or analgesia with intraoperative spinal anesthesia, a multimodal medication regimen, and an adductor canal block (protocol group). RESULTS: A total of 533 TKAs were included. The mean (SD) IV morphine equivalent dose (MED) requirement was 178.2 (98.0) for the control and 12.0 (24.6) for the protocol group (P < .001). Total mean (SD) opioid MED requirement was 241.7 (120.1) for the control group and 74.8 (42.7) for the protocol group (P < .001). The protocol group required only 6.7% of the IV opioids and the control group 30.9%. No difference in oral opioid requirements was found (P = .85). The control group required more opioid refills at the first postoperative visit (P < .001). CONCLUSIONS: The described analgesic protocol resulted in significant decreases in IV and total opioid requirement, and lower rates of opioid prescriptions at the first postoperative visit. These findings demonstrate a decrease in opioid utilization with modern perioperative analgesia protocols and reinforce multiple recommendations to decrease opioid exposure and access.

Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population.

BACKGROUND: Improved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1. METHODS: A retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05). RESULTS: Of those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]). CONCLUSION: Most patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.

Long-Term Survival of Metastatic Bladder Cancer Treated With Chemotherapy, Radiation, and Arthroplasty: A Case Report.

CASE: A 64-year-old man suffered a pathologic left femoral neck fracture. Biopsy demonstrated metastatic urothelial cancer with a nonmuscle invasive bladder cancer primary confirmed by cystoscopy. The patient underwent hemiarthroplasty, chemotherapy, radiation, and eventually, a conversion to total hip arthroplasty. Today, over a decade from the initial surgery, the patient remains alive and highly functional. To our knowledge, this is the only report of bone metastatic bladder cancer with over 10-year survival. CONCLUSION: Combined chemotherapy, radiation, and surgical resection of metastasis with reconstruction may confer a survival benefit in bony oligometastatic bladder cancer.

Hospital Discharge Within 1 Day After Total Joint Arthroplasty From a Veterans Affairs Hospital Does Not Increase Complication and Readmission Rates.

BACKGROUND: Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits. METHODS: After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05. RESULTS: Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901). CONCLUSION: Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement.

BACKGROUND: Although hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient's postdischarge experience. METHODS: We studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. RESULTS: The hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital's risk-standardized ED visit rate did not correlate with its readmission rate (r = -0.03, P = .50). If ED visits were included in a broader "readmission" measure, 246 (47.6%) hospitals would change perceived performance groups. CONCLUSION: Including ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization.