Orthopaedic and trauma research in Tanzania: A scoping review.

Tanzania is disproportionately burdened by musculoskeletal injuries as it faces unique challenges when dealing with trauma care. This scoping review aims to summarize and assess the current state of orthopaedic and trauma research in Tanzania. By identifying key themes, trends, and gaps in the literature, this review seeks to guide future research initiatives catered specifically to the needs of Tanzania's healthcare system. Utilizing the PRISMA-ScR protocol, OVID Medline, PubMed, and CINAHL databases were searched from inception to June 17, 2023, using keywords such as "Orthopaedics" "Trauma" and "Tanzania". One hundred and ninety-two eligible studies were included and the Arksey and O'Malley framework for scoping studies was followed. There was a notable growth of relevant publications from 2015 onward, with peaks in growth in the years 2019, 2021, and 2020. The studies employed diverse research methodologies, with cross-sectional (n = 41, 21%) and prospective studies (n = 39, 20%) being the most prevalent, and randomized-controlled trials being the least prevalent methodology, making up eight studies (4.2%). The most common study themes were trauma (n = 101, 52.6%), lower extremity (n = 31, 16%), and spine-related issues (n = 27, 14%). Only three studies looked at work-related injuries (1.6%). Road traffic injuries (RTIs) were the most common mechanism of trauma in 77.0% of the trauma focused studies. Fifty-three percent of the studies were conducted by a majority of Tanzanian authors. This scoping review highlights various trends in orthopaedic and trauma research in Tanzania, with a particular emphasis on road traffic-related injuries. Various gaps are explored, including a lack of research on work-related injuries and a paucity of experimental research. Our findings underline areas where future research is warranted. The future of orthopaedic and trauma care in Tanzania depends on the efforts and collaboration of both local and international stakeholders.

Outcomes of Total Knee Arthroplasty in Patients Who Have Ehlers-Danlos syndrome: A Matched Cohort Study.

INTRODUCTION: Total knee arthroplasty is an excellent surgical option for patients who have end-stage knee osteoarthritis. While rates of major postoperative complications have steadily decreased with modern implants and operative techniques, contemporary outcome data for patients who have Ehlers-Danlos syndrome is scarce. The goal of this study was to compare complication rates after primary total knee arthroplasty in patients who have Ehlers-Danlos syndrome versus matched controls. METHODS: A large administrative database was used to identify patients who underwent primary total knee arthroplasty from 2009 to 2020. Patients who had a diagnosis of Ehlers-Danlos syndrome were identified by International Classification of Disease Coding. Propensity scores were utilized to match these patients with controls at a 1:4 ratio based on age, sex, and various comorbidities. Multivariable logistic regression analysis was used to compare the rates of medical and surgical complications at 90 days and 2 years. A total of 188 patients who had Ehlers-Danlos syndrome and 752 controls were included in this study. RESULTS: After univariate analysis, Ehlers-Danlos patients exhibited significantly higher rates of wound complications (4.8 versus 0.9%, P = 0.001) at 90 days. When adjusted for comorbidities, Ehlers-Danlos patients still exhibited significantly increased odds of developing wound complications (OR [odds ratio] 7.06, P < 0.001). CONCLUSIONS: Patients who have Ehlers-Danlos syndrome undergoing total knee arthroplasty exhibited significantly higher rates of wound complications within 90 days postoperatively, compared to matched controls. Rates of instability, manipulation under anesthesia, periprosthetic joint infection, aseptic loosening, and aseptic revision arthroplasty did not significantly differ between the cohorts. This study found generally favorable short-term outcomes of total knee arthroplasty in this population; however, the inability to control for implant type and other confounding variables may have influenced the lack of difference in complication rates at 2 years. Surgeons should monitor for the potentially increased risk of wound complications and consider the possible need for increased constraint in this population during preoperative planning.

Early Versus Late Periprosthetic Joint Infection After Total Knee Arthroplasty: Do Patient Differences Exist?

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Little evidence exists comparing those with early versus late PJI. The purpose of the study was to determine comorbidity profile differences between patients developing early and late PJI. METHODS: There were 72,659 patients undergoing primary TKA from 2009 to 2021, who were identified from a commercial claims and encounters database. Subjects diagnosed with PJI were categorized as either 'early' (within 90 days of index procedure) or 'late' (> 2 years after index arthroplasty). Non-infected patients within these periods served as control groups following 4:1 propensity score matching on other extraneous variables. Logistic regression analyses were performed comparing comorbidities between groups. RESULTS: Patients were significantly younger in the late compared to the early infection group (58.1 versus 62.4 years, P < .001). When compared to those with early PJI, patients who had chronic kidney disease (13.3 versus 4.1%; OR [odds ratio] 5.17, P = .002), malignancy (20.4 versus 10.5%; OR 2.53, P = .009), uncomplicated diabetes (40.8 versus 30.6%; OR 2.00, P = .01), rheumatoid arthritis (9.2 versus 3.3%; OR 2.66, P = .046), and hypertension (88.8 versus 81.6%; OR 2.17, P = .04), were all significant predictors of developing a late PJI. CONCLUSIONS: When compared to patients diagnosed with early PJI following primary TKA, the presence of chronic kidney disease, malignancy, uncomplicated diabetes, rheumatoid arthritis, and hypertension, were independent risk factors for the development of late PJI. Younger patients who have these comorbidities may be targets for preoperative optimization interventions that minimize the risk of PJI.

Defining the Learning Period of a Novel Imageless Navigation System for Posterior Approach Total Hip Arthroplasty: Analysis of Surgical Time and Accuracy.

Introduction: The use of imageless navigation in total hip arthroplasty (THA) is frequently associated with prolonged surgical times, predominantly during the learning period. The purpose of the present study was to characterize the learning period of a novel imageless navigation system, specifically as it related to surgical time and acetabular navigation accuracy. Materials and Methods: This was a retrospective observational study of a consecutive group of 158 patients who underwent primary unilateral THA for osteoarthritis by a team headed by a single surgeon. All procedures used an imageless navigation system to measure acetabular cup inclination and anteversion angles, referencing a generic sagittal and frontal plane. Navigation accuracy was determined by assessing differences between intraoperative inclination and anteversion values and those obtained from standardized 6-week follow-up radiographs. Operative time and navigation accuracy were assessed by plotting moving averages of 7 consecutive cases. The learning period was defined using Mann-Kendall trend analyses, student t-tests and nonlinear regression modeling based on surgical time and navigation accuracy. Alpha error was 0.05. Results: The average surgical time was 67.3 min (SD:9.2) (range 45-95). The average navigation accuracy for inclination was 0.01° (SD:4.2) (range - 10 to 10), and that for anteversion was - 4.9° (SD:3.8) (range - 14 to 5). Average surgical time and navigation accuracy were similar between the first and final cases in the series with no learning period detected. Conclusions: There was no discernible learning period effect on surgical time or system measurement accuracy during the early phases of adoption for this imageless navigation system.

Outcomes of Unicompartmental Knee Arthroplasty in Patients Receiving Long-Term Anticoagulation Therapy: A Propensity-Matched Cohort Study.

BACKGROUND: Although total knee arthroplasty has been considered the gold-standard treatment for severe osteoarthritis of the knee, unicompartmental knee arthroplasty (UKA) has become an increasingly favorable alternative for single-compartment osteoarthritis of the knee. Few studies have examined potential high-risk populations undergoing this procedure. The purpose of this study was to investigate the outcomes of UKA in patients receiving long-term anticoagulation therapy. METHODS: In this study, a large administrative database was queried to identify patients undergoing UKA between 2009 and 2019, who were then divided into a cohort receiving long-term anticoagulation and a control cohort. Propensity scores were utilized to match these patients. Multivariable logistic regression was utilized to compare 90-day and 2-year complication rates between cohorts. RESULTS: Patients who were on long-term anticoagulation had significantly increased odds of extended length of stay, surgical site infection, wound complication, transfusion, deep vein thrombosis, pulmonary embolism, and readmission at 90-day follow-up. The long-term anticoagulation cohort also experienced significantly higher odds of periprosthetic joint infection and mechanical complications at 2-year follow-up; however, odds of conversion to total knee arthroplasty were not increased. CONCLUSIONS: This study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders.

Complications and opioid-prescribing patterns following genicular nerve radiofrequency ablation versus intra-articular injection: a matched cohort study.

BACKGROUND AND OBJECTIVES: Genicular nerve radiofrequency ablation (GNRFA) is an emerging procedure used to relieve pain from severe knee osteoarthritis. While there have been rare reports of significant complications, their incidence has not been well established. The objective of this study was to examine complication rates at 30 and 90 days post treatment as well as characterize opioid-prescribing patterns before and after treatment. METHODS: A large national database was queried to identify patients undergoing GNRFA from 2015 to 2022 and matched to control cohorts composed of patients receiving either intra-articular corticosteroid (CSI) or hyaluronic acid injection (HAI) of the knee. Complication rates at 30 and 90 days were analyzed. Opioid utilization was assessed in the 6 months before and after treatment. RESULTS: Rates of infection (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), septic arthritis (<0.1%, CI 0.003% to 0.4% vs 0.1%, CI 0.02% to 0.5%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.6%, CI 1.0% to 2.2%), pulmonary embolism (1.2%, CI 0.6% to 1.7% vs 1.3%, CI 1.1% to 2.5%), bleeding (<0.1%, CI 0.003% to 0.4% vs 0%, CI 0% to 0.3%), seroma (<0.1%, CI 0.003% to 0.4% vs 0.2%, CI 0.05% to 0.6%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) and thermal injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) were not different between CSI and GNRFA cohorts at 30 days. Rate of swelling was significantly greater in the GNRFA cohort (9.4%, CI 7.6% to 10.4% vs 6.4%, CI 4.8% to 7.2%, p=0.003) at 30 days. At 90 days, rates of septic arthritis (0.1%, CI 0.02% to 0.5% vs 0.3%, CI 0.08% to 0.7%), deep vein thrombosis (3.1%, CI 2.1% to 3.8% vs 3.1%, CI 2.2% to 3.9%), pulmonary embolism (1.5%, CI 0.9% to 2.1% vs 1.8%, CI 1.2% to 2.5%), and nerve injury (0%, CI 0% to 0.3% vs <0.1%, CI 0.003% to 0.4%) were not significantly different.Between HAI versus GNRFA cohorts, no significant differences were seen in rates of infection (0.3%, CI 0.08% to 0.07% vs 0.7%, CI 0.3% to 1.2%), septic arthritis (0.2%, CI 0.05% to 0.6% vs 0.4%, CI 0.2% to 0.9%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.9%, CI 1.2% to 2.7%), pulmonary embolism (1.5%, CI 0.9% to 2.2% vs 1.7%, CI 1.1% to 2.5%), bleeding (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), seroma (<0.1%, CI 0.03% to 0.4% vs 0%, CI 0% to 0.3%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%), swelling (14.0%, CI 11.6% to 15.1% vs 12.0%, CI 10.3% to 13.6%), and thermal injury (<0.1%, CI 0.03% to 0.4% vs <0.01%, CI 0.3% to 0.4%) at 30 days. Rates of infection (0.7%, CI 0.3% to 1.2% vs 1.4%, CI 0.9% to 2.1%), septic arthritis (0.3%, CI 0.1% to 0.8% vs 0.5%, CI 0.2% to 1.1%), deep vein thrombosis (3.6%, CI 2.6% to 4.4% vs 3.1%, CI 2.2% to 4.0%), pulmonary embolism (2.3%, CI 1.5% to 3.0% vs 2.1%, CI 1.4% to 3.0%) and nerve injury (0%, CI 0% to 0.3% vs 0.1%, CI 0.02% to 0.5%) were not significantly different at 90 days.There were no significant differences in level of pretreatment opioid utilization although overall consumption in mean daily morphine equivalents was greater in the GNRFA cohort. Opioid utilization significantly increased in the first 30 days after ablation in patients with no prior opioid use compared to controls. In patients with some and chronic prior opioid use, opioid requirements were generally decreased in all treatment groups at 6 months with no clearly superior treatment in reducing opioid consumption. CONCLUSION: Our study demonstrated that GNRFA possesses a safety profile similar to that of intra-articular injections although significant adverse events such as venous thromboembolism and septic arthritis may occur rarely. Although opioid utilization generally increased in the 30 days after ablation compared with intra-articular injection, similar reduction in opioid consumption at 6 months was seen in patients with prior opioid use in the ablation and control cohorts.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS: In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS: Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS: All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE: III, Retrospective review.

Chronic Anticoagulation is Associated With Increased Risk for Postoperative Complications Following Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: With an aging global population, the incidence of revision total hip arthroplasty (rTHA) is expected to increase markedly. While patients undergoing primary total hip arthroplasty who require chronic anticoagulation (AC) have been associated with increased postoperative complications, less is known about the impact of chronic AC status on postoperative complications in the rTHA setting. This study sought to compare complication rates following aseptic rTHA between patients who were on chronic AC and those who were not. METHODS: A large national database was utilized to retrospectively identify 9,421 patients who underwent aseptic rTHA between 2014 and 2019. Patients were divided into 2 cohorts: 1,790 patients (19.0%) were in the chronic AC cohort (ie, having an AC prescription filled within 6 months prior to and following rTHA), and 7,631 patients (81.0%) were not on chronic AC. Postoperative complications at 90-days and 2-years were compared between cohorts utilizing univariate and multivariate analyses, controlling for sex, age, and comorbidities. RESULTS: At 90-days, chronic AC patients had increased odds of prosthetic joint infections (PJIs) (odds ratio [OR] 3.2, P < .001), surgical site infections (OR 3.6, P < .001), and mechanical prosthetic complications (OR 3.5, P < .001), which included any aseptic loosening, implant dislocation, or broken prosthetic. At 2-years, chronic AC patients had increased odds of PJI (OR 3.3, P < .001) as well as mechanical prosthetic complications (OR 3.2, P < .001). Chronic AC patients were also at increased risk for reoperation within 2 years after initial aseptic rTHA (OR 1.9, P < .001). CONCLUSIONS: Patients on chronic AC have significantly higher odds of 90-day and 2-year complications after aseptic rTHA. This includes increased odds of PJI, surgical site infection, and mechanical prosthetic complications. Patients receiving chronic AC who undergo rTHA should be counseled on the risk-benefit ratio of their chronic AC status in a multidisciplinary setting to optimize their postoperative outcomes.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Complications Rates Among Revision Total Knee Arthroplasty Patients Diagnosed With COVID-19 Postoperatively.

BACKGROUND: The COVID-19 pandemic introduced a new set of challenges for the arthroplasty community, including the management of patients diagnosed with COVID-19 following revision total knee arthroplasty (rTKA) and its potential impact on postoperative recovery. This study sought to characterize the risks of postoperative COVID-19 infection among rTKA patients. METHODS: A large national database was utilized to query 8,022 total patients who underwent rTKA between 2018 and 2021, of which 60 had a COVID diagnosis within 90 days after surgery (rTKA/COVID positive). These patients were 1:10 propensity-score matched to 600 rTKA patients who did not have a 90-day postoperative COVID diagnosis (rTKA/COVID negative) and 600 COVID positive patients who did not undergo rTKA. Controlling for potential confounders, multivariate logistic regressions were utilized to compare 90-day postoperative complications between groups. RESULTS: Compared to rTKA/COVID negativepatients, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (odds ratio [OR] = 6.1, P < .001), pulmonary embolism (PE) (OR = 32.4, P < .001), deep venous thrombosis (DVT) (OR = 32.4, P < .001), and 90-day readmissions (OR = 2.1, P = .02). Similarly, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (OR = 4.3, P = .001), PE (OR = 36.8, P < .001), and DVT (OR = 36.8, P < .001) compared to COVID positive patients who did not undergo rTKA. CONCLUSIONS: Revision total knee arthroplasty patients diagnosed with COVID-19 postoperatively had increased rates of thromboembolic events, pneumoniae, and 90-day readmissions. Risk mitigation efforts would suggest extending the prophylactic anticoagulation period for rTKA patients diagnosed with postoperative COVID-19.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND: Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents. METHODS: A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome. RESULTS: Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%). CONCLUSIONS: These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Leveraging Artificial Intelligence and Digital Health to Address Health-Related Social Needs and Optimize Risk-Based Value in Orthopaedic Surgery.

As the health care landscape evolves toward value-based care and emphasizes health-related social needs, the importance of developing health policies and digital health solutions that foster health equity and risk-based reimbursement strategies has grown. Orthopaedic surgery, catering to a diverse patient population but challenged by a lack of workforce diversity, encounters distinct opportunities and obstacles in adopting digital health technologies for delivering equitable, high-value care. The integration of health-related social needs into the emerging value-based care model and risk-based reimbursement policies is important. Furthermore, the potential of incorporating robust artificial intelligence governance and big data analytics to enhance patient outcomes and support orthopaedic surgeons in treating their patient populations should be studied. There are crucial considerations for creating comprehensive digital health platforms tailored for orthopaedic surgery, and the significance of specialty-specific advocacy and collaboration among clinicians, policymakers, and MedTech companies cannot be understated.

Pent-up demand for total shoulder arthroplasty prior to Medicare eligibility at age 65 years: evidence from a national patient database and national survey data.

BACKGROUND: Rising utilization rates of total shoulder arthroplasty (TSA) paired with an aging US population herald increased future economic burden. Previous research has demonstrated evidence of "pent-up demand" in health care (delaying medical care until financially able) accompanying insurance status changes. The purpose of this study was to determine pent-up demand for TSA in the years leading up to Medicare coverage at age 65 years while identifying key drivers underlying this trend, including socioeconomic status. METHODS: The incidence rates of TSA were evaluated using the 2019 National Inpatient Sample database. The observed increase in incidence between the ages of 64 years (pre-Medicare group) and 65 years (post-Medicare group) was compared with the expected increase. The expected frequency of TSA was subtracted from the observed frequency of TSA to calculate pent-up demand. Excess cost was calculated by multiplying pent-up demand by the median cost of TSA. The Medicare Expenditure Panel Survey-Household Component was used to compare health care cost and patient experience between pre-Medicare patients (aged 60-64 years) and post-Medicare patients (aged 66-70 years). RESULTS: The expected and observed increases in TSA procedures from age 64 years to age 65 years were 402, for an incidence rate increase of 0.13/1000 population (12.8% increase), and 820, for an incidence rate increase of 0.24/1000 population (27% increase), respectively. The 27% increase represented a sharp jump in comparison to the 7.8% annual growth rate between age 65 years and age 77 years. This resulted in pent-up demand between age 64 years and age 65 years of 418 TSA procedures and excess cost of $7.5 million. Mean total out-of-pocket expenses were significantly higher for the pre-Medicare group than for the post-Medicare group ($1700 vs. $1510, P < .001). Compared with the post-Medicare group, the pre-Medicare group exhibited a significantly higher proportion of patients who delayed Medicare care because of cost (P < .001), could not afford medical care (P < .001), had problems paying medical bills (P < .001), and were unable to pay medical bills (P < .001). Physician-patient relationship experience scores were significantly worse in the pre-Medicare group (P < .001). These trends were even stronger for low-income patients when data were broken down by income status. CONCLUSIONS: Patients likely delay elective TSA until reaching Medicare eligibility at age 65 years, resulting in substantial added financial burden to the health care system. As US health care costs continue to rise, it will be crucial for orthopedic providers and policy makers to be aware of pent-up demand for TSA and its possible associated drivers, especially socioeconomic status.

The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental?

BACKGROUND: Whether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex. METHODS: This is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts. RESULTS: There was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002). CONCLUSION: Frailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.

Wound Complications Are Affected by Different Skin Closure Methods in Primary Hip and Knee Arthroplasty.

BACKGROUND: There is a lack of consensus on optimal skin closure and dressing strategies to reduce early wound complication rates after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: All 13,271 patients at low risk for wound complications undergoing primary, unilateral THA (7,816), and TKA (5,455) for idiopathic osteoarthritis at our institution between August 2016 and July 2021 were identified. Skin closure, dressing type, and postoperative events related to wound complications were recorded during the first 30 postoperative days. RESULTS: The need for unscheduled office visits to address wound complications was more frequent after TKA than THA (2.74 versus 1.78%, P < .001), and after direct anterior versus posterior approach THA (2.94 versus 1.39%, P < .001). Patients who developed a wound complication, had a mean of 2.9 additional office visits. Compared to the use of topical adhesives, skin closure with staples had the highest risk of wound complications (odds ratio 1.8 [1.07-3.11], P = .028). Topical adhesives with polyester mesh had higher rates of allergic contact dermatitis than topical adhesives without mesh (1.4 versus 0.5%, P < .0001). CONCLUSION: Wound complications after primary THA and TKA were often self-limited but increased burden on the patient, surgeon, and care team. These data, which suggest different rates of certain complications with different skin closure strategies, can inform a surgeon on optimal closure methods in their practice. Adoption of the skin closure technique with the lowest risk of complications in our hospital would conservatively result in a reduction of 95 unscheduled office visits and save a projected $585,678 annually.

Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study.

INTRODUCTION: Direct anterior approach (DAA) for total hip arthroplasty (THA) frequently utilizes fluoroscopy. The purpose of this study is to assess the impact of using a novel, imageless THA navigation system on radiation exposure and acetabular cup placement consistency. MATERIALS AND METHODS: This was a retrospective, single-surgeon cohort study of a consecutive group of patients who underwent DAA THA for osteoarthritis. An optic-based imageless navigation system was used to determine intraoperative acetabular inclination and anteversion angles referenced off of a generic coronal and sagittal plane in 71 cases (study group). These were compared with 71 manual cases (control group) for fluoroscopy exposure, operative duration, and acetabular placement variation. Cohorts were similar in their distributions of sex, race, ethnicity, and body mass index. Comparisons between groups were made using independent samples t tests. Alpha error was 0.05. RESULTS: Study patients experienced significantly less fluoroscopy exposure time {3.59 [Standard Deviation (SD) 1.95] vs. 9.15 (SD 5.98) seconds; p < 0.001} and dosage (0.30 [SD 0.23] vs. 0.78 [SD 0.63] mGy; p < 0.001). Study and control patients had similar operative times [82.69 (SD 11.70) vs. 89.54 (SD 14.60) minutes; p = 0.09]. The study group had a significantly lower radiographic variation for inclination and anteversion, based on mean proximity to the centroid of each cohort [3.55 (SD 1.88) vs. 5.39 (SD 3.51); p < 0.001] and also a greater proportion of cases that fell within 1 SD of the mean cohort inclination and anteversion (40.8% vs. 21.1%; p = 0.009). CONCLUSIONS: Use of a novel imageless navigation system for DAA THA significantly reduced fluoroscopic radiation exposure and improved consistency in acetabular cup placement.

Liposomal Bupivacaine and Ropivacaine Adductor Canal Blocks for Anterior Cruciate Ligament Reconstruction Provide Similar Postoperative Analgesia.

The purpose of this study was to compare postoperative pain following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients receiving an adductor canal block (ACB) with ropivacaine (R-ACB) or liposomal bupivacaine (LB-ACB). The secondary purpose was to compare opioid consumption. A prospective cohort study of patients undergoing ACLR at an academic medical center was conducted from November 1, 2018 to November 21, 2019. The first cohort received R-ACB and 30 tablets of 5/325 mg oxycodone/acetaminophen. After June 13, 2019, the second cohort received LB-ACB and 20 tablets of 5/325 mg oxycodone/acetaminophen with the reduction in opioids prescribed resulting from a hospital quality improvement initiative to decrease narcotic consumption. From postoperative days 0 through 6, pain was assessed thrice daily using a numeric rating scale. Total postoperative opioid consumption was reported via tablet count and converted to oral morphine equivalents (OMEs). During this period, 165 subjects underwent ACLR, and 126 met the eligibility criteria (44.4% female, 55.6% male; mean ± standard deviation: 28.7 ± 13.7 years). Sixty-six (52.4%) received LB-ACB, and 60 (47.6%) received R-ACB (p = 0.53). The most common graft utilized was quadriceps autograft (63.6% LB-ACB; 58.3% R-ACB, p = 0.76). Mean postoperative pain scores were similar between groups during the entire postoperative period (p ≥ 0.08 for POD 0-6). While postoperative opioid consumption was lower among patients receiving LB-ACB (median OME [interquartile range]: 28.6 [7.5-63.8] vs. 45.0 [15.0-75.0], p = 0.023), this only amounted to an average of 2.2 tablets. Patients receiving LB-ACB in the setting of ACLR reported similar postoperative pain compared with those receiving R-ACB. Despite the second aim of our study, we cannot make conclusions about the effect of each block on opioid consumption given that each cohort received different numbers of opioid tablets due to institutional pressure to reduce opioid prescribing. As few patients completed their opioid prescriptions or requested refills, further reduction in prescription size is warranted. Future studies are necessary to further elucidate the effect of LB-ACB versus R-ACB on postoperative pain and opioid consumption after ACLR.

Shoulder arthroplasty device clearance: an ancestral network analysis.

BACKGROUND: The US Food and Drug Administration (FDA) oversees medical device regulation and oversight in the United States, and the majority of shoulder arthroplasty devices are cleared via the 510(k) pathway, in which a device demonstrates "substantial equivalence" to a previously cleared predicate. The purpose of this study was to determine an interconnected ancestral network of shoulder arthroplasty devices and determine equivalency ties to devices subsequently recalled by the FDA for design-related issues. METHODS: The FDA 510(k) database was used to identify all legally marketed shoulder arthroplasty devices from May 28, 1976, to July 1, 2021. Direct predicate information obtained via clearance summary documents associated with each device was used to generate an ancestral genealogy network for all shoulder arthroplasty devices cleared between July 1, 2020, and July 1, 2021. FDA design recalls were analyzed, and the number of descendant devices was calculated for each recalled device. RESULTS: An evaluation of all 476 510(k) premarket notification pathway-cleared shoulder devices since 1976 identified 0-313 descendant devices for each. Eighty of these devices (16.8%) have since been recalled, of which 10 recalls were directly related to implant design issues. Furthermore, among 29 of the most recently cleared devices (July 1, 2020-July 1, 2021), 16 (55.2%) claim predicates devices that have subsequently been withdrawn from the market because of design-related failures. CONCLUSIONS: Shoulder arthroplasty devices are linked together via an interconnected FDA 510(k) equivalency approval network dating back to 1976 despite substantive changes in material specifications and device design, many of which have since been recalled. Many of the cleared modern devices claim predicates based on subsequently recalled prostheses.

Is there a difference in mobility and inpatient physical therapy need after primary total hip and knee arthroplasty? A decade-by-decade analysis from 60 to 99 years.

INTRODUCTION: Extended inpatient rehabilitation (PT) after total hip (THA) and knee arthroplasty (TKA) has a significant impact on total care costs. As patients age, extended PT might be required following THA and TKA. This study examined the relationship between patient age, functional mobility, inpatient PT need, and discharge disposition in THA and TKA patients. MATERIALS AND METHODS: This retrospective study included patients aged 60 + undergoing primary THA or TKA between 2018 and 2020 at an orthopedic hospital. Comparing by age-decade, 7374 (3600 THA, 3774 TKA) sexagenarians, 5350 (2367 THA, 2983 TKA) septuagenarians, 1356 (652 THA, 704 TKA) octogenarians, and 78 (52 THA, 26 TKA) nonagenarians were analyzed. We compared the number of PT sessions needed for discharge clearance and the postoperative functional mobility using the Activity Measure for Post-Acute Care (AM-PAC) tool. Statistical analyses included ANOVA with post-hoc Tukey's HSD for continuous data and Chi-squared test for categorical variables. RESULTS: The number of PT sessions required for discharge clearance increased with age after THA (3.3 ± 1.9 sessions vs 3.8 ± 2.1 vs 5.0 ± 2.7 vs 6.2 ± 3.0; p < 0.01) and TKA (4.0 ± 2.1 vs 4.7 ± 3.1 vs 5.2 ± 2.8 vs 5.0 ± 1.6; p < 0.01). The functional mobility improvement as measured by AM-PAC was significantly lower for nonagenarians after THA (4.9 ± 2.8 vs 5.1 ± 2.8 vs 4.6 ± 3.3 vs 3.3 ± 3.9; p < 0.01) and TKA (5.0 ± 2.9 vs 4.7 ± 3.2 vs 3.9 ± 3.4 vs 3.2 ± 2.6; p < 0.01). CONCLUSION: Patients in their eighth and ninth decade had less improvement in functional mobility during in-hospital rehabilitation and utilized more PT services. However, clinical results in the elderly are still satisfying and the data may be helpful for resource utilization planning and risk-adjustment in value-based payment models.