Frailty Is Associated With Increased 30-Day Adverse Events and Hospitalization Costs After Primary Total Hip Arthroplasty.

BACKGROUND: Frailty can predict adverse outcomes for multiple medical conditions and surgeries but is not well studied in total hip arthroplasty (THA). We evaluate the association between Hospital Frailty Risk Score and postoperative events and costs after primary THA. METHODS: Using the National Readmissions Database, we identified primary THA patients for osteoarthritis, osteonecrosis, or hip fracture from January to November 2017. Using Hospital Frailty Risk Score, we compared 30-day readmission rate, hospital course duration, and costs between frail and nonfrail patients for each diagnosis, controlling for covariates. Thirty-day complication and reoperation rates were compared using univariate analysis. RESULTS: We identified 167,700 THAs for osteoarthritis, 5353 for osteonecrosis, and 7246 for hip fractures. Frail patients had increased 30-day readmission rates (5.3% vs 2.5% for osteoarthritis, 7.1% vs 3.3% for osteonecrosis, 8.4% vs 4.3% for fracture; P < .01), longer hospital course (3.4 vs 1.9 days for osteoarthritis, 4.1 vs 2.1 days for osteonecrosis, 6.3 vs 3.9 days for fracture; P < .01), and increased costs ($18,712 vs $16,142 for osteoarthritis, $19,876 vs $16,060 for osteonecrosis, $22,185 vs $19,613 for fracture; P < .01). Frail osteoarthritis patients had higher 30-day complication (4.4% vs 1.9%; P < .01) and reoperation rates (1.6% vs 0.93%; P < .01). Frail osteonecrosis patients had higher 30-day complication rates (5.3% vs 2.6%; P < .01). Frail hip fracture patients had higher 30-day complication (6.6% vs 3.8%; P < .01) and reoperation rates (2.9% vs 1.8%; P < .01). CONCLUSION: Frailty is associated with increased healthcare burden and postoperative events after primary THA. Further research can identify high-risk patients and mitigate complications and costs.

Use of Cementless Metaphyseal Fixation in Revision Total Knee Arthroplasty in the United States.

BACKGROUND: Fixation options for revision total knee arthroplasty (rTKA) have expanded and now include cementless metaphyseal fixation. The utilization rates of these implants in the United States are not well known. The purpose of this study was to analyze trends in cementless metaphyseal fixation for rTKA within the American Joint Replacement Registry (AJRR). METHODS: The AJRR was queried for the years 2015-2019 to identify all rTKA with implant data. Trends in the use of cementless sleeves, metaphyseal cones, and any cementless metaphyseal fixation (sleeves + cones) were examined over the study period using logistic regression analysis. RESULTS: Twenty thousand two hundred and eighty rTKA were analyzed. Cementless metaphyseal fixation was used in 16% of rTKA and significantly increased over the study period (14% to 19%, P < .0001). Cementless metaphyseal fixation was more frequently utilized during revision for aseptic loosening than other diagnoses (OR 1.014, 95% CI 1.001-1.027). Cementless sleeve utilization decreased over time (11% to 9%, P = .004), driven by decreased use on the femur (4% to 2%, P < .0001). The use of cones increased significantly over time (3% to 9%, P < .0001), driven by increased use on the tibia (2% to 9%, P < .0001). Cones were 22 times more likely to be utilized on the tibia relative to the femur (P < .0001) and were more likely to be used in revisions for infection (OR 1.103, 95% CI 1.089-1.117) and aseptic loosening (OR 1.764, 95% CI 1.728-1.800). CONCLUSION: Cementless metaphyseal fixation has grown in popularity yet, still comprised only 16% of rTKA over a 5-year period. Most of the increase was due to the utilization of tibial metaphyseal cones.

Use of a monoblock dual-mobility acetabular component in primary total hip arthroplasty in patients at high risk of dislocation.

INTRODUCTION: Dislocation is amongst the most common complications following total hip arthroplasty (THA). Dual-mobility bearings have been suggested as one way to reduce the risk of dislocation, particularly among patients at increased risk. The purpose of this study was to determine the outcomes of a monoblock dual-mobility shell for patients at high risk for dislocation following primary THA. METHODS: A total of 155 primary THAs with a monoblock, cementless dual-mobility acetabular component were performed in patients at high risk for dislocation. Two patients died prior to their two-year follow-up. The remaining 153 THAs were followed for a mean of 5.1 years (range: 2.1 to 9.3). RESULTS: There were no dislocations; however, four patients underwent revision surgery: one for an early periprosthetic acetabular fracture, one for an early periprosthetic femoral fracture, one for a late periprosthetic femoral fracture, and one for leg-length discrepancy. Intraoperative complications included one periprosthetic acetabular fracture treated with protected weight-bearing and one intraoperative proximal femoral fracture treated with cerclage wiring. Harris Hip Scores improved from a mean of 42.4 points preoperatively to a mean of 82.4 points postoperatively (p < 0.001). No cups were radiographically loose. At a mean follow-up of 5.1 years, survivorship of the acetabular component was 99.3% (95% CI, 98.1-100%) and survivorship without any reoperation was 97.4% (95% CI, 95.9-100%). DISCUSSION: Although there were no dislocations in this high-risk population, periprosthetic fractures of the femur and acetabulum were common with the implants utilised.

Isolated tibial insert exchange in revision total knee arthroplasty : reliable and durable for wear; less so for instability, insert fracture/dissociation, or stiffness.

AIMS: This study aimed to determine outcomes of isolated tibial insert exchange (ITIE) during revision total knee arthroplasty (TKA). METHODS: From 1985 to 2016, 270 ITIEs were performed at one institution for instability (55%, n = 148), polyethylene wear (39%, n = 105), insert fracture/dissociation (5%, n = 14), or stiffness (1%, n = 3). Patients with component loosening, implant malposition, infection, and extensor mechanism problems were excluded. RESULTS: Survivorship free of any re-revision was 68% at ten years. For the indication of insert wear, survivorship free of any re-revision at ten years was 74%. Re-revisions were more frequent for index diagnoses other than wear (hazard ratio (HR) 1.9; p = 0.013), with ten-year survivorships of 69% for instability and 37% for insert fracture/dissociation. Following ITIE for wear, the most common reason for re-revision was aseptic loosening (33%, n = 7). For other indications, the most common reason for re-revision was recurrence of the original diagnosis. Mean Knee Society Scores improved from 54 (0 to 94) preoperatively to 77 (38 to 94) at ten years. CONCLUSION: After ITIE, the risk and reasons for re-revision correlated with preoperative indications. The best results were for polyethylene wear. For other diagnoses, the re-revision rate was higher and the failure mode was most commonly recurrence of the original indication for the revision TKA. Cite this article: Bone Joint J 2021;103-B(6):1103-1110.

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections.

BACKGROUND: A simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs. METHODS: Thirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years. RESULTS: Twelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics. CONCLUSION: Total femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success. LEVEL OF EVIDENCE: IV.

Direct Anterior Approach Total Hip Arthroplasty Is Not Associated with Increased Infection Rates: A Systematic Review and Meta-Analysis.

BACKGROUND: The direct anterior approach (DAA) for primary total hip arthroplasty (THA) has recently increased in popularity. Recent evidence has raised concerns about whether use of the DAA is associated with increased rates of superficial and deep infection. The aim of this study was to systematically assess the literature and comparatively evaluate the rate of superficial and deep infection following primary THA using the DAA and non-direct anterior (non-DAA) approaches. METHODS: This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Primary outcome measures evaluated were rates of superficial and deep infection in patients undergoing DAA and non-DAA primary THA. RESULTS: A total of 1,872 studies were identified in the original search, of which 15 studies satisfied inclusion criteria. Our analysis evaluated 120,910 primary THAs, including 14,908 DAA and 106,002 non-DAA. The rate of superficial infection was 1.08% for DAA compared with 1.24% for non-DAA (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.79 to 1.30, p = 0.921). The rate of deep infection was 0.73% for DAA compared with 0.51% for non-DAA (OR = 1.03, 95% CI = 0.80 to 1.32, p = 0.831). CONCLUSIONS: This study found no difference in the rate of superficial or deep infection after primary THA using the DAA versus other surgical approaches. Our results suggest that comparative infection risk need not be a primary driver in the choice of surgical approach. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intermediate to Long-Term Follow-up of Cementing Liners into Well-Fixed Acetabular Components.

BACKGROUND: The cementation of a new liner into a well-fixed acetabular component is common during revision total hip arthroplasty (THA) for many indications, but most commonly for lack of a modern, compatible, highly cross-linked polyethylene (HXLPE) liner. However, little is known about the intermediate-term to long-term durability of this strategy. The purpose of this study was to evaluate the implant survivorship, risk of complications, clinical outcomes, and radiographic results of cementing a new HXLPE liner into a well-fixed acetabular component. METHODS: We retrospectively identified 323 revision THAs in which a nonconstrained HXLPE liner was cemented into a well-fixed acetabular component. The mean age at the time of the revision THA was 63 years, and 50% of patients were female. The most common indications for revision THA were polyethylene wear and osteolysis (48%), aseptic femoral loosening (35%), and hip instability (8%). The mean follow-up was 9 years. RESULTS: Polyethylene liner failure occurred in 11 cases (3%). In all cases, the cemented liner dissociated from the acetabular component. At 10 years, the survivorship free from any revision was 80% (95% confidence interval [CI], 75% to 84%) and the survivorship free from any reoperation was 77% (95% CI, 72% to 82%). The most common reason for re-revision was dislocation (45% of reoperations). A dislocation occurred in 17% of cases. Hips that underwent revision for instability were significantly more likely to dislocate compared with hips that underwent revision for liner wear (hazard ratio [HR], 2.3 [95% CI, 1.2 to 4.5]; p = 0.02). Elevated rim or face-changing liners were significantly more likely to dissociate than flat liners (HR, 9.0 [95% CI, 1.2 to 70.6]; p = 0.04). CONCLUSIONS: Cementation of a nonconstrained HXLPE liner into a well-fixed acetabular component during revision THA provided durable fixation with only a small number of failures at the cement interface (3%). Instability after this procedure remains a concern, but this is multifactorial in nature. These data support the continued use of this technique, when necessary, during revision THA. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Excellent two-year survivorship of 3D-printed metaphyseal cones in revision total knee arthroplasty.

AIMS: Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system. METHODS: We reviewed 142 revision TKAs in 139 patients using 202 cones (134 tibial, 68 femoral) which were undertaken between 2015 and 2016. A total of 60 involved tibial and femoral cones. Most cones (149 of 202; 74%) were used for Type 2B or 3 bone loss. The mean age of the patients was 66 years (44 to 88), and 76 (55 %) were female. The mean body mass index (BMI) was 34 kg/m2 (18 to 60). The patients had a mean of 2.4 (1 to 8) previous operations on the knee, and 68 (48%) had a history of prosthetic infection. The mean follow-up was 2.4 years (2 to 3.6). RESULTS: Survivorship free of cone revision for aseptic loosening was 100% and survivorship free of any cone revision was 98%. Survivorships free of any revision and any reoperation were 90% and 83%, respectively. Five cones were revised: three for infection, one for periprosthetic fracture, and one for aseptic tibial loosening. Radiologically, three unrevised femoral cones appeared loose in the presence of hinged implants, while the remaining cones appeared stable. All cases of cone loosening occurred in patients with Type 2B or 3 defects. The mean Knee Society score (KSS) improved significantly from 50 (0 to 94) preoperatively to 87 (72 to 94) (p < 0.001). Three intraoperative fractures with cone impaction (two femoral, one tibial) healed uneventfully. CONCLUSION: Novel 3D-printed titanium cones, with a reamer-based system, yielded excellent early survivorship and few complications in patients with severe bone loss undergoing difficult revision TKA. The diversity of cone options, relative ease of preparation, and outcomes rivalling those of previous designs of cone support their continued use. Cite this article: Bone Joint J 2020;102-B(6 Supple A):107-115.

Are Postoperative Hip Precautions Necessary After Primary Total Hip Arthroplasty Using a Posterior Approach? Preliminary Results of a Prospective Randomized Trial.

BACKGROUND: It is unclear whether posterior hip precautions after primary total hip arthroplasty (THA) reduce the incidence of early postoperative dislocation. METHODS: We performed a prospective randomized study to evaluate the effect of hip precautions on incidence of early dislocation after primary THA using a posterior approach. Between January 2016 and April 2019, 587 patients (594 hips) were consented and randomized into restricted or unrestricted groups. No significant demographic or surgical differences existed between groups. The restricted group was instructed to refrain from hip flexion >90°, adduction across midline, and internal rotation for 6 weeks. 98.5% (585 of 594) of hips were available for minimum 6-week follow-up (291 restricted and 294 unrestricted). Power analysis showed that 579 hips per group are needed to demonstrate an increase in dislocation rate from 0.5% to 2.5% with 80% power. RESULTS: At average follow-up of 15 weeks (range, 6-88), there were 5 dislocations (incidence, 0.85%). Three posterior dislocations occurred in the restricted group at a mean of 32 days (range, 17-47), and 2 posterior dislocations occurred in the unrestricted group at a mean of 112 days (range, 21-203), with no difference in dislocation rate between groups (1.03% vs 0.68%; odds ratio, 0.658; 95% confidence interval, 0.11-3.96; P = .647). At 6 weeks, unrestricted patients endorsed less difficulty with activities of daily living, earlier return to driving, and more time spent side sleeping (P < .05). CONCLUSION: Preliminary analysis suggests that removal of hip precautions after primary THA using a posterior approach was not associated with early dislocation and facilitated return to daily functions. Investigation to appropriate power is warranted.

Is There a Benefit to Modularity for Femoral Revisions When Using a Splined, Tapered Titanium Stem?

BACKGROUND: Proposed benefits of modularity for femoral revisions in total hip arthroplasty (THA) include more precise biomechanical restoration and improved stability, but this has not been proven with use of a splined, tapered design. This study's purpose is to compare (1) complication rates, (2) functional outcomes, and (3) radiographic measures of subsidence, offset, and leg length discrepancy with the use of modular vs monoblock splined, tapered titanium stems in revision THA. METHODS: We retrospectively reviewed 145 femoral revisions with minimum 2-year follow-up (mean, 5.12 years; range, 2-17.3 years). Patients receiving a modular (67) or monoblock (78) splined, tapered titanium stem for femoral revision were included. RESULTS: There were no statistically significant differences in rates of reoperation (22.3% vs 17.9%; P = .66), intraoperative fracture (9.0% vs 3.8%; P = .30), postoperative fracture (3.0% vs 1.3%; P = .47), dislocation (11.9% vs 5.1%; P = .23), or aseptic loosening (4.5% vs 6.4%; P = .73) between the modular and monoblock cohorts, respectively. There were similar results regarding subsidence >5 mm (10.4% vs 12.8%; P = .22), LLD >1 cm (35.8% vs 38.5%; P = .74), restoration of hip offset (-5.88 ± 10.1 mm vs -5.07 ± 12.1 mm; P = .67), and Harris Hip Score (70.7 ± 17.9 vs 73.9 ± 19.7; P = .36) between groups. Multivariate regression showed no differences in complications (P = .44) or reoperations (P = .20) between groups. CONCLUSION: Modular and monoblock splined, tapered titanium stems demonstrated comparable complication rates, functional outcomes, and radiographic parameters for femoral revisions. However, a limited number of patients with grade IIIB or IV femoral bone loss received a monoblock stem. Future investigations are required to determine whether modularity is beneficial for more complex femoral defects.

Inpatient Versus Outpatient Arthroplasty: A Single-Surgeon, Matched Cohort Analysis of 90-Day Complications.

BACKGROUND: Although some prior work supports the safety of same-day arthroplasty performed in a hospital, concerns remain when these procedures are performed in a free-standing ambulatory surgery center. The purpose of this study is to compare 90-day complication rates between matched cohorts that underwent inpatient vs outpatient arthroplasty at an ambulatory surgery center. METHODS: A single-surgeon cohort of 243 consecutive patients who underwent outpatient arthroplasty was matched with 243 inpatients who had the same procedure. One-to-one nearest-neighbor matching with respect to gender, age, American Society of Anesthesiologists Score, and body mass index was utilized. The 486 primary arthroplasties included 178 unicondylar knees (36.6%), 146 total hips (30.0%), 92 total knees (18.9%), and 70 hip resurfacings (14.5%). Ninety-day outcomes including reoperation, readmission, unplanned clinic or emergency department visits, and major and minor complications were compared using a 2-sample proportions test. RESULTS: The 2 cohorts were similar in distribution of demographic variables, demonstrating successful matching. The inpatient and outpatient cohorts both had readmission rates of 2.1% (P = 1.0). With the number of subjects studied, there were no statistically significant differences in rates of major complications (2.1% vs 2.5%, P = 1.0), minor complications (7.0% vs 7.8%, P = .86), reoperations (0.4% vs 2.1%, P = .22), emergency department visits (1.6% vs 2.5%, P = .52), or unplanned clinic visits (3.3% vs 5.8%, P = .19). CONCLUSION: This study suggests that arthroplasty procedures can be performed safely in an ambulatory surgery center among appropriately selected patients without an increased risk of complications.

Short-term Complications After Revision Hip Arthroplasty for Prosthetic Joint Infection Are Increased Relative to Noninfectious Revisions.

BACKGROUND: Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is associated with significant morbidity and cost. The purpose of this study was to determine how rates of perioperative complications, operative duration, and postoperative length of stay (LOS) in patients undergoing revision THA for PJI compare to primary THA and to revision THA for non-PJI. METHODS: We used the National Surgical Quality Improvement Program registry from 2005 to 2015 to identify all patients who underwent primary and revision THA. Patients were placed into cohorts based on the surgical procedure and by indication, including (1) primary THA, (2) revision THA for PJI, and (3) revision THA for non-PJI. Differences in 30-day postoperative medical complications, hospital readmissions, operative duration, and LOS were compared using bivariate and multivariate analyses. RESULTS: One lakh fourteen thousand five hundred five THA patients were identified, with 102,460 (89.5%) patients undergoing a primary THA and 12,045 (10.5%) undergoing a revision procedure. Of the 12,045 revision procedures, 10,777 (89.5%) were for non-PJI indications and 1268 (10.5%) were for PJI. Relative to primary THA, patients undergoing revision THA for PJI had an increased rate of total complications (odds ratio [OR] 3.96), sepsis (OR 13.15), deep surgical site infections (SSIs, OR 8.58), superficial SSI (OR 2.14, P = .002), nonhome discharge (OR 1.85), readmissions (OR 2.46), LOS (+3.0 days), and operative duration (+61 minutes). Compared with non-PJI revisions, PJI revisions had an increased rate of total complications (OR 2.42), sepsis (OR 5.51), deep SSI (OR 2.12), nonhome discharge (OR 1.47), and LOS (+1.8 days). CONCLUSION: Revision THA for PJI is associated with increased postoperative complications, nonhome discharge, and LOS relative to non-PJI revision THA. Separate care pathways and reimbursement bundles should be considered for patients with PJI. LEVEL OF EVIDENCE: III.

Are patients being evaluated for periprosthetic joint infection prior to referral to a tertiary care center?

BACKGROUND: Patients with a painful or failed total joint arthroplasties should be evaluated for periprosthetic joint infection (PJI). The purpose of this study is to determine if patients referred to a tertiary care center had been evaluated for PJI according to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines. METHODS: One hundred thirteen patients with painful hip (43) or knee (70) arthroplasties were referred to a single provider by orthopaedic surgeons outside our practice between 2012 and 2014. We retrospectively evaluated the workup by referring physicians, including measurement of serum erythrocyte sedimentation rate and C-reactive protein, performance of a joint aspiration if these values were abnormal, and obtainment of synovial fluid white blood cell count, differential, and cultures. RESULTS: Sixty-two of 113 patients (55%) did not have a workup that followed AAOS guidelines. Serum erythrocyte sedimentation rate and C-reactive protein were ordered for 64 of the 113 patients (57%). Of 25 patients with elevated inflammatory markers warranting aspiration, 15 (60%) had an aspiration attempted, with synovial fluid white blood cell, differential, and cultures obtained in 9 of 12 (75%) aspirations that yielded fluid. Of the 62 patients with an incomplete infection workup, 11 (18%) had a bone scan, 6 (10%) a computed tomography scan, and 3 (5%) a magnetic resonance imaging. Twelve of the 113 patients (11%) were ultimately diagnosed with PJI, with 5 undiagnosed prior to referral. CONCLUSIONS: The AAOS guidelines to evaluate for PJI are frequently not being followed. Improving awareness of these guidelines may avoid unnecessary and costly evaluations and delay in the diagnosis of PJI.

Adverse Local Tissue Reaction After a Metal-on-Metal Total Hip Prosthesis Without Elevated Serum Metal Ion Levels.

In the 1990s, metal-on-metal (MoM) bearings were reintroduced in total hip arthroplasty (THA), having the proposed advantages of decreased wear and improved stability. However, catastrophic adverse local tissue reaction (ALTR) secondary to metal debris from both the bearing surface and the head-neck junction is a well-recognized complication. The measurement of metal ion levels in the serum is often a first-line test to identify failure of a MoM bearing. The authors describe a 70-year-old man who presented with a multiply revised MoM THA and a large periprosthetic fluid collection incidentally seen during computed tomography for renal nephrolithiasis. The patient reported painless, progressive swelling over the lateral aspect of the hip. An infectious workup including serum erythrocyte sedimentation rate, C-reactive protein, and intraarticular hip aspiration yielded negative results. Metal ion levels in the serum, including a minimally elevated cobalt level, were unremarkable, and metal-lymphocyte transformation testing yielded negative results. Radiographic imaging revealed progressive osteolysis around the proximal femur, and magnetic resonance imaging showed large fluid collections with irregular wall thickening surrounding the gluteal and iliopsoas musculature. At revision surgery, a large fluid collection and corrosion at the head-neck junction were present. Pathology specimens confirmed the presence of an ALTR. This report presents a previously undescribed case of an ALTR secondary to MoM THA in the absence of elevated serum metal ion levels. This indicates the necessity of considering all aspects of a patient's clinical presentation, imaging modalities, and laboratory testing in the evaluation and diagnosis of a symptomatic MoM THA. [Orthopedics. 2018; 41(3):e438-e441.].

A classification-based approach to the patella in revision total knee arthroplasty.

BACKGROUND: There is a paucity of data to guide management of the patella in revision total knee arthroplasty (RTKA). The purpose of this study was to review our experience with patellar management in RTKA. METHODS: We retrospectively reviewed 422 consecutive RTKAs at a minimum of 2 years (mean, 42 months). Patellar management was guided by a classification that considered stability, size, and position of the implanted patellar component, thickness/quality of remaining bone stock, and extensor mechanism competence. RESULTS: Management in 304 aseptic revisions included retention of a well-fixed component in 212 (69.7%) and revision using an all-polyethylene component in 46 (15.1%). Patella-related complications included 5 extensor mechanism ruptures (1.6%), 3 cases of patellar maltracking (1.0%), and 2 periprosthetic patellar fractures (0.7%). Of 118 2-stage revisions for infection, an all-polyethylene component was used in 88 (74.6%), patelloplasty in 20 (16.9%), and patellectomy in 7 (5.9%). Patella-related complications included 4 cases of patellar maltracking (3.4%), 3 extensor mechanism ruptures (2.5%), and 1 periprosthetic patellar fracture (0.8%). CONCLUSIONS: Septic revisions required concomitant lateral releases more frequently (38.1% vs 10.9%; P < .02) but had a similar rate of patellar complications (6.8% vs 3.3%; P = .40). No cases required rerevision specifically for failure of the patellar component. Patients who had a patelloplasty had worse postoperative Knee Society functional scores than those with a retained or revised patellar component. In most aseptic RTKAs, a well-fixed patellar component can be retained. If revision is required, a standard polyethylene component is sufficient in most septic and aseptic revisions. Rerevisions related to the patellar component are infrequent.

Same-Day Discharge Compared with Inpatient Hospitalization Following Hip and Knee Arthroplasty.

BACKGROUND: Discharge from the hospital on the day of (same-day) hip and knee arthroplasties has become more common; however, to our knowledge, few studies have compared morbidity between same-day and inpatient surgical procedures. The aims of this study were to compare matched cohorts of patients who underwent same-day and inpatient hip or knee arthroplasty in terms of postoperative complications and 30-day readmission rates. METHODS: Patients who underwent primary elective total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty from 2005 to 2014 were identified from the National Surgical Quality Improvement Program registry. Patients discharged the day of the surgical procedure were matched 1:1 with patients who had an inpatient stay using propensity scores. The rates of 30-day adverse events and readmission were compared between matched cohorts using the McNemar test. Risk factors for 30-day readmission following same-day procedures were identified using multivariate regression. RESULTS: Of 177,818 patients identified, 1,236 (0.70%) underwent a same-day surgical procedure. After matching, there were no differences in overall adverse events or readmission between same-day and inpatient groups, although inpatients had increased thromboembolic events (p = 0.048) and same-day patients had an increased rate of return to the operating room (p = 0.016). When procedures were assessed individually, the only difference identified was that the same-day total knee arthroplasty cohort had an increased return to the operating room compared with the inpatient total knee arthroplasty cohort (p = 0.046). Body mass index of ≥35 kg/m (p = 0.035), insulin-dependent diabetes (p = 0.041), non-insulin-dependent diabetes (p = 0.013), and age of ≥85 years (p = 0.039) were associated with 30-day readmission following same-day surgical procedures. Infection was the most common reason for reoperation and readmission following same-day procedures. CONCLUSIONS: No significant differences in overall postoperative complications or readmission were found between matched cohorts of patients who underwent same-day and inpatient hip and knee arthroplasties, although inpatients had a higher rate of thromboembolic events and same-day patients had a higher rate of reoperation. Patients with a body mass index of ≥35 kg/m, diabetes, and an age of ≥85 years had an increased risk of 30-day readmission following same-day procedures, which was most commonly due to infection. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Player Statistics in Major League Baseball Players Before and After Achilles Tendon Repair.

BACKGROUND: No currently available literature evaluates the effect of Achilles tendon repair on professional baseball players in the Major League Baseball (MLB). QUESTIONS/PURPOSES: The purpose of this study was to determine the impact of Achilles tendon rupture and repair on MLB players in terms of return to play and batting/fielding performance metrics. METHODS: Achilles tendon rupture data were retrospectively collected using information from the MLB disabled list, injury reports, MLB game summaries, player profiles, and publicly available news articles. Four pair-matched control MLB position players were selected for each of the players who underwent advanced analysis. Baseline characteristics were compared between injured players and controls using Fisher's exact or Student's t test. RESULTS: Overall, the incidence of Achilles tendon rupture reported in MLB has increased substantially since 1996. Rate of return to play in MLB after Achilles tendon rupture and repair is 62% for position players (non-pitchers) who suffer the injury. There was no association of injury with any player metric. Compared with injury to the non-power side, injury to the power side was associated with fewer plate appearances, fewer triples, an increase in percentage of at-bats with strikeouts, and decreased speed score. CONCLUSION: The incidence of Achilles tendon rupture in MLB has increased substantially since 1996. While comparison suggests that overall Achilles tendon injury does not have an effect on MLB player statistics in the years following surgical repair, subset analysis of injury to the rear (power-generating) leg may lead to a decline in those statistics which denote a player's speed and running ability.

Sepsis Within 30 Days of Geriatric Hip Fracture Surgery.

BACKGROUND: Sepsis after hip fracture typically develops from one of the 3 potential infectious sources: urinary tract infection (UTI), pneumonia, and surgical site infection (SSI). The purpose of this investigation is to determine (1) the proportion of cases of sepsis that arises from each of these potential infectious sources; (2) baseline risk factors for developing each of the potential infectious sources; and (3) baseline risk factors for developing sepsis. METHODS: The National Surgical Quality Improvement Program database was searched for geriatric patients (aged >65 years) who underwent surgery for hip fracture during 2005-2013. Patients subsequently diagnosed with sepsis were categorized according to concomitant diagnosis with UTI, SSI, and/or pneumonia. Multivariate regression was used to test for associations while adjusting for baseline characteristics. RESULTS: Among the 466 patients who developed sepsis (2.4% of all patients), 157 (33.7%) also had a UTI, 135 (29.0%) also had pneumonia, and 36 (7.7%) also had SSI. The rate of sepsis was elevated in patients who developed UTI (13.0% vs 1.7%; P < .001), pneumonia (18.2% vs 1.8%; P < .001), or SSI (14.8% vs 2.3%; P < .001). The mortality rate was elevated among those who developed sepsis (21.0% vs 3.8%; P < .001). CONCLUSION: Sepsis occurs in about 1 in 40 patients after geriatric hip fracture surgery. Of these septic cases, 1 in 3 is associated with UTI, 1 in 3 with pneumonia, and 1 in 15 with SSI. The cause of sepsis is often unknown on clinical diagnosis, and this distribution of potential infectious sources allows clinicians for direct identification and treatment.

A Prospective Randomized Trial of Mini-Incision Posterior and 2-Incision Total Hip Arthroplasty: Minimum 5-Year Follow-Up.

BACKGROUND: We previously described the results of a randomized controlled trial of mini-posterior vs 2-incision total hip arthroplasty and were unable to demonstrate significant differences in early outcomes. As less-invasive anterior approaches remain popular, the purpose of this report was to re-examine the outcomes at a minimum 5-year follow-up. METHODS: Seventy-two patients undergoing primary total hip arthroplasty were randomized to a mini-posterior or 2-incision approach. Complications, revisions, and clinical outcome measures were compared. Radiographs were reviewed for implant loosening. A power analysis using a minimal clinically important difference value of 6 points for the Harris hip score revealed 28 patients required per group. RESULTS: At a mean of 8.2 years (range, 5-10 years), 6 patients died without revision surgery and 63 of 66 living patients were reviewed. There were 6 total failures, 3 in each group. For unrevised patients, there were no significant differences between groups (posterior vs 2-incision) in the Harris hip score (95.5 ± 3.5 vs 95.7 ± 6.3; P = .88), 12-item Short Form Survey physical composite score (50.5 ± 8.5 vs 49.0 ± 9.1; P = .53), 12-item Short Form Survey mental composite score (57.3 ± 4.1 vs 55.4 ± 8.0; P = .25), or single assessment numeric evaluation score (97.1 ± 3.7 vs 97.8 ± 5.2; P = .55). CONCLUSION: We found no differences in midterm outcomes between the 2 approaches. Given the increased complexity, operative time, and need for fluoroscopy with the 2-incision approach combined with equivalent early and midterm outcomes, the 2-incision approach has been abandoned in the senior author's practice.