Did the Comprehensive Care for Joint Replacement Bundled Payment Program Impact Sex Disparities in Total Hip and Knee Arthroplasties?

BACKGROUND: Sex disparities have been noted across various aspects of total hip/knee arthroplasty (THA/TKA). Given incentives to standardize care, bundled payment initiatives including the Comprehensive Care for Joint Replacement (CJR) program may reduce disparities. This study aimed to assess the CJR program's impact on sex disparities in THA/TKA care and outcomes. METHODS: This retrospective cohort study included 259,673 THAs (61.7% women) and 506,311 TKAs (64.0% women) from a large national database (2013 to 2017). Sex disparities were assessed for care and outcomes related to the period (1) before surgery, (2) during hospitalization for THA/TKA, and (3) after discharge. Disparities were reported as women:men ratios. Difference-in-differences analyses estimated the impact of the CJR program on pre-existing sex disparities. RESULTS: For both THA and TKA, women were less likely than men to present with a Charlson-Deyo comorbidity index >0 (women:men ratio 0.88 to 0.92), but were more likely to require blood transfusions (women:men ratio 1.48 to 1.79) and be discharged to institutional postacute care (women:men ratio 1.50 to 1.66). Difference-in-differences models demonstrated that the CJR bundled payment program reduced sex disparities in institutional postacute care discharges (THA: -2.28%; 95% confidence interval [CI] -4.20 to -0.35%, P = .02; TKA: -2.07%; 95% CI -3.93 to -0.20%; P = .03) and THA 90-day readmissions (-1.00%, 95% CI -1.88 to -0.13%, P = .02), indicating a differential impact of CJR in women versus men for some outcomes. CONCLUSIONS: While sex disparities in THA/TKA persist, the CJR program demonstrates potential to impact such differences. Future research should focus on how potential mechanisms could be leveraged to reduce disparities.

Randomized Controlled Trials Comparing Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction Surgery Are Statistically Fragile: A Systematic Review.

PURPOSE: To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction. METHODS: The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size. RESULTS: We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI. CONCLUSIONS: There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions. CLINICAL RELEVANCE: We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT.

Prior COVID-19 and Venous Thromboembolism Risk in Total Joint Arthroplasty in Patients Over 65 Years of Age.

BACKGROUND: The COVID-19 pandemic has been associated with increased risks of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, there is limited literature investigating prothrombotic states and complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We investigated (1) trends in VTE, PE, and DVT rates post-THA and TKA from 2016 to 2019 compared to 2020 to 2021 and (2) associations between prior COVID-19 diagnosis and VTE, PE, and DVT. METHODS: A national dataset was queried for elective THA and TKA cases from 2016 to 2021. We first assessed trends in 90-day VTE prevalence between 2016 to 2019 and 2020 to 2021. Second, we investigated associations between previous COVID-19 and 90-day VTE with regression models. RESULTS: From 2016 to 2021, a total of 2,422,051 cases had an annual decreasing VTE prevalence from 2.2 to 1.9% (THA) and 2.5 to 2.2% (TKA). This was evident for both PE and DVT (all trend tests P < .001). After adjusting for covariates (including vaccination status), prior COVID-19 was associated with significantly increased odds of developing VTE in TKA patients (odds ratio 1.2, 95% confidence interval 1.1 to 1.4, P = .007), but not DVT or PE (P > .05). There were no significant associations between prior COVID-19 and VTE, DVT, or PE after THA (P > .05). CONCLUSIONS: Our study suggests that a previous diagnosis of COVID-19 is associated with increased odds of VTE, but not DVT or PE, in TKA patients. Ongoing data monitoring is needed given our effect estimates, emerging COVID-19 variants, and evolving vaccination rates.

The iliac kickstand screw: anatomic CT analysis of screw trajectory and osseous corridor for screw placement.

INTRODUCTION: The 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium. OBJECTIVE: Using a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw. METHODS: 50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured. RESULTS: 50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes. CONCLUSIONS: The novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.

Did the COVID-19 Pandemic Coincide With an Increase in Osteonecrosis as Indication for Total Hip Arthroplasty in Older Patients?

BACKGROUND: Osteonecrosis of the femoral head is a common indication for total hip arthroplasty (THA). It is unclear to what extent the COVID-19 pandemic has impacted its incidence. Theoretically, the combination of microvascular thromboses and corticosteroid use in patients who have COVID-19 may increase the risk of osteonecrosis. We aimed to (1) assess recent osteonecrosis trends and (2) investigate if a history of COVID-19 diagnosis is associated with osteonecrosis. METHODS: This retrospective cohort study utilized a large national database between 2016 and 2021. Osteonecrosis incidence in 2016 to 2019 was compared to 2020 to 2021. Secondly, utilizing a cohort from April 2020 through December 2021, we investigated whether a prior COVID-19 diagnosis was associated with osteonecrosis. For both comparisons, Chi-square tests were applied. RESULTS: Among 1,127,796 THAs performed between 2016 and 2021, we found an osteonecrosis incidence of 1.6% (n = 5,812) in 2020 to 2021 compared to 1.4% (n = 10,974) in 2016 to 2019; P < .0001. Furthermore, using April 2020 to December 2021 data from 248,183 THAs, we found that osteonecrosis was more common among those who had a history of COVID-19 (3.9%; 130 of 3,313) compared to patients who had no COVID-19 history (3.0%; 7,266 of 244,870); P = .001). CONCLUSION: Osteonecrosis incidence was higher in 2020 to 2021 compared to previous years and a previous COVID-19 diagnosis was associated with a greater likelihood of osteonecrosis. These findings suggest a role of the COVID-19 pandemic on an increased osteonecrosis incidence. Continued monitoring is necessary to fully understand the impact of the COVID-19 pandemic on THA care and outcomes.

Female Authorship in the US Orthopaedics Literature: A Bibliometric Analysis of Trends.

INTRODUCTION: Although orthopaedic surgery continues to be the field with the smallest proportion of women, efforts have been made to increase the gender diversity in the workforce. Some data exist on how this increased female representation manifests itself in research and authorship. However, a comprehensive overview-beyond general orthopaedics journals and including subspecialty journals-is currently missing. The objective of this study was to analyze female authorship trends in four high-impact general orthopaedic journals and the highest impact journal in each orthopaedic subspecialty. METHODS: This bibliometric analysis extracted original research articles published from groups within the United States from Medline from January 2011 to December 2020. We included four high-impact general orthopaedic journals and the highest impact journal in eight orthopaedic subspecialties. Authors' gender was determined using the 'gender' R package. We assessed annual proportion of female authors in first authors, last authors, and any author, separately for all included articles and stratified by journal. Authorship was assessed by Cochran-Armitage trend tests. RESULTS: There has been increasing female authorship from 2011 to 2020 for female first authors, but not female last authors or total authorship. Of the journals studied, 3 of 12 had a markedly increased percentage of female first authors and 1 of 12 had a markedly increased percentage of female last authors, and there were no journals with an increasing total amount of female total authors. DISCUSSION: The increasing trend in female authorship is primarily due to increases in first author publications and is not consistent across subspecialty journals. Future research should identify driving factors for these differences and potential methods to increase representation.

Complications After Percutaneous Osteotomies of the Calcaneus.

Background: Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies. Methods: One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables. Results: The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity. Discussion: In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication. Level of Evidence: Level IV, retrospective analysis.

Association of Drain Use in Ankle Arthrodesis With Increased Blood Transfusion Risk: A National Observational Study.

Background: Closed wound drainage has been extensively studied in the hip and knee arthroplasty literature with equivocal results on its clinical benefits. Although also used in orthopaedic surgeries like ankle arthrodesis and ankle arthroplasty, large-scale data are currently lacking on utilization patterns and real-world effectiveness. We, therefore, aimed to address this research gap in this distinct surgical cohort using national claims data. Methods: Using the Premier Healthcare claims database from 2006 to 2016, ankle arthrodesis (n=10,085) and ankle arthroplasty (n=4,977) procedures were included. The main effect was drain use, defined by detailed billing descriptions. Outcomes included blood transfusion, 90-day readmission, and length and cost of hospitalization. Mixed-effects models measured associations between drain use and outcomes. Odds ratios (OR, or % change), 95% CIs, and P values are reported. Results: Overall, drains were used in 11% (n=1,074) and 15% (n=755) of ankle arthrodesis and ankle arthroplasty procedures, respectively. Drain use dramatically decreased over the years in both surgery types: from 14% to 6% and 24% to 7% between 2006 and 2016, for arthrodesis and ankle arthroplasty procedures, respectively. After adjustment for relevant covariates, drain use was associated with increased odds of blood transfusion in ankle arthrodesis surgery (OR 1.4, CI 1.1-1.8, P = .0168), whereas differences that were statistically but not clinically significant were seen in cost and length of stay. In total ankle arthroplasty, no statistically significant associations were observed between drain use and the selected outcomes. Conclusion: This is the first national study on drain use in ankle surgery. We found a decrease in use over time. Drain use was associated with higher odds of blood transfusion in ankle arthrodesis patients. Although this negative effect may be mitigated by the rapidly decreasing use of drains, future studies are needed to discern drivers of drain use in this distinct surgical population. Level of Evidence: Level III, retrospective cohort study.

Racial Differences in Care and Outcomes After Total Hip and Knee Arthroplasties: Did the Comprehensive Care for Joint Replacement Program Make a Difference?

BACKGROUND: There is a paucity of literature on racial differences across a full total joint arthroplasty (TJA) "episode of care" and beyond. Given various incentives, the Comprehensive Care for Joint Replacement (CJR) program in the U.S. may have impacted preexisting racial differences across this care continuum. The purposes of the present study were (1) to assess trends in racial differences in care/outcome characteristics before, during, and after TJA surgery and (2) to assess if the CJR program coincided with reductions in these racial differences. METHODS: This retrospective cohort study includes data on 1,483,221 TJAs (based on Medicare claims data, 2013 to 2018). Racial differences between Black and White patients were assessed for (1) preoperative characteristics (Deyo-Charlson comorbidity index, patient sex, and age), (2) characteristics during hospitalization (length of stay, blood transfusions, and combined complications), and (3) postoperative characteristics (90 and 180-day readmission rates and institutional post-acute care). Additionally, Medicare payments for each period were assessed. Racial differences (Black versus White patients) were expressed in terms of odds ratios (ORs) and 95% confidence intervals (CIs) per year. A "difference-in-differences" analysis (comparing before and after CJR implementation, with non-CJR hospitals being used as controls) estimated the association of the CJR program with changes in racial differences. RESULTS: In both 2013 and 2018, Black patients (n = 74,390; 5.0%) were more likely than White patients to have a higher Deyo-Charlson comorbidity index (score of >0) (OR = 1.32 [95% CI = 1.28 to 1.36] and OR = 1.32 [95% CI = 1.28 to 1.37]), to require more transfusions (OR = 1.55 [95% CI = 1.49 to 1.62] and OR = 1.77 [95% CI = 1.56 to 2.01]), to be discharged to institutional post-acute care (OR = 1.40 [95% CI = 1.36 to 1.44] and OR = 1.49 [95% CI = 1.43 to 1.56]), and to be readmitted within 90 days (OR = 1.38 [95% CI = 1.32 to 1.44] and OR = 1.21 [95% CI = 1.13 to 1.29]) (p < 0.05 for all). Adjusted difference-in-differences analyses demonstrated that the CJR program coincided with reductions in racial differences in 90-day readmission (-1.24%; 95% CI, -2.46% to -0.03%) and 180-day readmission (-1.28%; 95% CI, -2.52% to -0.03%) (p = 0.044 for both). CONCLUSIONS: Racial differences persist among patients managed with TJA. The CJR program coincided with reductions in some racial differences, thus identifying bundle design as a potential novel strategy to target racial disparities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hand and Upper Extremity Trauma in the Undocumented Immigrant Population in the United States.

Undocumented immigrants in the United States are at risk for upper extremity trauma due to occupational exposure, and decreased access to healthcare can worsen outcomes. The purpose of this study was to compare documented versus undocumented patients in a large cohort of patients in New York City's most diverse neighborhood in order to characterize upper extremity trauma in this population. METHODS: The Elmhurst Hospital trauma database was examined for patients admitted with upper extremity trauma from April 2016 to December 2019. Charts were examined for demographic information, documentation status, injury mechanism, and outcomes. RESULTS: Of the 1041 patients included, 865 (83.1%) were documented and 176 (16.9%) were undocumented. Undocumented immigrants were younger (40.5 versus 62.4 years, P < 0.0001) and predominantly men (83.5% versus 57.1%, P < 0.0001) with fewer comorbidities (42.6% versus 64.6%, P < 0.0001). Occupational injury was three times as likely in undocumented immigrants (13.6% versus 4.6%, P < 0.0001) and these patients were nearly twice as likely to be harmed from violence (19.9% versus 10.2%, P = 0.0003). Increased rates of injury during bicycle/motorcycle accidents (8.0% versus 3.0%, P = 0.0017) or being struck as a pedestrian (21.6% versus 14.3%, P = 0.0149) were found in the undocumented cohort, with falls (39.8% versus 59.3%, P < 0.0001) or vehicle collisions (0.6% versus 3.5%, P = 0.0402). CONCLUSIONS: Undocumented patients with upper extremity trauma represent a younger/healthier cohort, but are more likely to be injured at work or by violence. Documentation status plays a role in injury characteristics.

Trends in Private Equity Acquisition of Orthopaedic Surgery Practices in the United States.

BACKGROUND: Independent orthopaedic practices in the United States have become attractive targets for acquisition by hospital systems and private equity (PE) firms because of the increasing demand for outpatient surgery. Consolidation in this market will have notable effects on the delivery and cost of orthopaedic services. In this study, we identified major trends in orthopaedic practice acquisitions over the past decade. METHODS: A list of acquisition deals between 2010 and 2019 was compiled from four business databases: S&P Capital IQ, CB Insights, Thomson ONE, and Zephyr. Deals were categorized as PE-backed or not PE-backed. Headquarter locations of the buying and selling companies and transaction value were obtained for each deal when available. RESULTS: A total of 68 deals were obtained of which 5 (7.4%) were PE-backed. The buyer and seller were located in the same state in 50 (73.5%) of the deals. Transaction values were available for only four deals ranging from $2.52 million to $35 million. CONCLUSION: Our results suggest that consolidation of orthopaedic practices from 2010 to 2019 was driven by large healthcare entities rather than PE firms. Furthermore, intrastate acquisitions were markedly more common than interstate acquisitions, possibly because of greater legal feasibility and ease of clinical integration.

Development of a standardized histopathology scoring system for intervertebral disc degeneration in rat models: An initiative of the ORS spine section.

BACKGROUND: Rats are a widely accepted preclinical model for evaluating intervertebral disc (IVD) degeneration and regeneration. IVD morphology is commonly assessed using histology, which forms the foundation for quantifying the state of IVD degeneration. IVD degeneration severity is evaluated using different grading systems that focus on distinct degenerative features. A standard grading system would facilitate more accurate comparison across laboratories and more robust comparisons of different models and interventions. AIMS: This study aimed to develop a histology grading system to quantify IVD degeneration for different rat models. MATERIALS & METHODS: This study involved a literature review, a survey of experts in the field, and a validation study using 25 slides that were scored by 15 graders from different international institutes to determine inter- and intra-rater reliability. RESULTS: A new IVD degeneration grading system was established and it consists of eight significant degenerative features, including nucleus pulposus (NP) shape, NP area, NP cell number, NP cell morphology, annulus fibrosus (AF) lamellar organization, AF tears/fissures/disruptions, NP-AF border appearance, as well as endplate disruptions/microfractures and osteophyte/ossification. The validation study indicated this system was easily adopted, and able to discern different severities of degenerative changes from different rat IVD degeneration models with high reproducibility for both experienced and inexperienced graders. In addition, a widely-accepted protocol for histological preparation of rat IVD samples based on the survey findings include paraffin embedding, sagittal orientation, section thickness < 10 µm, and staining using H&E and/or SO/FG to facilitate comparison across laboratories. CONCLUSION: The proposed histological preparation protocol and grading system provide a platform for more precise comparisons and more robust evaluation of rat IVD degeneration models and interventions across laboratories.

Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play).

Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.