How-To Create an Orthopaedic Systematic Review: A Step-by-step Guide Part II: Study Execution.

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review.

High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA.

BACKGROUND: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it. QUESTIONS/PURPOSES: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms? METHODS: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs. RESULTS: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]). CONCLUSION: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Custom Triflange Acetabular Implants for Complex Hip Revisions: A Case Series.

Revision total hip arthroplasty (THA) presents a formidable challenge when addressing extensive acetabular defects, particularly in severe cases classified under Paprosky types 3A and 3B and American Academy of Orthopaedic Surgeons types 3 and 4. Traditional methods often fall short, prompting the potential use of custom triflange acetabular components or patient-specific acetabular implants (PSAIs). These implants are specifically designed to conform to an individual's anatomy, aiming to enhance defect reconstruction and pelvic stabilization. This case series describes the utilization of advanced 3-dimensional printing and rapid prototyping technologies to construct customized acetabular components, which can be instrumental in enabling precise preoperative planning and surgical execution for these difficult acetabular cases and potentially leading to improved surgical outcomes.

How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide. Part III: Executing a Meta-Analysis.

At the top of the evidence-based pyramid, systematic reviews stand out as the most powerful, synthesizing findings from numerous primary studies. Specifically, a quantitative systematic review, known as a meta-analysis, combines results from various studies to address a specific research question. This review serves as a guide on how to: (1) design; (2) perform; and (3) publish an orthopedic arthroplasty systematic review. In Part III, we focus on how to design and perform a meta-analysis. We delineate the advantages and disadvantages of meta-analyses compared to systematic reviews, acknowledging their potential challenges due to time constraints and the complexities posed by study heterogeneity and data availability. Despite these obstacles, a well-executed meta-analysis contributes precision and heightened statistical power, standing at the apex of the evidence-based pyramid. The design of a meta-analysis closely mirrors that of a systematic review, but necessitates the inclusion of effect sizes, variability measures, sample sizes, outcome measures, and overall study characteristics. Effective data presentation involves the use of forest plots, along with analyses for heterogeneities and subgroups. Widely-used software tools are common in this domain, and there is a growing trend toward incorporating artificial intelligence software. Ultimately, the intention is for these papers to act as foundational resources for individuals interested in conducting systematic reviews and meta-analyses in the context of orthopaedic arthroplasty, where applicable.

How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide Part I: Study Design.

Systematic reviews are conducted through a consistent and reproducible method to search, appraise, and summarize information. Within the evidence-based pyramid, systematic reviews can be at the apex when incorporating high-quality studies, presenting the strongest form of evidence given their synthesis of results from multiple primary studies to level IV evidence, depending on the studies they incorporate. When combined and supplemented with a meta-analysis using statistical methods to pool the results of 3 or more studies, systematic reviews are powerful tools to help answer research questions. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic arthroplasty systematic review and meta-analysis. In Part I, we discuss how to develop an appropriate research question as well as source and screen databases. To date, commonly used databases to source studies include PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science. Although not all-encompassing, this paper serves as a starting point for those interested in performing and/or critically reviewing lower extremity arthroplasty systematic reviews and meta-analyses.

Are Femoral Stems in Primary Total Knee Arthroplasty Cost Effective in High Fracture Risk Patients? A Risk Model and Cost Analysis.

Femoral stemmed total knee arthroplasty (FS TKA) may be used in patients deemed higher risk for periprosthetic fracture (PPF) to reduce PPF risk. However, the cost effectiveness of FS TKA has not been defined. Using a risk modeling analysis, we investigate the cost effectiveness of FS in primary TKA compared with the implant cost of revision to distal femoral replacement (DFR) following PPF. A model of risk categories was created representing patients at increasing fracture risk, ranging from 2.5 to 30%. The number needed to treat (NNT) was calculated for each risk category, which was multiplied by the increased cost of FS TKA and compared with the cost of DFR. The 50th percentile implant pricing data for primary TKA, FS TKA, and DFR were identified and used for the analysis. FS TKA resulted in an increased cost of $2,717.83, compared with the increased implant cost of DFR of $27,222.29. At 50% relative risk reduction with FS TKA, the NNT for risk categories of 2.5, 10, 20, and 30% were 80, 20, 10, and 6.67, respectively. At 20% risk, FS TKA times NNT equaled $27,178.30. A 10% absolute risk reduction in fracture risk obtained with FS TKA is needed to achieve cost neutrality with DFR. FS TKA is not cost effective for low fracture risk patients but may be cost effective for patients with fracture risk more than 20%. Further study is needed to better define the quantifiable risk reduction achieved in using FS TKA and identify high-risk PPF patients.

Journal Metrics of Orthopaedic Journals between 2016 and 2021: Trends and Comparisons with Other Specialties.

Bibliometric analysis plays a crucial role in elucidating publication trends and aids scholars in gauging the reach of prospective journals for their research dissemination. Concerns with impact factor (IF) have led us to examine the trends in IF, corrected IF (cIF), and Citescore in orthopaedic journals from 2016 to 2021 and compare them with internal medicine and general surgery journals. Journal IF and cIF were obtained from Journal Citation Reports and Citescore data from the Elsevier Scopus database for the years 2016 to 2021. Orthopaedic journals were categorized, and 10 medicine and surgery journals were selected for comparison. Mean values were analyzed to identify trends. The study included 52 orthopaedic journals, evenly split between the United States and the rest of the world, predominantly publishing in English. Mean IF in orthopaedic journals increased from 1.93 (2016) to 2.78 (2021), with similar rises in cIF and Citescore. These trends were consistent in specialty and general orthopaedic journals. No significant differences were found in mean IF between these categories. Medicine and surgery journals also experienced significant IF increases. Orthopaedic journals have experienced growing esteem and extent from 2016 to 2021. Specialty and general orthopaedic journals showed parallel growth. Researchers can utilize this analysis for informed publishing decisions, potentially expanding their readership.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020).

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

Intraincisional Pin Placement is Safe for Robotic-Assisted Total Knee Arthroplasty.

BACKGROUND: While robotic-arm assisted total knee arthroplasty (RA-TKA) has seen a major increase in its utilization, it requires bone array pins to be fixed into the femur and tibia, which intrinsically carries a risk. As it is currently off-label with some robotic platforms to place pins intraincisional, we aimed to evaluate the safety of intraincisional pin placement during RA-TKAs. METHODS: A prospective cohort of 2,343 patients who underwent RA-TKA at a North American Healthcare System between January 2018 and March 2022 was included. Primary outcomes included periprosthetic fracture or infection (eg, superficial or deep). Secondary outcomes included 1-year reoperation rate due to any cause. Cases were retrospectively reviewed to determine whether complications could be attributed to metaphyseal intraincisional pin placement (4.0 mm pins; two tibial and two femoral). The 90-day follow-up was 100% and the 1-year follow-up rate was 70.6% (n = 1,655). RESULTS: The pin-site related periprosthetic fracture incidence at 90 days was 0.09% (2 out of 2,343). The 90-day infection incidence was 1.4% (superficial: 22; deep: 13). The 1-year reoperation rate was 1.8% (29 out of 1,655). The most common causes of reoperation at 1-year were deep infection (n = 14; 0.83%), superficial infection (n = 3; 0.18%), periprosthetic fracture, mechanical symptoms, instability, and hematoma (n = 2; 0.12% for each). CONCLUSIONS: One in 1,172 patients may experience a pin-related periprosthetic fracture after RA-TKA with intraincisional bone array pin placement. There was a low 90-day infection incidence and reoperations within 1-year after RA-TKA were rare.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

BACKGROUND: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. RESULTS: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. DISCUSSION: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

A Longitudinal Analysis of Weight Changes before and after Total Knee Arthroplasty: Weight Trends, Patterns, and Predictors.

Longitudinal data on patient trends in body mass index (BMI) and the proportion that gains or loses significant weight before and after total knee arthroplasty (TKA) are scarce. This study aimed to observe patients longitudinally for a 2-year period and determine (1) clinically significant BMI changes during the 1 year before and 1 year after TKA and (2) identify factors associated with clinically significant weight changes.A prospective cohort of 5,388 patients who underwent primary TKA at a tertiary health care institution between January 2016 and December 2019 was analyzed. The outcome of interests was clinically significant weight changes, defined as a ≥5% change in BMI, during the 1-year preoperative and postoperative periods, respectively. Patient-specific variables and demographics were assessed as potential predictors of weight change using multinomial logistic regression.Overall, 47% had a stable weight throughout the study period (preoperative: 17% gained, 15% lost weight; postoperative: 19% gained, 16% lost weight). Patients who were older (odds ratio [OR] = 0.95), men (OR = 0.47), overweight (OR = 0.36), and Obese Class III (OR = 0.06) were less likely to gain weight preoperatively. Preoperative weight loss was associated with postoperative weight gain 1 year after TKA (OR = 3.03). Preoperative weight gain was associated with postoperative weight loss 1 year after TKA (OR = 3.16).Most patients maintained a stable weight before and after TKA. Weight changes during the 1 year before TKA were strongly associated with reciprocal rebounds in BMI postoperatively, emphasizing the importance of ongoing weight management during TKA and the recognition of patients at higher risk for weight gain.Level of evidence II (prospective cohort study).

Hip Abductor Reconstruction with the Use of Mesh and Distal Cerclage Cable Fixation: A Case Report and Surgical Technique.

CASE: This is a case of a 71-year-old female patient with recurrent instability and complex hip abductor deficiency after total hip arthroplasty (THA) who was treated successfully with an abductor reconstruction with gluteal transfer with mesh reconstruction. The patient returned to nonassisted ambulation with no further THA dislocations at the 1-year follow-up. CONCLUSION: Abductor deficiencies after THA are complex and have a high potential for long-term disability if not properly diagnosed and treated. A modified gluteal transfer with mesh reconstruction and distal fixation with cerclage cable allowed for sustained restoration of functional hip abduction and stability after revision THA.

Return to Sports and Return to Work After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Return to work (RTW) and sports (RTS) are critical gauges to improvement among patients after total knee arthroplasty (TKA). This study aimed to determine rates, timelines, and prognostic factors associated with RTW and RTS outcomes after primary TKA. METHODS: A systematic review was conducted on MEDLINE, Embase, and CENTRAL databases, with 44 studies meeting inclusion/exclusion criteria. The risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions tool. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios and associated 95% confidence intervals (CIs). RESULTS: The pooled RTW rate across all studies was 65% (95% CI, 51%-77%), with rates varying significantly from 10% to 98%. The mean time to RTW was of 12.9 weeks (range, 5-42). A time point analysis showed increasing RTW rates with a maximum rate at 1 year of 90%. Increased age was associated with lower RTW rates (p < 0.001). The RTS rate ranged from 36% to 100%, with a pooled rate of 82% (95% CI, 72%-89%). The mean time to RTS was 20.1 weeks (range, 16-24). A wide range of reported recurrence rates was observed among different sports (subgroup differences, p ≤ 0.001). The RTS ranged from 43% to 98%, with a pooled proportion of 76% (95% CI, 59%-87%, I2 = 91%) for low-intensity sports, and from 0% to 55% for high-intensity sports, with a pooled proportion of 35% (95% CI, 20-52, I2 = 70%). CONCLUSION: Most patients successfully return to sports and work after TKA, with rates of RTW increasing to 90% after 1 year. Such outcomes are heavily influenced by nonmodifiable (e.g., age) and modifiable (e.g., intensity of sports/employment) factors. Generally, young adults and patients with low-demand jobs can be reinitiated earlier, albeit with increasing restrictions with rising intensity. Providers should screen patients for desire to RTW and/or RTS after surgery and provide appropriate recommendations as part of necessary preoperative education and postoperative care. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Fractures Sustained During Total Knee Arthroplasty: A Critical Analysis Review.

¼ While the occurrence of postoperative periprosthetic fractures around total knee arthroplasties (TKAs) are well reported, little is known about intraoperative fractures that occur during TKA. Intraoperative fractures during TKA can occur in femur, tibia, or patella. It is a rare complication with an incidence of 0.2% to 4.4%.¼ Risk factors of periprosthetic fractures include osteoporosis, anterior cortical notching, chronic corticosteroid use, advanced age, female sex, neurologic disorders, and surgical technique.¼ Fractures can potentially occur at any stage of the TKA including exposure, bone preparation, placement of trial components, cementation, insertion of the final components, and seating of the polyethylene insert. Forced flexion during trialing increases the risk for patella fracture, tibial plateau, or tubercle fractures especially when there is under resection of the bone.¼ Management guidelines for these fractures are lacking with current options being observation, internal fixation, the use of stems and augments, increasing constraint of the prosthesis, implant revision, and modifying the postoperative rehabilitation.¼ Finally, the outcomes of intraoperative fractures are not well reported in the literature.

Team Approach: Use of Opioids in Orthopaedic Practice.

¼: The opioid epidemic represents a serious health burden on patients across the United States. ¼: This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions. ¼: The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use. ¼: Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available. ¼: The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.