Periprosthetic Fractures: A Rising Tide of Hip Arthroplasty Failure Noted in the American Joint Replacement Registry and the Preventative Role of Cemented Stems.

BACKGROUND: This investigation examined cemented femoral component use in total hip arthroplasty (THA) and its impact on the incidence of periprosthetic fractures (PPFx), a common failure mode in THA. The study leverages data from the American Joint Replacement Registry (AJRR) to assess trends in cemented femoral component usage over time, its association with PPFx rates, and compares the survivorship and 90-day complication rates between cemented and cementless femoral component THAs. METHODS: Primary THAs, captured in the AJRR, in patients aged 65 years and older from 2012 to 2021 were analyzed. Variables considered included age, sex, race, region, teaching status, year, Charlson Comorbidity Index (CCI), and institution bed size. Analysis compared fixation types for THA on all-cause linked revision and PPFx. Logistic regression models analyzed the odds ratios for all-cause linked revision and PPFx for any follow-up time as well as for 90-day revision. The models were adjusted for the listed variables. RESULTS: During the study period, the rate of cement utilization as a percentage of primary THAs performed and reported to the AJRR increased from 4.4 to 8.3%. The rate of THA failure from PPFx increased from 11.4 to 33.3%. When both fixation groups were compared in the univariate analysis, there was a statistically significant difference in all demographic variables (P < 0.001). To account for this, multivariable logistic regression models were applied. In our models, cemented stems showed a 54.4% (OR [odds ratio]: 0.456, 95% CI [confidence interval]: 0.347 to 0.599, P < 0.0001) and 65.8% (OR: 0.342, 95% CI: 0.237 to 0.493, P < 0.0001) lower risk of PPFx linked and PPFx early linked revision, respectively. CONCLUSION: Periprosthetic fractures are becoming a leading failure mode for THAs in the AJRR. Given cemented fixation's relative resistance to this failure mode compared to cementless fixation, we should consider increasing the utilization of this technique.

Lower Associated Risk of Revision with All-Polyethylene Tibial Components in Total Knee Arthroplasty: An Analysis of the American Joint Replacement Registry.

BACKGROUND: Despite the potential advantage of all-polyethylene tibial components, modular metal-backed component use predominates the market in the United States for total knee arthroplasty (TKA). This is partially driven by concerns about the associated revision risk due to the lack of modularity with all-polyethylene components. This study utilized the American Joint Replacement Registry (AJRR) to compare the associated risk of all-cause revision and revision for infection for all-polyethylene versus modular metal-backed tibial components. METHODS: An analysis of primary TKA cases in patients aged 65 years and older was performed with AJRR data linked to Centers for Medicare and Medicaid Services data from 2012 to 2019. Analyses compared all-polyethylene to modular metal-backed tibial components. We identified 485,024 primary TKA cases, consisting of 479,465 (98.9%) metal-backed and 5,559 (1.1%) all-polyethylene. Cox proportional hazard regression analyses created hazard ratios (HRs) to evaluate the association of design and the risk of all-cause revision while adjusting for sex, age and the competing risk of mortality. Event-free survival curves evaluate time to revision. RESULTS: The all-polyethylene tibia group demonstrated a decreased risk for all-cause revision (HR = 0.37, 95% CI [confidence interval]: 0.24 to 0.55, P < 0.0001) and revision for infection (HR = 0.41, 95% CI: 0.22 to 0.77, P < 0.0001). Event-free survival curves demonstrated a decreased risk of all-cause revision that persisted across time points until 8 years post-TKA. CONCLUSION: In the United States, all-polyethylene tibial component use for TKA remains low compared to modular metal-backed designs. A decreased associated risk for revision should ease concerns about the use of all-polyethylene components in patients aged 65 years or older, and future investigations should investigate the potential cost and value savings associated with expanded use in this population.

Antibiotic calcium sulphate beads lower the bacterial burden and prevent infection in a mouse model of periprosthetic joint infection.

Aims: Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation. Methods: A mouse model of PJI of the knee was used. Mice were randomized into groups with intervention at the time of surgery (postoperative day (POD) 0): a sterile control (SC; n = 6); infected control (IC; n = 15); systemic vancomycin (SV; n = 9); vancomycin powder (VP; n = 21); and vancomycin bead (VB; n = 19) groups. Delayed inoculation was introduced during an arthrotomy on POD 7 with 1 × 105 colony-forming units (CFUs) of a bioluminescent strain of Staphylococcus aureus. The bacterial burden was monitored using bioluminescence in vivo. All mice were killed on POD 21. Implants and soft-tissue were harvested and sonicated for analysis of the CFUs. Results: The mean in vivo bioluminescence in the VB group was significantly lower on POD 8 and POD 10 compared with the other groups. There was a significant 1.3-log10 (95%) and 1.5-log10 (97%) reduction in mean soft-tissue CFUs in the VB group compared with the VP and IC groups (3.6 × 103 vs 7.0 × 104; p = 0.022; 3.6 × 103 vs 1.0 × 105; p = 0.007, respectively) at POD 21. There was a significant 1.6-log10 (98%) reduction in mean implant CFUs in the VB group compared with the IC group (1.3 × 100 vs 4.7 × 101, respectively; p = 0.038). Combined soft-tissue and implant infection was prevented in 10 of 19 mice (53%) in the VB group as opposed to 5 of 21 (24%) in the VP group, 3 of 15 (20%) in the IC group, and 0% in the SV group. Conclusion: In our in vivo mouse model, antibiotic-releasing calcium sulphate beads appeared to outperform vancomycin powder alone in lowering the bacterial burden and preventing soft-tissue and implant infections.

A Comparative Evaluation of Conventional Instrumentation and Accelerometer-Based Navigation in the Practice of a High-Volume Unicompartmental Knee Arthroplasty (UKA) Surgeon.

Background: Component malpositioning and joint malalignment following unicompartmental knee arthroplasty (UKA) increase the risk for revision. This study investigates whether accelerometer-based navigation (NAV) decreases radiographic outliers with respect to component placement and joint alignment in comparison to conventional instrumentation in UKA. Methods: A radiographic review of UKAs was performed by a single surgeon following adoption of an accelerometry-guided navigation system (OrthAlign, Aliso Viejo, CA). This cohort was then compared to previous patients undergoing UKA with conventional instrumentation. Six-week postoperative radiographs were used to compare femoral coronal and sagittal angles, tibial coronal and sagittal angles, the net coronal angle, tibial component rotation, and medial tibial overhang. Outliers in implant positioning were compared between groups. Patient variables including age, gender, body mass index, American Society of Anesthesiology, and surgical time (incision until the start of closure) were also compared between groups. Results: Eighty-eight UKA's were reviewed (49 conventional instrumentation [CI] patients; 39 NAV patients). Using 2-sample t-tests, no significant differences were found in patient demographics, radiographic parameters, and operative times between the CI and NAV cohorts. Using chi-squared tests, no significant difference was found in the number of radiographic outliers between the CI and NAV cohorts. Conclusions: Our study found that a high-volume UKA surgeon achieved a low rate of radiographic outliers in both NAV and CI cohorts. This data suggests that NAV is no different from conventional instrumentation with respect to implant positioning, overall joint alignment, and operative time when used by a high-volume UKA surgeon.

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study.

BACKGROUND: Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up. METHODS: Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria. RESULTS: Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA. CONCLUSIONS: A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets. LEVEL OF EVIDENCE: Case series (IV).

Comparison of complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures.

INTRODUCTION: Most geriatric hip fractures occur in the femoral neck (FN) and intertrochanteric (IT) regions of the femur, while a minority occur in the subtrochanteric (ST) region. Relative outcomes based on the anatomical subtype of fracture are not well studied. This study characterizes postoperative complications and outcomes of hip fractures distinguished by anatomic region. MATERIALS AND METHODS: The targeted hip fracture series of the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify geriatric (≥ 65 years) patients who sustained operative FN, IT, and ST hip fractures. Primary patient demographic and perioperative data were collected and correlated with 30-day postoperative complications and outcomes. Multivariate regression was used to calculate relative risks of adverse events (AEs) between groups. RESULTS: In total, 8220 geriatric hip fracture patients were identified. Risk-adjusted 30-day mortality was not significantly different between patients with ST (5.8%, p = 0.735) and IT (7.3%, p = 0.169) femur fractures relative to those with FN fractures (6.6%). The overall risk-adjusted rate of minor and major medical AEs within 30 days and risk-adjusted rate of wound complications was not significantly different between FN, IT, and ST fractures. Patients with IT [34.4%, OR 2.35 (2.35-3.08), p < 0.001] and ST fractures [49.8%, OR 5.94 (4.58-7.70), p < 0.00] had higher risk-adjusted incidence of postoperative blood transfusion relative to FN fractures (18.5%). Furthermore, patients with IT fractures had a slightly lower risk-adjusted incidence of unplanned reoperation [2.1 vs. 2.7%, OR 0.69 (0.47-0.99), p = 0.046] and hospital readmission (7.8 vs. 9.2%, OR 0.76 [0.63-0.91], p = 0.003) than patients with FN fractures. CONCLUSIONS: With respect to anatomic region, geriatric hip fractures have similar short-term mortality and medical AE profiles with differences in transfusion, reoperation, and readmission rates. Knowledge of these short-term outcomes may guide surgeons in counseling hip fracture patients peri-operatively.

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty, a National Registry Study.

BACKGROUND: The purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry. METHODS: Adult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA. RESULTS: On multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions. CONCLUSION: Black, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.

Lower Rates of Ceramic Femoral Head Use in Non-White Patients in the United States, a National Registry Study.

BACKGROUND: The purpose of our study was to investigate the association of race and ethnicity with the use of the newest technology and postoperative outcomes in total hip arthroplasty (THA) using the American Academy of Orthopaedic Surgeons (AAOS) American Joint Replacement Registry (AJRR). METHODS: Adult THA procedures were queried from the AJRR from 2012 to 2020. A mixed-effects multivariate regression model was used to evaluate the association of race and ethnicity with the use of the newest technology (ceramic femoral head, dual-mobility implant, and robotic assist) at 30-day, and 90-day readmission. A proportional subdistribution hazard model was used to model a risk of revision THA. RESULTS: There were 85,188 THAs with complete data for an analysis of outcomes and 103,218 for an analysis of ceramic head usage. The median length of follow-up was 37.9 months (interquartile range [IQR] 21.6 to 56.3 months). In multivariate models, compared to White non-Hispanic patients, Black (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.92, P < .001), Hispanic (OR 0.76, CI 0.59-0.99, P = .037), Asian (OR 0.74, CI 0.55-1.00, P = .045), and Native American (OR 0.52, CI 0.30-0.87, P = .004) patients all had significantly lower rates of ceramic head use in THA. Compared to White non-Hispanic patients, Asian (hazard ratio [HR] 0.39, CI 0.18-0.86, P = .008) and Hispanic (HR 0.43, CI 0.19-0.98, P = .043) patients had significantly lower rates of revision. No differences in 30-day or 90-day readmission rates were seen. CONCLUSION: Black, Hispanic, Native American, and Asian patients had lower rates of ceramic head use in THA when compared to White patients. These differences did not translate into worse clinical outcomes on a short-term follow-up. In fact, Asian patients had lower revision rates compared to non-Hispanic White patients. Additional study is necessary to evaluate the long-term consequence of lower ceramic head use in non-White patients in the United States.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes.

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Severity and location of lumbar spine stenosis affects the outcome of total knee arthroplasty.

BACKGROUND: Recent studies have noted that patients with pre-existing lumbar spinal stenosis (LSS) have lower functional outcomes after total knee arthroplasty (TKA). Given that LSS manifests heterogeneously in location and severity, its influence on knee replacement merits a radiographically targeted analysis. We hypothesize that patients with more severe LSS will have diminished knee mobility before and after TKA. METHODS: This retrospective case series assessed all TKAs performed at our institution for primary osteoarthritis from 2017-2020. Preoperative lumbar magnetic resonance image (MRI) with no prior lumbar spine surgery was necessary for inclusion. Stenosis severity was demonstrated by (1) anterior-posterior (AP) diameter of the thecal sac and (2) morphological grade. TKA outcomes in 103 cases (94 patients) were assessed by measuring preoperative and postoperative arc of motion (AOM), postoperative flexion contracture, and need for manipulation under anesthesia. RESULTS: Patients with mild stenosis did significantly better in terms of postoperative knee AOM. As AP diameter decreased at levels L1-2, L2-3, L3-4, and L4-5, there was a significant reduction in preoperative-AOM (p < 0.001 for each), with a 16 degree decrease when using patients' most stenotic level (p < 0.001). The same was noted with respect to increased morphological grade (p < 0.001), with a 5 degree decrease for patients' most stenotic level (p < 0.001). CONCLUSION: Severe LSS, which is readily demonstrated by a reduction in the AP diameter of the thecal sac or increased morphological grade on MRI, correlated with a significant reduction in preoperative AOM that was not improved after TKA. Persistent postoperative reductions in AOM may contribute to reduced patient satisfaction and recovery. LEVEL OF EVIDENCE: Level 4.

Wide en bloc resection of an extraskeletal myxoid chondrosarcoma about the knee with single-stage knee extensor mechanism reconstruction: A case report.

Soft tissue sarcomas about the patellar tendon necessitate wide resection and thus present a significant reconstructive challenge. This article describes the novel use of a synthetic mesh graft to reconstruct the knee extensor mechanism as a single stage procedure after wide en bloc resection of an extraskeletal myxoid chondrosarcoma (EMC) in a patient with an invasive mass that was intimately associated with her patellar tendon.

Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis.

Chronic patellar dislocation in the setting of severe knee osteoarthritis is a rare clinical problem. Surgical management often consists of total knee arthroplasty combined with realignment of the extensor mechanism. Several techniques have been described to anatomically restore the extensor apparatus, and literature regarding this topic consists mainly of case reports. We describe a technique using combined medial patellofemoral ligament reconstruction using allograft tissue and total knee arthroplasty with patellar resurfacing for the treatment of chronic patellar dislocation and severe osteoarthritis.

Blood transfusion rates and predictors following geriatric hip fracture surgery.

BACKGROUND: Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion. RESULTS: In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001). CONCLUSIONS: Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

Surgical Hip Dislocation and Fresh Osteochondral Allograft Transplantation for Femoroacetabular Impingement and Concomitant Chondral Lesion.

Chondral lesions of the hip in young patients are frequently associated with additional articular pathology. Parafoveal osteochondral lesions have been reported to be a manifestation of cam lesions in the setting of femoroacetabular impingement (FAI). Although arthroscopic surgery is useful to treat intra- and extra-articular pathology, large lesions located in areas that are difficult to access represent a limitation of the technique. Open surgical dislocation and osteochondral allograft transplantation (OCA) allow treatment of larger surface areas and underlying morphologic abnormalities such as cam lesions. We present our technique for open surgical dislocation of the hip through a stepped trochanteric osteotomy, osteochondral transplantation of fresh-stored femoral head allograft, and osteoplasty of the head/neck junction.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model.

BACKGROUND: Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA). METHODS: A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion. RESULTS: Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%. CONCLUSION: This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

Postacute Care Utilization in Postsurgical Orthogeriatric Hip Fracture Care.

INTRODUCTION: Among surgical patients, utilization of institutional-based postacute care (PAC) presents a notable financial burden and is associated with increased risk of complications and mortality rates when compared with discharge home. The purpose of this study was to identify predictors of postdischarge disposition to PAC in geriatric patients after surgical fixation of native hip fractures. METHODS: We have done a query of the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained surgical femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to compute risk factors for discharge to and prolonged stay (>30 days) in PAC. RESULTS: Eight thousand one hundred thirty-three geriatric hip fracture patients with sufficient follow-up data were identified. Of these, 6,670 patients (82.0%) were initially discharged to PAC after their hip fracture episode of care, and 2,986 patients (36.7%) remained in PAC for >30 days. Age (odds ratio [OR] 1.06 [1.05 to 1.08], P < 0.001), partial (OR 2.41 [1.57 to 3.71], P < 0.001) or total dependence (OR 3.03 [1.92 to 4.46], P < 0.001) for activities of daily living, dementia (OR 1.62 [1.33 to 1.96], P < 0.001), diabetes (OR 1.46 [1.14 to 1.85], P = 0.002), hypertension (OR 1.32 [1.10 to 1.58], P = 0.002), and total hospital length of stay (OR 1.04 [1.01 to 1.08], P = 0.006) were independent risk factors for discharge to PAC. Age (OR 1.05 [1.04 to 1.06], P < 0.001), partial (OR 2.86 [1.93 to 3.79], P < 0.001) or total dependence (OR 3.12 [1.45 to 4.79], P < 0.001) for activities of daily living, American Society of Anesthesiologist's classification (OR 1.27 [1.13 to 1.43], P < 0.001), dementia (OR 1.49 [1.28 to 1.74], P < 0.001), and total hospital length of stay (OR 1.10 [1.08 to 1.13], P < 0.001) were independent risk factors for prolonged PAC stay >30 days. DISCUSSION: Discharge to PAC is the norm among patients undergoing hip fracture surgery. Provider foreknowledge of risk factors may help improve hip fracture outcomes and decrease healthcare costs.

Contemporary Surgical Indications and Referral Trends in Revision Total Hip Arthroplasty: A 10-Year Review.

BACKGROUND: Revision total hip arthroplasty (THA) represents nearly 15% of all hip arthroplasty procedures in the United States and is projected to increase. The purpose of our study was to summarize the contemporary indications for revision THA surgery at a tertiary referral medical center. We also sought to identify the indications for early and late revision surgery and define the prevalence of outside institution referral for revision THA. METHODS: Using our institution's arthroplasty registry, we identified a retrospective cohort of 870 consecutive patients who underwent revision THA at our hospital from 2004 to 2014. Records were reviewed to collect data on patient's primary and revision THA procedures, and the interval between primary THA and revision surgery was determined. RESULTS: Aseptic loosening (31.3%), osteolysis (21.8%), and instability (21.4%) were the overall most common indications for revision THA and the most common indications for revision surgery within 5 years of primary THA. Aseptic loosening and osteolysis were the most common indications for revision greater than 5 years from primary THA. Only 16.4% of revised hips had their index arthroplasty performed at our hospital, whereas 83.6% were referred to our institution. CONCLUSIONS: Aseptic loosening, osteolysis, and instability remain the most common contemporary indications for revision THA in an era of alternative bearings and modular components. Most of our revisions were referred from outside institutions, which highlights the transfer of a large portion of the revision THA burden to tertiary referral centers, a pattern that could be exacerbated under future bundled payment models.

Manipulation Under Anesthesia: A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee.

OBJECTIVES: This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months. INTERVENTION: Closed knee MUA. OUTCOME MEASUREMENTS: Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA. RESULTS: The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12). DISCUSSION: MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.