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Aims: Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. Methods: We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA. Results: Robotic-assisted THA resulted in a lower proportion (1.5%) of implant waste compared to navigation-guided THA (2.0%) and manual THA (1.9%) (all p < 0.001). Both navigated and manual THA were more likely to waste acetabular shells (odds ratio (OR) 4.5 vs 3.1) and polyethylene liners (OR 2.2 vs 2.0) compared to robotic-assisted THA after adjusting for demographic and perioperative factors, such as surgeon experience (p < 0.001). While implant waste decreased with increasing experience for procedures performed manually (p < 0.001) or with navigation (p < 0.001), waste rates for robotic-assisted THA did not differ based on surgical experience. Conclusion: Robotic-assisted THAs wasted a smaller proportion of acetabular shells and polyethylene liners than navigation-guided and manual THAs. Individual implant waste rates vary depending on the type of technology used intraoperatively. Future studies on implant waste during THA should examine reasons for non-implantation in order to better understand and develop methods for cost-saving.
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Aims: Sagittal plane imbalance (SPI), or asymmetry between extension and flexion gaps, is an important issue in total knee arthroplasty (TKA). The purpose of this study was to compare SPI between kinematic alignment (KA), mechanical alignment (MA), and functional alignment (FA) strategies. Methods: In 137 robotic-assisted TKAs, extension and flexion stressed gap laxities and bone resections were measured. The primary outcome was the proportion and magnitude of medial and lateral SPI (gap differential > 2.0 mm) for KA, MA, and FA. Secondary outcomes were the proportion of knees with severe (> 4.0 mm) SPI, and resection thicknesses for each technique, with KA as reference. Results: FA showed significantly lower rates of medial and lateral SPI (2.9% and 2.2%) compared to KA (45.3%; p < 0.001, and 25.5%; p < 0.001) and compared to MA (52.6%; p < 0.001 and 29.9%; p < 0.001). There was no difference in medial and lateral SPI between KA and MA (p = 0.228 and p = 0.417, respectively). FA showed significantly lower rates of severe medial and lateral SPI (0 and 0%) compared to KA (8.0%; p < 0.001 and 7.3%; p = 0.001) and compared to MA (10.2%; p < 0.001 and 4.4%; p = 0.013). There was no difference in severe medial and lateral SPI between KA and MA (p = 0.527 and p = 0.307, respectively). MA resulted in thinner resections than KA in medial extension (mean difference (MD) 1.4 mm, SD 1.9; p < 0.001), medial flexion (MD 1.5 mm, SD 1.8; p < 0.001), and lateral extension (MD 1.1 mm, SD 1.9; p < 0.001). FA resulted in thinner resections than KA in medial extension (MD 1.6 mm, SD 1.4; p < 0.001) and lateral extension (MD 2.0 mm, SD 1.6; p < 0.001), but in thicker medial flexion resections (MD 0.8 mm, SD 1.4; p < 0.001). Conclusion: Mechanical and kinematic alignment (measured resection techniques) result in high rates of SPI. Pre-resection angular and translational adjustments with functional alignment, with typically smaller distal than posterior femoral resection, address this issue.
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Background: Although there have been several studies describing risk factors for complications after outpatient total hip arthroplasty (THA), data describing the timing of such complications is lacking. Methods: Patients who underwent outpatient or inpatient primary THA were identified in the 2012-2019 National Surgical Quality Improvement Program database. For 9 different 30-day complications, the median postoperative day of diagnosis was determined. Multivariable regressions were used to compare the risk of each complication between outpatient vs inpatient groups. Multivariable Cox proportional hazards modeling was used to evaluate the differences in the timing of each adverse event between the groups. Results: After outpatient THA, the median day of diagnosis for readmission was 12.5 (interquartile range 5-22), surgical site infection 15 (2-21), urinary tract infection 13.5 (6-19.5), deep vein thrombosis 13 (8-21), myocardial infarction 4.5 (1-7), pulmonary embolism 15 (8-25), sepsis 16 (9-26), stroke 2 (0-7), and pneumonia 6.5 (3-10). On multivariable regressions, outpatients had a lower relative risk (RR) of readmission (RR = 0.73), surgical site infection (RR = 0.72), and pneumonia (RR = 0.1), all P < .05. On multivariable cox proportional hazards modeling, there were no statistically significant differences in the timing of each complication between outpatient vs inpatient procedures (P > .05). Conclusions: The timing of complications after outpatient THA was similar to inpatient procedures. Consideration should be given to lowering thresholds for diagnostic testing after outpatient THA for each complication during the at-risk time periods identified here. Although extremely rare, this is especially important for catastrophic adverse events, which tend to occur early after discharge.
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PURPOSE: The purpose of this study was to examine the effects of intraoperative technology use on the rate of using polyethylene liners 15 mm or greater during primary total knee arthroplasty (TKA). METHODS: There were 103,295 implants from 16,386 primary unilateral TKAs performed on 14,253 patients at a single institution between 1 January 2018, and 30 June 2022, included in the current study. Robotic assistance and navigation guidance were used in 1274 (8%) and 8345 (51%) procedures, respectively. The remaining 6767 TKAs (41%) were performed manually. Polyethylene liners were manually identified and further subcategorised by implant thickness. Patients who underwent robotic-assisted TKA were younger (p < 0.001) and more likely to be male (p < 0.001) compared to patients who underwent navigation-guided or manual TKAs. RESULTS: Average polyethylene liner thickness was similar between groups (10.5 ± 1.5 mm for robotic-assisted TKAs, 10.9 ± 1.8 mm for navigation-guided TKAs and 10.8 ± 1.8 mm for manual TKAs). The proportions of polyethylene liners 15 mm or greater used were 4.9%, 3.8% and 1.9% for navigation-guided, manual and robotic-assisted procedures, respectively (p < 0.001). Multivariate regression analyses demonstrated that navigation-guided (odds ratio [OR]: 2.6, 95% confidence Interval [CI]: [1.75-4.07], p < 0.001) and manual (OR: 2.0, 95% CI: [1.34-3.20], p = 0.001) procedures were associated with an increased use of polyethylene liners 15 mm or greater. CONCLUSION: Robotic-assisted TKA was associated with a lower proportion of polyethylene liners 15 mm or greater used compared to navigation-guided and manual TKA. These findings suggest that robotic assistance can reduce human error via a more precise cutting system, limit over-resection of the tibia and flexion-extension gap mismatch and ultimately allow for more appropriately sized implants. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
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PURPOSE: The purpose of this study was to compare the precision of bony resections during total knee arthroplasty (TKA) performed using different computer-assisted technologies. METHODS: Patients who underwent a primary TKA using an imageless accelerometer-based handheld navigation system (KneeAlign2®, OrthAlign Inc.) or computed tomography-based large-console surgical robot (Mako®, Stryker Corp.) from 2017 to 2020 were retrospectively reviewed. Templated alignment targets and demographic data were collected. Coronal plane alignment of the femoral and tibial components and tibial slope were measured on postoperative radiographs. Patients with excessive flexion or rotation preventing accurate measurement were excluded. RESULTS: A total of 240 patients who underwent TKA using either a handheld (n = 120) or robotic (n = 120) system were included. There were no statistically significant differences in age, sex, and BMI between groups. A small but statistically significant difference in the precision of the distal femoral resection was observed between the handheld and robotic cohorts (1.5° vs. 1.1° difference between templated and measured alignments, p = 0.024), though this is likely clinically insignificant. There were no significant differences in the precision of the tibial resection between the handheld and robotic groups (coronal plane 0.9° vs. 1.0°, n.s.; sagittal plane 1.2° vs. 1.1°, n.s.). There were no significant differences in the rate of overall precision between cohorts (n.s.). CONCLUSIONS: A high degree of component alignment precision was observed for both imageless handheld navigation and CT-based robotic cohorts. Surgeons considering options for computer-assisted TKA should take other important factors, including surgical principles, templating software, ligament balancing, intraoperative adjustability, equipment logistics, and cost, into account. LEVEL OF EVIDENCE: III.
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BACKGROUND: Although a genetic component to hip osteoarthritis (OA) has been described, focused evaluation of the genetic components of end-stage disease is limited. We present a genomewide association study for patients undergoing total hip arthroplasty (THA) to characterize the genetic risk factors associated with end-stage hip osteoarthritis (ESHO), defined as utilization of the procedure. METHODS: Patients who underwent primary THA for hip OA were identified in a national patient data repository using administrative codes. Fifteen thousand three hundred and fifty-five patients with ESHO and 374,193 control patients were identified. Whole genome regression of genotypic data for patients who underwent primary THA for hip OA corrected for age, sex, and body mass index (BMI) was performed. Multivariate logistic regression models were used to evaluate the composite genetic risk from the identified genetic variants. RESULTS: There were 13 significant genes identified. Composite genetic factors resulted in an odds ratio 1.04 for ESHO (P < .001). The effect of genetics was lower than that of age (Odds Ratio (OR): 2.38; P < .001) and BMI (1.81; P < .001). CONCLUSION: Multiple genetic variants, including 5 novel loci, were associated with end-stage hip OA treated with primary THA. Age and BMI were associated with greater odds of developing end-stage disease when compared to genetic factors.
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Artroplastia de Reemplazo de Cadera , Osteoartritis de la Cadera , Humanos , Estudio de Asociación del Genoma Completo , Osteoartritis de la Cadera/genética , Osteoartritis de la Cadera/cirugía , Índice de Masa Corporal , Modelos LogísticosRESUMEN
BACKGROUND: As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence. METHODS: Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression. RESULTS: The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD. CONCLUSIONS: The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Humanos , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Alta del Paciente , Estudios Retrospectivos , Tiempo de Internación , Factores de Riesgo , Dolor Postoperatorio/etiología , Complicaciones Posoperatorias/etiología , Artroplastia de Reemplazo de Cadera/efectos adversosRESUMEN
BACKGROUND: Adhesive capsulitis of the shoulder involves loss of passive range of motion with associated pain and can develop spontaneously, with no obvious injury or inciting event. The pathomechanism of this disorder remains to be elucidated, but known risk factors for adhesive capsulitis include diabetes, female sex, and thyroid dysfunction. Additionally, transcriptional profiling and pedigree analyses have suggested a role for genetics. Identification of elements of genetic risk for adhesive capsulitis using population-based techniques can provide the basis for guiding both the personalized treatment of patients based on their genetic profiles and the development of new treatments by identification of the pathomechanism. METHODS: A genome-wide association study (GWAS) was conducted using the U.K. Biobank (a collection of approximately 500,000 patients with genetic data and associated ICD-10 [International Classification of Diseases, 10th Revision] codes), comparing 2,142 patients with the ICD-10 code for adhesive capsulitis (M750) to those without. Separate GWASs were conducted controlling for 2 of the known risk factors of adhesive capsulitis-hypothyroidism and diabetes. Logistic regression analysis was conducted controlling for factors including sex, thyroid dysfunction, diabetes, shoulder dislocation, smoking, and genetics. RESULTS: Three loci of significance were identified: rs34315830 (in WNT7B; odds ratio [OR] = 1.28; 95% confidence interval [CI], 1.22 to 1.39), rs2965196 (in MAU2; OR = 1.67; 95% CI, 1.39 to 2.00), and rs1912256 (in POU1F1; OR = 1.22; 95% CI, 1.14 to 1.31). These loci retained significance when controlling for thyroid dysfunction and diabetes. The OR for total genetic risk was 5.81 (95% CI, 4.08 to 8.31), compared with 1.70 (95% CI, 1.18 to 2.36) for hypothyroidism and 4.23 (95% CI, 2.32 to 7.05) for diabetes. CONCLUSIONS: The total genetic risk associated with adhesive capsulitis was significant and similar to the risks associated with hypothyroidism and diabetes. Identification of WNT7B, POU1F1, and MAU2 implicates the Wnt pathway and cell proliferation response in the pathomechanism of adhesive capsulitis. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Bursitis , Diabetes Mellitus , Hipotiroidismo , Articulación del Hombro , Humanos , Femenino , Estudio de Asociación del Genoma Completo , Bursitis/genética , Factores de Riesgo , Hipotiroidismo/complicaciones , Rango del Movimiento ArticularRESUMEN
AIMS: The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. METHODS: This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. RESULTS: In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. CONCLUSION: SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology.Cite this article: Bone Jt Open 2022;3(9):684-691.
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BACKGROUND: End-stage knee osteoarthritis (OA) is a highly debilitating disease for which total knee arthroplasty (TKA) serves as an effective treatment option. Although a genetic component to OA in general has been described, evaluation of the genetic contribution to end-stage OA of the knee is limited. To this end, we present a genome-wide association study involving patients undergoing TKA for primary knee OA to characterize the genetic features of severe disease on a population level. METHODS: Individuals with the diagnosis of knee OA who underwent primary TKA were identified in the U.K. Biobank using administrative codes. The U.K. Biobank is a data repository containing prospectively collected clinical and genomic data for >500,000 patients. A genome-wide association analysis was performed using the REGENIE software package. Logistic regression was also used to compare the total genetic risk between subgroups stratified by age and body mass index (BMI). RESULTS: A total of 16,032 patients with end-stage knee OA who underwent primary TKA were identified. Seven genetic loci were found to be significantly associated with end-stage knee OA. The odds ratio (OR) for developing end-stage knee OA attributable to genetics was 1.12 (95% confidence interval [CI], 1.10 to 1.14), which was lower than the OR associated with BMI (OR = 1.81; 95% CI, 1.78 to 1.83) and age (OR = 2.38; 95% CI, 2.32 to 2.45). The magnitude of the OR for developing end-stage knee OA attributable to genetics was greater in patients <60 years old than in patients ≥60 years old (p = 0.002). CONCLUSIONS: This population-level genome-wide association study of end-stage knee OA treated with primary TKA was notable for identifying multiple significant genetic variants. These loci involve genes responsible for cartilage development, cartilage homeostasis, cell signaling, and metabolism. Age and BMI appear to have a greater impact on the risk of developing end-stage disease compared with genetic factors. The genetic contribution to the development of severe disease is greater in younger patients. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo de Rodilla , Osteoartritis de la Rodilla , Humanos , Persona de Mediana Edad , Osteoartritis de la Rodilla/genética , Osteoartritis de la Rodilla/cirugía , Estudio de Asociación del Genoma Completo , Articulación de la Rodilla/cirugía , Factores de RiesgoRESUMEN
BACKGROUND: Insurance companies are increasingly making unilateral determinations of admission status for primary total knee arthroplasty (TKA). These determinations may differ from those based on surgeon-derived criteria for outpatient knee replacement. The goal of this study is to determine if insurance company determinations of outpatient status are as reliable as surgeon-derived criteria in predicting outpatient discharge after TKA. METHODS: We retrospectively reviewed 709 patients who were preoperatively authorized for outpatient TKA. Patients were stratified into 2 groups: "outpatient per surgeon" (appropriate for outpatient surgery per institutional protocols) or "outpatient per insurance" (appropriate for inpatient surgery per institutional protocols but denied inpatient status by insurance). The primary endpoint of this study was the conversion rate of outpatient to inpatient stay. Univariate logistic regression was performed to compare the odds of conversion to inpatient stay between outpatient per surgeon and outpatient per insurance procedures and other covariates. RESULTS: The cohort included 434 outpatient per insurance (61.2%) and 275 outpatient per surgeon (38.8%) patients. Surgeons accurately predicted outpatients' discharge 92.0% of the time, while insurance companies did so 81.3% of time (P < .001). Outpatient per insurance procedures (odds ratio [OR] 2.20, P = .003) and body mass index >35 kg/m2 (OR 1.82, P = .026) had higher odds of being converted to inpatient. Males had higher odds (OR 1.52, P < .001) of being discharged as outpatient. CONCLUSION: Determining inpatient versus outpatient status is a complex decision involving both clinical and social factors. Surgeons accurately predicted outpatient discharge 92% of the time. Moreover, outpatient per insurance procedures were twice as likely to be converted to inpatient status. Therefore, insurance companies should leave deciding admission status up to both the patient and surgeon.
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Artroplastia de Reemplazo de Rodilla , Seguro , Cirujanos , Humanos , Tiempo de Internación , Masculino , Pacientes Ambulatorios , Alta del Paciente , Estudios RetrospectivosRESUMEN
INTRODUCTION: Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption. METHODS: Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses. RESULTS: A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864). DISCUSSION: The DAA was associated with slightly lower patient-reported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.
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Analgésicos Opioides , Artroplastia de Reemplazo de Cadera , Dolor Postoperatorio , Analgésicos Opioides/uso terapéutico , Humanos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Medición de Resultados Informados por el Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND: Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described. QUESTIONS/PURPOSES: (1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA? METHODS: Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups. RESULTS: Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04). CONCLUSION: Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Artroplastia de Reemplazo de Rodilla/métodos , Falla de Prótesis , Infecciones Relacionadas con Prótesis/etiología , Reoperación/métodos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: The orthopedic in-training examination (OITE) continues to evolve over time. It is important for orthopedic residents and residency programs to have an up-to-date understanding of the content and resources being used on the OITE to study and tailor curricula accordingly. This study presents an updated analysis of the OITE hand domain from 2014 to 2019. METHODS: All OITE questions related to hand surgery from 2014 to 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, and bibliometric factors related to cited references. RESULTS: Of the 1600 OITE questions, there were 113 hand surgery questions (7.1%) over a 6-year period. The most commonly tested topics were nerve (n = 22; 19%), fracture/dislocation (n = 21; 19%), and tendon/ligament (n = 19; 17%). Complex clinical management questions were the most common taxonomic category (n = 66; 58%). Two hundred fifty-two references were cited, the most common of which were from the Journal of Hand Surgery (American Volume) (n = 76; 30%), Journal of the American Academy of Orthopaedic Surgeons (n = 27; 11%), and Hand Clinics (n = 21; 8%). Publication lag decreased over the study period (P = .009). Twenty-five questions (22%) used imaging modalities, and 21 (19%) used clinical photos. Compared with a prior analysis from 2002 to 2006, there were more questions related to nerves (19.5% vs 9.8%, P = .041). CONCLUSIONS: Residents and residency programs can benefit from an updated understanding of OITE hand surgery content and resources. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE.
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Internado y Residencia , Ortopedia , Educación de Postgrado en Medicina , Evaluación Educacional , Mano/cirugía , Humanos , Ortopedia/educaciónRESUMEN
BACKGROUND: Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are two treatment options for end-stage degenerative hip conditions. The objective of this single-center retrospective cohort study was to compare implant survival and patient-reported outcomes (PROs) in young patients (≤35 years) who underwent HRA or THA. METHODS: All patients aged 35 years or younger who underwent HRA or THA with a single high-volume arthroplasty surgeon between 2004 and 2015 were reviewed. The sample included 33 THAs (26 patients) and 76 HRAs (65 patients). Five-year implant survival and minimum 2-year PROs were compared between patient cohorts. RESULTS: Three patients in the THA group (9%) were revised within 5 years for instability (n = 1), squeaking (n = 1), or squeaking with a ceramic liner fracture (n = 1). No patients who underwent HRA were revised. The University of California, Los Angeles, activity score, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement increased by 74%, 64%, and 49%, respectively, among all patients. Compared to the HRA cohort, patients who underwent THA had lower preoperative and postoperative University of California, Los Angeles, activity, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement scores, yet there were no differences in the absolute improvements in any of the three measures between the two groups. CONCLUSIONS: Excellent functional outcomes were seen in young patients undergoing either HRA or THA. Although young patients undergoing THA started at lower preoperative baseline and postoperative PROs than patients undergoing HRA, both groups improved by an equal amount after surgery, suggesting that both HRA and THA afford a similar degree of potential improvement in a young population.
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INTRODUCTION: The Orthopaedic In-Training Examination (OITE), produced by the American Academy of Orthopaedic Surgeons (AAOS), plays an important role in the educational mission of orthopaedic residency programs nationwide. An up-to-date understanding of this examination is critical for programs to develop an appropriate curriculum and for individuals to identify learning resources. This study presents an updated analysis of the basic science section of the OITE from 2014 to 2019. METHODS: All questions from the OITE from 2014 to 2019 were reviewed. Each question from the basic science section was categorized by topic and taxonomy. The use of radiographic images or other clinical media was recorded. The reference section was analyzed for bibliometric factors. Pearson chi-square tests were used as appropriate for statistical comparison. RESULTS: In total, 185 of 1,600 questions in the basic science section were used over the 6-year study period (11.6%). The proportion of basic science questions ranged from 10.7% to 12.0% from year to year. The most frequently tested topics were cellular and molecular biology (23.8%), physiology/pathophysiology (16.8%), and pharmacology (10.8%). There was an increase in the number of biostatistics questions from 2017 to 2019 compared with the number from 2014 to 2016 (P = 0.02). The most common taxonomic category was knowledge recall (89.7%). A total of 383 references were cited from 122 sources. The 3 most common sources accounting for 44.4% of all citations were produced by the AAOS. DISCUSSION: The basic science section of the OITE accounts for approximately 11% of all questions, with the most common taxonomy being knowledge recall (89.7%). Recent tests have emphasized biostatistics, highlighting the importance of incorporating biostatistics into residency education. Reference materials produced by the AAOS were highly cited in this section.
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Internado y Residencia , Ortopedia , Competencia Clínica , Educación de Postgrado en Medicina , Evaluación Educacional , Humanos , Ortopedia/educaciónRESUMEN
BACKGROUND: The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding. METHODS: Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations. RESULTS: Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding. CONCLUSION: h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.
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Industrias , Cirujanos , Adulto , Artroplastia , Humanos , Estados UnidosRESUMEN
BACKGROUND: Multiple stakeholders are interested in improving patient experience after primary total hip arthroplasty due to shifts toward patient-centered care. Patient free-text narratives are a potentially valuable but largely unexplored source of data. METHODS: The records of 383 patients who underwent primary total hip arthroplasty between August 2016 and August 2019 were combined with vendor-supplied patient satisfaction data, which included patient free-text comments and the Press Ganey satisfaction survey. A total of 1295 patient comments were analyzed for sentiment, and negative comments were categorized into nine themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not. Multivariable regression was used to determine perioperative variables associated with providing a negative comment. RESULTS: Of the 1295 patient comments: 54% were positive, 24% were negative, 10% were mixed, and 12% were neutral. Top two themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in studied outcomes (eg. peak pain intensity, length of stay, or improvements in hip injury and osteoarthritis outcome scores Jr. and pain visual analog scale scores at 6-week follow-up) between those who provided negative comments vs those who did not (P > .05). However, patients who made negative comments were less likely to recommend their hospital care to peers (P < .001). Finally, patients who had >2 allergies (P = .024) were more likely to provide negative comments. CONCLUSION: The present study demonstrates that patient satisfaction appears not to be a reliable sole proxy for traditional objective outcome measures of pain relief and functional improvement.
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Artroplastia de Reemplazo de Cadera , Humanos , Manejo del Dolor , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Encuestas y CuestionariosRESUMEN
BACKGROUND: Recent studies have examined the impact of the COVID-19 pandemic on the practice of total joint arthroplasty. A scoping review of the literature with compiled recommendations is a useful tool for arthroplasty surgeons as they resume their orthopedic practices during the pandemic. METHODS: In June 2020, PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, CINAHL, medRxiv, and bioRxiv were queried for articles using controlled vocabulary and keywords pertaining to COVID-19 and total joint arthroplasty. Studies were characterized by their region of origin, design, and Center of Evidence Based Medicine level of evidence. The identified relevant studies were grouped into 6 categories: changes to future clinical workflow, education, impact on patients, impact on surgeons, technology, and surgical volume. RESULTS: The COVID-19 pandemic has had a significant impact on arthroplasty practice, including the disruption of the clinical teaching environment, personal and financial consequences for patients and physicians, and the drastic reduction in surgical volume. New pathways for clinical workflow have emerged, along with novel technologies with applications for both patients and trainees. CONCLUSIONS: The COVID-19 pandemic emphasizes the recent trend in arthroplasty toward risk stratification and outpatient surgery, which may result in improved clinical outcomes and significant cost-savings. Furthermore, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.
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BACKGROUND: It is vital for orthopedic residents and residency programs to have a current understanding of the materials and resources utilized on the Orthopedic In-Training Examination (OITE) to tailor resident educational curricula accordingly. This study presents an updated analysis of the hip and knee section of the OITE. METHODS: All OITE questions related to hip and knee reconstruction over six examinations between 2014 and 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, resident performance, and references. RESULTS: There were 166 hip and knee reconstruction questions of 1600 OITE questions (10.4%) over a six-year period. The most commonly tested topics include mechanical properties of total knee and hip implants (10.8%), instability after THA (10.8%), periprosthetic fracture (10.2%), and prosthetic joint infection (10.2%). A total of 362 references were cited from 68 different sources. The most common sources were JOA, JBJS, JAAOS, and CORR, which were collectively responsible for 68% of all citations. There was an average publication lag of 7.1 years, with 75% of all citations falling within 10 years of the question date. Compared with a prior analysis from 2005 and 2009, there were significantly more complex multistep questions regarding treatment and fewer one-step knowledge recall questions (P = .003). Similarly, recent tests had significantly more questions involving interpretation of radiographs (55%, P < .001) and advanced imaging (9.6%, P < .001), compared with a decade ago. CONCLUSIONS: The OITE continues to evolve over time, incorporating recent literature and topics. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE hip and knee section.