Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model.

BACKGROUND: A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research. METHODS: A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM. RESULTS: Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept). CONCLUSIONS: There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.

Detecting contamination events during robotic total joint arthroplasty.

BACKGROUND: Robot-assisted total joint arthroplasty (robotic-TJA) has become more widespread over the last 20 years due to higher patient satisfaction and reduced complications. However, robotic TJA may have longer operative times and increased operating room traffic, which are known risk factors for contamination events. Contamination of surgical instruments may be contact- or airborne-related with documented scalpel blade contamination rates up to 9%. The robot arm is a novel instrument that comes in and out of the surgical field, so our objective was to assess whether the robot arm is a source of contamination when used in robotic TJA compared to other surgical instruments. METHODS: This was a prospective, single-institution, single-surgeon pilot study involving 103 robotic TJAs. The robot arm was swabbed prior to incision and after closure. Pre- and postoperative control swabs were also collected from the suction tip and scalpel blade. Swabs were incubated for 24 hours on tryptic soy agar followed by inspection for growth of any contaminating bacteria. RESULTS: A contamination event was detected in 10 cases (10%). The scalpel blade was the most common site of contamination (8%) followed by the robot arm (2%) and suction tip (0%). DISCUSSION: Robotic TJA is contaminated with bacteria at a rate around 10%. Although the robot arm is an additional source of potential contamination, the robot arm accrues bacterial contamination infrequently compared to the scalpel blade. CONCLUSION: Contamination of the robot arm during robotic TJA is minimal when compared to contamination of the scalpel blade.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Range of motion measurements do not correlate with patient reported outcome measures in the early post-operative period following ankle fracture.

BACKGROUND: Early mobilization following ankle fracture open reduction and internal fixation (ORIF) improves long-term patient functionality. Because of this, numerous resources have been spent to increase patient adherence to post-operative mobilization, with range of motion (ROM) measurements generally considered an important outcome in patient recovery. In this study we investigated how ankle ROM correlates to patient function, self-sufficiency in performing activities of daily living (ADLs), and pain in the early post-operative period. METHODS: This was a prospective, observational study on patients undergoing ORIF of ankle fractures. We collected patient reported outcome measures (PROMs) and ROM measurements at the 2-week, 6-week, 12-week, and 6 month post-operative visit. We collected three PROMs: pain intensity (VAS), pain self-efficacy questionnaire (PSEQ-2), and foot and ankle ability measurement (FAAM). ROM of the ankle was measured by goniometer. ANOVA and post-hoc Tukey tests were used to examine statistical differences in PROMs over time. Pearson correlation tests were used to examine the association between ROM and PROMs. RESULTS: One-hundred and twenty-three participants enrolled in this study in the perioperative period. Pain intensity was higher at enrollment compared to week 6 (post-hoc p = 0.006), after which pain intensity did not differ significantly. FAAM scores for activities or daily living (ADL) were increased at all study visits compared to enrollment (post-hoc p < 0.001). FAAM-Sports scores were higher compared to enrollment at the week 12 and 6 month visits (post-hoc p < 0.001). No significant improvements in goniometer measurements were noted across any timepoints. There were no significant correlations between ROM and PROMs at any of the study visits. CONCLUSION: In our cohort of patients, there was no correlation between ROM and patient pain, self-efficacy or functionality in the early post-operative period following ankle ORIF. The lack of correlation between PROMs and ROM indicates that ROM may be both a poor indicator of patient improvement for physicians to guide post-operative treatment as well as a poor motivator for patient adherence to post-operative exercises. In the future, it is important to study reliable outcome measures in early recovery that can be utilized to track patient recovery from ankle ORIF.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes.

BACKGROUND: Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS: The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS: Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION: Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 202x;4x(x):xx-xx.].

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons.

BACKGROUND: More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed. OBJECTIVE: To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization. DESIGN/PARTICIPANTS: Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates. MAIN MEASURES: Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization. KEY RESULTS: Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization. CONCLUSION: Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Arthroplasty for femoral neck fractures is at risk for under restoration of lateral femoral offset.

PURPOSE: The aim of the study was to determine the restoration of hip biomechanics through lateral offset, leg length, and acetabular component position when comparing non-arthroplasty surgeons (NAS) to elective arthroplasty surgeons (EAS). METHODS: 131 patients, with a femoral neck fracture treated with a THA by 7 EAS and 20 NAS, were retrospectively reviewed. 2 blinded observers measured leg-length discrepancy, femoral offset, and acetabular component position. Multivariate logistic regression models examined the association between the surgeon groups and restoration of lateral femoral, acetabular offset, leg length discrepancy, acetabular anteversion, acetabular position, and component size, while adjusting for surgical approach and spinal pathology. RESULTS: NAS under-restored 4.8 mm of lateral femoral offset (43.9 ± 8.7 mm) after THA when compared to the uninjured side (48.7 ± 7.1 mm, p = 0.044). NAS were at risk for under-restoring lateral femoral offset when compared to EAS (p = 0.040). There was no association between lateral acetabular offset, leg length, acetabular position, or component size and surgeon type. CONCLUSIONS: Lateral femoral offset is at risk for under-restoration after THA for femoral neck fractures, when performed by surgeons that do not regularly perform elective THA. This indicates that lateral femoral offset is an under-appreciated contributor to hip instability when performing THA for a femoral neck fracture. Lateral femoral offset deserves as much attention and awareness as acetabular component position since a secondary analysis of our data reveal that preoperative templating and intraoperative imaging did not prevent under-restoration.

Development of a 3-Step theory of suicide ontology to facilitate 3ST factor extraction from clinical progress notes.

OBJECTIVE: Suicide risk prediction algorithms at the Veterans Health Administration (VHA) do not include predictors based on the 3-Step Theory of suicide (3ST), which builds on hopelessness, psychological pain, connectedness, and capacity for suicide. These four factors are not available from structured fields in VHA electronic health records, but they are found in unstructured clinical text. An ontology and controlled vocabulary that maps psychosocial and behavioral terms to these factors does not exist. The objectives of this study were 1) to develop an ontology with a controlled vocabulary of terms that map onto classes that represent the 3ST factors as identified within electronic clinical progress notes, and 2) to determine the accuracy of automated extractions based on terms in the controlled vocabulary. METHODS: A team of four annotators did linguistic annotation of 30,000 clinical progress notes from 231 Veterans in VHA electronic health records who attempted suicide or who died by suicide for terms relating to the 3ST factors. Annotation involved manually assigning a label to words or phrases that indicated presence or absence of the factor (polarity). These words and phrases were entered into a controlled vocabulary that was then used by our computational system to tag 14 million clinical progress notes from Veterans who attempted or died by suicide after 2013. Tagged text was extracted and machine-labelled for presence or absence of the 3ST factors. Accuracy of these machine-labels was determined for 1000 randomly selected extractions for each factor against a ground truth created by our annotators. RESULTS: Linguistic annotation identified 8486 terms that related to 33 subclasses across the four factors and polarities. Precision of machine-labeled extractions ranged from 0.73 to 1.00 for most factor-polarity combinations, whereas recall was somewhat lower 0.65-0.91. CONCLUSION: The ontology that was developed consists of classes that represent each of the four 3ST factors, subclasses, relationships, and terms that map onto those classes which are stored in a controlled vocabulary (https://bioportal.bioontology.org/ontologies/THREE-ST). The use case that we present shows how scores based on clinical notes tagged for terms in the controlled vocabulary capture meaningful change in the 3ST factors during weeks preceding a suicidal event.

An External Acetabular Alignment Guide Decreases Positional Variance.

INTRODUCTION: Certain patient and operative factors limit accurate estimation of acetabular component positioning during total hip arthroplasty (THA). This study aimed to determine whether an intraoperative external alignment guide decreases variance in acetabular component positioning. MATERIALS AND METHODS: Adult patients who underwent primary THA from 2014-2018 were reviewed. Exclusion criteria were navigation, robot-assisted surgery, and inflammatory, post-traumatic, or avascular arthritis. One surgeon used an external guide while the second surgeon resected osteophytes and utilized available anatomical landmarks for positioning. Anteversion and inclination, variance, "safe zone" positioning, operative time, and hip instability were assessed. Multivariable regression models were used to examine effects on primary and secondary outcomes. RESULTS: 409 patients were included, of which 182 underwent component placement with landmarks only. Patients undergoing component placement with landmarks only were younger (p=0.002) and more often smokers (p=0.016). After multivariable risk adjustment, use of the external alignment guide was independently associated with 2.7° higher anteversion (CI: 1.6° to 3.8°) and smaller anteversion variance (-0.3, CI: -0.6 to 0.1) compared to landmarks only. It was independently associated with 3.2° higher inclination (CI: 2.0° to 4.4°), but there was no difference in inclination variance (-0.1, CI: -0.3 to 0.2). The external alignment guide was independently associated with a 14-minute shorter operative time (CI: 9.6 to 18.7) and smaller operative time variance (-0.9, CI: -1.2 to 0.6). DISCUSSION: Use of anatomical landmarks alone was associated with increased likelihood of safe zone positioning but lower precision and longer operative time. While this study was limited by lack of randomization and its retrospective nature, an acetabular positioner may be preferable to palpable or visible anatomy alone for acetabular component placement.

Is Operative Time Associated With Obesity-related Outcomes in TKA?

BACKGROUND: Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA. QUESTIONS/PURPOSES: We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes? METHODS: In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m2, < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m2, 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m2, 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m2, 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m2, 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m2, 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted. RESULTS: After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration. CONCLUSION: We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

How often does homelessness precede criminal arrest in veterans? Results from the U.S. survey of prison inmates.

Research has shown links between homelessness and criminal legal involvement in military veterans. The present study aimed to determine the magnitude and directionality of this association by investigating the incidence of, and factors associated with, homelessness preceding criminal arrest among veterans. Data on incarcerated veterans (N = 1,602) were analyzed from the 2016 Survey of Prison Inmates conducted by the U.S. Bureau of Justice Statistics. In this survey, 27% of incarcerated veterans reported homelessness 12 months before criminal arrest. In multivariable logistic regression analyses, higher odds of experiencing homelessness preceding criminal arrest were associated with younger age, non-White race, substance use disorder (with or without serious mental illness [SMI]), history of previous arrests, parental history of incarceration, and history of homelessness before age 18. These factors were found to be the same for nonveterans, as were rates of homelessness before arrest. However, incarcerated veterans were more likely to have mental disorders, including SMI, posttraumatic stress disorder (PTSD), and personality disorders. In contrast, incarcerated nonveterans were more likely to have a criminal history, including past arrests, parental incarceration, and juvenile detention. Although policymakers may be aware that some veterans they serve are at risk of criminal legal involvement, these national data reveal the magnitude and directionality of this problem: more than one in four incarcerated veterans experienced homelessness before criminal arrest. Identifying characteristics of veterans who experienced homelessness before criminal arrest directly informs service providers of demographic, historical, and clinical factors to evaluate and address to prevent criminal legal involvement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing.

BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN: Qualitative study of semi-structured telephone interviews. PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans.

BACKGROUND: Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes. OBJECTIVES: To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older. RESEARCH DESIGN: Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions. SUBJECTS: Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447). METHODS: Mental illness, SUD, medical multimorbidity. RESULTS: An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49). CONCLUSIONS: Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Does Operative Time Modify Obesity-related Outcomes in THA?

BACKGROUND: Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. QUESTIONS/PURPOSES: We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? METHODS: This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. RESULTS: A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. CONCLUSION: Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. LEVEL OF EVIDENCE: Level III, therapeutic study.

Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties.

BACKGROUND: The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI. METHODS: We identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria. RESULTS: There were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041). CONCLUSION: Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI. LEVEL OF EVIDENCE: Prognostic Level IV.

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty.

BACKGROUND: The COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes. METHODS: This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. RESULTS: SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission. CONCLUSION: SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

Supine Knee Positioning Does Not Interfere with Mobile-Bearing Unicompartmental Knee Arthroplasty Performance.

The Food and Drug Administration has only approved mobile-bearing unicompartmental knee arthroplasty (MB-UKA) to be performed with a hanging leg holder. The purpose of this study is to evaluate the impact of a supine knee position on MB-UKA performance.In total, 16 cadavers were randomized so that either the right or left knee was placed in the flexed or supine positions. One board-certified orthopaedic surgeon and three adult reconstruction fellows that attended the required Oxford partial knee instructional course performed four operations in each position. The primary outcome was final knee balance. Secondary outcomes included procedure duration, timing of individual surgical steps, implant sizes, range of motion, implant alignment, and fracture. A Students t-test was used to examine differences between positions with significance set at p < 0.05. Secondary analyses using two one-sided tests were conducted to explore equivalence between the two positions.There was no significant difference in mean final balance between supine (1.7 mm ± standard deviation [SD] = 1.5 mm) and flexed (1.3 ± 1.3 mm) positions (p = 0.390). There were also no significant differences between positions for procedure time (p = 0.497), tibia coronal alignment (p = 0.614), tibial slope (p = 0.194), femoral component sagittal alignment (p = 0.091), and fractures (n = 0). Exploratory equivalence analyses indicated that the positions were equivalent for final balance (p = 0.002).MB-UKA performed in the supine position is not significantly different from the flexed position in terms of ligament balance, overall procedure time, and radiographic appearance. These initial safety data warrant further clinical investigations and support the expansion of the surgical technique to include performing MB-UKAs in the supine position.

Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration.

BACKGROUND: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures. METHODS: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined. RESULTS: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476. CONCLUSIONS: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.

Suicide theory-guided natural language processing of clinical progress notes to improve prediction of veteran suicide risk: protocol for a mixed-method study.

INTRODUCTION: The state-of-the-art 3-step Theory of Suicide (3ST) describes why people consider suicide and who will act on their suicidal thoughts and attempt suicide. The central concepts of 3ST-psychological pain, hopelessness, connectedness, and capacity for suicide-are among the most important drivers of suicidal behaviour but they are missing from clinical suicide risk prediction models in use at the US Veterans Health Administration (VHA). These four concepts are not systematically recorded in structured fields of VHA's electronic healthcare records. Therefore, this study will develop a domain-specific ontology that will enable automated extraction of these concepts from clinical progress notes using natural language processing (NLP), and test whether NLP-based predictors for these concepts improve accuracy of existing VHA suicide risk prediction models. METHODS AND ANALYSIS: Our mixed-method study has an exploratory sequential design where a qualitative component (aim 1) will inform quantitative analyses (aims 2 and 3). For aim 1, subject matter experts will manually annotate progress notes of clinical encounters with veterans who attempted or died by suicide to develop a domain-specific ontology for the 3ST concepts. During aim 2, we will use NLP to machine-annotate clinical progress notes and derive longitudinal representations for each patient with respect to the presence and intensity of hopelessness, psychological pain, connectedness and capacity for suicide in temporal proximity of suicide attempts and deaths by suicide. These longitudinal representations will be evaluated during aim 3 for their ability to improve existing VHA prediction models of suicide and suicide attempts, STORM (Stratification Tool for Opioid Risk Mitigation) and REACHVET (Recovery Engagement and Coordination for Health - Veterans Enhanced Treatment). ETHICS AND DISSEMINATION: Ethics approval for this study was granted by the Stanford University Institutional Review Board and the Research and Development Committee of the VA Palo Alto Health Care System. Results of the study will be disseminated through several outlets, including peer-reviewed publications and presentations at national conferences.