Secondary Hip Labral Reconstruction Yields Inferior Minimum 2-Year Functional Outcomes to Primary Reconstruction Despite Comparable Intraoperative Labral Characteristics.

PURPOSE: To compare intraoperative labral characteristics and minimum 2-year functional outcomes of allograft labral reconstruction in primary versus revision hip arthroscopy across multiple orthopaedic centers. METHODS: A retrospective multicenter hip arthroscopy registry was queried for patients with completed labral reconstruction surgeries from January 2014 to March 2023 with completed 2-year international Hip Outcome Tool-12 (iHOT-12) reports. Age, sex, and major intraoperative variables also were collected. Patients were placed in cohorts based on whether their arthroscopic allograft labral reconstruction was a primary procedure or secondary procedure (reconstruction following failed hip arthroscopy). One-way analysis of variance was performed on continuous variables. χ2 test was performed on categorical variables. Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and Substantial Clinical Benefit (SCB) also was assessed. RESULTS: In total, 77 patients met the inclusion and exclusion criteria and had complete information. The primary reconstruction group (n = 50) was significantly older than the secondary reconstruction group (n = 27) (47.5 ± 10.5 vs 39.1 ± 8.8 years; P = .001). In both cohorts, most patients had labral bruising, advanced labral degeneration, and/or grade III complexity of labral tearing. There was no difference in any recorded intraoperative findings (P = .160, P = .783, P = .357, respectively). Each cohort experienced significant improvement in iHOT-12 scores (P < .0001). However, patients undergoing secondary labral reconstruction reported inferior iHOT-12 scores (60.1 ± 29.2 vs 74.8 ± 27.0; P = .030). Patients undergoing primary reconstruction were more likely to reach MCID, PASS, and nearly normal SCB (92 vs 66.7%, P = .024; 68.0 vs 40.7%, P = .021; 76.0 vs 48.1%, P = .014, respectively). CONCLUSIONS: Primary and secondary allograft labral reconstruction show clinical improvement, but primary reconstruction demonstrates better outcomes and greater percentage of patients reaching MCID, PASS, and nearly normal SCB than reconstruction in the revision setting. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic case-control study.

Diet Composition's Effect on Chronic Musculoskeletal Pain: A Narrative Review.

BACKGROUND: In the medical setting, clinicians frequently attend to patients with chronic musculoskeletal pain. Recent literature demonstrates diet may play a role in inflammation and musculoskeletal pain. OBJECTIVES: The purpose of this narrative review is to present the most current literature on the effect of common diet regimes, additions, and eliminations on chronic musculoskeletal pain. STUDY DESIGN: This is a narrative review of the literature on the effect of 1) Mediterranean diets; 2) vegetarian and vegan diets; 3) oils, seafood, and omega-3 fatty acids; 4) fruits; 5) spices and herbal teas; and 6) elimination diets on patient-reported musculoskeletal pain scores. METHODS: In January 2023, the Google Scholar and PubMed databases were reviewed to identify research on the effect of common diet regimes and additions on self-reported pain outcomes in patients with chronic musculoskeletal pain. RESULTS: A total of 32 original research articles and a systematic review were included and used to develop grades of recommendation. There is fair evidence that diverse, plant-based Mediterranean, vegetarian, and vegan diets may reduce musculoskeletal pain. Other dietary considerations, including adding marine oils, seafood, omega-3 fatty acids, antioxidant-rich fruits, and turmeric may also benefit patients with chronic musculoskeletal pain. There is poor-quality or insufficient evidence to support adding olive oil, ginger, or herbal teas to reduce pain. While eliminating aspartame and monosodium glutamate may reduce inflammation, there is poor-quality evidence that it reduces musculoskeletal pain. LIMITATIONS: This narrative review is not systematic in nature; instead, it aims to provide a current update on the effect of various diet regimes, additions, and eliminations on chronic musculoskeletal pain. The studies in this review are limited in sample size, study period, and robust comparisons to controls. This review is limited to studies on patients with either rheumatoid arthritis, osteoarthritis, or fibromyalgia due to the lack of relevant literature on other musculoskeletal pain conditions. CONCLUSIONS: Clinicians can play a role in the well-being of patients with chronic musculoskeletal pain through holistic interventions such as a dietary emphasis on plant-based regimes. Further research is necessary to elucidate the relationship between diet, inflammatory markers, and disease states, as well as the safety and contraindications of these dietary changes.

Editorial Commentary: Cam Femoroacetabular Impingement Requires Dynamic Assessment of Beta-Angle (Femoroacetabular Excursion Angle) and Consideration of Femoral and Acetabular Version: Cam Impingement in Patients With Acetabular or Femoral Retroversion May Warrant Greater Osteoplasty.

Radiographs, magnetic resonance imaging, and computed tomography scans have been commonly used to evaluate femoroacetabular impingement (FAI) and are well accepted forms of surgical planning. Assessing and addressing both the femoral and acetabular sides result in a combination of "one-sided" treatments that, in sum, net a successful treatment of FAI. However, combining one-sided approaches may not consider the dynamic interaction of the femoral head with the acetabulum. Elevated alpha angles alone can be indicative of a cam-type lesion without necessitating the presence of functional FAI. The presence of a cam-type lesion on lateral radiographs, as suggested by a positive alpha angle, does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle. Assessment of the beta angle, or femoroacetabular excursion angle, has the potential to address dynamic nature of FAI more accurately by directly measuring the degree of clearance between the femoral head and acetabulum. In addition, a comprehensive assessment of physical examination findings, particularly range of motion, as well as a summation of acetabular and femoral version (as measured by the McKibbin Index), are required. Cam-type of FAI poses a larger challenge in the patient with acetabular or femoral retroversion, which may warrant greater and more localized osteoplasty, distally, during hip arthroscopy.

Primary total hip arthroplasty in patients older than 90 years of age: a retrospective matched cohort study.

INTRODUCTION: Advanced age is considered a major risk factor for postoperative complications in total hip arthroplasty (THA). Consequently, older patients undergoing THA may require more detailed pre-procedural examinations and more healthcare resources postoperatively than younger patients. The purpose of this study was to compare discharge parameters and complication rates of THA in patients ⩾90 years old to those <90 years old. METHODS: A retrospective review of 14,824 THA patients from 2011 to 2021 at a high-volume, urban academic centre was conducted. Patients ⩾90 years old were propensity-matched to a control group of patients aged <90 years old. Patient demographics, surgical time, hospital length of stay (LOS), discharge disposition, and 90-day revision, readmission, and mortality rates were collected. Demographic differences and outcomes were assessed using chi-square and independent sample t-tests. RESULTS: After propensity matching, the average age in the younger cohort (YC, n = 54) was 75.81 ± 7.89, and 91.61 ± 1.73 for the older cohort (OC, n = 54). The OC had a longer LOS than the YC (mean 3.90 vs. 3.06 days; p = 0.031). Discharge disposition significantly differed (p = 0.007); older patients were more likely to be discharged to skilled nursing facilities (33.3% vs. 14.8%) or acute rehabilitation centres (14.8% vs. 3.7%) and less likely to be discharged to prior place of residence (home self-managed/home with services, 51.9% vs. 79.6%). There was no significant difference in surgical time (93.87 ± 29.75 vs. 96.09 ± 26.31 min; p = 0.682), 90-day revision rate (3.7% vs. 0%; p = 0.153), 90-day readmission rate (9.4% vs. 3.7%; p = 0.543), and 90-day mortality rate (1.9% vs. 1.9%; p = 1.000). CONCLUSIONS: Although THA patients over 90 years of age had a longer LOS and differing discharge disposition, these patients had similar complications compared to their younger counterparts. Thus, our study supports similar efficacy of THA in patients 90 years and older relative to younger THA candidates.

Total hip arthroplasty for hip fractures in patients older than 80 years of age: a retrospective matched cohort study.

INTRODUCTION: Increasing age and hip fractures are considered risk factors for post-operative complications in total hip arthroplasty (THA). Consequently, older adults undergoing THA due to hip fracture may have different outcomes and require additional healthcare resources than younger patients. This study aimed to identify the influence of age on discharge disposition and 90-day outcomes of THA performed for hip fractures in patients ≥ 80 years to those aged < 80. MATERIALS AND METHODS: A retrospective review of 344 patients who underwent primary THA for hip fracture from 2011 to 2021 was conducted. Patients ≥ 80 years old were propensity-matched to a control group < 80 years old. Patient demographics, length of stay (LOS), discharge disposition, and 90-day post-operative outcomes were collected and assessed using Chi-square and independent sample t tests. RESULTS: A total of 110 patients remained for matched comparison after propensity matching, and the average age in the younger cohort (YC, n = 55) was 67.69 ± 10.48, while the average age in the older cohort (OC, n = 55) was 85.12 ± 4.77 (p ≤ 0.001). Discharge disposition differed between the cohorts (p = 0.005), with the YC being more likely to be discharged home (52.7% vs. 27.3%) or to an acute rehabilitation center (23.6% vs. 16.4%) and less likely to be discharged to a skilled nursing facility (21.8% vs. 54.5%). 90-day revision (3.6% vs. 1.8%; p = 0.558), 90-day readmission (10.9% vs. 14.5%; p = 0.567), 90-day complications (p = 0.626), and 90-day mortality rates (1.8% vs 1.8%; p = 1.000) did not differ significantly between cohorts. CONCLUSION: While older patients were more likely to require a higher level of post-hospital care, outcomes and perioperative complication rates were not significantly different compared to a younger patient cohort. Payors need to consider patients' age in future payment models, as discharge disposition comprises a large percentage of post-discharge expenses. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Emergency department visits following total joint arthroplasty: do revisions present a higher burden?

AIMS: Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. METHODS: We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. RESULTS: Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). CONCLUSION: ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA. Cite this article: Bone Jt Open 2022;3(7):543-548.

Impact of Indication for Revision THA on Resource Utilization.

BACKGROUND: Demographic variables play an important role in outcomes following revision total hip arthroplasty (rTHA). Surgical and in-patient variables as well as outcomes vary between indications for rTHA. The purpose of this study was to investigate the impact of the indication for the rTHA on costs and postoperative outcomes. METHODS: This retrospective cohort analysis investigated all patients who underwent unilateral, aseptic rTHA at an academic orthopaedic specialty hospital who had at least 1-year postoperative follow-up. In total, 654 patients were evaluated and categorized based on their indication for aseptic rTHA. Demographics, direct and total procedure costs, surgical factors, postoperative outcomes, and re-revision rates were collected and compared between indications. RESULTS: Younger patients had the greatest leg length discrepancy (LLD) and older patients had the highest incidence of periprosthetic fracture (PPF) (P = .001). The greatest proportion of full revisions were found for LLD (16.7%) and head/polyethylene liner-only revisions for metallosis/adverse tissue reaction (100%). Operative time was significantly longest for LLD revisions and shortest for metallosis/adverse tissue reaction revisions (P < .001). Length of stay was longest for periprosthetic fracture and shortest for LLD and stiffness/heterotopic ossification (P < .001). Re-revision rate was greatest for implant failure and lowest for LLD. Total cost was highest for PPF (148.9%) and lowest for polyethylene liner wear (87.7%). CONCLUSIONS: Patients undergoing rTHA for indications such as PPF and aseptic loosening were associated with longer operative times, length of stay and higher total and direct costs. Therefore, they may need increased perioperative attention with respect to resource utilization, risk stratification, surgical planning, and cost-reducing measures. LEVEL III EVIDENCE: Retrospective Cohort Study.

The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge.

BACKGROUND: Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations. METHODS: We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables. RESULTS: Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131). CONCLUSION: Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system. LEVEL III EVIDENCE: Retrospective Cohort Study.

Antibiotic Therapy in 2-Stage Revision for Periprosthetic Joint Infection: A Systematic Review.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) are at risk for developing periprosthetic joint infection (PJI). To treat PJI, orthopaedic surgeons can perform 1-stage or 2-stage revision arthroplasty. Although 2-stage revision yields superior long-term outcomes, the optimal antibiotic therapy duration and route of administration between stages remain uncertain. In this systematic review, we aimed to identify if variations in antibiotic therapy, duration, and administration during 2-stage hip or knee revision arthroplasty affect PJI eradication rates and surgical outcome measures. METHODS: A literature search was performed using the PubMed and Google Scholar databases to identify all original reports from January 2000 to June 2021 involving 2-stage revision arthroplasty to treat PJI. Studies were included if they specified antibiotic duration, an intravenous (IV) route of antibiotic administration, type of antibiotic, and 2-stage revision PJI eradication rate and had a mean or median follow-up of at least 2 years after the second-stage operation. Included studies were classified into 3 groups based on the length of IV antibiotic therapy after prosthesis explantation: prolonged IV antibiotic therapy of 4 to 6 weeks, shortened IV antibiotic therapy of ≤2 weeks, and shortened course of IV antibiotic therapy followed by 6 to 12 weeks of oral antibiotics. RESULTS: Nine studies were included. Three studies utilizing a prolonged IV antibiotic therapy had PJI eradication rates of 79% to 96%. Four studies using a shortened IV antibiotic therapy showed PJI eradication rates of 88% to 100%. Finally, 2 studies utilizing a shortened course of IV antibiotic therapy with oral antibiotics had PJI eradication rates of 95% and 97%. There was no significant difference in eradication rates across IV antibiotic duration strategies, despite a diverse array of cultured microorganisms across the studies. CONCLUSIONS: Although the numbers are small, this systematic review suggests that prolonged IV antibiotic duration, shortened IV antibiotic duration, and shortened IV antibiotic duration supplemented with oral antibiotics confer similar PJI eradication rates after hip or knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

ICD-10 Coding Mismatch in Computer and Robotic Assisted Primary Total Hip Arthroplasty.

BACKGROUND: The International Statistical Classification of Disease, 10th Revision Procedural Coding System (ICD-10-PCS) is a granular procedural classification system with the ability to precisely classify types of technology utilized in total hip arthroplasty (THA). However, coding nuances and the rapidly evolving nature of technology may lead to coding inaccuracies. The purpose of this study is to determine the accuracy of ICD-10-PCS coding in computer-navigated and robotic THA and discuss its implications on clinical data. METHODS: The arthroplasty database at a single institution was retrospectively reviewed for all primary computer and robotic assisted THAs performed between October 2015 to November 2020. The type of technology utilized was determined from the surgical record and compared with the ICD-10-PCS codes applied to each procedure. RESULTS: A total of 3721 technology-assisted THAs were identified and reviewed. 87.5% of technology-assisted THAs were coded with the correct type of technology. The most common error in computer navigated THA was the omission of the technology code, while the most common error in robotic assisted THA was the designation of codes for both computer navigation and robotic assistance. CONCLUSION: The granular nature of ICD-10-PCS allows for precise distinction between types of technology-assisted THA. However, rates of coding inaccuracy bring concern for the integrity of this data. The inaccuracy of ICD-10-PCS data is not insignificant and should bring concern for the validity of collective data sets that use it exclusively for its procedural granularity.

Impact of aortic valve disease on outcomes of aortic root replacement.

BACKGROUND AND AIM OF THE STUDY: Aortic stenosis (AS) has been associated with higher mortality in patients undergoing aortic root replacement (ARR). In this analysis, we compare the outcomes among patients with moderate to severe AS or aortic insufficiency (AI) undergoing ARR in a tertiary aortic center. METHODS: A total of 889 patients underwent ARR from 1997 to 2020, of whom 798 had AI and 91 had AS. We excluded valve-sparing procedures. The primary endpoint consisted of major adverse events (MAEs), including operative mortality, myocardial infarction, tracheostomy, new dialysis, and cerebrovascular accidents. All patients had either a mechanical or biologic composite valve-graft implanted using button and exclusion techniques. Propensity score matching (PSM) was used to compare outcomes. Long-term survival was estimated using the Kaplan-Meier method. RESULTS: Patients with AI had a higher incidence of connective tissue disorder (8.0% vs. 0.0%; p = .01) and were more likely to be classified as having an urgent or emergent procedure (22.4% vs. 8.8%; p = .004). PSM achieved a good balance between the groups. There was no difference in MAE rates, postoperatively (AI vs. AS, 1.6% vs. 1.6%; p = .85). Long-term survival was similar at 5 years in the matched cohorts (AI vs. AS, 75.9% vs. 95.5%; p = .36). CONCLUSION: In patients undergoing ARR, the presence of moderate to severe AI or AS does not impact operative outcomes. ARR can be carried out with excellent outcomes and low operative mortality when performed in specialized centers.