Nuclear Imaging in Orthopaedic Practice: A Critical Analysis Review.

¼ Nuclear imaging techniques, including bone scintigraphy, labeled leukocyte scintigraphy, positron emission tomography (PET), and single-photon emission computed tomography (SPECT) combined with computed tomography (CT), have wide applications in orthopaedics for evaluating trauma, painful total joint arthroplasty, musculoskeletal infection, and orthopaedic oncology.¼ Three-phase bone scintigraphy is a first-line, highly sensitive nuclear medicine study for evaluating orthopaedic pathology when initial studies are inconclusive. However, its specificity is limited, and findings may be falsely positive for up to 2 years after total joint arthroplasty because of physiologic bone remodeling.¼ Labeled leukocyte scintigraphy or gallium scintigraphy can improve diagnostic accuracy in patients with a positive bone scan and suspected musculoskeletal or periprosthetic joint infection.¼ 18-Fluorodeoxyglucose PET/CT demonstrates high sensitivity and specificity for diagnosing bone neoplasms, infections, and metabolic disorders. Emerging PET/magnetic resonance imaging technology offers reduced radiation exposure and greater soft-tissue detail but presents technical and cost challenges.¼ SPECT/CT provides valuable functional and anatomic detail for characterizing the extent and location of bone pathology, serving as an important adjunct to other imaging modalities.¼ Ultimately, the choice of nuclear imaging modality should consider the specific clinical context, diagnostic accuracy, impact on management, and cost-effectiveness on a case-by-case basis.

Comparing the Rate of Dissolution of Two Commercially Available Synthetic Bone Graft Substitutes.

This study characterized the dissolution properties of two commercially available bone substitutes: 1) A calcium sulfate hemihydrate (CSH)/brushite/ß-tricalcium phosphate (TCP) graft containing 75% calcium sulfate (CaS) and 25% calcium phosphate; and 2) a CaS/hydroxyapatite (HA) bone graft substitute composed of 40% HA and 60% CaS. Graft material was cast into pellets (4.8mm OD x 3.2mm). Each pellet was placed into a fritted thimble and weighed before being placed into 200 mL of deionized water. The pellets were removed from water at days 1, 2, 3, 4, 6, 8, 14, 18 or until no longer visible. The mass and volume of each pellet was calculated at each timepoint to determine rate of dissolution. Analysis of variance (ANOVA) was performed on all data. Statistical significance was defined as p < 0.05. The CaS/HA pellets were completely dissolved after day 8, while the CSH/brushite/ß- TCP pellets remained until day 18. The CSH/brushite/ß-TCP pellets had significantly more mass and volume at days 1, 2, 3, 4, 6, and 8 timepoints. The CSH/brushite/ß-TCP pellets lost 46% less mass and 53% less volume over the first 4 days as compared to CaS/HA pellets. The CSH/brushite/ß-TCP pellets had a rough, porous texture, while the CaS/HA pellets had a smooth outer surface. Overall the CSH/brushite/ß-TCP pellets dissolved approximately twice as slow as the CaS/HA pellets in vitro. As these in-vitro findings might have in-vivo implications, further clinical data is required to further confirm and establish the optimal synthetic bone substitute strategy or antibiotic delivery carrier.

Advancements in treatment strategies for periprosthetic joint infections: A comprehensive review.

Periprosthetic joint infection (PJI) presents a critical challenge in orthopedic care, contributing to significant patient morbidity and healthcare costs. This burden is expected to increase secondary to growing demand for total joint arthroplasty (TJA). Despite the profound significance of PJI, there is currently no universally accepted "gold standard" diagnostic criteria using serum biomarker thresholds; latest criteria fail to differentiate acute infections from chronic or consider time since initial surgery. Furthermore, contemporary PJI treatment, which conventionally requires 2-stage revision surgery in conjunction with rigorous antibiotic treatment, can be particularly taxing on patients. Fortunately, recent years have seen marked evolution in both PJI diagnosis and treatment methods. Contemporary research supports time-dependent serum biomarker thresholds with greater sensitivity and specificity than previously reported, as well as alternative surgical options which may be more suitable for certain patients. The following narrative review aims to describe the significance and pathogenesis of PJI before characterizing current challenges, novel innovations, and the future landscape of PJI diagnosis and management. Here, we spotlight the emerging utility of novel biomarkers and metagenomic next-generation sequencing for diagnosis, advancements in patient-centered surgical outcome prediction tools for PJI risk assessment and prevention, and evolving surgical techniques including 1-stage and a "hybrid" 1.5-stage revision surgeries. Additionally, we explore cutting-edge therapeutic modalities including peptide and bacteriophage-based treatments, intraoperative anti-biofilm gel, the VT-X7 antibiotic pump, and promising immune-based interventions. Ultimately, these advancements hold the potential to revolutionize PJI management, offering hope for improved outcomes and reduced burdens on healthcare systems.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: The purpose of this study was to examine reported MCID and PASS values for PROMs following shoulder instability surgery and assess variability in published values depending on the surgery performed. Secondarily, our aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS usage in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values following Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, Pubmed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English, and studies reporting utilization MCID or PASS for patient reported outcome measures (PROMS) following Latarjet, Bankart, Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using median and range. Categorical variables, including PROMs reported and MCID/PASS methods, were described using percentages. As MCID is a patient-level metric and not a group-level metric, the authors validated that all included studies reported proportions (%) of subjects that met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely utilized outcome threshold which was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (ASES) (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (SANE) (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (WOSI) (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit (SCB) or maximal outcome improvement (MOI). CONCLUSION: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. While MCID has been the most frequently reported metric, there is considerable inter-study variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental, since they allow us to know what is a clinically significant improvement for the patient.

Predictive Modeling of Medical and Orthopaedic-Related 90-Day-Readmissions Following Primary Total Knee Arthroplasty.

BACKGROUND: As the demand for total knee arthroplasty (TKA) escalates, 90-day readmissions have emerged as a pressing clinical and economic concern for the current value-based health care system. Consequently, health care providers have focused on estimating the risk levels of readmitted patients; however, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following TKA. METHODS: A prospective cohort of primary unilateral TKAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 10,521 patients). Unplanned readmissions were reviewed individually to determine their primary cause, either medical or orthopaedic-related. Orthopaedic-related readmissions were specific complications affecting the joint, prosthesis, or surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently. RESULTS: Overall, the rate of 90-day readmissions was 6.7% (n = 704). Over 82% of these readmissions were due to medical-related causes (n = 580), with the remaining 18% being orthopaedic-related (n = 124) readmissions. The area under the curve for the 90-day readmission model was 0.68 (95% confidence interval: 0.67 to 0.70). Sex, smoking, length of stay, and discharge disposition were associated with orthopaedic readmission, while age, sex, race, the Charlson Comorbidity Index, insurance, surgery day, opioid overdose risk score, length of stay, and discharge disposition were associated with medical-related 90-day readmissions. CONCLUSIONS: Medical-related readmissions after TKA are more prevalent than orthopaedic-related readmissions. Through successfully constructing and validating multiple 90-day readmission predictive models, we highlight the distinct risk profiles for medical and orthopaedic-related readmissions. This emphasizes the necessity for nuanced, patient-specific risk stratification and preventive measures.

Surgical Management of Chronic Morel-Lavallée Lesion with Minimal Cosmetic Scarring: A Case Report.

Introduction: Morel-Lavallée lesion (MLL) is a closed degloving injury that occurs after traumatic damage to soft tissue, leading to the formation of an encapsulated serosanguinous collection of fluid. Although some MLLs resolve spontaneously, chronic MLLs present with a significant risk of infection and may impede patients' quality of life. Chronic lesions require surgical intervention to evacuate and debride the hematoma, often resulting in severe cosmetic damage postoperatively. Case Report: We documented a large 19.4 cm × 4.2 cm × 15.10 cm MLL on the right lateral hip that presented a significant impediment to the patient's daily functions. After the failure of conservative management, the patient was treated surgically through a minimal incision debridement procedure, utilizing a wound drain and vacuum-assisted compressional dressing upon closure. Excellent 1-year post-operative outcomes were achieved with no recurrence of the lesion and limited cosmetic evidence of the MLL. Conclusion: This case highlights the value of a limited incisional debridement procedure for the management of a chronic Morel-Lavellée lesion. When using this technique, surgeons can effectively treat these lesions with promising short-term outcomes and minimal wound scarring.

Establishing minimal clinically important differences and patient acceptable symptom state thresholds following birmingham hip resurfacing.

INTRODUCTION: Birmingham Hip Resurfacing (BHR) has emerged as a compelling and innovative alternative to total hip arthroplasty (THA), especially among young, active patients. However, the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds have not yet been determined for patients undergoing BHR. Therefore, the current study aimed to (1) determine the MCID and PASS thresholds for both the Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS physical function shortform (PS), for patients who underwent BHR; and (2) identify factors influencing the achievement of MCID and PASS for HOOS-Pain and HOOS-PS. METHODS: Prospectively collected data from patients undergoing BHR was analyzed. Patients with osteoarthritis and completed preoperative and 1-year postoperative PROMs were included. Distribution-based and anchored-based approaches were used to estimate MCID and PASS, respectively. The optimal cut-off point for PASS thresholds was calculated using the Youden index. RESULTS: MCID for HOOS-Pain and PS were calculated to be 9.2 and 9.3, respectively. The PASS threshold for HOOS-Pain and PS were ≥ 77.7 and ≥ 87.3, respectively. The current study identified several factors affecting postoperative achievement of thresholds. Baseline Mental Component Summary (MCS) scores were a predictor for achieving MCID for postoperative HOOS-Pain, achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Furthermore, baseline HOOS-Pain was a significant predictor for achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. CONCLUSIONS: MCID and PASS thresholds were established for HOOS-Pain and PS domains following BHR with most patients achieving these clinically meaningful benchmarks. Additionally, several factors affecting achievement of MCID and PASS were identified, including modifiable risk factors that may allow clinicians to implement optimization strategies and further improve outcomes.

Conversion Birmingham Hip Resurfacing in Managing Post-traumatic Arthritis With Retained Femoral Hardware: A Case Report.

CASE: A 70-year-old man with a year-long history of arthritic pain in his left hip presented to our clinic. He had a left intertrochanteric hip fracture 6 years ago, fixed with an open reduction internal fixation with a cephalomedullary nail. He underwent a conversion Birmingham Hip Resurfacing (BHR) with removal of the proximal helicoidal blade and retention of the intramedullary nail. At 7-year follow-up, the patient reported satisfactory clinical outcomes and excellent radiographic fixation. CONCLUSION: This case highlights using conversion BHR in patients with post-traumatic arthritis with retained femoral hardware as an alternative to conventional total hip arthroplasty.

Clinical outcomes in prospective versus retrospective studies on arthroscopic Bankart repair: a systematic review.

BACKGROUND: The majority of the current literature on arthroscopic Bankart repair is retrospective, and discrepancies exist regarding clinical outcomes including recurrent instability and return to play among studies of different levels of evidence. PURPOSE: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" was used, with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score out of 100. A χ2 test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies. RESULTS: A total of 193 studies were included in the analysis, with 53 prospective studies and 140 retrospective in design. These studies encompassed a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of redislocation in the prospective studies was 8.0% vs. 5.9% in retrospective studies (P < .001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective studies (P = .004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (P = .013). There was no significant difference in terms of overall rate to return to play between prospective and retrospective studies (90% and 91%, respectively; P = .548). The overall rate of non-instability complications in the prospective cohort was 0.27% vs. 0.78% in the retrospective studies (P = .002). CONCLUSIONS: The overall rates of recurrent dislocations-subluxations are higher in prospective studies than retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty.

BACKGROUND: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider. METHODS: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio. RESULTS: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187). CONCLUSIONS: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization.

PURPOSE: This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery. METHODS: A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used. RESULTS: A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study. CONCLUSION: The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Predictive Modeling of Medical- and Orthopaedic-Related 90-Day Readmissions Following Primary Total Hip Arthroplasty.

BACKGROUND: The rate of unplanned hospital readmissions following total hip arthroplasty (THA) varies from 3 to 10%, representing a major economic burden. However, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to: (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate; and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following THA. METHODS: A prospective cohort of primary unilateral THAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 8,893 patients) using a validated institutional data collection system. Orthopaedic-related readmissions were specific complications affecting the prosthesis, joint, and surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently. RESULTS: Overall, the rate of 90-day readmissions was 5.6%. Medical readmissions (4.2%) were found to be more prevalent than orthopaedic-related readmissions (1.4%). The area under the curve for the 90-day readmission model was 0.71 (95% confidence interval: 0.69 to 0.74). Factors significantly associated with medical-related readmissions were advanced age, Black race, education, Charlson Comorbidity Index, surgical approach, opioid overdose risk score, and nonhome discharge. In contrast, risk factors linked to orthopaedic-related readmissions encompassed body mass index, patient-reported outcome measure phenotype, nonosteoarthritis indication, opioid overdose risk, and nonhome discharge. CONCLUSIONS: Of the overall 90-day readmissions following primary THA, 75% were due to medical-related complications. Our successful predictive model for complication-specific 90-day readmissions highlights how different risk factors may disproportionately influence medical versus orthopaedic-related readmissions, suggesting that patient-specific, tailored preventive measures could reduce postoperative readmissions in the current value-based health care setting.

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons.

INTRODUCTION: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics. METHODS: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted. RESULTS: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance (P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons. CONCLUSION: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon. STUDY DESCRIPTION: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

24-Year-Old Patient with Klippel-Trenaunay Syndrome Underwent Cementless Robotic Cruciate-Retaining TKA: A Case Report.

CASE: A 24-year-old man with Klippel-Trenaunay syndrome (KTS) presented with severe knee osteoarthritis unresponsive to conservative measures. Owing to end-stage, debilitating arthritic symptoms, surgery was pursued. Careful preoperative, multidisciplinary planning/treatment included magnetic resonance imaging to characterize the venous malformations throughout the right lower extremity, preoperative sclerotherapy, sirolimus, and robotic-assisted cementless total knee arthroplasty (TKA). CONCLUSION: Cementless robotic-assisted TKA with selective patellar resurfacing can be a viable option for young KTS patients with severe osteoarthritis when a meticulous multidisciplinary approach, including sclerotherapy and advanced imaging, is undertaken to analyze vascular abnormalities, minimize surgical risks, preserve bone stock, and optimize outcomes.

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

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

Clinical Significance Thresholds in Primary and Revision Latarjet Procedures With Comparable Outcome Achievements.

BACKGROUND: Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results. PURPOSE: To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated. RESULTS: The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively. CONCLUSION: This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making.

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

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

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future.

ABSTRACT: The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.