A Remote Physical Therapy Program Demonstrates Similar Outcomes Compared to In-Person, Supervised Physical Therapy after Same-Day Discharge Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: A growing number of total knee arthroplasty (TKA) patients are candidates for same-day discharge (SDD). Previous research has shown that internet-based remote physical therapy (RPT) can produce equivalent outcomes to supervised outpatient physical therapy (OPT) after TKA. We sought to compare outcomes between RPT and OPT in patients undergoing SDD TKA using an electronic remote perioperative management (ERPM) program. METHODS: Patients undergoing SDD TKA were enrolled in an ERPM program and randomized to ERPM + RPT or ERPM + OPT. Preoperative and 6-week functional assessments included knee range of motion (ROM), timed up and go (TUG), and 4-meter gait speed. Numerical Rating Scale (NRS) pain scores were evaluated preoperatively, at 6 and 12 weeks, and satisfaction was assessed at 6, 12, and 52 weeks postoperatively. Participants completed the Veterans Rand 12 Item Health Survey (VR-12 MCS/PCS) and Knee Injury and Osteoarthritis Outcome Score (KOOS, Jr.) preoperatively and at 6, 12, and 52 weeks postoperatively. Outpatient PT utilization was collected 90 days postoperatively. RESULTS: Out of 197 initially randomized patients, 76 remained in the ERPM + RPT group and 95 in the ERPM + OPT group after withdrawals and crossovers. Baseline characteristics showed no significant differences between the two groups. No clinically relevant differences were observed in knee ROM, NRS pain, patient-reported outcomes, functional assessments, or satisfaction at any follow-up time. Participants in the ERPM + OPT group attended an average of 11.57 PT sessions, incurring a total cost of $462.8 and 133 minutes of travel. Conversely, the ERPM + RPT group experienced no expenses or travel time. CONCLUSION: Patients in the ERPM + RPT group had similar outcomes, lower costs, and saved time compared to patients in the ERPM + OPT group after SDD TKA. Further analysis is needed to determine predictive indicators for crossovers.

The "Inside-Out" Anterior Osteotomy of the Proximal Femur via the Direct Anterior Approach in Revision Hip Arthroplasty.

Osteotomy techniques used for wide exposure during femoral component revision include the extended trochanteric osteotomy and its modifications. We describe an anterior proximal femur osteotomy technique starting from the inside of the femoral canal at the bone-implant interface and heading outward. The technique is used in conjunction with the extended direct anterior approach and allows direct access to and visualization of the anterior, medial, and lateral bone-implant interfaces. This technique is most useful for the removal of collared, fully hydroxyapatite-coated double-tapered femoral stems, in which bone-implant interfaces need to be accessed for removal of a well-osseointegrated hip arthroplasty implant.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis.

Background: Internal fixation (IF) has historically been favored for the treatment of femoral neck fractures (FNFs) in young, nongeriatric patients. However, recent literature reporting high reoperation rates among those receiving IF, taken in conjunction with favorable survivorship of modern bearing surfaces in total hip arthroplasty (THA), has begun to question this paradigm. Our study sought to compare outcomes between IF and THA for FNFs in patients aged 40-59 years. Methods: Using the Truven MarketScan Database, we performed a retrospective propensity-score-matched cohort study on patients aged 40-59 years who underwent surgical management of an isolated FNF (THA or IF). Patients with pathologic fracture were not included. Analysis was conducted on patients aged 40-49 and 50-59 years separately. A subgroup analysis was performed on those patients with 1 year and 3 years of follow-up. Multivariate analysis, controlling for baseline patient information, was then performed. Results: Seven hundred sevety-eight 40- to 49-year-old patients and 3470 50- to 59-year-old matched patients (IF and THA) were included in this study. A multivariate analysis found that patients aged 40-49 years who underwent IF were at higher odds of both 1-year (odds ratio 2.35, 95% confidence interval 1.22-4.54, P = .011) and 3-year (odds ratio 5.68, 95% confidence interval 2.21-14.60, P < .001) reoperation. Similar results were found in those aged 50-59 years. While complication rates were similar, postoperative anemia and 90-day visits to the emergency room were more common after THA in both age cohorts. Conclusions: While THA is associated with increased postoperative anemia and resource utilization compared with IF, patients aged 40-59 years who undergo IF for FNF are at increased risk of reoperation in the first 3 postoperative years. This information should be used to assist in shared decision-making with patients in this age group.

Use of a threaded-coupled femoral extraction device allows for higher extraction force when compared to loop or vice grip devices; A potted stem analysis.

BACKGROUND: Extraction of a well-fixed femoral stem during revision total hip arthroplasty presents a technical challenge to the operating surgeon. The option of several stem designs during implantation necessitates the availability of extraction tools to be utilised intra-operatively. This study aims to compare the amount of axial force generated from using a threaded-coupled extraction device, loop extraction device, and vice-grip universal extraction set on a potted total hip arthroplasty stem construct. METHODS: A size 7 Stryker Accolade® II femoral stem (Stryker, Mahwah, NJ) was potted within a 5.20 cm inner diameter polyvinyl chloride pipe using a potting medium with tensile strength and lap shear of 1000psi. This construct was coupled to a material testing system whose force transducer was calibrated to a recording speed of 1000 frames per second. The extractors were coupled to the potted stem, and a force of 1.32 J was applied ten times sequentially to each construct. Force was recorded in Newtons. RESULTS: The maximum average force for the threaded, loop, and Shukla extractors was 111.46 ± 1.77 N, 90.22 ± 0.87 N, and 64.70 ± 9.03 N (p < 0.01). Loss of coupling was not experienced with any extractor. CONCLUSION: Within our study, the forces observed per constant load when utilising a threaded-coupled extraction device that attaches to the shoulder of the implant were significantly higher than those seen when using an extraction device that couples to the neck of the femoral stem.

Postoperative acetabular component position in revision hip arthroplasty: a comparison of the anterior and posterior approaches.

BACKGROUND: While previously considered unsuitable for revision total hip arthroplasty (rTHA), the direct anterior approach (DAA) can be extended to allow for safe acetabular component revision. In primary hip arthroplasty, the DAA and its associated fluoroscopy, has been shown to produce more acceptable component positioning. However, there is little data comparing the DAA to the posterior approach (PA) for rTHA. We hypothesised that, the DAA with intraoperative fluoroscopy would allow for more precise acetabular component positioning when compared to those performed using a PA. METHODS: 50 consecutive patients (25 DAA and 25 PA) undergoing rTHA were included. Radiographic analysis of postoperative acetabular component position was then performed. Univariate and multivariate analyses was performed to assess the contribution of approach on cup positioning inside classically defined "safe zones". RESULTS: Baseline patient characteristics were similar. The PA was associated with more cups placed outside the Lewinnek (48% vs. 12%, p = 0.005) and the Danoff (52% vs. 28%, p = 0.083) "safe zones" when compared to the DAA. Multivariate analysis revealed that operative approach was the only patient or surgical factor associated with component position outside of the "safe zones" (Lewinnek [OR = 13.6; 95% CI, 2.12-87.9, p = 0.006] and Danoff [OR = 7.7; 95% CI, 1.48-40.1, p = 0.015]). CONCLUSION: Our results suggest that the DAA allows for more reproducible and precise cup placement in RTHA. The safe-zone paradigm remains a useful index of accurate cup positioning and the DAA, with use of intraoperative fluoroscopy, offers more consistent acetabular component positioning when compared to the PA.

Preoperative opioid use is a risk factor for complication following revision total hip arthroplasty.

BACKGROUND: The demand for revision total hip arthroplasty (THA) procedures continues to increase. A growing body of evidence in primary THA suggests that preoperative opioid use confers increased risk for complication. However, it is unknown whether the same is true for patients undergoing revision procedures. The purpose of this study was to investigate whether or not there was a relationship between preoperative opioid use and surgical complications, medical complications, and healthcare utilisation following revision THA. METHODS: This is a retrospective cohort study using the Truven Marketscan database. Patients undergoing revision THA were identified. Preoperative opioid prescriptions were queried for 1 year preoperatively and were used to divide patients into cohorts based on temporality and quantity of opioid use. This included an opioid naïve group as well as an "opioid holiday" group (6 months opioid naïve period after chronic use). Demographic and complication data were collected and both univariate and multivariate analysis was then performed. RESULTS: 62.5% of patients had received an opioid prescription in the year preceding surgery. Patients with continuous preoperative opioid use had higher odds of the following: infection (superficial or deep surgical site infection; OR 1.29; 95% CI, 1.03-1.62, p = 0.029), wound complication (OR 1.36; 95% CI, 1.02-1.82, p = 0.037), sepsis (OR 1.90; 95% CI 1.08-3.34, p = 0.026), and revision surgery (OR 1.54, 95% CI, 1.28-1.85, p < 0.001). This group also had higher care utilisation including extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p < 0.001). An opioid holiday mitigated some of this increased risk as this cohort has baseline (i.e. same as opioid naïve) risk (p > 0.05 for all comparison). CONCLUSIONS: Opioid use prior to revision THA is common and is associated with increased risk of postoperative complication. Given that risk was reduced by a preoperative opioid holiday, this represents a modifiable risk factor which should be discussed and addressed preoperatively to optimise outcomes.

Medicaid Payer Status Is Associated With Increased 90-Day Resource Utilization, Reoperation, and Infection Following Aseptic Revision Total Hip Arthroplasty.

Background: Prior literature has demonstrated increased resource utilization and perioperative complications in patients with a Medicaid payor status undergoing primary total hip and knee arthroplasty. This relationship has yet to be explored in patients undergoing revision total hip arthroplasty (rTHA). Methods: The National Readmissions Database was queried from 2010 to 2015 for all patients undergoing aseptic rTHA. 90-day complication data were collected, and patients were separated into two cohorts based on insurance payor type: Medicaid and non-Medicaid. Patients were propensity score matched 2:1 on a number of comorbid and operative characteristics. The relationship between Medicaid payor status and postoperative outcomes was then assessed using binomial logistic regression analysis. Results: 3,110 Medicaid patients were identified and matched to 6,175 non-Medicaid patients. Medicaid patients had increased odds of an early prosthetic joint infection (Odds Ratio [OR] 1.29, p=0.019), superficial surgical site infection (OR: 1.48, p=0.003), and early reoperation (OR: 1.18, p=0.045). Medicaid patients also experienced higher odds of readmissions, extended length of stay, non-home discharge status, and medical complications. Finally, the Medicaid cohort had a $3,332 (95% CI: 2,412-4,253, p<0.001) increased adjusted total cost of care when compared to the non-Medicaid cohort. Conclusion: This study identifies the Medicaid payor status as an independent risk factor for increased resource utilization, reoperation, and infection in the early postoperative period for patients undergoing rTHA. This relationship is likely due to an interplay of multiple variables, including socioeconomic status and access to care. Level of Evidence: IV.

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study.

BACKGROUND: As the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes. METHODS: In this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression. RESULTS: In total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001). CONCLUSION: THA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.

Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study.

Balancing postoperative analgesia with minimizing opioid consumption remains a challenge. We aim to document trends in opioid consumption for patients undergoing total hip arthroplasty (THA) and hypothesize that preoperative patient education will decrease postoperative opioid consumption. This is a prospective study of patients undergoing elective primary THA. Preoperatively, patients completed a survey regarding opioid-use history, surgical history, and pain tolerance. Patients were randomized to receive preoperative education on opioid use or no formal education. Six weeks postoperatively, patients completed a questionnaire regarding opioid use, disposal, and pain control. Ninety-five patients were included. Preoperative education was not associated with taking fewer narcotic medications (p = 0.790) and did not significantly alter disposal practices (p = 0.255). Depression was correlated with increased opioid use (mean difference 24 tabs, p = 0.001) and linked to longer duration of opioid use postoperatively (20.3 +/- 15.6 versus 7.2 +/- 7.3 days, p < 0.001). History of prior surgical procedure was associated with fewer narcotics taken (mean difference 26 tabs, p = 0.01). Depression is correlated with increased opioid use. Preoperative education did not affect opioid use or disposal frequency. (Journal of Surgical Orthopaedic Advances 30(3):144-149, 2021).

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient.

BACKGROUND: Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications. METHODS: This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses. RESULTS: Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001). CONCLUSION: Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized, Single-Blind, Controlled Trial.

BACKGROUND: The direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy. METHODS: This single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively. RESULTS: Ninety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively. CONCLUSION: This study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule's role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.

Metformin Use Is Associated with Fewer Complications in Patients with Type-2 Diabetes Undergoing Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

BACKGROUND: Diabetes is a well-established risk factor for complications following total knee arthroplasty (TKA), and the incidence of type-2 diabetes is increasing. Metformin is considered first-line therapy for type-2 diabetes and has been shown to reduce all-cause mortality and to possess anti-inflammatory properties. The impact of metformin use as it relates to outcomes following TKA is unknown. The purpose of this study was to investigate this relationship. METHODS: This is a retrospective cohort study using the Truven MarketScan database. Adult patients undergoing unilateral, primary TKA were identified. We included only patients with a preoperative diagnosis of type-2 diabetes and established 2 cohorts based on metformin status. Propensity score matching was performed to match patients who used metformin to those who did not (1-to-1). Patients were matched on factors including age, sex, insulin status, other diabetic medications, comorbidities, complexity of diabetes, and smoking status. Regression analysis was then performed on matched cohorts to examine 90-day outcomes. A subgroup analysis was performed on 1-year revision rates. RESULTS: After matching, there were 32,186 patients in both the metformin group and the no-metformin group, resulting in a total of 64,372 included patients. Baseline characteristics were similar between groups. Regression analysis, performed on matched cohorts, demonstrated that the no-metformin group had increased odds of readmission (odds ratio [OR], 1.09 [95% confidence interval (CI), 1.04 to 1.15]; p < 0.001), emergency department presentation (OR, 1.09 [95% CI, 1.04 to 1.14]; p < 0.001), extended length of stay (OR, 1.12 [95% CI, 1.06 to 1.15]; p < 0.001), periprosthetic joint infection (OR, 1.30 [95% CI, 1.13 to 1.50]; p < 0.001), deep vein thrombosis (OR, 1.17 [95% CI, 1.09 to 1.26]; p < 0.001), acute kidney injury (OR, 1.21 [95% CI, 1.09 to 1.33]; p < 0.001), hypoglycemic events (OR, 1.25 [95% CI, 1.01 to 1.54]; p = 0.039), and 1-year revision (OR, 1.16 [95% CI, 1.01 to 1.33]; p = 0.033). CONCLUSIONS: Metformin use in patients with type-2 diabetes undergoing TKA appears to be associated with lower odds of multiple complications and resource utilization parameters, including periprosthetic joint infection and 1-year revision rates. Given the frequency with which TKA is performed in patients with type-2 diabetes, this knowledge has the potential to improve optimization protocols and outcomes in this group of patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Extraction Techniques for Well-fixed, Infected Hip Arthroplasty Implants.

Removal of well-fixed total hip arthroplasty components is a fundamental necessity to cure chronic prosthetic hip joint infection. However, the benefits of infection eradication must be weighed against the potential morbidity associated with implant removal. Preoperative identification of implant type, knowledge of its design characteristics, availability of specialized instrumentation and knowledge of specific surgical techniques are key elements of success. With proper preoperative planning and surgical technique, removal of well-fixed total hip arthroplasty components can be accomplished safely and can provide improvements in quality of life for patients suffering from the symptoms associated with prosthetic hip joint infection. (Journal of Surgical Orthopaedic Advances 30(4):235-242, 2021).

Anterior Revision Hip Arthroplasty is Associated With Higher Wound Complications but Fewer Dislocations Compared to Posterior Revision Hip Surgery.

BACKGROUND: Wound complication after primary direct anterior (DAA) hip arthroplasty has been reported in the literature but there has been no comparison regarding revision anterior vs revision posterior (PA) hip arthroplasty. The authors hypothesize that anterior approach revision surgery may have increased wound complications compared with posterior hip revisions and also report on secondary outcome metrics. METHODS: Ninety-nine DAA and 191 PA revisions were included for analysis. Preoperative demographic characteristics, indication for revision, operative details, type of revision performed, components utilized, and postoperative complications were compared between DAA and PA groups including multivariate analysis. RESULTS: The DAA cohort demonstrated an increased risk of superficial wound complications (7.1% vs 0.5%, P = .003) and a decreased dislocation rate (2.0% vs 13.1%, P = .002). There was a trend toward increased overall complications in the PA group (OR 1.71, P = .078). CONCLUSION: Revision DAA THA is associated with an increased risk of superficial wound complications, but may impart a decreased dislocation rate.

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty.

BACKGROUND: Depression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA. METHODS: This is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications. RESULTS: In total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001). CONCLUSIONS: NOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.

Preoperative Analgesia, Complications, and Resource Utilization After Total Hip Arthroplasty: Tramadol Is Associated With Less Risk Than Other Preoperative Opioid Medications.

BACKGROUND: Preoperative opioid use is known to be detrimental to outcomes after total hip arthroplasty (THA). This is concerning as multiple societies recommend tramadol for the management of arthritis. The purpose of this study was to determine if tramadol is associated with postoperative complications, increased resource utilization, and revision when compared with patients receiving nontramadol opioids (NTOs) and those who are opioid naive (ON). METHODS: This is a retrospective cohort study using the Truven MarketScan databases (Truven Health, Ann Arbor, MI). Adult patients undergoing primary THA were identified and divided into 4 cohorts based on preoperative opioid medications (ie, ON, tramadol-only [TO], or NTOs; ±tramadol). Demographics, comorbidities, and 90-day complications were collected and compared between cohorts. Revision rates were compared at 3 years. Univariate and multivariate analyses were performed. Finally, preoperative prescription patterns were trended during the study period. RESULTS: About 198,357 patients, including 18,694 TO and 106,768 ON, were identified. Compared with ON, TO patients had similar rates of complications and revision surgery (P > .05) but had slightly higher emergency department visits (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 1.01-1.12; P = .027), readmissions (OR, 1.16; 95% CI, 1.09-1.22; P < .001), and nonhome discharges (OR, 1.07; 95% CI, 1.02-1.12; P = .010). TO patients had significantly lower odds of incurring most examined complications, including revision surgery, when compared with NTO (P < .05). From 2009 to 2018, the proportion of patients prescribed preoperative opioids decreased. CONCLUSION: Preoperative TO is associated with less postoperative risk than NTO use and is similar to opioid naivety. Fortunately, the number of patients receiving preoperative NTOs appears to be decreasing. Our results support tramadol as an appropriate pre-THA analgesic.

The impact of preoperative tramadol-only use on outcomes following total knee arthroplasty - Is tramadol different than traditional opioids?

BACKGROUND: Opioid use prior to total knee arthroplasty (TKA) is known to have detrimental influence on postoperative outcomes. Whether or not the same is true for tramadol is currently unclear. The aim of this study was to clarify the relationship between preoperative tramadol and postoperative complications. METHODS: The Truven Marketscan® Databases were used to conduct this retrospective cohort study. Patients undergoing primary TKA were identified and divided into cohorts based on preoperative medication status (i.e. opioid naïve, tramadol-only, or non-tramadol opioids). Patient demographics, comorbidities, and 90-day outcomes were collected and compared between cohorts. Revision rates were analyzed at 1- and 3-years postoperatively. Univariate and multivariate analysis was performed. RESULTS: 336,316 patients were included and 23,097 (6.9%) were preoperative tramadol-only users. Tramadol-only patients (v. opioid naïve) had increased odds of 90-day readmission (OR-1.07, 95%CI 1.02-1.12, p = 0.004), wound complication (OR-1.13, 95%CI 1.01-1.27, p = 0.34), and 3-year revision rates (OR-1.35, 95%CI 1.19-1.53, p < 0.001). However, when compared to the preoperative opioid cohorts, tramadol-only patients had decreased odds of nearly all outcomes. Over the study period, the number of patients receiving preoperative opioids decreased while the proportion of patients prescribed tramadol-only increased. CONCLUSIONS: While tramadol-only use has lower risk than traditional opioids, tramadol-only use preceding TKA is associated with increased rates of readmission, wound complication and revision surgery. This is important information for prescribers who may be using tramadol to treat symptomatic knee arthrosis prior to arthroplasty referral and for thought leaders producing clinical practice guidelines. LEVEL OF EVIDENCE: Level III, Prognostic.

Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two high-volume procedures that were delayed due to COVID-19. QUESTIONS/PURPOSES: To help strategize an effective return to elective orthopedic surgery, we aimed to quantify the volume of THA and TKA cases delayed across the USA and estimate the time required to care for these patients when non-urgent surgery resumes. METHODS: Population-level data was used to estimate monthly THA and TKA procedural volume from 2011 to 2017. Using linear regression, we used this data to project monthly procedural volumes for 2020 to 2023. Nine different permutations were modeled to account for variations in case delay rates (50%, 75%, 100%) and in resumption of non-urgent procedure timing. Two recovery pathways using the highest volume month as a surrogate for maximum operative capacity, and a second using the highest month + 20% were used to simulate a theoretical expansion of current capacity. RESULTS: The projected national volume of delayed cases was 155,293 (mid-March through April; 95% CI 142,004 to 168,580), 260,806 (through May; 95% CI 238,658 to 282,952), and 372,706 (through June; 95% CI 341,699 to 403,709). The best- and worst-case scenarios for delayed cases were 77,646 (95% CI 71,002 to 84,290) and 372,706 (95% CI 341,699 to 403,709), respectively. The projected catch-up time varied between 9 and nearly 35 months for the best- and worst-case scenarios. The addition of 20% increased productivity decreased this time to between 3.21 and 11.59 months. CONCLUSION: The COVID-19 pandemic has generated a significant backlog of THA and TKA procedures. Surgeons, administrators, and policymakers should account for these modeled estimates of case volume delays and projected demands.

Managing Resident Workforce and Education During the COVID-19 Pandemic: Evolving Strategies and Lessons Learned.

BACKGROUND: The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs. METHODS: In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures. RESULTS: Our 5 tenants support a 2-team system, whereby the residents are divided into cycling "active-duty" and "working remotely" factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department. CONCLUSIONS: The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.