End-stage renal disease patients have comparable results to renal transplant patients after shoulder arthroplasty.

Background: End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points. Results: Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts. Conclusion: SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery.

Background: Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision. Results: Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions. Conclusions: Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Renal Transplant Patients Have a Lower Risk of Complications and Mortalities After Total Knee Arthroplasty Compared to Those on Hemodialysis: A Large National Database Study.

BACKGROUND: Total knee arthroplasty (TKA) in end-stage renal disease is associated with complications. Controversy exists whether elective TKA should be performed while patients are on hemodialysis (HD) or following renal transplant (RT). This study compares TKA outcomes in HD versus RT patients. METHODS: A national database was retrospectively reviewed using International Classification of Diseases codes to identify HD and RT patients who underwent primary TKA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared using Wald and Chi-squared tests. The primary outcome was in-hospital mortalities while secondary outcomes included quality outcomes and medical/surgical complications. Multivariate regressions were used to determine independent associations. Significance was determined with a 2-tailed P value of .05. There were 13,611 patients who underwent TKA (61.1 HD and 38.9% RT). Patients who had RT were younger, had fewer comorbidities, and more likely to have private insurance. RESULTS: The RT patients had a lower rate of mortality (odds ratio (OR) 0.23, P < .01)), complications (OR 0.63, P < .01), cardiopulmonary complications (OR 0.44, P = .02), sepsis (OR 0.22, P < .001), and blood transfusion (OR 0.35, P < .001) during the index hospitalization. This cohort was also found to have decreased length of stay (-2.0 days, P < .001), non-home discharge (OR 0.57, P < .001), and hospital cost (-$5,300, P < .001). Patients who had RT had a lower rate of readmission (OR 0.54, P < .001), periprosthetic joint infection (OR 0.50, P < .01), and surgical site infection (OR 0.37, P < .001) within 90 days. CONCLUSION: These findings suggest that HD patients are a high-risk population in TKA compared to RT patients and warrant stringent perioperative monitoring.

Comparison of total hip arthroplasty outcomes between haemodyalisis and renal transplant patients.

INTRODUCTION: Total hip arthroplasty (THA) in end-stage renal disease (ESRD) patients is associated with increased complications. Controversy exists whether elective THA should be performed while these patients are on haemodialysis (HD) or following renal transplant (RT). This study seeks to compare THA outcomes in HD versus RT patients. METHODS: A national database was retrospectively reviewed using ICD codes to identify all HD and RT patients who underwent primary THA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared between cohorts using Wald and chi-square tests. The primary outcome was in-hospital mortality, while secondary outcomes included length of stay (LOS), non-home discharge, cost, readmission, and medical/surgical complications. Multivariate regression was used to determine independent associations. Significance was determined with a 2-tailed p-value of 0.05. RESULTS: 11,133 patients underwent THA, 61.6% HD and 39.4% RT patients. RT patients were younger, had fewer comorbidities, and more likely to have private insurance. After adjusting for these differences, RT patients had a lower rate of mortality (OR 0.31, p = 0.01), complications (OR 0.54, p < 0.01), cardiopulmonary complications (OR 0.54, p = 0.04), sepsis (OR 0.43, p < 0.01), and blood transfusion (OR 0.39, p < 0.001) during the index hospitalisation. RT was associated with decreased LOS (-2.0 days, p < 0.001), non-home discharge (OR 0.35, p < 0.001), and hospital cost (-$6,000, p < 0.001). RT had a lower rate of readmission (OR 0.60, p < 0.001) and revision surgery (OR 0.24, p = 0.01) within 90 days. CONCLUSIONS: These findings suggest HD patients are a high-risk population in THA compared to RT patients and warrant stringent perioperative monitoring.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.

Renal disease is a risk factor for complications and mortality after open reduction internal fixation of proximal humerus fractures.

Background: Renal osteodystrophy predisposes renal disease patients to fracture. Proximal humerus fractures (PHFs) frequently undergo open reduction internal fixation (ORIF); however, the effect of renal disease on outcomes is unknown. Methods: A retrospective review of the Nationwide Readmissions Database used International Classification of Diseases, 9th Revision, codes to identify patients who underwent ORIF for closed PHF from 2010 to 2014 with no renal disease, predialysis chronic renal disease (CRD), and end-stage renal disease (ESRD). Results: A total of 85,433 patients were identified, including 5498 (6.4%) CRD and 636 (0.7%) ESRD. CRD and ESRD patients had increased age, comorbidities, and rates of Medicare insurance. After adjusting for differences, CRD and ESRD patients were at increased risk of any complication (odds ratio [OR] 2.48, 1.66), blood transfusion (OR 1.85, 3.31), respiratory complications (OR 1.14, 1.59), acute renal failure (OR 4.80, 1.67), systemic infection (OR 2.00, 3.14), surgical site infection (OR 1.52, 3.87), longer length of stay (7.1 and 12.9 days vs. 5.9 days), and higher cost ($21,669 and $35,413 vs. $20,394) during index hospitalization, as well as surgical site infection (OR 1.43, 3.03) and readmission (OR 1.61, 3.69) within 90 days of discharge, respectively, compared with no renal disease patients. During index hospitalization, CRD patients also had increased risk for periprosthetic fracture (OR 4.97) and cardiac complications (OR 1.47), whereas ESRD patients had increased risk of mortality (OR 5.79), wound complication (2.67), and deep vein thrombosis (OR 16.70). Conclusion: These findings suggest renal patients are at increased risk for complications after PHF ORIF, highlighting the importance of close perioperative monitoring and appropriate patient selection in this population, including strong consideration of nonoperative management.

Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis.

BACKGROUND: In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17). CONCLUSION: Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D. LEVEL OF EVIDENCE: III.

Epidemiology of Revision Total Knee Arthroplasty in the United States, 2012 to 2019.

Background: As primary total knee arthroplasty volume continues to increase, so will the number of revision total knee arthroplasty (rTKA) procedures. The purpose of this study is to provide an updated perspective on the incidence, indications, and financial burden of rTKA in the United States. Material and methods: This was a retrospective epidemiologic analysis using the National Inpatient Sample. International Classification of Diseases ninth and tenth revision codes were used to identify patients who underwent rTKA and create cohorts based on rTKA indications from 2012 to 2019. National and regional trends for length of stay, cost, and discharge location were evaluated. Results: A total of 505,160 rTKA procedures were identified. The annual number of rTKA procedures increased by 29.6% over the study period (56,490 to 73,205). The top 3 indications for rTKA were aseptic loosening (23.1%), periprosthetic joint infection (PJI) (20.4%), and instability (11.0%). Over the study period, the proportion of patients discharged to skilled nursing facility decreased from 31.7% to 24.1% (P < .001). Hospital length of stay decreased from 4.0 days in 2012 to 3.8 days in 2019 (P < .001). Hospital costs increased by $1300 from $25,730 to $27,077 (P < .001). The proportion of rTKA cases performed at urban academic centers increased (52.1% to 74.3%, P < .001) while that at urban nonacademic centers decreased (39.0% to 19.2%, P < .001). Conclusion: The top 3 indications for rTKA were aseptic loosening, PJI, and instability, with PJI becoming the most common indication in 2019. These cases are increasingly being performed at urban academic centers and away from urban nonacademic centers. Level of Evidence: 3 (Retrospective cohort study).

Revision Total Hip Arthroplasty in Solid Organ Transplant Patients: A Propensity Score-Matched Cohort Study for Aseptic and Infected Revisions.

BACKGROUND: Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total hip arthroplasty (THA) are at an increased risk of postoperative complications. The purpose of this study is to use a large, national database to investigate revision THA (rTHA) outcomes in SOT patients. METHODS: Nationwide Readmissions Database (NRD) from 2010-2018 was used, and ICD-9 and ICD-10 codes were used to identify all patients who underwent rTHA, including those with history of SOT. Propensity score matching (PSM) was used to analyze rTHA outcomes in SOT patients comparted to matched controls. Separate analysis performed for patients undergoing rTHA for prosthetic joint infection (PJI) vs other causes. RESULTS: A total of 414,756 rTHA, with 1837 of those being performed in SOT patients, were identified. Of these, 65,961 and 276 were performed for PJI in non-SOT and SOT patients, respectively. For non-PJI patients, SOT patients had higher 90-day all-cause readmission rates (24.0% vs 19.4%, P = .03) but lower rate for readmission related to rTHA (6.0% vs 9.2%, P = .03), but no difference readmission for specific rTHA complications, mortality (0.6% vs 1.3%, P = .20), or revision rTHA. Of PJI patients, SOT patients had no difference in overall 90-day readmission (38.6 vs 31.3%, P = .280), readmission for specific rTHA complications, re-revision, or mortality (4.7% vs 6.0%, P = .63). CONCLUSIONS: SOT patients undergoing rTHA for aseptic reasons are higher risk of overall readmission but lower risk of readmission related to rTHA than appropriately matched controls. SOT PJI patients undergoing had similar rates of readmission, mortality, and revision surgery compared to matched non-SOT PJI patients.

Cemented Versus Noncemented Total Knee Arthroplasty Outcomes.

INTRODUCTION: Aseptic loosening remains one of the most common indications for revision total knee arthroplasty (TKA). Given the demographic shift to a younger and more active TKA patient population, some surgeons have revisited noncemented fixation given its potential for lower rates of long-term aseptic loosening. The purpose of this study was to compare the demographics and complications between patients undergoing noncemented and cemented TKA. METHODS: Using the MKnee subset of the PearlDiver database, diagnosis and procedure codes were used to identify patients who had undergone cemented or noncemented TKA for osteoarthritis with a minimum 2-year follow-up. Propensity score matching was done to compare risk-adjusted medical and surgical complication profiles at 90 days, 1 year, and 2 years. RESULTS: Of 203,574 patients identified, 3.2% underwent noncemented TKA and 96.8% underwent cemented TKA. Using propensity-matched analysis, there was no difference in 90-day medical complications. Noncemented TKA was associated with a greater risk of periprosthetic joint infection throughout the study (90-day odds ratio [OR] 1.34, 1-year OR 1.27, 2-year OR 1.27, P < 0.05). Noncemented TKA was associated with a greater risk of periprosthetic fracture at 1 year and 2 years (1 year OR 2.19, 2 years OR 1.89, P < 0.05). No notable difference was observed in risk of aseptic loosening between the two groups. DISCUSSION: Noncemented TKA is associated with a higher rate of periprosthetic joint infection and periprosthetic fracture. Additional studies are needed to compare long-term rates of aseptic loosening between noncemented and cemented TKA. LEVEL OF EVIDENCE: Level III.

Revision total knee arthroplasty outcomes in solid organ transplant Patients, a matched cohort study of aseptic and infected revisions.

BACKGROUND: Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total knee arthroplasty (TKA) are at an increased risk of postoperative complications. The purpose of this study is to utilize a large, national database to investigate revision TKA (rTKA) outcomes in SOT patients. METHODS: This was a retrospective review utilizing the Nationwide Readmissions Database (NRD) and ICD-9 codes to identify patients who underwent rTKA from 2010-2014 with a history of at least one SOT. Propensity-score-matching (PSM) was used to compare rTKA outcomes in SOT patients compared to matched patients without SOT. RESULTS: A total of 303,867 rTKAs, with 464 of those being performed in SOT patients, were included in the study. Of these, 71,903 and 182 were performed for PJI in non-SOT and SOT patients, respectively. rTKA was performed most frequently in kidney transplant patients (53.0%) followed by liver transplant patients (34.3%). For non-PJI patients, SOT patients had a higher 90-day readmission rate than matched non-SOT rTKA patients (23.2% vs 12.6%, p = 0.006). However, there were no differences in 90-day readmission rates for specific rTKA complications, subsequent revision rTKA, or mortality. Among patients undergoing rTKA for PJI, there was no difference in overall 90-day readmission rate, readmission for specific rTKA complications, subsequent revision rTKA, or mortality. CONCLUSIONS: While the increased medical comorbidities associated with SOT place patients at increased risk for complications following rTKA, it appears that SOT alone does not do so when patients are matched based on overall medical comorbidity.

Trends of Femoral Neck Fracture Treatment Using Total Hip Arthroplasty: Reported From the American Joint Replacement Registry.

INTRODUCTION: Total hip arthroplasty (THA) rather than hemiarthroplasty for displaced femoral neck fracture (FNF) is often chosen for younger patients who are more active and/or have underlying hip osteoarthritis. However, instability remains the primary concern of doing THA. Dual mobility (DM) has been shown to decrease this risk through a larger effective head size and greater head-to-neck ratio compared with conventional THA. The purpose of this study was to identify femoral head size and DM usage patterns for the treatment of FNF with THA in the United States using the American Joint Replacement Registry. METHODS: A retrospective cohort study was conducted, including all primary THAs done for FNF from 2012 to 2019. THA and FNF were defined using Current Procedural Terminology or International Classification of Diseases-9 or -10 diagnosis and procedure codes. Analysis was based on patient demographics, femoral head size, and DM usage. Descriptive statistics were used using a Pearson chi-square test. All analyses were conducted using SAS version 9.4, and statistical significance was set at P < 0.05. RESULTS: There were 18,752 THAs done by 3,242 surgeons at 789 institutions during the 8-year study period. The overall population was 66% female, and the mean age was 72.3 ± 11.8 years. The most commonly used femoral head size was 36 mm (48.5%) followed by 32 mm (24.5%), ≤28 mm (10.7%), DM (10.8%), and ≥40 mm (5.7%). A trend was observed toward decreased use of ≤28, 32, and ≥40-mm heads starting in 2016 across the years and increased use of 36-mm heads (P < 0.0001). A significant increase was observed in the usage of DM over time from 6.4% in 2012 to 16.2% in 2019 (P < 0.0001). DISCUSSION: Most of the femoral heads used were ≥36 mm, and the use of DM increased during the study period. Additional analysis is warranted to understand how these trends will affect overall outcomes and postoperative dislocation rates.

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients.

BACKGROUND: The purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group. METHODS: This was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge. RESULTS: From 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA. CONCLUSION: In this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA. LEVEL OF EVIDENCE: 3 (Retrospective cohort study).

Impact of delayed intervention on clinical outcomes following traumatic hip fracture in the elderly: A national analysis.

The present study sought to evaluate clinical outcomes of delayed intervention following hip fractures. Adults (≥60 years) who underwent operative intervention for hip fracture following traumatic fall were identified using the 2008-2018 National Inpatient Sample. Patients were classified as Delayed if repair was >48 h after admission and otherwise considered Early. Of an estimated 1,942,905 patients, 148,441 (7.6%) were Delayed. Delayed more commonly suffered neck fractures, underwent hip arthroplasty and were managed at low-volume hospitals. After adjustment, delayed operation was associated with greater likelihood of mortality (adjusted odds ratio (AOR): 1.28, 95% CI: 1.17-1.40), studied complications, hospitalization duration and costs.

Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) After Primary Spinal Fusion: An Analysis of Outcomes and Risk Factors from 2005 to 2014.

BACKGROUND: Ogilvie syndrome (OS) is a rare but serious condition seen in the postoperative period. This was an epidemiologic study using data from the National Inpatient Sample from 2005 to 2014 to look at incidence, risk factors, and outcomes associated with OS after primary spine fusion. METHODS: International Classification of Diseases, Ninth Revision codes were used to identify patients who underwent spine fusion surgery. Patients were separated into 2 cohorts based on the diagnosis of OS. Outcome measures and risk factors for cohorts were analyzed using multivariate logistic regression and compared. RESULTS: Over the 10-year study period, 3,884,395 patients underwent primary spine fusion surgery. Among these, 0.04% developed OS during the index hospitalization. The greatest incidence seen in primary fusion involved the thoracic spine (0.15%). OS was more common after spine fusion for spine deformity (P < 0.001). Patients with OS were more likely to be men (P < 0.001), older (P < 0.0001), and have more comorbidities (P < 0.0001). Patients with OS were more likely to require postoperative blood transfusions (odds ratio [OR], 3.39; 95% confidence interval [CI], 2.51-4.59; P < 0.001) and sustain any complication (OR, 4.20; 95% CI, 3.17-5.57; P < 0.001). Patients with OS had a longer length of stay (15.7 vs. 3.9 days; P < 0.001) and increased average hospitalization cost ($63,037.03 vs. $26,792.19; P < 0.001). The development of OS was associated with fluid electrolyte disorder (OR, 4.06; 95% CI, 2.99-5.51; P < 0.001). CONCLUSIONS: OS is a rare but serious complication of primary spine fusion surgery. Identifying the specific risk factors, symptoms, and potential complications related to OS is critical to aid in decreasing the significant morbidity associated with its development.

Instability Is the Most Common Indication for Revision Hip Arthroplasty in the United States: National Trends From 2012 to 2018.

BACKGROUND: As primary total hip arthroplasty volume continues to increase, so will the number of revision total hip arthroplasty (rTHA) procedures. These complex cases represent a significant clinical and financial burden to the health-care system. METHODS: This was a retrospective review using the National Inpatient Sample. International Classification of Diseases, 9th and 10th revision codes were used to identify patients who underwent rTHA and create cohorts based on rTHA indications from 2012 to 2018. National and regional trends for length of stay (LOS), cost, and discharge location were evaluated. RESULTS: A total of 292,250 rTHA procedures were identified. The annual number of rTHA procedures increased by 28.1% from 2012 to 2018 (37,325 to 47,810). The top 3 indications for rTHA were instability (20.4%), aseptic loosening (17.8%), and infection (11.1%). Over the study period, the proportion of patients discharged to skilled nursing facility decreased from 44.2% to 38% (P < .001). Hospital LOS decreased on average from 4.8 to 4.4 days (P < .001). Infections had the highest average LOS (7.3 days) followed by periprosthetic fractures (6.5 days). Hospital costs decreased over the study period, from $25,794 to $24,555 (P < .001). The proportion of rTHA cases performed at urban academic centers increased (58.0% to 75.3%, P < .001) while the proportion performed at urban nonacademic centers decreased (35.5% to 19.4%, P < .001). CONCLUSION: Instability was the most common indication for rTHA between 2012 and 2018. The proportion of rTHA performed in urban academic centers has increased substantially, away from urban nonacademic centers. While cost and LOS have decreased, significant geographic variability exists.

National Trends in Total Hip Arthroplasty Bearing Surface Usage in Extremely Young Patients Between 2006 and 2016.

BACKGROUND: Long-term implant durability is a key concern when considering total hip arthroplasty (THA) in young patients. The ideal bearing surface used in these patients remains unknown. The purpose of this study was to analyze trends in THA bearing surface use from 2006 to 2016 using a large, pediatric national database. METHODS: This was a retrospective review from January 1, 2006, to December 31, 2016, using the Kids' Inpatient Database. International Classification of Diseases, 9th revision and 10th revision codes were used to identify patients who underwent THA and create cohorts based on bearing surfaces: metal-on-metal, metal-on-polyethylene, ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC). Annual utilization of each bearing surface and associated patient and hospital demographics were analyzed. RESULTS: A total of 1004 THAs were identified during the 11-year study period. The annual number of THAs performed increased by 169% from 2006 to 2016. The mean patient age was 17.1 years. The most prevalent bearing surface used in 2006 was CoC (37.3%), metal-on-metal (31.8%) in 2009, and CoP in 2012 and 2016 (50.6% and 64.8%, respectively). From 2006 to 2016, utilization of CoP increased from 5.0% to 64.8%, representing a 1196% increase over the study period. CONCLUSIONS: The number of THAs performed in pediatric patients is increasing significantly. Although CoC was previously the most commonly used bearing surface in this patient population, CoP is currently the most common. Further investigation is needed to determine whether bearing longevity and clinical outcomes with CoP are superior to other bearing surfaces.

Analysis of the Digital Footprint of Orthopaedic Surgeons.

INTRODUCTION: Patients increasingly rely on Google search to guide their choice of healthcare providers. Despite this trend, there is limited literature systematically characterizing the online presence of orthopaedic surgeons. The goal of this study was to identify the information patients see after queries of Google search when selecting orthopaedic surgeon providers. METHODS: The Physician Comparable downloadable file from the Centers for Medicare and Medicaid Services was deduplicated and filtered. A list of orthopaedic surgeons within the United States was generated, of which a randomized sample was taken and queried using a Google Custom Search. The results for each surgeon's first page were classified into the following categories: (1) hospital-controlled content website, (2) third-party health website, (3) social media website, (4) primary academic journals, or (5) other. RESULTS: The most frequently returned website was third-party health websites (43.3%). Statistically significant differences were observed in the categories across multiple comparisons, including academic and nonacademic orthopaedic surgeons, male and female providers, and surgeons from different graduation years. DISCUSSION: Most of the results were attributed to third-party websites demonstrating that orthopaedic surgeons do not have notable control over their digital footprint. Increased patient visibility of physician-controlled websites and an objective rating system for patients remain potential areas of growth.

Utilization trends and outcomes of computer-assisted navigation in spine fusion in the United States.

BACKGROUND CONTEXT: Computer-assisted navigation (CAN) has emerged in spine surgery as an approach to improve patient outcomes. While there is substantial evidence demonstrating improved pedicle screw accuracy in CAN as compared to conventional spinal fusion (CONV), there is limited data regarding clinical outcomes and utilization trends in the United States. PURPOSE: The purpose of this study was to determine the utilization rates of CAN in the United States, identify patient and hospital trends associated with both techniques, and to compare their results. STUDY DESIGN: Retrospective review of national database. PATIENT SAMPLE: Nationwide Inpatient Sample (NIS), United States national database. OUTCOME MEASURES: CAN utilization, mortality, medical complications, neurologic complications, discharge destination, length of hospital stay, cost of hospital stay. METHODS: The NIS database was queried to identify patients undergoing spinal fusion with CAN or CONV. CAN and CONV utilization were tracked by year and anatomic location (cervical, thoracic, lumbar/lumbosacral). Patient demographics, hospital characteristics, index length of stay (LOS), and cost of stay (COS) were compared between the cohorts. After multivariate adjustment, index hospitalization clinical outcomes were compared. RESULTS: A total of 4,275,413 patients underwent spinal fusion surgery during the study period (2004 to 2014). CONV was performed in 98.4% (4,208,068) of cases and CAN was performed in 1.6% (67,345) of cases. The utilization rate of CAN increased from 0.04% in 2004 to 3.3% in 2014. Overall, CAN was performed most commonly in the lumbar/lumbosacral region (70.4%) compared to the cervical (20.4%) or thoracic (9.2%) regions. When normalized to region-specific rates of fusion with any technique, the proportional utilization of CAN was highest in the thoracic spine (2.7%), followed by the lumbar/lumbosacral (2.2%) and cervical (0.9%) regions. CAN utilization was positively correlated with patient factors including increasing age and number of medical comorbidities. Multivariate adjusted clinical outcomes demonstrated that compared to CONV, CAN was associated with a statistically significant decreased risk of mortality (0.28% vs 0.31%, OR=0.67, 95% CI: 0.46-0.97, p=.035) and increased risk of blood transfusions (9.1% vs 6.7%, OR=1.19, 95% CI: 1.02-1.39, p=.032). However, there was no difference in risk of neurologic complications. CAN patients had an increased average LOS (4.44 days vs. 3.97 days, p<.0001) and average COS ($34,669.49 vs $26,784.62, p<.0001) compared to CONV patients. CONCLUSIONS: CAN utilization increased in the United States from 2004-2014. Use of CAN was proportionately higher in the thoracic and lumbar/lumbosacral regions and in older patients with more comorbidities. Given the continued trend towards increased CAN utilization, large-scale studies are needed to determine the impact of this technology on long-term clinical outcomes.