Medial Calcar Density Measured via Opportunistic Computed Tomography Is Well Represented by the Dorr C Classification.

Introduction The canal-to-calcar isthmus (CC) ratio has been previously correlated with proximal femur osteology, but its relationship with bone density is not well established. Our purpose was to assess the relationship between femoral bone density, measured on opportunistic quantitative CT in Hounsfield units (HU), and CC ratio. Methods A total of 148 THA patients were included. The CC ratio was measured on anteroposterior hip radiographs. Using perioperative CT scans, a 1 cm diameter area was identified on a single mid-coronal slice in the medial calcar just proximal to the intertrochanteric ridge. The mean HU was calculated in this region to represent calcar bone density. Results Twenty-four percent (n = 35) of patients were classified as Dorr A (average CC ratio 0.47 [0.45; 0.48]), 67% (n = 96) as Dorr B (0.62 [0.55; 0.68]), and 11% (n = 17) as Dorr C (0.78 [0.77; 0.80]). There was a significant difference between Dorr A and Dorr C femurs (769 (144) vs. 588 (154) HU) as well as between B and C femurs (718 (166) vs. 588 (154) HU). The CC ratio was correlated with calcar bone density on CT (-0.370). Conclusion CC ratio is correlated with bone density determined by HU measurements on an opportunistic quantitative computed tomography scan, and bone density HU values were able to accurately differentiate bone density in Dorr A and B from Dorr C femurs. These findings suggest that the CC ratio is a reliable measurement to predict bone density in Dorr C femurs. Therefore, arthroplasty surgeons can confidently use the Dorr classification for patients with Dorr C femurs when preoperatively planning for THA.

Impact of COVID-19 on Pulmonary Embolism Rates in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the incidence and severity of pulmonary embolism (PE) in patients undergoing total hip and knee arthroplasties after the onset of the coronavirus disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: Patients who underwent a total hip arthroplasty or a total knee arthroplasty between 2017 and 2022 and had a PE within 90 days postoperatively were included. Demographics, medical history, procedural information, and PE outcomes were collected and evaluated. RESULTS: There were 5933 procedures and 17 PE events (0.27%) before COVID-19 compared with 3273 procedures and 16 PE events (0.49%) after COVID-19 (P=.12). There was an increase in intensive care unit admission after COVID-19 (44% vs 0%, P<.05). CONCLUSION: This study showed a trend toward an increased incidence of PE events in the post-COVID-19 cohort and a statistically significant increase in the severity. [Orthopedics. 202x;4x(x):xx-xx.].

Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series.

Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following TKA.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center.

Background: Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose: We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods: We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results: Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion: In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

Social Risk Determinants for Successful Same Calendar Day Discharge in Total Joint Arthroplasty.

Background: While many studies have examined the impact of comorbidities on the success of same calendar day discharge (SCDD) in total joint arthroplasty (TJA), literature surrounding the impact of social determinants is lacking. Purpose: We sought to investigate the relationship between various social determinants and success of SCDD after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: We conducted a retrospective review of 1160 THA and 1813 TKA performed at a single academic institution between November 2020 and August 2022. Social factors including substance use, occupation, marital status, income, and participation in physical exercise were included. In addition, aspects of discharge planning were reviewed such as living situation and transportation details. Results: Overall, 952 (32%) patients had successful SCDD, whereas 2021 (68%) patients were discharged on postoperative day 1 (POD1) or greater. Successful SCDD patients were more likely to have health care (4.8% vs 2.5%) and active (5.4% vs 4.6%) rather than sedentary occupations, be married (79.6% vs 67.4%), have access to transportation (95.6% vs 92.9%), live in a higher median income area ($64,044 [16,183] vs $61,572 [14,594]), and exercise weekly (62.6% vs 23.9%). Interestingly, the successful patients had more stories in their homes (1.62 [0.56] vs 1.43 [0.53]), more stairs to enter their homes (5.19 [5.22] vs 4.60 [5.24]), lived farther from the hospital (43.3 [138.0] vs 32.0 [75.9] miles), and a higher prevalence of alcohol use (60.7% vs 44.7%) and tobacco use (19.3% vs 17.3%). Conclusion: These findings may help arthroplasty surgeons to better understand the social factors that contribute to successful SCDD in TJA patients, ultimately aiding in patient selection and preoperative counseling.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success.

BACKGROUND: The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA). METHODS: There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours). RESULTS: In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer. CONCLUSIONS: Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Large Femoral Heads With Small Acetabular Components: An Examination of 10-Year Polyethylene Wear.

Highly cross-linked polyethylene (HXLPE) has improved polyethylene (PE) wear rates while decreasing osteolysis and aseptic loosening. However, concerns exist regarding the risk of mechanical failure with thin HXLPE liners in total hip arthroplasty (THA). Our purpose was to evaluate long-term outcomes and PE wear rates in primary THAs pairing large femoral heads with small acetabular components and thin HXLPE liners. We retrospectively reviewed 29 patients who underwent 33 primary THAs using large femoral heads (32 or 36 mm) with small acetabular components (48 or 50 mm) and thin HXLPE liners (3.9 or 5.9 mm) at minimum 10-year follow-up. PE liner wear was measured using a validated radiographic technique. Mean age was 66 years, 97% of the patients were women, and mean body mass index was 26.3 kg/m2. Thirty hips (90.9%) had ceramic femoral heads, and 13 hips (39%) had 36-mm femoral heads with 3.9-mm HXLPE liners. All cases used a neutral PE design. Mean linear wear rate and volumetric wear rate were 0.04 mm/year and 39.6 mm3/year, respectively, at mean 10.9-year follow-up. There were no instances of liner fracture, liner dissociation, or revision. Mean Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) was 92.1. In the largest long-term study of primary THAs using large femoral heads with small acetabular components and thin HXLPE liners, we found low linear and volumetric wear rates and no cases of liner mechanical failures. Thin HXLPE liners are a safe and viable option for THA surgeons. [Orthopedics. 2024;47(2):118-122.].

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BACKGROUND: Same calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting. METHODS: A retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded. RESULTS: All SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA. CONCLUSION: TJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

Does Automated Impaction Improve Femoral Component Sizing and Alignment in Total Hip Arthroplasty?

BACKGROUND: While automated impaction can provide a more standardized process for femoral canal preparation, little is known regarding its effect on femoral component sizing and position. The purpose of our study was to directly compare femoral component canal fill ratio (CFR) and coronal alignment between primary total hip arthroplasty (THA) procedures performed with automated impaction versus manual mallet impaction. METHODS: A retrospective analysis was performed on 184 patients who underwent primary THA by a single arthroplasty surgeon between 2017 and 2021 with a modern cementless femoral component using either the direct anterior or posterolateral approach. The final cohort was divided into 2 groups based on impaction technique during broaching: automated (N = 122) or manual (N = 62). A propensity score match was used to match for age, body mass index, sex, high versus standard offset stem, and preoperative femoral bone quality. Radiographic review was performed to measure intramedullary prosthetic CFR and coronal alignment. RESULTS: The automated cohort trended toward the use of a larger stem (5.67 versus 4.82, P = .006) and had a larger CFR at all 4 levels within the proximal femur (P = .004). The automated cohort had a more valgus and reliable coronal alignment (-0.57 (SD 1.50) versus -0.03 (SD 2.17) degrees, P = .03) and significantly shorter operative time (mean 78 versus 90 minutes, P < .001). There were no intraoperative or postoperative periprosthetic fractures in either cohort. CONCLUSION: Automated impaction in primary THA is a safe technique for femoral preparation, which resulted in improved stem coronal alignment, optimized canal fill within the proximal femur, and reduced operative times.

Incidental findings on CT scans for robot-assisted total joint arthroplasty.

INTRODUCTION: This study documented the incidence of incidental findings from preoperative computerized-tomography (CT) scans obtained for robotic-arm-assisted total joint arthroplasty (TJA) and its effect on patient management. METHODS: A retrospective review was conducted for patients who underwent robotic-arm assisted primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from 2016 to 2020. All patients obtained preoperative CT scans which were formally read by fellowship-trained musculoskeletal radiologists. CT's were flagged with incidental findings and those requiring physician follow-up were identified as significant. RESULTS: A total of 1519 patients (mean age, 66 years ±9; 849 females) were evaluated. Seventy-three (4.81%) patients had incidental CT scan findings, and 25 (1.65%) patients had significant incidental findings. Four patients required additional imaging and two patients required intervention. CONCLUSION: This study found a 4.81% incidence of incidental findings from preoperative CT scans for robotic-arm-assisted THA and TKA. Of these findings, less than 2% required physician follow-up and less than 1% required intervention. With the increasing popularity of robotic-arm assisted total joint arthroplasty, it is important to consider the necessity of detection and management of associated incidental findings from preoperative CT scans.

A Role for Outpatient Total Joint Arthroplasty During the COVID-19 Pandemic.

Outpatient total joint arthroplasty (TJA) gained favor during the COVID-19 pandemic. Our objective was to critically evaluate the safety and short-term outcomes of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) throughout the pandemic compared with pre-pandemic given their increased use. This was a retrospective review of 941 patients who underwent elective, outpatient TKA and THA at a single institution. Patients were divided into two cohorts: pre-pandemic (N=611) and pandemic (N=330). Data points included demographics, comorbidities, failure of same calendar day discharge (SCDD), and 90-day readmissions and re-operations. The pandemic cohort was older (61.0 vs 59.0 years; P=.001) and had a higher Charlson Comorbidity Index (2 vs 1; P=.004). There were no differences between the pandemic and pre-pandemic cohorts regarding SCDD failures (23.3% vs 21.9%; P=.623) and reoperations (4.2% vs 6.2%; P=.205). The pandemic cohort had a lower readmission rate (4.8% vs 8.2%; P=.056). Overall, patients who had failure of SCDD more commonly underwent TKA than THA (63.5% vs 36.5%; P<.001), were older (63.0 vs 58.5 years; P<.001), had a higher body mass index (30.8 vs 29.9 kg/m2; P=.006) and Charlson Comorbidity Index (2 vs 1; P<.001), had an American Society of Anesthesiologists class greater than 2 (51.2% vs 31.6%; P<.001), received physical therapy later postoperatively (4.15 vs 3.12 hours; P<.001), and had a history significant for myocardial infarction (P=.025), chronic kidney disease (P=.004), or diabetes (P=.003). This study supports broadening indications for outpatient TJA because we found a shift toward older patients with more comorbidities successfully undergoing the procedure. [Orthopedics. 2023;46(5):303-309.].

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.

Cost Disclosure of Surgeon "Scorecards": Effects on Operating Room Costs for Total Hip and Knee Arthroplasty.

Background: Rising health care costs, coupled with an emphasis on cost containment, continue to gain importance. Surgeon cost scorecards developed to track case-based expenditures can help surgeons compare themselves with their peers and identify areas of potential quality improvement. Purpose: We sought to investigate what effect surgeon scorecards had on operating room (OR) costs in orthopedic surgery. Methods: Our hospital distributed OR cost scorecards to 4 adult reconstruction fellowship-trained orthopedic surgeons beginning in 2012. The average direct per-case supply cost of procedures was calculated quarterly and collected over a 5-year period, and each surgeon's data were compared with that of their peers. All 4 surgeons were made aware of the costs of other surgeons at the 2-year mark. The initial 2 years of data was compared with that of the final 2 years. Results: The average direct per-case supply cost ranged from $4955 to $5271 for total knee arthroplasty (TKA) and $5469 to $5898 for total hip arthroplasty (THA) during the initial 2-year period. After implementing disclosures, the costs for TKA and THA, respectively, ranged from $4266 to $4515 (14% annual cost savings) and from $5073 to $5727 (5% annual cost savings); 3 of the 4 surgeons said that cost transparency altered their practice. Conclusion: Our comparison suggests that orthopedic surgeons' participation in a program of operative cost disclosure may be useful to them; we found a possible association with reduced per-case costs for TKA and THA at our institution over a 5-year period. More rigorous study that incorporates the effects of the scorecards on patient outcomes is warranted.

Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians.

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support "early" discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student's t test and for categorical data using χ2 testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

Gunshot Wound Resulting in Femoral Neck Fracture Treated With Staged Total Hip Arthroplasty.

A 39-year-old male presented with multiple gunshot wounds and resultant left comminuted femoral head and neck fractures with retained intraarticular bullet fragments. Successful staged reconstruction was performed with initial placement of an antibiotic spacer and subsequent conversion to total hip arthroplasty. Staged reconstruction with an antibiotic spacer and conversion to total hip arthroplasty is a viable treatment approach for a gunshot wound resulting in intraarticular bullet fragments and comminuted femoral head and neck fractures not amenable to open reduction and internal fixation to reduce the risk of periprosthetic joint infection.

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.

Discrepancies in Work-Family Integration Between Female and Male Orthopaedic Surgeons.

BACKGROUND: Female surgeons, representing 6.5% of the American Academy of Orthopaedic Surgeons, are particularly vulnerable to work-family conflict. This conflict may deter women from considering orthopaedic surgery as a specialty. The study objective was to identify differences in work-family integration between female and male orthopaedic surgeons in the United States. METHODS: An anonymous survey collecting data within the domains of work, family, and satisfaction was completed by 347 orthopaedic surgeons (153 female, 194 male). Differences in responses between males and females were identified. RESULTS: Female surgeons were younger than males (mean, 41.1 versus 50.1 years; p < 0.001) and earlier in their careers, with 60.3% of males in practice >10 years compared with 26.1% of females (p < 0.001). Consulting (7.8% versus 31.4%; p < 0.001), course faculty positions (19.0% versus 39.2%; p < 0.001), and academic and leadership titles (30.7% versus 47.4%; p = 0.002) were significantly less common among females. There was a significant income disparity between females (mean yearly income, $300,000 to $400,000) and males (mean, $400,000 to $500,000; p < 0.001). Females were more likely to have never married (12.4% versus 2.6%; p < 0.001), or they married at a later mean age (30.2 ± 4.7 versus 28.3 ± 3.9 years; p < 0.001). Females were more likely to have no children (29.4% versus 7.8%; p < 0.001), require fertility treatment (32.0% versus 11.9%; p < 0.001), and not have children until after completing their medical training (63.0% versus 31.1%; p < 0.001). Female surgeons reported more responsibility in parenting (p < 0.001) and household duties (p < 0.001) than males. Work-family balance satisfaction was 72.3% in females and 82.1% in males (p = 0.081). CONCLUSIONS: This study highlights deficiencies in work-family integration that appear to uniquely impact female orthopaedic surgeons. Female surgeons delay starting a family, more frequently require fertility treatments, carry more responsibility at home, have fewer academic and leadership roles, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family integration must be addressed to attract, support, and retain women as successful orthopaedic surgeons.

The successful implementation of the Navio robotic technology required 29 cases.

Robotic-assisted total knee arthroplasty (RA-TKA) has potential benefits of improved restoration of mechanical alignment, accuracy of bony resection, and balancing. The purpose of this study was to determine the number of cases necessary for a single surgeon to achieve a constant, steady-state surgical time. The secondary purpose was to identify which steps demonstrated the most time reduced. This was a prospective study assessing intraoperative time for 60 RA-TKA with the Navio surgical system. Overall arthroplasty time and duration for each step were recorded. Statistical analysis included a nonlinear regression and survival regression. Successful implementation required 29 cases to achieve a steady-state. The average time decreased from 41.8 min for the first cohort to 31.1 min for the last cohort, a 26% decrease. The step with the greatest reduction was the "Review of Intraoperative Plan" with a reduction of 2.1 min. This study demonstrates surgical times averaging below 60 min and a learning curve that is complete in 29 cases with the surgeon reporting a high level of confidence with the system at 10 cases. Though Navio assisted TKA showed a significantly slower operative time, we are hopeful that future generations of robotic technology will be more efficiently implemented by surgeons.

A Role for Modern Primary Cementless Femoral Stems in Revision Hip Arthroplasty.

BACKGROUND: In revision total hip arthroplasty (THA) cases with preserved femoral metaphyseal bone, tapered proximally porous-coated "primary" femoral stems may be an option. The objective of this study was to compare outcomes of patients with Paprosky I or II femoral bone loss undergoing revision THA with either a primary metaphyseal-engaging cementless stem or a revision diaphyseal-engaging stem. METHODS: This was a retrospective analysis of 70 patients with Paprosky I or II femoral bone loss who underwent femoral revision. 35 patients who were revised using a primary cementless femoral stem were compared with 35 patients who underwent femoral revision using a revision diaphyseal-engaging stem. The groups were similar regarding age, gender, body mass index, and American Society of Anesthesiologists. Clinical and radiographic outcomes and complications were compared over an average follow-up of 2.9 years (SD 1.4). RESULTS: Revision THA was most commonly performed for periprosthetic joint infection (N = 27, 38.6%). The groups were similar with regards to Paprosky femoral classification (P = .56), length of stay (P = .68), discharge disposition (P = .461), operative time (P = .20), and complications (P = .164). There were no significant differences between primary and revision femoral stem subsidence (0.12 vs. 0.75 mm, P = .18), leg length discrepancy (2.3 vs. 4.05 mm, P = .37), and Hip Disability and Osteoarthritis Outcome Score Jr (73.1 [SD 21.1] vs. 62.8 [SD 21.7], P = .088). No patient underwent additional revision surgery involving the femoral component. CONCLUSION: Use of modern primary cementless femoral stems is a viable option for revision hip arthroplasty in the setting of preserved proximal femoral metaphyseal bone. Outcomes are not inferior to those of revision stems and offer potential benefits.