Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty from 2013 to 2022 - An Analysis from an Urban Orthopaedic Hospital.

INTRODUCTION: As worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. METHODS: A retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based, academic medical center between January 2013 and September 2022 was performed. Trends in patients' age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients' ZIP code), race, and Charlson comorbidity index (CCI) were evaluated using the Mann-Kendall test. RESULTS: In the last decade, mean patient age (65 to 68 years, P < 0.001) and CCI (1.4 to 2.3, P < 0.001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = 0.002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = 0.015) and BMI < 30 (42.5 to 36.8%, P = 0.020) decreased. The distribution of patients' race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = 0.211) and low SES (12.9 to 11.3%, P = 0.283) patients consistently represented a minority of TKA patients. CONCLUSIONS: Over the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥ 40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations.

Knotless suture in revision total joint arthroplasty: a prospective randomized controlled trial.

INTRODUCTION: The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting. METHODS: A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups. RESULTS: The use of barbed sutures decreased closure time by 6 min (30.1 vs. 36.1 min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5 mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up. CONCLUSION: Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique. LEVEL OF EVIDENCE: I.

Increased patient body mass index is associated with increased surgeon physiologic stress during total hip arthroplasty.

INTRODUCTION: While increased body mass index (BMI) in patients undergoing total hip arthroplasty (THA) increases surgical complexity, there is a paucity of objective studies assessing the impact of patient BMI on the cardiovascular stress experienced by surgeons during THA. The aim of this study was to assess the impact of patient BMI on surgeon cardiovascular strain during THA. METHODS: We prospectively evaluated three fellowship-trained arthroplasty surgeons performing a total of 115 THAs. A smart-vest worn by the surgeons recorded mean heart rate, stress index (correlate of sympathetic activation), respiratory rate, minute ventilation, and energy expenditure throughout the procedures. Patient demographics as well as perioperative data including surgical approach, surgery duration, number of assistants, and the timing of the surgery during the day were collected. Linear regression was utilized to assess the impact of patient characteristics and perioperative data on cardiorespiratory metrics. RESULTS: Average surgeon heart rate, energy expenditure, and stress index during surgery were 98.50 beats/min, 309.49 cal/h, and 14.10, respectively. Higher patient BMI was significantly associated with increased hourly energy expenditure (P = 0.027), mean heart rate (P = 0.037), and stress index (P = 0.027) independent of surgical approach. Respiratory rate and minute ventilation were not associated with patient BMI. The number of assistants and time of surgery during the day did not impact cardiorespiratory strain on the surgeon. CONCLUSION: The physiologic burden on surgeons during primary THA significantly increases as patient BMI increases. This study suggests that healthcare systems should consider adjusting reimbursement models to account for increased surgeon workload due to obesity. Further surgeons should adopt strategies in operative planning and case scheduling to handle this added physical strain. LEVEL OF EVIDENCE: III.

The Impact of Obesity on Total Hip Arthroplasty Outcomes When Performed by High-Volume Surgeons-A Propensity Matched Analysis From a High-Volume Urban Center.

BACKGROUND: Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons. METHODS: A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases. RESULTS: The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056). CONCLUSIONS: Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons. LEVEL OF EVIDENCE: III.

Should high-risk patients seek out care from high-volume surgeons?

Aims: Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Methods: Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Results: Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. Conclusion: The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

The Financial Burden of Patient Comorbidities on Total Hip Arthroplasties-A Matched Cohort Analysis of High Comorbidity Burden and Non-High Comorbidity Burden Patients.

BACKGROUND: The impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB). METHODS: We retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group). RESULTS: Total (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049). CONCLUSIONS: Increased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations. LEVEL OF EVIDENCE: III.

Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis.

Background: Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA. Methods: We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study. Results: The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF. Conclusions: The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Innovations in the Isolation and Treatment of Biofilms in Periprosthetic Joint Infection: A Comprehensive Review of Current and Emerging Therapies in Bone and Joint Infection Management.

Periprosthetic joint infections (PJIs) are a devastating complication of joint arthroplasty surgeries that are often complicated by biofilm formation. The development of biofilms makes PJI treatment challenging as they create a barrier against antibiotics and host immune responses. This review article provides an overview of the current understanding of biofilm formation, factors that contribute to their production, and the most common organisms involved in this process. This article focuses on the identification of biofilms, as well as current methodologies and emerging therapies in the management of biofilms in PJI.

The Financial Feasibility of Bilateral Total Knee Arthroplasty: A Matched Cohort Analyses of Revenue and Contribution Margin Between Simultaneous and Staged Procedures.

BACKGROUND: Financial analyses of simultaneous bilateral total knee arthroplasty versus staged bilateral total knee arthroplasty (simBTKA and staBTKA, respectively) have shown improved cost-effectiveness of simBTKA, though revenue and contribution margin (CM) for these procedures have not been investigated. Our analyses compared surgical outcomes, revenues, and CMs between simBTKA and staBTKA. METHODS: We retrospectively reviewed all patients who underwent simBTKA (both procedures done on the same day) and staBTKA (procedures done on a different day within one year) between 2012 and 2021. Patients were 1:1 propensity matched based on baseline characteristics. Surgical outcomes, as well as revenue, cost, and CM of the inpatient episode were compared between groups. Of the 2,357 patients evaluated (n = 595 simBTKA, n = 1,762 staBTKA), 410 were included in final matched analyses (205 per group). RESULTS: Total (P < .001) and direct (P < .001) costs were significantly lower for simBTKA procedures compared to overall costs of both staBTKA procedures. Significantly lower revenue for simBTKA procedures (P < .001), resulted in comparable CM between groups (P = .477). Postoperative complications including 90-day readmission (P = 1.000), 90-day revision (P = 1.000) and all-cause revision at latest follow-up (P = .083) were similar between groups. CONCLUSIONS: In our propensity-matched cohort, lower costs for simBTKA compared to staBTKA were matched by lower revenues, with a resulting similar CM between procedures. Given that postoperative complication rates were similar, both procedures had comparable cost-effectiveness. Future research is needed to identify patients for whom simBTKA may represent a better surgical intervention compared to staBTKA with respect to clinical and patient reported outcomes.

Does experience with total knee arthroplasty in morbidly obese patients effect surgical outcomes.

INTRODUCTION: Literature examining the risks, benefits, and potential complications of TKA in morbidly obese patients is conflicting. Surgeons with more experience performing TKA on morbidly obese patients may generate superior outcomes. This study sought to assess whether complication rates and implant survivorship in morbidly obese TKA patients varies between high (HV) and low (LV) volume surgeons. METHODS: A retrospective review was performed to include all morbidly obese (BMI ≥ 40) patients that underwent primary TKA between January 2016 and July 2021 at our high-volume center. Demographics and clinical outcomes were collected and compared between surgeons with a higher morbidly obese TKA volume (> 10 annual cases) and surgeons with a lower morbidly obese TKA volume. RESULTS: A total of 964 patients (HV 91 [9.4%], LV 873 [90.6%]) were identified. The HV surgeon and LV surgeons had an average annual volume of 15.3 and 5.2 cases, respectively. The average BMI for the HV and LV cohorts were 44.5 ± 3.7 and 44.0 ± 3.6, respectively (p = 0.160). The HV surgeon had significantly lower operative times (105.7 ± 17.4 vs. 110.7 ± 29.6 min, p = 0.018), and a lower 90-day minor complication rate (0.0% vs. 4.7%, p = 0.035). For patients with at least 2-year follow-up, all-cause revision (3.4% vs. 12.5%, p = 0.149) and revision due to PJI (0.0% vs. 5.8%, 0.193) rates were numerically lower in the HV cohort. Improvements in KOOS, JR and VR-12 scores were similar at 3-month and 1-year follow-up. Freedom from all-cause revision (HV: 96.6% vs. LV: 80.4%, p = 0.175) and revision due to PJI (HV: 100.0% vs. LV: 93.6%, p = 0.190, p = 0.190) at latest follow-up did not statistically differ between groups. CONCLUSION: The HV surgeon had significantly lower operative time and 90-day minor complication rates and numerically lower all-cause revision and revision due to PJI rates when performing TKA in morbidly obese patients. Surgeon's experience may affect surgical outcomes after TKA in morbidly obese patients. LEVEL OF EVIDENCE: III.

Outcomes of Enterobacter cloacae-Associated Periprosthetic Joint Infection Following Hip Arthroplasties.

Background: Periprosthetic joint infections (PJIs) represent a serious complication following total hip arthroplasty (THA) and are associated with significant morbidity. While recent data suggest that Enterobacter cloacae is an emerging source of PJI, characteristics and outcomes of E. cloacae-associated infections are rarely described. The study aimed to present and describe the findings and outcomes of E. cloacae-associated PJI in our department. Methods: This is a retrospective descriptive study of patients who underwent revision THA for E. cloacae-associated PJI between 2011 and 2020 and has a minimum follow-up of 2 years. Outcomes included organism characteristics as well as clinical outcomes, represented by the number of reoperations needed for PJI eradication and the Musculoskeletal Infection Society (MSIS) outcome reporting tool score. Of 108 revision THAs, 12 patients (11.1%) were diagnosed with E. cloacae-associated PJI. Results: The majority of cases had a polymicrobial PJI (n=8, 66.7%). Five E. cloacae strains (41.7%) were gentamicin-resistant. Six patients (50.0%) underwent 2 or more revisions, while 3 of them (25.0%) required 4 or more revisions until their PJI was resolved. When utilizing the MSIS outcome score, the first surgical intervention was considered successful (MSIS score tiers 1 and 2) for 5 patients (41.7%) and failed (tiers 3 and 4) for 7 patients (58.3%). Conclusions: E. cloacae is emerging as a common source of PJI following hip arthroplasty procedures. The findings of our study suggest that this pathogen is primarily of polymicrobial nature and represents high virulence and poor postoperative outcomes, as represented by both an increased number of required revision procedures and high rates of patients with MSIS outcome scores of 3 and 4. When managing patients with E. cloacae-associated PJI, surgeons should consider these characteristics and inform patients regarding predicted outcomes.

Intraoperative three-dimensional navigation for surgical treatment of osteoid osteoma in the upper extremity: A series of 19 cases.

The surgical treatment for osteoid osteoma (OO) in the upper extremity is challenging due to the difficulty in locating the lesion and the crowding of sensitive structures within the anatomy. This study aimed to describe the outcomes of navigated minimally invasive radiofrequency ablation and those of navigated mini open-intralesional curettage in treating these lesions. Nineteen consecutive patients with OO in the upper limb who underwent navigated surgery were included. The average QuickDASH and Numeric Pain Rating Scale improved from 62.2 ± 23.7 to 11.7 ± 16.9 and from 8.1 ± 1.6 to 0.5 ± 1.8, respectively (p < .01 each) following the procedure. Two complications were recorded: one patient had persistent radial nerve palsy, and one patient had transient partial radial nerve weakness. In conclusion, navigation is an important tool in the surgical treatment of OO in the upper limb. A mini open approach to identify and protect neurovascular structures is recommended.

Addition of gentamicin for antibiotic prophylaxis in hip hemiarthroplasty does not decrease the rate of surgical site infection.

BACKGROUND: The addition of Gram-negative coverage to antibiotic prophylaxis protocols prior to elective total hip arthroplasty (THA) has been reported to reduce periprosthetic joint infection (PJI). However, it is unknown whether adding a Gram-negative-targeted antibiotic agent improves outcomes in the trauma population. This study aimed to investigate whether the addition of a single, pre-operative dose of Gentamicin is associated with lower rates of PJI in patients undergoing hemiarthroplasty (HA) as treatment for a hip fracture. METHODS: We retrospectively reviewed cases of patients who underwent HA as treatment for a hip fracture from January 2011 to January 2022, and had a minimum 1-year of follow-up. Patients were divided into two groups based on the antibiotic prophylaxis they received during surgery: cefazolin (control group) or cefazolin with addition of Gentamicin (case group). The primary outcome was the rate of surgical site infections (SSI), and secondary outcomes included rates of prosthetic joint infection (PJI) and superficial SSIs. RESULTS: The final study population consisted of 1521 patients. 336 patients (22.1%) were in the case group and 1185 (77.9%) patients were in the control group. Rates of SSI were comparable between the groups (3.8% for the case group vs. 2.8% in the control group, p = 0.34). This held true for both PJIs (3.5 vs. 2.5%, p = 0.3) and superficial SSIs (0.29 vs. 0.33%, p = 0.91). The distribution of the causing pathogen was similar between the groups (p = 0.84). Gentamicin susceptibility rates of the Gram-negative bacteria associated with PJI were similar between the cohorts (p = 0.51). CONCLUSIONS: The addition of a single, pre-operative dose of Gentamicin to the antibiotic prophylaxis protocol of patients undergoing HA as treatment for a hip fracture was not associated with lower rates of SSI, PJI or superficial SSI. The findings of this study indicate that the prophylactic benefits of Gentamicin may not apply to HA as they do to THA.

Refractory Pseudomonas aeruginosa infections treated with phage PASA16: A compassionate use case series.

BACKGROUND: A growing number of compassionate phage therapy cases were reported in the last decade, with a limited number of clinical trials conducted and few unsuccessful clinical trials reported. There is only a little evidence on the role of phages in refractory infections. Our objective here was to present the largest compassionate-use single-organism/phage case series in 16 patients with non-resolving Pseudomonas aeruginosa infections. METHODS: We summarized clinical phage microbiology susceptibility data, administration protocol, clinical data, and outcomes of all cases treated with PASA16 phage. In all intravenous phage administrations, PASA16 phage was manufactured and provided pro bono by Adaptive Phage Therapeutics. PASA16 was administered intravenously, locally to infection site, or by topical use to 16 patients, with data available for 15 patients, mainly with osteoarticular and foreign-device-associated infections. FINDINGS: A few minor side effects were noted, including elevated liver function enzymes and a transient reduction in white blood cell count. Good clinical outcome was documented in 13 out of 15 patients (86.6%). Two clinical failures were reported. The minimum therapy duration was 8 days with a once- to twice-daily regimen. CONCLUSIONS: PASA16 with antibiotics was found to be relatively successful in patients for whom traditional treatment approaches have failed previously. Such pre-phase-1 cohorts can outline potential clinical protocols and facilitate the design of future trials. FUNDING: The study was funded in part by The Israeli Science Foundation IPMP (ISF_1349/20), Rosetrees Trust (A2232), United States-Israel Binational Science Foundation (2017123), and the Milgrom Family Support Program.

Go Big or Go Home: Obesity and Total Joint Arthroplasty.

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.

Monoblock tapered stems in management of UCS B2 and B3 periprosthetic fractures in revision total hip arthroplasty.

Aims: United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures. Methods: A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up. Results: For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively. Conclusion: Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern.

Total Knee Arthroplasty in a Patient with Ipsilateral Painless Hip Arthrodesis: Technical Surgical Tips and a Novel Method for Intraoperative Navigation-Assisted Planning.

Total knee arthroplasty (TKA) in the setting of a previous ipsilateral hip fusion/arthrodesis is an uncommon and challenging procedure. There is little information available in the literature on the challenges and techniques available to perform TKA in these patients. For a traditional TKA procedure, the patient is placed in the supine position and various knee-positioning devices are used to allow for adequate knee and hip flexion, which is required for surgical exposure and tibia preparation. Ipsilateral hip arthrodesis presents two major challenges: (1) Hip flexion is crucial for adequate knee flexion while the patient is supine during the TKA procedure, and (2) the use of advanced technology, specifically computer navigation and robotic-assisted surgery techniques, is limited due to the inability to acquire the hip center of rotation during surgery, due to the lack of hip motion. Therefore, equipment and positioning must be adjusted by the surgeon to facilitate TKA in these patients. This article reports the case of a 72-year-old male patient with a long-standing, painless right hip arthrodesis, presenting with end-stage osteoarthritis of the right knee, leg-length discrepancy, and an 11.6° difference between the mechanical and anatomical axes of the femur. We describe the unique surgical planning as well as the surgical positioning options that allow for adequate knee flexion and proper surgical exposure. Furthermore, we describe a novel method of computer-assisted navigation for intra-operative planning and execution utilizing a reflected tibia as a template for the distal femoral cut.

The effect of patient body mass index and sex on the magnification factor during pre-operative templating for total hip arthroplasty.

INTRODUCTION: Pre-operative templating prior to hip arthroplasty has traditionally used implant-company-provided acetates, which assumed a magnification factor between 115% and 120%. In recent years, pre-operative planning has been performed with digital calibration devices, in order to calculate the magnification factor. However, these devices are not without their limitations and are not readily available at many institutions. As previous reports suggest a wide range of magnification factors, the determination of an optimal magnification factor is currently unclear. We investigated the relationship between obesity and gender on the magnification factor in order to improve the accuracy of pre-operative templating. PATIENTS AND METHODS: Ninety-seven consecutive pre-operative calibrated pelvic radiographs using the KingMark calibration were analyzed using the TraumaCad templating software. The magnification factor calculated by the software was considered the true magnification factor and analysis was made in order to assess the effect of sex and body mass index (BMI) on the magnification factor. A linear regression analysis was utilized to create a predictive model for optimal magnification factor value. RESULTS: Magnification factor was significantly affected by sex (male, 120.0% vs. female 121.2%, p < 0.01) and by categorized BMI (obese 121.8% vs. non-obese 119.9%, p < 0.001). A positive linear association was found between BMI and the magnification factor (r = 0.544). The magnification factor was significantly different between the following sub-groups: obese female, non-obese female, obese male, and non-obese male (p < 0.001). When applying the model formulated by the linear regression analysis, the calculated magnification factor was within 2% of the true magnification factor for the majority of patients (n = 83, 85.6%). CONCLUSIONS: BMI and gender have a significant effect on the magnification factor. Future determination of the magnification factor should consider the influence of these variables in order to improve the accuracy of pre-operative templating in THA.

Trends in Revision Total Hip Arthroplasty Cost, Revenue, and Contribution Margin 2011 to 2021.

BACKGROUND: Revision total hip arthroplasty (rTHA) is a costly procedure, and its prevalence has been steadily increasing over time. This study aimed to examine trends in hospital cost, revenue, and contribution margin (CM) in patients undergoing rTHA. METHODS: We retrospectively reviewed all patients who underwent rTHA from June 2011 to May 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed Medicaid, or commercial insurance. Patient demographics, revenue (any payment the hospital received), direct cost (any cost associated with the surgery and hospitalization), total cost (the sum of direct and indirect costs), and CM (the difference between revenue and direct cost) were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analyses were used to determine the overall trend's significance. Of the 1,613 patients identified, 661 were covered by Medicare, 449 by government-managed Medicaid, and 503 by commercial insurance plans. RESULTS: Medicare patients exhibited a significant upward trend in revenue (P < .001), total cost (P = .004), direct cost (P < .001), and an overall downward trend in CM (P = .037), with CM for these patients falling to 72.1% of 2011 values by 2021. CONCLUSION: In the Medicare population, reimbursement for rTHA has not matched increases in cost, leading to considerable reductions in CM. These trends affect the ability of hospitals to cover indirect costs, threatening access to care for patients who require this necessary procedure. Reimbursement models for rTHA should be reconsidered to ensure the financial feasibility of these procedures for all patient populations.

Positive Preoperative Colonization With Methicillin Resistant Staphylococcus Aureus Is Associated With Inferior Postoperative Outcomes in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status. METHODS: We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group). RESULTS: The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately. CONCLUSION: Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA.