A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care.

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

Association Between Digitally Provided Education and 90-Day Return to Sexual Activity Following Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Contemporary total knee arthroplasty patients have increased expectations of returning to predisease function, including sexual activity (SA). The purpose of this study was to determine whether patients using a digital care management platform (DCMP) were more likely to have a higher rate and frequency of return to SA. METHODS: We conducted an exploratory analysis of a prospective, multicenter, randomized controlled trial that enrolled patients undergoing total knee arthroplasty. A total of 304 patients were randomized to a DCMP (n = 119) providing preoperative and postoperative education regarding return to SA or standard postoperative care (control group; n = 185). Return to SA, assessed via questionnaire, patient-reported outcome measures, Timed Up and Go test, single leg stance, active range of motion and need for manipulation under anesthesia were assessed at 90 days postoperatively. RESULTS: More patients in the DCMP group returned to SA compared to control at 90 days (58.4 versus 39.6%, P = .018); however, the control group resumed SA sooner (33.1 versus 42.0 days, P = .023). Patients who returned to SA were younger (61.6 versus 65.9 year), more often men (56 versus 35%) (P < .001), higher performing on the Timed Up and Go and single leg stance tests (P < .001), and had greater active range of motion (P = .007). There were no differences in patient-reported outcome measures or need for manipulation under anesthesia between patients that returned to SA and those who did not. CONCLUSIONS: More patients using a DCMP resumed SA at 90 days; however, patients in the control group returned to SA sooner. Those who returned to SA were younger, possessed greater physical function, and were more often men.

Projected Prevalence of Obesity in Aseptic Revision Total Hip and Knee Arthroplasty.

Background: The purpose of this study was to develop projections of the prevalence of obesity in aseptic revision THA and TKA patients through the year 2029. Methods: The National Surgical Quality Improvement Project (NSQIP) was queried for years 2011-2019. Current procedural terminology (CPT) codes 27134, 27137, and 27138 were used to identify revision THA and CPT codes 27486 and 27487 were used to identify revision TKA. Revision THA/TKA for infectious, traumatic, or oncologic indications were excluded. Participant data were grouped according to body mass index (BMI) categories: underweight/normal weight, <25 kg/m2; overweight, 25-29.9 kg/m2; class I obesity, 30.034.9 kg/m2; class II obesity, 35.0-39.9 kg/m2; morbid obesity ≥ 40 kg/m2. Prevalence of each BMI category was estimated from year 2020 to year 2029 through multinomial regression analyses. Results: 38,325 cases were included (16,153 revision THA and 22,172 revision TKA). From 2011 to 2029, prevalence of class I obesity (24% to 25%), class II obesity (11% to 15%), and morbid obesity (7% to 9%) increased amongst aseptic revision THA patients. Similarly, prevalence of class I obesity (28% to 30%), class II obesity (17% to 29%), and morbid obesity (16% to 18%) increased in aseptic revision TKA patients. Conclusion: Prevalence of class II obesity and morbid obesity demonstrated the largest increases in revision TKA and THA patients. By 2029, we estimate that approximately 49% of aseptic revision THA and 77% of aseptic revision TKA will have obesity and/or morbid obesity. Resources aimed at mitigating complications in this patient population are needed. Level of Evidence: III.

Presence of a Lateral Trochlear Osteophyte Predicts Medial Unicompartmental Arthroplasty Failure at Midterm Follow-up.

Background: Specific clinical and radiographic risk factors for medial unicompartmental knee arthroplasty (UKA) failure are incompletely understood. The purpose of this study was to perform a midterm survivorship analysis of medial UKA from a single, nondesigner surgeon. Based on observations from clinical practice, we hypothesized that the presence of a lateral trochlear osteophyte on preoperative Merchant radiographs may be predictive of medial UKA failure secondary to progressive osteoarthritis (OA). Methods: Patients who underwent a mobile-bearing medial UKA by a single surgeon with minimum 24 months of clinical follow-up from 2008 to 2019 were retrospectively identified. Radiographic parameters, including the presence of a lateral trochlear osteophyte, were measured. Kaplan-Meier survivorship analyses were performed. Cox proportional hazards models were used to evaluate variables as risk factors for UKA failure, defined as reoperation or component revision. Results: A total of 233 UKAs were included. The mean age was 60 years, mean BMI 32 kg/m2, and 53% of patients were male. The mean follow-up duration was 5.7 years (range, 2.0-13.1 years). Using any reoperation as an endpoint, the 10-year survival was 91%. Using any component revision as an endpoint, the 10-year survival was 93%. Using revision due to progressive OA as an endpoint, the 10-year survival was 95%. The presence of a lateral trochlear osteophyte was associated with an increased risk of any reoperation (hazard ratio 3.6; 95% confidence interval 1.3-9.5) and increased risk of revision due to progressive OA (hazard ratio 9.8; 95% confidence interval 2.9-32.7). Conclusions: The presence of a lateral trochlear osteophyte on preoperative Merchant view radiographs was associated with an increased risk of medial UKA failure.

Did Rapid Expansion of Same Day Discharge Hip and Knee Arthroplasty During the COVID-19 Pandemic Increase Early Complications?

Background: The COVID-19 pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA) including more patients undergoing same day discharge (SDD) following total joint arthroplasty (TJA). The purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipated that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications. Methods: We retrospectively queried the ACS-NSQIP database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Patients with length of stay greater than 0 were excluded. Primary outcome was any complication at 30 days. Secondary outcomes included readmission and re-operation 30 days. Results: A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). Combined data to include THA and TKA patients did not find a statistical difference in the rate of complications or readmission but did note a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028). Conclusion: Rapid expansion of SDD TJA during the COVID-19 pandemic did not increase overall complication, readmission, or re-operation rates. Level of Evidence: IV.

Analysis of New Orthopaedic Technologies in Large Database Research.

ABSTRACT: Improvements in orthopaedic surgery go hand in hand with technological advances. The present article outlines the historical and current uses of large databases and registries for the evaluation of new orthopaedic technologies, providing insights for future utilization, with robotic-assisted surgery as the example technology.

Rates of Antimicrobial Resistance With Extended Oral Antibiotic Prophylaxis After Total Joint Arthroplasty.

Background: There is increased interest and utilization of extended oral antibiotic prophylaxis (EOAP) following primary and revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). The purpose of this study was to look for potential associations between EOAP and differential rates of antimicrobial resistance or epidemiology of organisms causing periprosthetic joint infection (PJI) following primary and aseptic revision THAs/TKAs. Methods: Patients who developed PJI following a primary or aseptic revision TKA/THA at a single institution from 2009 to 2020 were retrospectively identified. Patients who received at least 7 days of EOAP following the surgery were noted. Rates of antimicrobial resistance were compared between standard antibiotic prophylaxis and EOAP cohorts using the Fisher's exact test. Results: One hundred twenty-eight cultures were obtained from 119 patients with PJI. Fourty-four cases (37%) developed PJI after EOAP. Staphylococcus aureus was the most frequently isolated organism (30% of all cultures; 78% were methicillin-sensitive). Rates of antimicrobial resistance were similar between standard antibiotic prophylaxis and EOAP cohorts in all but 2 instances: Increased resistance to erythromycin and trimethoprim-sulfamethoxazole was observed in coagulase-negative Staphylococci isolates in the EOAP cohort (89% vs 21%, P < .01; 44% vs 0%, P = .02). An increased frequency of gram-negative organisms was observed in the EOAP group (22% vs 8%, P = .03). Conclusions: Rates of antimicrobial resistance were not significantly different between EOAP and standard antibiotic prophylaxis cohorts except in coagulase-negative Staphylococci. The increased frequency of gram-negative infections was present in the EOAP cohort. Larger, multicenter studies are needed to better understand the impact of EOAP on antimicrobial resistance and PJI epidemiology. Level of Evidence: Level III; retrospective cohort study.

Does Isolated Unilateral Hip or Knee Osteoarthritis Lead to Adverse Changes in Extremity Composition?

Background: While muscle atrophy is a function of normal aging, loss of muscle in the setting of hip and knee osteoarthritis (OA) has been observed using radiographic studies. There is limited data available regarding changes in extremity composition using bioimpedance (BIA). The purpose of this study was to assess the changes in extremity composition in patients with isolated, unilateral hip or knee OA using BIA. Methods: Patients presenting to our institution's adult reconstruction clinic from February 2020 to April 2021 were retrospectively reviewed to identify those with isolated, unilateral hip and knee OA. The InBody 770 Body Composition Analyzer (InBody USA, Cerritos, California) was used to perform a complete body composition assessment, per protocol. Lean extremity mass (LEM), fat mass (FM), intracellular water (ICW), extremity body water (EBW = ICW + extracellular water (ECW)) and phase angle (PA) were determined. Differences between the affected (OA) and unaffected (no OA) extremities were compared using t-tests. Results: 38 patients had isolated hip OA. The mean age was 60.8 (±11.7) years, mean BMI was 31.7 (±6.8) kg/m2, and 39.5% were female. LEM, FM, EBW, ICW, and PA were significantly decreased in the hip OA extremity (LEM: 20.0 vs. 20.4 kg, p=0.0008, FM: 8.8 vs. 8.9 kg, p=0.0049, EBW: 15.7 vs 16.0, p=0.0011, ICW: 9.5 vs. 9.7 L, p=0.0004, PA: 4.5 vs 4.9º, p<0.0001). There were 25 patients with isolated knee OA. Mean age was 62.8 (±11.3) years, mean BMI was 33.6 (±6.9) kg/m2, and 52.0% were female. FM and PA were significantly lower in the knee OA extremity (11.3 vs 11.4 kg, p=0.0291, 4.5 vs 4.9º, p<0.0001). There were no significant differences in LEM, EBW, and ICW between the knee OA extremity and the unaffected extremity. Conclusion: Patients with isolated, unilateral hip OA had decreased LEM, FM, EBW, and ICW in the affected extremity. Both unilateral hip and knee OA was associated with decreased PA, suggestive of greater underlying dysfunction in muscle or cellular performance. Further study is needed to better define when these abnormalities develop, how they progress over time, and the impact of targeted interventions in reversing these changes. Level of Evidence: III.

Comparison of Patient-Reported Outcomes and Functional Assessment Using a Marker-Less Image Capture System in End-Stage Knee Arthritis.

BACKGROUND: Patient self-assessment of knee function in end-stage osteoarthritis (OA) and following total knee arthroplasty (TKA) using patient-reported outcome measures (PROMs) has become standard for defining disability. The relationship of PROMs to functional performance requires a continued investigation. The purpose of this study was to determine correlations between patient demographics, PROMs, and functional performances using a marker-less image capture system (MICS). METHODS: Patients indicated for elective TKA completed the Knee Injury and Osteoarthritis Score for Joint Replacement (KOOS-JR) and an office-based functional assessment using a MICS. Patient age, body mass index (BMI), and gender were collected. A total of 112 patients were enrolled. Their mean age was 65.0 (±9.7) years, mean BMI was 32.5 (±6.6) kg/m2, and mean KOOS-JR was 14.5 (±5.7). The relationships between patient characteristics, KOOS-JR, MICS Alignment (coronal), MICS Mobility (flexion), and composite Total Joint scores were described using Spearman's correlation coefficients. RESULTS: BMI was weakly correlated with KOOS-JR (ρ = -0.22, P = .024), whereas age was not. Age and BMI were not correlated with performance scores. There were weak to no correlations between KOOS-JR and MICS Alignment (ρ = -0.01, P = .951), Mobility (ρ = 0.33, P < .001), and Total Joint scores (ρ = 0.06, P = .504). CONCLUSION: This study found no strong correlation between KOOS-JR and functional performance using a validated MICS for patients with end-stage knee OA. Further study is warranted in determining the relationship between PROMs and performance to optimize outcomes of patients undergoing nonoperative or surgical interventions for knee OA. The use of high-fidelity functional assessment tools that can be integrated into clinical workflow, such as the MICS used in this study, should permit PROM/functional performance comparisons in large populations.

Prevalence of Sarcopenia and Sarcopenic Obesity in an Academic Total Joint Arthroplasty Practice.

Background: Body mass index (BMI) is routinely used for preoperative risk stratification; however, it does not provide a detailed assessment of body composition and intentional weight loss alone may not decrease complications. Sarcopenia-a disorder involving low muscle mass, quality, or performance-has been associated with an increased risk for postoperative complications and is treatable through nutritional supplementation or resistance training. It, counterintuitively, may occur with obesity as "sarcopenic obesity"; however, the prevalence is not widely known. The purpose of this study was to assess the prevalence of sarcopenia and sarcopenic obesity. Material and methods: Patients underwent body composition assessment using multifrequency bioimpedance testing (InBody 770, InBody USA, California). They were classified as sarcopenic based on the appendicular skeletal muscle index and obese by percent body fat. Body composition parameters were compared between obesity or sarcopenia groups and traditional BMI-based obesity definitions. Results: A total of 219 patients underwent body composition assessment. The mean age was 62.1 years, BMI was 34.3 kg/m2, and 53.8% were female. Fifty-seven (26.0%) patients were not obese or sarcopenic, 130 (59.4%) were obese not sarcopenic, 18 (8.2%) were sarcopenic nonobese, and 14 (6.4%) were sarcopenic obese. There was heterogeneity in body composition between groups. Sarcopenic patients were older than those without sarcopenia. Skeletal muscle mass, body fat mass, and appendicular skeletal muscle index increased with increasing BMI. Conclusion: Sarcopenia and sarcopenic obesity were found in nearly 15% of patients. Measures of muscle quantity increased with higher BMI may influence the prevalence of sarcopenia in the morbidly obese, and these patients may require specialized criteria accounting for increased body mass.

Projected Prevalence of Obesity in Primary Total Knee Arthroplasty: How Big Will the Problem Get?

BACKGROUND: Obesity is a well-established risk factor for complications following primary total knee arthroplasty (TKA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary TKA patients in the United States through 2029. METHODS: Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27447 was used to identify primary TKA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS: A total of 8,372,221 individuals were included (7,986,414 BRFSS, 385,807 NSQIP TKA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary TKA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary TKA from 60% to 64%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 69% of primary TKA will be obese/morbidly obese. CONCLUSION: By 2029, we estimate ≥69% of primary TKA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Not all Total Hip and Knee Arthroplasties Are the Same: What Are the Implications in Large Database Studies?

BACKGROUND: The use of claims databases for research after total hip and knee arthroplasty (THA, TKA) has increased exponentially. These studies rely on accurate coding, and inadvertent inclusion of patients with nonroutine indications may influence results. The purpose of this study was to evaluate the complexity of THA and TKA captured by CPT code and determine if complication rates vary based on the indication. METHODS: The NSQIP database was queried using CPT codes 21730 and 27447 to identify patients undergoing THA and TKA from 2018 to 2019. The surgical indication was classified based on the ICD-10 diagnosis code as routine primary, complex primary, inflammatory, fracture, oncologic, revision, infection, or indeterminant. Patient factors and 30-day complications, readmission, reoperation, and wound complications were compared. RESULTS: A total of 86,009 THA patients had 703 ICD-10 diagnosis codes and 91.4% were routine primary indications. Complication rates were: routine primary 7.4%, complex primary 11.3%, inflammatory 12.5%, fracture 23.9%, oncologic 32.4%, revision 26.9%, infection 38.7%, and indeterminant 10.3% (P < .0001). 137,500 TKA patients had 552 ICD-10 diagnosis codes and 96.1% were routine primary cases. Complication rates were: routine primary 5.9%, complex primary 8.0%, inflammatory 7.2%, fracture 38.9%, oncologic 32.7%, revision 13.3%, infection 37.7%, and indeterminant 9.6% (P < .0001). Routine primary arthroplasty had significantly lower rates of reoperation, readmission, and wound complications. CONCLUSION: Using CPT code alone captures 10% of THA and 4% of TKA patients with procedures for nonroutine primary indications. It is essential to recognize identification of patients simply by CPT code has the potential to inadvertently introduce bias, and surgeons should critically assess methods used to define the study populations.

What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications?

BACKGROUND: Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA. METHODS: Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI. RESULTS: A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m2, of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m2 as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed. CONCLUSION: Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.

Are Body Mass Index Cutoffs Creating Racial, Ethnic, and Gender Disparities in Eligibility for Primary Total Hip and Knee Arthroplasty?

BACKGROUND: Unabated increases in the prevalence of obesity among American adults have disproportionately affected women, Black persons, and Hispanic persons. The purpose of this study was to evaluate for disparity in rates of patient eligibility for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on race and ethnicity and gender by applying commonly used body mass index (BMI) eligibility criteria to two large national databases. METHODS: We retrospectively reviewed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2015-2019 for primary THA and TKA and the National Health and Nutrition Examination Survey (NHANES) from 2011-2018. Designations of race and ethnicity were standardized between cohorts. BMI cutoffs of <50 kg/m2, <45 kg/m2, <40 kg/m2, and <35 kg/m2 were then applied. Rates of eligibility for surgery were examined for each respective BMI cutoff and stratified by age, race and ethnicity, and gender. RESULTS: 143,973 NSQIP THA patients, 242,518 NSQIP TKA patients, and 13,255 NHANES participants were analyzed. Female patients were more likely to be ineligible for surgery across all cohorts for all modeled BMI cutoffs (P < .001 for all). Black patients had relatively lower rates of eligibility across all cohorts for all modeled BMI cutoffs (P < .0001 for all). Hispanic patients had disproportionately lower rates of eligibility only at a BMI cutoff of <35 kg/m2. CONCLUSION: Using BMI cutoffs alone to determine the eligibility for primary THA and TKA may disproportionally exclude women, Black persons, and Hispanic persons. These data raise concerns regarding further disparity and restriction of arthroplasty care to vulnerable populations that are already marginalized. LEVEL OF EVIDENCE: Retrospective Cohort Study, Level III.

Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get?

BACKGROUND: Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029. METHODS: Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS: A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese. CONCLUSION: By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.