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

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

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients.

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

Effect of Parkinson's Disease on Hemiarthroplasty Outcomes After Femoral Neck Fractures.

BACKGROUND: The purpose of this study was to evaluate the outcomes following hemiarthroplasty (HA) for femoral neck fractures (FNFs) in patients with Parkinson's disease (PD) compared with patients without PD. METHODS: This was a retrospective review utilizing the Nationwide Readmissions Database, a national database incorporating inpatient hospitalization information. Using the Nationwide Readmissions Database, patients who underwent HA for FNF between 2010-2014 were identified. International Classification of Diseases, 9th Revision, codes were used to find a subset of patients with PD. Primary outcomes of interest included death, hospital readmission, periprosthetic fracture, postoperative dislocation, any revision surgery, and revision surgery for instability, fracture, or infection. RESULTS: There were a total of 7721 (4%) patients with PD. There was no difference in the risk of death or any postoperative complications during index hospitalization for these patients. However, PD patients had an increased risk of hospital readmission (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.02-1.26) and postoperative dislocation (OR = 2.10, 95% CI: 1.58-2.80) within 90 days of surgery. PD patients also had an increased risk of revision surgery for instability (OR = 2.20, 95% CI: 1.48-3.28), despite no difference in the risk of any revision surgery, revision surgery for fracture, or revision surgery for infection. CONCLUSION: In this retrospective cohort study, PD patients who underwent a HA for FNF had a greater risk of postoperative dislocation and revision surgery for instability within 90 days. These findings are not only important to consider when managing these at-risk patients but also stress the need to allocate operative and postoperative resources to prevent and treat instability. LEVEL OF EVIDENCE: 3 (Retrospective cohort study).

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.

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

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

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

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

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.

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

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

Incidence and Risk Factors for the Development of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) in Total Joint Arthroplasty Patients.

BACKGROUND: Acute colonic pseudo-obstruction (Ogilvie syndrome [OS]) is a rare but devastating condition that can develop in orthopaedic patients postoperatively. The objective of this study was to identify the risk factors for developing OS after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to compare the outcomes between patients who did and did not develop OS postoperatively. METHODS: This was a retrospective review using the National Inpatient Sample, a national database incorporating inpatient hospitalization information. ICD-9 codes were used to identify patients who underwent primary and revision THA or TKA. Patients were separated based on the diagnosis of OS. Primary outcomes assessed included patient mortality, postoperative complications, length of stay, and cost during index hospitalization. RESULTS: From 2001 to 2014, a total of 12,541,169 patients underwent primary and revision THA or TKA. Of those, 3,182 patients (0.03%) developed OS postoperatively. There was an increased incidence of OS in revision THA and TKA compared with primary THA and TKA. Fluid and electrolyte disorders were associated with the largest increased adjusted risk of OS. Patients with OS had an increased adjusted risk of overall postoperative complications and being discharged to skilled nursing facility. Patients with OS had an increased average length of stay and hospitalization cost compared with patients without OS. DISCUSSION: Given our findings, the risk factors for the development of OS, including revision surgery, should be identified and minimized during the perioperative period to prevent the development of this morbid and potentially life-threatening complication. LEVEL OF EVIDENCE: III (Retrospective cohort study).

Analysis of the Digital Footprint of Orthopaedic Surgeons.

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

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

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

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

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

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

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

Trends in Operative Time and Short-Term Outcomes After Conventional and Navigated Total Knee Arthroplasty.

BACKGROUND: Adoption of navigated total knee arthroplasty (Nav-TKA) is increasing. However, it has been suggested that a perceived decrease in surgical efficiency and a lack of proven superior functional outcomes associated with Nav-TKA have hindered its widespread adoption. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who had undergone TKA with or without navigation between 2012 and 2018. Patients were further subclassified based on the type of navigation used, image-guided or imageless. Multivariate logistic regression was used to compare operative time and 30-day complication rates between conventional TKA (Conv-TKA) and Nav-TKA with and without image guidance. RESULTS: A total of 316,210 Conv-TKAs and 8554 Nav-TKAs (8270 imageless, 284 image-guided) were identified. Across the study period, the use of Nav-TKA was associated with a 1.5-minute increase in operative time. However, the overall time burden decreased over the study period, and by 2018, the mean operative time for Nav-TKA was 2.4 minutes less than that of Conv-TKA. Compared with Conv-TKA, Nav-TKA was associated with decreased rates of postoperative transfusion and surgical site complications but a similar incidence of systemic thromboembolism. CONCLUSIONS: This is the first large-scale database study to examine the differences in operative time between Conv-TKA and Nav-TKA. The time burden associated with Nav-TKA decreased over the study period and even reversed by 2018. Nav-TKA was associated with lower rates of postoperative transfusion and surgical site complications. Further studies are needed to evaluate the long-term and functional outcomes between conventional and navigated knee arthroplasty techniques.

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

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

Outcomes of Total Hip Arthroplasty in Patients With Acetabular Protrusio.

BACKGROUND: Acetabular protrusio (AP) is associated with distorted anatomic landmarks and insufficient bone stock that increases complexity of total hip arthroplasty (THA). This study used a large national database to compare outcomes after THA in patients with and without AP. METHODS: The Nationwide Readmissions Database was used to identify patients with and without AP who underwent THA from 2010 to 2014. Primary outcomes analyzed included complications during index hospitalization and within 90 days of THA. RESULTS: Propensity score matching generated 4,395 patients without AP and 4,603 patients with AP. Patients with AP were older (68.1 versus 65.2 years, P < 0.0001), more predominantly women (82.1% versus 55.9%), and had more medical comorbidities as measured by the Elixhauser Comorbidity Index (2.29 versus 1.89, P < 0.0001). Patients with AP had an increased risk of requiring bone graft (odds ratio [OR] = 47.97, 95% confidence interval [CI]: 14.27 to 161.22), receiving a blood transfusion (OR = 1.90, 95% CI: 1.57 to 2.29), and suffering a periprosthetic fracture (OR = 2.56, 95% CI: 1.10 to 5.97) within 90 days of THA. Length and cost of index hospitalization were greater for patients with AP (5.0 versus 4.3 days, P = 0.002; $19,211.88 versus $27,736.30, P < 0.0001). CONCLUSION: Given the current emphasis on hospital cost optimization, it is important to ensure that patients with AP are managed appropriately. Attention should be placed on comprehensive preoperative planning and postoperative monitoring in this population.

Trends and patient factors associated with technology-assisted total hip arthroplasty in the United States from 2005 to 2014.

BACKGROUND: Technology-assisted total hip arthroplasty (TA-THA) using either computer-assisted navigation or robotic assistance has become increasingly more popular. The purpose of this study was to examine the trends and patient factors associated with TA-THA. METHODS: This is a retrospective review utilizing the National Inpatient Sample, a large national database incorporating inpatient hospitalization information. International Classification of Diseases, 9th Revision codes were used to identify patients with hip osteoarthritis who underwent primary total hip arthroplasty (THA). Patients were then separated into those who underwent TA-THA or conventional THA. Outcomes of interest included annual TA-THA utilization; patient and hospital characteristics associated with TA-THA; and trends for length of stay (LOS), cost, and discharge to home. RESULTS: From 2005 to 2014, a total of 2,588,304 patients with hip osteoarthritis who underwent THA were identified in the National Inpatient Sample database. Of those, 39,700 (1.5%) underwent TA-THA. The number of TA-THA procedures increased from 178 (0.1% of all THA) in 2005 to 10,045 (3.0% of all THA) in 2014, which represented a 30-fold increase in incidence (P-trend <.0001). TA-THA was associated with Hispanic race, higher patient income, and the Western region of the United States. During the study period, there was a trend toward decreased LOS and increased discharge to home for both TA-THA and conventional THA. TA-THA was associated with higher inpatient cost. CONCLUSION: TA-THA is being increasingly used in the United States and is associated with specific patient factors. However, the value of TA-THA compared to conventional THA remains unclear and should be assessed with future research. LEVEL OF EVIDENCE: III (retrospective cohort study).

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014.

BACKGROUND CONTEXT: Metastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life. PURPOSE: The purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD. DESIGN: This was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD). PATIENT SAMPLE: All patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study. OUTCOME MEASURES: Mortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed. METHODS: International Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts - those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared. RESULTS: The number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85-3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66-3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18-1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41-1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68-2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20-2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27-2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53-0.96, p=.026). CONCLUSIONS: The number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.

An Early Look at Operative Orthopaedic Injuries Associated with Electric Scooter Accidents: Bringing High-Energy Trauma to a Wider Audience.

BACKGROUND: There is a new method of transportation that started in our community in late 2017- rideshare electric scooters (e-scooters). These scooters have proven immensely popular and can now be found in many cities around the world. Despite the pervasiveness of e-scooters, their associated injury patterns are poorly understood. The purpose of this study was to describe our department's experience at the epicenter of the e-scooter phenomenon that is sweeping the globe and to characterize operative orthopaedic injuries that are related to e-scooter accidents. METHODS: We performed a retrospective chart review of all of the operative orthopaedic cases and trauma consults at 2 trauma centers (a level-I center and a level-II center) between September 2017 and August 2019. We identified all operative injuries in which the cause of injury was an e-scooter accident. Data that included demographics, mechanism of injury, diagnosis, and treatment were collected. RESULTS: Seventy-five operative injuries were identified in 73 patients during the study period. The mean patient age was 35.4 years (range, 14 to 74 years), and the median age was 32 years. There were 4 pediatric patients (14, 15, 15, and 17 years old). Thirty-two patients (43.8%) sustained upper-extremity injuries, and 42 patients (57.5%) sustained lower-extremity injuries; 1 of these patients had both upper and lower-extremity injuries. Nine patients (12.3%) had open fractures. There were 7 hip fractures in patients with an average age of 42.4 years (range, 28 to 68 years). Seventy-one (97.3%) of 73 patients were e-scooter riders, and 2 (2.7%) were pedestrians who were struck by e-scooter riders. CONCLUSIONS: E-scooters can cause serious injury. Seventy-three patients required operative treatment in just the first 2 years of e-scooter use in our community. Operative injuries occurred throughout the skeletal system, and several were injuries that are typically associated with high-energy trauma. Although, as a rule, e-scooter use is limited to adults and banned in high pedestrian-traffic areas in our city, the inclusion of 4 underage riders and 2 pedestrians in our cohort suggests that these rules are not always followed. As e-scooters continue to increase in popularity, additional steps should be taken to regulate their use and protect riders and the public.

Effect of Kidney Disease on Hemiarthroplasty Outcomes After Femoral Neck Fractures.

OBJECTIVE: To compare the outcomes of patients with predialysis chronic kidney disease (CKD) or end-stage renal disease (ESRD) with the outcomes of patients with no kidney disease after hemiarthroplasty (HA) for femoral neck fractures (FNF). DESIGN: Retrospective review utilizing the Nationwide Readmissions Database. SETTING: National database incorporating inpatient data from 22 states. PATIENTS: Using the Nationwide Readmissions Database, 214,399 patients who underwent HA after FNF between 2010 and 2014 were identified and divided into 3 groups using ICD-9 diagnosis codes: no kidney disease (n = 176,300, 82%), predialysis CKD (n = 34,400, 16%), and ESRD (n = 3,698, 2%). INTERVENTION: HA for FNF. MAIN OUTCOME MEASUREMENT: Mortality, blood transfusion, and postoperative complications during index hospitalization. Hospital readmission, postoperative dislocation, periprosthetic fracture, and revision surgery within 90 days of surgery. RESULTS: Compared to patients with no kidney disease, ESRD patients had an increased risk of mortality [odds ratio (OR) = 3.76, 95% confidence interval (CI), 2.95-4.78], blood transfusion (OR = 2.35, 95% CI, 2.08-2.64), and postoperative complications (OR = 1.64, 95% CI, 1.45-1.86) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 3.09, 95% CI, 2.72-3.50). Interestingly, even patients with predialysis CKD had an increased risk of mortality (OR = 1.80, 95% CI, 1.59-2.05), blood transfusion (OR = 1.66, 95% CI, 1.59-1.75), and postoperative complications (OR = 2.37, 95% CI, 2.25-2.50) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 1.43, 95% CI, 1.37-1.51). CONCLUSIONS: This retrospective cohort study demonstrates that both ESRD and CKD patients have worse outcomes compared to patients with no kidney disease after HA for FNF. LEVEL OF EVIDENCE: Prognostic Level III. See instructions for authors for a complete description of levels of evidence.