The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes.

PURPOSE: Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. METHODS: We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement. RESULTS: Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively. CONCLUSION: Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

The impact of surgical trainee involvement in total hip arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes.

PURPOSE: Concerns persist that trainee participation in surgical procedures may compromise patient care and potentiate adverse events and costs. We aimed to analyse the potential impact and consequences of surgical trainee involvement in total hip arthroplasty (THA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. METHODS: We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in October 2021. Eligible studies reported a direct comparison between THA cases performed with and without trainee involvement. RESULTS: Eighteen publications met our eligibility criteria and were included in our study. The included studies reported on 142,450 THAs completed on 142,417 patients. Specifically, 48,155 and 94,295 surgeries were completed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 5,662) and without (n = 14,763) trainee involvement were 106.20 and 91.41 min, respectively. Mean overall complication rates were 6.43% and 5.93% for THAs performed with (n = 4842) and without (n = 12,731) trainees. Lastly, the mean Harris Hip Scores (HHS) for THAs performed with (n = 442) and without (n = 750) trainee participation were 89.61 and 86.97, respectively. CONCLUSION: Our systematic review confirmed previous studies' reports of increased operative time for THA cases with trainee involvement. However, based on the overall similar complication rates and functional hip scores obtained, patients should be reassured concerning the relative safety of trainee involvement in THA. Future prospective studies with higher levels of evidence are still needed to reinforce the existing evidence.

Heterotopic Ossification After Revision Carpal Tunnel Release Causing Mixed Ulnar and Median Compression Neuropathy.

We report a case of heterotopic ossification formation 6 years after a revision carpal tunnel release in a 46-year-old woman, causing new-onset mixed ulnar and median nerve compression symptoms. The patient underwent excision of the heterotopic ossification mass along with decompression of the median and ulnar nerves, and postoperative radiation. Four years after treatment, the patient was completely asymptomatic with full range of motion in her hand and wrist.

Complement C3-α and C3-ß Levels in Synovial Fluid But Not in Blood Correlate With the Severity of Osteoarthritis Research Society International Histopathological Grades in Primary Knee Osteoarthritis.

BACKGROUND: Primary osteoarthritis (OA) is the most common cause of knee arthritis worldwide. The knee synovial fluid complement C3-ß chain levels have been shown to correlate with clinical symptoms of knee OA. It is not known whether the complement C3 in the synovial fluid is derived from the circulation or is produced locally in the knee. METHODS: Fifty primary OA patients undergoing a total knee arthroplasty procedure were evaluated for biochemical analyses of C3-α and C3-ß chains in the synovial fluid and blood plasma. These levels were corelated with the severity of corresponding knee OA based on the Osteoarthritis Research Society International (OARSI) grade. RESULTS: Both synovial C3-α and C3-ß levels correlated significantly with the severity of OA. Neither plasma C3-α levels nor C3-ß levels significantly correlated with OARSI grading. Neither synovial C3-α levels nor C3-ß correlated significantly with plasma C3-α or C3-ß levels, respectively. Synovial C3-α chain and C3-ß chain levels were significantly higher in the grade >6 group. In plasma, neither C3-α chain levels nor C3-ß chain levels were significantly different between the groups. Neither synovial C3-α nor C3-ß levels significantly correlated with plasma erythrocyte sedimentation rate or C-reactive protein levels. CONCLUSION: In knee primary OA, C3 seems to be produced and released locally into the synovial fluid instead of being derived from blood in the circulation. Synovial C3 levels, but not blood plasma C3, correlate with the histopathological severity of primary OA in the knee. Synovial C3 may be an important factor in the pathogenesis of primary OA clinical symptoms and a potential target for therapeutic intervention.

Complications in Patients Undergoing Spinal Fusion After THA.

INTRODUCTION: Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. QUESTIONS / PURPOSES: Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? PATIENTS AND METHODS: A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). RESULTS: Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). CONCLUSION: We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. LEVEL OF EVIDENCE: Level III, therapeutic study.

Adult Reconstruction Studies Presented at AAOS and AAHKS 2011-2015 Annual Meetings. Is There a Difference in Future Publication?

BACKGROUND: The purpose of this study was to compare adult reconstruction abstracts presented at the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) annual meetings. METHODS: A total of 1355 podium and 1731 poster presentations from the adult reconstruction sections of the AAOS and AAHKS meetings from 2011 to 2015 were reviewed for publication in peer-reviewed literature. Authors who were added or removed from the original abstract and the final manuscript were recorded. The corresponding journals were assigned the most recent impact factor. The publication rates for each annual meeting, the mean changes in authorship and journal's impact factors were compared. RESULTS: There were 2129 abstracts presented at AAOS and 957 abstracts presented at AAHKS. The overall publication rate was different between AAOS and AAHKS (56% vs 60%, P = .030). Compared with AAOS, there were more AAHKS abstracts published in 2011 (57% vs 77%, P = .0008) and 2012 (57% vs 76%, P = .0001); however, there were no significant differences in 2013, 2014, or 2015. The mean overall change in authors was lower for AAOS compared with AAHKS abstracts (0.78 vs 1.06, P < .0001). The mean journal's impact factors for AAOS and AAHKS publications were also similar (2.86 vs 2.85, P = .874). CONCLUSION: AAOS and AAHKS abstracts presented in the adult reconstruction subspecialty had a similar overall rate of publication, change in authorship, and impact factor. It would be beneficial if further studies subdivided these into basic and clinical science and review articles.

Outcomes of Revision Joint Arthroplasty Due to Metal Allergy and Hypersensitivity: A Systematic Review.

BACKGROUND: Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could fail due to various well-known causes. Furthermore, metal allergy-related complications have recently gained attention as one of the potential causes of failure when the common reasons have been excluded. Reported symptoms from metal allergy can include chronic eczema, joint effusions, joint pain, and limited range of motion. Few studies have explored the outcomes of patients undergoing revisions due to allergic complications. The aim of our study is to quantitatively evaluate the outcomes of revision joint arthroplasty due to metal allergy and hypersensitivity.

Atrial Septal Defect Increases the Risk for Stroke After Total Hip Arthroplasty.

BACKGROUND: Atrial septal defect (ASD) and patent foramen ovale (PFO) are 2 of the most common congenital heart diseases in adults and pose important risks of perioperative acute ischemic stroke (AIS) from paradoxical emboli. We evaluated the following: (1) the prevalence of ASD/PFO in the total hip arthroplasty (THA) population; (2) the rate of perioperative AIS during index admissions; and (3) the risk for perioperative AIS after THA for patients with ASD/PFO vs matched controls. METHODS: We identified 393,652 patients in the Nationwide Inpatient Sample who underwent THA between January 1, 2007, and December 31, 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify patients with ASD/PFO and perioperative AIS. Propensity scores matched 252 patients with ASD/PFO to 756 controls (3:1 ratio) without ASD/PFO according to age, gender, race, Deyo comorbidity score, year of surgery, and stroke risk factors. Logistic regression models assessed risk for perioperative AIS. RESULTS: The prevalence of ASD/PFO was 64 per 100,000 THA patients. The rate of perioperative AIS was 99 per 100,000 THA in the general THA population. The rate of perioperative AIS was 7.14% for ASD/PFO patients compared with 0.26% in matched controls (P < .001). Risk for perioperative AIS was 29 times greater for patients with ASD/PFO compared with matched controls (odds ratio, 29.00; 95% confidence interval, 6.68-125.89; P < .001). CONCLUSION: Patients with ASD/PFO undergoing THA are at a significantly higher risk of perioperative AIS. Orthopedic surgeons should discuss this risk with patients before surgery. The efficacy of mechanical and pharmacologic thromboprophylactic measures to reduce perioperative AIS among ASD/PFO patients warrants further investigation.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BACKGROUND: Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. METHODS: We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients undergoing surgery at teaching hospitals had longer lengths of stay (ß = 3.2%; P < .001) and higher costs of admission (ß = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). CONCLUSION: Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Is Day of Surgery Associated With Adverse Clinical and Economic Outcomes Following Primary Total Knee Arthroplasty?

BACKGROUND: As orthopedics transition to value-based purchasing, hospitals and providers are incentivized to identify inefficiencies of care delivery. In our experience, weekends are characterized by decreased staffing of ancillary services to coordinate patient discharges, which can lead to prolonged hospital stays for many of our primary total knee arthroplasty (TKA) admissions. METHODS: We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State. We used mixed effects regression models to compare length of stay (LOS), 90-day readmission, and cost according to the day of TKA. RESULTS: Mean LOS was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). There was no significant difference in 90-day readmission risk according to day of surgery. Mean cost was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). When LOS was held constant across every day of the week, the mean cost of TKA decreased by $247 for Wednesday, $627 for Thursday, and $394 for Friday. CONCLUSION: Primary TKA performed later in the week is associated with an increased LOS and increased costs of admission, but a similar risk of 90-day readmission. Preferential scheduling of primary TKA cases early in the week, as well as the development of standardized clinical care pathways with appropriate weekend staffing of social work and rehabilitation services, could help to decrease the daily variation in LOS and increase the value of TKA episodes.

van Neck-Odelberg Disease: A 3.5-Year Follow-Up Case Report and Systematic Review.

V an Neck-Odelberg disease (VND) is a benign skeletal overgrowth of the ischiopubic synchondrosis (IPS) in prepubescent patients. There is a paucity of long-term follow-up data and reviews on management decision-making. We report on a 15-year-old female, with a history of sickle-cell disease (HbSS), presenting with unilateral groin pain. Patient's physical examination, radiographs, and a literature-review determined a diagnosis of VND. Conservative treatment was issued. Clinical symptoms resolved at three months, followed by complete lesion resolution at three years. Additionally, a search of Medline (PubMed), EMBASE, and OVID databases was performed. Reports including VND/IPS diagnosis, treatment, or follow-up decisions were identified. Systematic-review found 17 relevant articles, reporting on 29 patients. Patients presented with groin (51.7%) or buttock (20.7%) pain, and were diagnosed using X-ray (n=23) and magnetic resonance imaging (MRI) (n=17). Twenty-five patients were treated conservatively, with two (8.0%) reports of surgical intervention. Average follow-up was 6.25 months. Our case report and systematic-review support conservative treatment for VND.

Does Atrial Septal Defect Increase the Risk of Stroke Following Total Hip and Knee Arthroplasty?

INTRODUCTION: Atrial septal defect (ASD) is a common asymptomatic congenital heart condition that predisposes patients to paradoxical emboli in the cerebral vasculature. In this study, we evaluated the prevalence of ASD and risk of stroke for patients with ASD undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). MATERIALS AND METHODS: We used the New York Statewide Planning and Research Cooperative System to identify 258,911 elective primary THA/TKA between 2005 and 2014, including 140 patients with ASD. Logistic regression models calculated odds ratios (OR) and 95% confidence intervals (CI) and controlled for demographic and medical risk factors for stroke. RESULTS: The prevalence of ASD was 54 per 100,000 patients undergoing THA/TKA. The rate of stroke within 30 days of surgery was 5.7% (95% CI: 2.5%, 11.0%) for patients with ASD, and 0.1% (95% CI: 0.1%, 0.1%) for all other patients. In regression models, the risk of stroke was 70 times greater (OR: 70.0, 95% CI: 32.9, 148.9) for patients with ASD compared to patients without this condition (p<0.001). CONCLUSIONS: Patients with ASD undergoing THA and TKA are predisposed to stroke in the postoperative period. Orthopaedic surgeons indicating patients for surgery and internists performing preoperative medical clearance should be aware of these risks and discuss them prior to surgery. The efficacy of pharmacological and surgical measures to reduce postoperative stroke within this patient population should be topics of future investigation.

Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?

INTRODUCTION: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081. CONCLUSIONS: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

Hip fusion takedown to a total hip arthroplasty-is it worth it? A systematic review.

INTRODUCTION: Patients with surgically or spontaneously fused hips are often dissatisfied with their overall function and the debilitating effect on adjacent joints. Therefore, in properly selected patients, hip fusion-takedown and conversion to total hip arthroplasty (THA) can result in improved function and decreased pain. We aimed to (1) evaluate the indications for conversion, (2) evaluate the clinical outcomes, (3) analyze the overall complications, and (4) identify the overall satisfaction following the procedure. METHODS: A systematic and comprehensive literature search was performed to analyze studies evaluating conversion of hip fusion to THA. After reviewing 3,882 studies, 27 total studies (1,104 hips) met our inclusion/exclusion criteria and were included in our final analysis. A weighted mean of rates was determined for each complication, including infection, instability, loosening, nerve-related, abductor-related, venous thrombotic event, and revision. RESULTS: The study population consisted of 53.2% male and 46.8% female subjects. The mean age at time of conversion was 52 years (range 36-65 years), the mean time until follow-up was 9.2 years (range 2.5-17.3), and the mean duration of arthrodesis was 27.7 years (range 11-40.2). As measured by Harris Hip Score, overall clinical outcomes improved from 58.1 points (range 42.4-70 points) pre-operatively to 80.0 (range 62-93.5) post-operatively. The specific complication rates were 5.3% (range 0-43.6%) for infection, 2.6% (range 0-15.4%) for instability, 6.2% (range 0-17.2%) for loosening, 4.7% (range 0-13%) for nerve-related complications, 13.1% (range 0-87%) for abductor-related complications, and 1.2% (range 0-13%) for venous thrombotic events. The revision rate was 12.0% (range 0-43.6%). CONCLUSION: Takedown of a fused-hip can be a challenging procedure. Although patients can benefit functionally, both patients and surgeons need to be aware of the complications and increased risk of further revision procedures, which should be an important part of the pre-operative discussion.

Conversion of a Surgically Arthrodesed Knee to a Total Knee Arthroplasty-Is it Worth it? A Meta-Analysis.

BACKGROUND: Conversion of a surgically arthrodesed knee to total knee arthroplasty (TKA) is an option for a select group of patients who are not satisfied with their results. However, there is a paucity of literature on this topic. A systematic review of literature was performed to (1) describe the overall demographic characteristics; (2) evaluate the clinical outcomes; (3) determine the overall rate of complications; and (4) evaluate the overall satisfaction of patients who underwent conversion of an arthrodesed knee to TKA. METHODS: A comprehensive literature search was systematically performed to evaluate all studies included in the literature until July 2015. The specific search terms used were "fusion knee" and "arthrodesis knee," which revealed a total of 2206 studies. A review and selection of these abstracts were then performed based on inclusion and/or exclusion criteria; a total of 10 articles were used for final review. RESULTS: There were a total of 98 surgically arthrodesed knees that subsequently underwent TKA. Patients had a mean age of 55 years and were followed up for a mean of 5 years. Using a random effects model, there was an overall complication rate of 47%, an overall revision rate of 25%, and an overall failure rate of 11%. However, most patients were overall satisfied with the procedure. CONCLUSION: Fusion takedown is a challenging procedure that should only be performed by experienced surgeons after extensive discussion with the patients. The clinical outcomes are good with overall patient satisfaction, but complication rates are high including risk of repeat fusion or amputation.

Down Syndrome Increases the Risk of Short-Term Complications After Total Hip Arthroplasty.

BACKGROUND: Down syndrome is the most common chromosomal abnormality and is associated with degenerative hip disease. Because of the recent increase in life expectancy for patients with this syndrome, orthopaedic surgeons are likely to see an increasing number of these patients who are candidates for total hip arthroplasty (THA). METHODS: Using Nationwide Inpatient Sample (NIS) data from 1998 to 2010, we compared the short-term adverse outcomes of THA among 241 patients with Down syndrome and a matched 723-patient cohort. Specifically, we assessed: (1) incidence of THA; (2) perioperative medical and surgical complications during the primary hospitalization; (3) length of stay; and (4) hospital charges. RESULTS: The annual mean number of patients with Down syndrome undergoing THA was 19. Compared to matched controls, Down syndrome patients had an increased risk of perioperative (OR, 4.33; P<.001), medical (OR, 4.59; P<.001) and surgical (OR, 3.51; P<.001) complications during the primary hospitalization. Down syndrome patients had significantly higher incidence rates of pneumonia (P=.001), urinary tract infection (P<.001), and wound hemorrhage (P=.027). The mean lengths of stay for Down syndrome patients were 26% longer (P<.001), but there were no differences in hospital charges (P=.599). CONCLUSION: During the initial evaluation and pre-operative consultation for a patient with Down syndrome who is a candidate for THA, orthopaedic surgeons should educate the patient, family and their clinical decision makers about the increased risk of medical complications (pneumonia and urinary tract infections), surgical complications (wound hemorrhage), and lengths of stay compared to the general population.

Barbed sutures in total hip and knee arthroplasty: what is the evidence? A meta-analysis.

INTRODUCTION: Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures. METHODS: A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures. RESULTS: Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n = 290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n = 298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p < 0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p = 0.95) and for major complication was not significantly different (OR 2.94, p = 0.27). The overall mean savings including both THA and TKA was USD 298 per case. CONCLUSIONS: In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures. LEVEL OF EVIDENCE: Level I.

Total Joint Arthroplasty in Nonagenarians: What Are the Risks?

With recent increases in life expectancy in the United States, the number of nonagenarians (age 90-99 years) presenting for lower extremity joint arthroplasty (TJA) will likely rise. Utilizing the National Surgical Quality Improvement Program database, we compared 30-day outcomes of TJA between nonagenarians and controls (age <90 years). Nonagenarians had lower mean BMI, no difference in mean number of comorbidities, and shorter mean operation time. Compared to controls, nonagenarians had longer mean length-of-stay, higher readmission rate, and higher risk of postoperative adverse events. Given these findings, orthopaedic surgeons should be aware of the increased risks of TJA in nonagenarians, and should discuss these risks with potential surgical candidates during a shared decision-making process.

Does HIV Infection Increase the Risk of Short-Term Adverse Outcomes Following Total Knee Arthroplasty?

Using the Nationwide Inpatient Sample, we assess the: (1) demographic trends; (2) complications; and (3) length of hospital stay among total knee arthroplasty (TKA) patients with and without human immunodeficiency virus (HIV). The study population consisted of 2772 patients with HIV and 5,672,314 controls. Patients with HIV were more likely to be younger, male, and nonwhite. Patients with HIV were at an increased risk for perioperative wound infections (OR=2.78; P=0.024), although they were not at an increased risk for overall complications (OR=1.21; P=0.321). Mean length of stay was 17% longer for patients with HIV (P<0.001). Given these findings, orthopedic surgeons should have a low threshold to work up a patient with HIV for a wound infection following TKA.

No additional benefit with use of a fibrin sealant to decrease peri-operative blood loss during primary total knee arthroplasty.

Blood loss remains a substantial problem associated TKA. This study evaluated the efficacy of a fibrin sealant on: (1) blood loss; (2) blood transfusions; and (3) length of stay. We evaluated the records of 113 consecutive patients with sealant and 70 without sealant. There was no significant difference in the hemoglobin levels (all 9.5-10 g/dL) on each of three postoperative days. There was also no significant difference in the intraoperative blood loss, postoperative blood loss or the total perioperative blood loss in both groups. The mean requirement in each patient was 2.5 ± 2.4 units in the fibrin sealant group compared to 2.0 ± 0.8 units in the non-fibrin sealant group. We have stopped using fibrin sealant based on this study.