Primary Total Hip Arthroplasty Outcomes for Labral Tears are Comparable to Advanced Osteoarthritis.

BACKGROUND: There is a paucity of evidence on outcomes following total hip arthroplasty (THA) in patients who have symptomatic degenerative labral tears and mild to moderate osteoarthritis. The purpose of this study was to determine if outcomes of primary THA in the setting of painful, symptomatic labral tear, and mild to moderate arthritic changes (MMOA) were comparable to outcomes of primary THA performed for severe arthritic changes (AOA). Primary outcomes were patient-reported outcomes (PRO) scores. Secondary outcomes included length of stay (LOS) and perioperative complications. METHODS: This was a retrospective investigation of all THAs between January 2018 and July 2022. There were 111 patients who had THA due to failure of non-operative treatment of a degenerative labral tear without advanced arthritic changes (MMOA cohort, Kellgren-Lawrence (KL) Grades 1 to 3). These patients were matched to 111 patients who underwent THA for advanced OA (AOA cohort, KL Grade 4). Patient-reported outcomes (PROs) included the Western Ontario McMaster Universities Arthritis Index (WOMAC). The average age for the labral tear cohort was 59 years, with 50.6% women, compared to 70 years (P < 0.001), and 49.4% women (P = 0.93) in the advanced OA cohort. RESULTS: There were no differences in preoperative PROs, complications, or length of stay (LOS) between groups. When looking at postoperative PROs between cohorts, the labral tear cohort had less improvement in WOMAC-S (24.3 versus 34.0, P = 0.005) and WOMAC-F (26.3 versus 36.0, P = 0.005) at 12 months and greater improvement in WOMAC-P at 12 months (38.3 versus 34.7, P = 0.04). The SF12-P scores were significantly higher among the labral tear cohort compared to the AOA cohort at 12 months (48.5 versus 47.8, P < 0.001). The SF12-M scores were significantly higher in the AOA cohort compared to the labral tear cohort at 3 months (47.1 versus 47.4, P = 0.02) and 12 months (46.7 versus 47.6, P < 0.001). In the multivariate analysis, the change in WOMAC-P at 12 months was significantly better for labral tear patients (OR [odds ratio] 7.5 versus, P = 0.008, CI (confidence interval) [6.85 to 8.14]). CONCLUSION: Our study showed that patients who have symptomatic degenerative labral tears with mild to moderate arthritic changes have comparable outcomes to patients who have advanced OA following primary THA. Given suboptimal outcomes with hip arthroscopy for labral tear in the setting of early arthritis, primary THA can be a reasonable treatment modality for patients failing non-operative treatments.

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty.

BACKGROUND: Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. METHODS: We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05. RESULTS: The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). CONCLUSIONS: Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

Predictors of Reoperation and Survival Experience (Minimum 1 Year) for Primary Versus Conversion Total Hip Arthroplasty in Young Patients.

BACKGROUND: Total hip arthroplasty (THA), including primary and conversion procedures, is commonly used for many types of joint disease in patients aged below 65 years, though few studies have evaluated THA outcomes in young patients (≤ 40 years old). This study examined a large cohort of patients who underwent THA at a young (≤ 40 years old) age to identify predictors of reoperation and compare survivorship between primary and conversion THAs. METHODS: A retrospective study was conducted on 497 patients who underwent 612 primary and conversion THAs at 40 years old or younger between 1990 and 2020. Medical records were reviewed to collect patient/surgical data. A multivariable logistic regression model identified independent predictors of reoperation, and Kaplan-Meier analysis with log-rank tests was used to compare survival curves by THA type. RESULTS: The median age at surgery (interquartile range) was 31 years (25 to 36). The median follow-up time was 6.6 years (range, 3.8 to 10.5). Conversion THAs had an increased rate of both revisions (12.3 versus 5.6%, P = 0.02) and nonrevision reoperations (8.9 versus 3.2%, P = 0.03) compared to primary THAs. A ceramic-on-ceramic articulation (odds ratio: 5.17; P = 0.03) and a higher estimated blood loss (odds ratio: 1.0007; P = 0.03) were independent predictors of reoperation for primary and conversion THA, respectively. Conversion THAs had a lower 15-year survival (77.8 versus 90.8%, P = 0.009) compared to primary THAs. CONCLUSIONS: Patients ≤ 40 years old who underwent primary and conversion THAs demonstrated an impressive 15-year survival comparable to that of older populations (74 to 93%), while conversion procedures had a higher reoperation rate. Although primary THA may be more ideal, there are promising outcomes for patients who need THA at a younger age than typically implemented, especially for those who are very young (≤ 30 years old).

High femoral offset as a risk factor for aseptic femoral component loosening in cementless primary total hip arthroplasty.

PURPOSE: Lateralized stems in primary cementless total hip arthroplasty (THA) showed to be associated with aseptic femoral loosening. However, femoral head length also affects femoral offset but was not considered so far. This study analyzed the impact of high femoral offset (hFO) combinations, formed by lateralized stems or large femoral head lengths, on aseptic femoral component loosening. METHODS: Retrospective cohort study was performed including all patients that underwent primary cementless THA at our institution between July 2004 and December 2016. Patients were screened for aseptic femoral component loosening and grouped in aseptic loosening (AL) and non-aseptic loosening (nAL) group. Medical records were screened; implant details were noted and classified in hFO and standard femoral offset (sFO) combinations. Supposed risk factors for aseptic loosening were analyzed. RESULTS: Two thousand four hundred fifty-nine THA could be included, containing 14 THA (0.6%) with aseptic femoral component loosening. The AL group contained 11 hFO combinations (78.6%), whereas in the nAL group, 1315 hFO combinations (53.8%) were used. Subgroup analysis showed significant difference between two groups for hFO combinations (p = 0.014), age (p = 0.002), NSAR (p = 0.001), and bilateral THA on same day (p = 0.001). The multiple logistic regression analysis showed that hFO combination was the only variable for increased probability of aseptic loosening (OR, 3.7; p = 0.04). CONCLUSION: High femoral offset combinations, formed by lateralized stems or large femoral head lengths in our collective of standard straight stems implanted by an anterior approach, show a 3.7-fold increased probability for aseptic femoral component loosening. Adjustment of the postoperative protocol may be considered in these cases to ensure proper stem ingrowth.

Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study.

BACKGROUND: Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients. METHODS: A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications. RESULTS: The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION: Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

The AAHKS Best Podium Presentation Research Award: A Second Dose of Dexamethasone Reduces Postoperative Opioid Consumption and Pain in Total Joint Arthroplasty.

BACKGROUND: The optimal administration of dexamethasone for postoperative pain management and recovery following primary elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A retrospective review was conducted of 2,256 primary elective THAs and 1,951 primary elective TKAs between May 2020 and April 2021. Patients who received 2 perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received 1 perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores. RESULTS: The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48-hour and 48 to 72-hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60-hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48-hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION: The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control. LEVEL III EVIDENCE: Retrospective Cohort Study.

Monobloc Dual Mobility With a Minimum 5-Year Follow-Up: A Safe and Effective Solution in Primary Total Hip Arthroplasty.

BACKGROUND: Instability constitutes over 20% of revisions after total hip arthroplasty (THA). Dual mobility (DM) designs were introduced as a solution to this problem. However, the few publications that have reported promising results for monobloc DM constructs have been limited by sample size or length of follow-up. The purpose of this study is to evaluate mid-term outcomes (minimum 5-year follow-up) of a single-surgeon series utilizing a monobloc DM acetabular component in patients with high risk for dislocation. METHODS: This is a single-surgeon consecutive series of 207 primary THAs implanted with a monobloc DM component in patients who were considered at high risk for dislocation. Patient demographics and case-specific data were collected retrospectively. All patients had a minimum of 5-year follow-up. The Mann-Whitney U test was used to assess continuous variables, whereas categorical variables were analyzed using the chi-square test. Survival probability was calculated using the Kaplan-Meier method. RESULTS: Radiographic analysis did not reveal acetabular radiolucency in any patients, and there were no revisions for aseptic loosening. In addition, there were no dislocations. Seven of 205 patients (3.4%) were revised, 5 on the femoral side due to periprosthetic fracture and the remaining two for infection. Survivorship of the acetabular component from revision was 99%. The mean Veteran RAND (VR-12) physical score improved from 7 (standard deviation [SD]: 13.7) preoperatively to 9.5 (SD: 17.6) at the final follow-up. Similarly, the hip disability osteoarthritis score improved from 8 (SD: 17.9) preoperatively to 21.2 (SD: 37). CONCLUSION: Monobloc DM components reliably prevent dislocation after primary THA in high-risk patients. At mid-term follow-up, this DM monobloc component demonstrates excellent implant survivorship, radiographic fixation, and improved functional outcomes.

Primary THA Using Thin Polyethylene Liners and Large Femoral Heads: A Minimum 5-Year Follow-Up.

BACKGROUND: Large femoral head sizes are commonly used in total hip arthroplasty (THA) to minimize the risk of instability. With small acetabular cup-size, large femoral head diameter often results in the use of thin polyethylene liners. The purpose of this study was to evaluate clinical and radiographic results of large femoral heads against thin polyethylene liners with minimum 5-year follow-up. METHODS: This was a retrospective review identifying 58 primary THAs utilizing thin polyethylene inserts from one manufacturer (X3 polyethylene, Stryker, Mahwah, NJ) and large femoral heads (36 mm or greater) with minimum 5-year follow-up. A total of 3 patients were deceased and 11 lost to follow-up, leaving 44 patients for review. All patients were female with mean age 65.7 (range 26-85) and mean body mass index (BMI) 29.9 (range 19.6-45.4). Average length of follow-up was 8.5 years (range 5.1-11.3). Outcome measures included survivorship, complications, PROMs and radiographic analysis. RESULTS: There were four revisions: two aseptic loosening, one prosthetic joint infection, and one recurrent dislocation. Average HOOS-Jr, FJS-12, and patient satisfaction using Likert score was 94.3/100, 92.9/100, and 4.69/5.00, respectively, with 94% of patients reporting being satisfied or very satisfied. Radiographic analysis at average of 8.5 years demonstrated well-fixed implants without evidence of progressive radiolucent lines, osteolysis, or failure of the polyethylene liner. Survivorship using failure of the thin polyethylene liner as the endpoint was 100% at an average of 8.5 years. CONCLUSION: Thin polyethylene liners used with large femoral head sizes in small acetabular cups demonstrated excellent results at average 8.5-year follow-up with no cases of liner fracture or osteolysis.

Mepivacaine Versus Bupivacaine Spinal Anesthesia for Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Mepivacaine is an intermediate acting amide local anesthetic that can be used for neuraxial anesthesia in total joint arthroplasty (TJA) with a shorter duration of action (1.5-2 hours) compared to the more commonly used local anesthetic bupivacaine. The purpose of this study was to perform a systematic review and meta-analysis comparing bupivacaine and mepivacaine spinal anesthesia during elective TJA and the surgical outcomes of the time to full neurologic motor return, pain, mobility, length of stay (LOS), and complications including transient neurologic symptoms and urinary function. METHODS: PubMed, Ovid MEDLINE, and Ovid Embase were screened for "arthroplasty, spinal anesthesia, bupivacaine, and mepivacaine," in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 159 studies were screened and 5 studies were evaluated. Data were compared regarding motor function return, mobility (distance ambulated), pain (visual analog scale [VAS]), LOS, and postoperative complications. RESULTS: Full-text screening yielded 5 studies (3 randomized controlled trials and 2 retrospective cohort studies), with a total of 1,550 patients. Mepivacaine spinals had an earlier return to motor function (154 minutes vs 170 minutes, 95% CI: [-31.6, -0.9], P = .04), shorter LOS (25.95 hours vs 29.96 hours, 95% CI: [-6.8, -1.2], P = .01), and decreased urinary retention (7.15% vs 10.58%, 95% CI: [-6.3%, -0.6%], P = .02) with no differences in pain (VAS 3.57 vs 3.68, 95% CI: [-2.1, 1.9], P = .90) or distance ambulated (94.2 ft vs 89.1 ft, 95% CI: [-15, 25.2], P = .60) compared to bupivacaine spinal anesthesia. CONCLUSIONS: The method of anesthesia administration has been an increasing area of focus for quicker and safer recovery to allow for early ambulation and facility discharge. The rapid recovery facilitated by mepivacaine may further enable outpatient TJA and enhance patient recovery. LEVEL OF EVIDENCE: III.

What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients.

BACKGROUND: This study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts? METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis. RESULTS: The 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001). CONCLUSION: The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort. LEVEL OF EVIDENCE: III.

To Bundle or Not to Bundle? The Financial Impact of Pathologic Hip Disease on Hip Arthroplasty Episodes of Care.

BACKGROUND: The Comprehensive Care for Joint Replacement model aims to support more efficient care for patients. We examined the impact of patient and surgical characteristics, post-acute care, and clinical outcomes on episode of care (EOC) costs in patients undergoing hip arthroplasty for all diagnoses. METHODS: We retrospectively collected data from a large database of patients undergoing hip arthroplasty for oncologic and nononcologic diagnoses between 2014 and 2017. We compared EOC costs and outcomes between the 2 groups using Student's t-tests. We estimated the association between an oncologic-associated procedure and EOC costs from a multiple regression analysis. RESULTS: There were 2122 total patients included: 1993 in the nononcologic group and 129 in the oncologic group. The length of stay was significantly greater in the oncologic group (7.2 vs 4.2 days, P = .00). In the post-acute period, a greater proportion of oncologic patients was readmitted (29% vs 14%, P = .05) and discharged to skilled nursing (93% vs 51%, P = .00). Index hospitalization costs (mean difference [MD] $1561, P = .05), skilled nursing costs (MD $5932, P = .001), and total EOC costs (MD $20,012, P = .00) were all greater in the oncologic group. Along with increasing age and fracture diagnosis, an oncologic diagnosis is independently associated with greater EOC costs from a multivariate analysis (ß = 16,163 ± 2258, P = .00, r2 = 29%). CONCLUSION: Comprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease because hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population.

Uncemented Total Hip Arthroplasty Through the Direct Anterior Approach: Analysis of a Consecutive Series of 275 Hips With a Minimum Follow-Up of 10 Years.

BACKGROUND: The purpose of this study was to document complications, outcomes, and 10-year survivorship of primary total hip arthroplasty (THA) using a direct anterior approach with an uncemented, straight, hydroxyapatite-coated stem and an uncemented cup. METHODS: A retrospective, consecutive series of 275 primary THAs through a direct anterior approach with traction table using Medacta Versafit cup and Quadra-H stem with a minimum of 10-year follow-up was identified. The cumulative 10-year survival of the implants was estimated using Kaplan-Meier estimator. All complications, reoperations, and failures were analyzed. Subjective and clinical outcomes (Subjective Hip Value, Western Ontario and McMaster Universities Osteoarthritis Index, and Harris Hip Score) were measured. RESULTS: Of 256 patients (275 hips, 143 men and 113 women) with a mean age of 63 (range, 24-85) years, 48 (19%) patients (52 hips) deceased not related to the surgery after a mean time 49 months (range, 3-118) postoperatively. At >10-year follow-up, 9 THAs were revised. The overall implant survival rate was 96.8% (95% confidence interval, 94.4-98.7) at 10 years. One cup and 1 stem were revised because of aseptic loosening. At the last follow-up, the median Subjective Hip Value was 90% (range, 20-100), the Western Ontario and McMaster Universities Osteoarthritis Index score reached a median of 0.2 points (range, 0-6.3), and the median Harris Hip Score points was 99 (range, 29-100). CONCLUSION: Primary THA through an anterior minimal invasive approach with the mentioned implants showed low revision rates and good to excellent clinical outcome after at least 10 years.

Does Preoperative Opioid Use Increase the Risk of Early Revision Total Hip Arthroplasty?

BACKGROUND: The purpose of this study is to evaluate the impact of preoperative opioid use on the risk of subsequent revison after primary total hip arthroplasty (THA). METHODS: The Humana database was queried for unilateral THA between 2007-2015. Patients were tracked for the occurrence of an ipsilateral revision THA for 2 years. Factors analyzed included preoperative opioid use (defined as a history of opioid prescription filled within 3 months preceding primary THA), age, sex, diabetes, anxiety/depression, chronic kidney disease, and obesity (body mass index > 30 kg/m2). Multivariate logistic regression analysis was used to determine odds ratios. RESULTS: A total of 17,695 primary THA patients were analyzed and 0.88% (n = 155) underwent revision THA within 2 years. Preoperative opioid use occurred in 36.7% of all. Females comprised 58.7% of the total cohort and 80% were >50 years. Preoperative opioid users were significantly more likely to undergo early THA revision (1.2% vs 0.7%, P < .001). Other patient factors that significantly increased the risk of early THA revision included obesity (1.3% vs 0.8%, P = .03) and a preoperative diagnosis of anxiety/depression (1.9% vs 0.8%, P = .006). CONCLUSION: Opioid use within 3 months preceding THA independently predicts an increased risk of early revision. Additionally, independent predictors of early revision include obesity and a diagnosis of anxiety/depression. Factors such as these will need to be considered in risk adjustment models when assessing quality of care or implementing bundled payment initiatives. Further research is needed to evaluate whether discontinuing opioids before surgery mitigates this risk.

Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment.

BACKGROUND: Trochanteric bursitis (TB) remains a common complication after total hip arthroplasty (THA), with an incidence between 3% and 17%, depending on the surgical approach, with the posterior approach (PA) being relatively protective compared to the lateral approach. The purposes of this study were to determine the incidence of TB after primary THA, identify potential risk factors for TB, and examine the utility of different modes of treatment. METHODS: Retrospective cohort data of 990 primary THAs performed in a single institution, including 613 PAs and 377 direct anterior approaches (DAAs), were analyzed. Data abstracted included demographic data, operative diagnosis, comorbidities, radiographic assessment, and other specific predictors of interest that were compared between patients diagnosed with TB following THA and controls. RESULTS: The incidence of TB following primary THA was 5.4% (54/990) for the entire cohort. The incidence did not differ significantly between the PA and DAA (5% vs 6.1%, respectively; P = .47). Charlson comorbidity index and American Society of Anesthesiology did not differ significantly in the TB group. Lumbar spinal stenosis and history of past smoking were significantly more common in patients who developed TB (P = .03, P = .01, respectively), but did not continue to be significant risk factors on multivariate analysis. All patients were treated nonoperatively by the time of final follow-up. Seventy-four percent required a local steroid injection and 30% required treatment with more than one modality. CONCLUSION: The occurrence of TB is not influenced by the surgical approach (PA or DAA), and could not be predicted by specific comorbidities or radiographic measurements. However, it can be effectively treated conservatively in most cases.

Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years.

BACKGROUND: Delta ceramics may be the bearing of choice for younger and active patients due to its improved toughness and wear characteristics, provided there is no risk of fracture. However, ceramic fracture is the most serious complication related to this type of bearing. Although millions of Delta ceramics have been implanted worldwide, short to midterm results have been scarcely reported in the literature. The purpose of this study was to report the complication rate at short to midterm follow-up associated with the bearing surface used in a series of primary total hip arthroplasties with Delta ceramic-on-ceramic bearings performed in a single institution. METHODS: A total of 939 cases (880 patients) undergoing primary total hip arthroplasty with fourth-generation Delta ceramic-on-ceramic bearings were retrospectively reviewed. They were followed for an average of 5.3 years (2-10 years). RESULTS: One hip experienced a liner fracture, 2 cups presented early loosening due to friction between the acetabular screw and the backside of the liner, one femoral ball head had a fracture; one case of squeaking was reported, which is impending revision. Considering revision or impending revision in relationship with the bearing surface as the end point, the mean survival rate was 99.3% (confidence interval 95%, 98.3%-99.7%) at 2-10 years. CONCLUSION: This study showed a low rate of ceramic fracture compared with others; however, it was much higher than the complication rate presented by the manufacturers. The complications observed were directly related to technical errors that surgeons should avoid when using this type of surface.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital.

BACKGROUND: Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model. METHODS: Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013. RESULTS: In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period. CONCLUSION: Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Quantifying Blood Loss and Transfusion Risk After Primary vs Conversion Total Hip Arthroplasty.

BACKGROUND: Primary total hip arthroplasty (THA) and conversion THA may result in substantial blood loss, sometimes necessitating transfusion. Despite the complexities of the latter, both are grouped in the same category for quality assessment and reimbursement. This study's purpose was to compare both blood loss and transfusion risk in primary and conversion THA and identify their associated predictors. METHODS: A total of 1616 patients who underwent primary and conversion THA at a single hospital from 2009-2013 were reviewed (primary THA = 1575; conversion THA = 41). Demographics, comorbidities, and perioperative data were collected from electronic records. Blood loss was calculated using a validated method. Transfusion triggers were based on standardized criteria. Separate multivariable regression models for blood loss and transfusion were performed. RESULTS: Conversion THA patients were younger (P = .002), had lower age-adjusted Charlson scores (P = .006), longer surgeries (P < .001), higher blood loss (P < .001), and more transfusions (P < .001). Primary and conversion THA groups were different in terms of surgical approach (P < .001), anesthesia type (P = .002), and venous thromboembolism prophylaxis (P = .01). Compared to primary THA, conversion THA had an average 478.9 mL higher blood loss (P = .003) and increased adjusted odds ratio of 3.2 (P = .019) for transfusion. CONCLUSION: Conversion THA leads to higher blood loss and transfusion compared with primary THA. These differences were quantified in the present study and showed consistent results between the 2 metrics. The differences between these procedures should be addressed during quality assurance because conversion THA is associated with higher resource utilization, which is important in the allocation of resources and tiered reimbursement strategies.

The Association of ASA Class on Total Knee and Total Hip Arthroplasty Readmission Rates in an Academic Hospital.

Total hip and knee arthroplasties are two of the most successful orthopaedic procedures. However, with the increasing demand, estimated future costs for these procedures are enormous. Recent data suggest post-discharge care may account for up to 35% of total episode payments. Yet, little is known about targets that can help improve quality and reduce cost. This retrospective study shows an ASA score of ≥ 3 is associated with a 2.9 times (P = 0.0082) greater risk of re-admission in total joint arthroplasty patients. The current literature corroborates this finding by demonstrating an increase risk of post-operative complications in patients with an ASA of ≥ 3. Therefore, the ASA score is a potential target for interventions designed to increase quality and lower cost in arthroplasty patients.

Patient Perceptions of Same-Day Discharge Versus Overnight Stay After Total Joint Arthroplasty: Results of a Survey.

Background: In the COVID-19 era, there has been increasing interest in same-day discharge (SDD) after total joint arthroplasty (TJA). However, patient perception of SDD is not well reported. Purpose: We sought to understand patients' perceptions and preferences of postoperative care by surveying patients who have completed both an overnight stay (ONS) and an SDD after TJA. Methods: We emailed survey links to 67 patients who previously underwent either 2 total hip arthroplasties (THAs) or 2 total knee arthroplasties (TKAs). Results: Fifty-two patients (78%) responded to the survey. Thirty-four (65%) patients underwent staged, bilateral TKAs, and 18 (35%) patients underwent staged, bilateral THAs. Overall, 63% of patients preferred their SDD, 12% had no preference, and 25% preferred their ONS, with no difference in preference between TKA and THA groups. Those who preferred their SDD reported being more comfortable at home. Those who preferred their ONS felt their pain and concerns were better addressed. No differences were found in comfort, sleep quality, appetite, burden on family, return to function, feelings of being discharged too soon, overall experience, 30-day emergency department (ED) visits, or readmissions within 30 days between patients' SDD and ONS. There was a small statistically significant difference between patients' perception of safety between SDD and ONS. Conclusion: Our survey found that most patients reported a preference for SDD after TJA over ONS. Although there was a small difference in patient perception of safety, there were no differences in return to the ED or readmissions after SDD and ONS.

Long-term follow-up of total hip arthroplasty using polyethylene-ceramic composite (sandwich) liner.

INTRODUCTION: Ceramic-on-ceramic bearings have been widely used since their introduction in the 1970s. First-generation ceramics have very high fracture (breakage) rates. To overcome this, in the 1990s, modular cotyloid insert designs were developed, consisting of a ceramic and polyethylene composite (sandwich-type) liner; however, high implant fracture rates were observed in the medium term. We aimed to estimate the cumulative incidences of revision surgery (implant failure) and implant failure due to fractures, survival rates (time-to-revision surgery and time-to-fracture), and the long-term clinical and radiological outcomes in our series. METHODS: This was an observational, longitudinal, ambispective, single-centre study based on patients who underwent primary total hip arthroplasty (THA) using a sandwich-type liner (Cerasul), only available in our tertiary hospital between January 1999 and December 2002. Cumulative incidences were estimated and the 95% confidence interval (95% CI) was calculated. The Kaplan-Meier method was used to assess the time-to-revision surgery and time-to-fracture. RESULTS: 54 patients (49 men) were included, accounting for 59 sandwich-type linear implants. The mean (range) age was 47.4 (22-57) years. The primary THA indications were osteoarthritis (28 patients), osteonecrosis (14), childhood pathology sequelae (11), and inflammatory arthritis (6). The cumulative incidence of revision surgery by implants was 8.5% (5/59, 95% CI, 3.5-19.2%), 9.3% by patients (5/54, 95% CI, 4.0-19.9%), and 5.1% by implant fractures (3/59, 95%CI, 1.7-13.9%). The median (Interquartile Range, IQR) time-to-revision surgery was 158 (72.5-161) months, and the time to fracture was 182 (138-215) months. All primary THAs had good clinical and long-term survival outcomes. All implants had signs of solid fixation. CONCLUSIONS: After a 20-year follow-up period, the polyethylene-ceramic sandwich-type liner showed a long survival rate and low cumulative incidence of implant fracture; however, implant fractures remain the main complication. Orthopaedic surgeons should be aware that some patients still have this type of prosthesis and must be capable of responding quickly if a fracture occurs.