Mini-open Femoroacetabular Osteoplasty in Patients With Tönnis Grade 2 or Higher Osteoarthritis is Associated With a Higher Risk of Subsequent Conversion to THA.

BACKGROUND: The severity of degenerative changes of the hip is known to adversely impact the outcomes of the treatment of femoroacetabular impingement (FAI). Although the operative indications for FAI have expanded to include patients with moderate degrees of hip osteoarthritis, the exact stage of hip osteoarthritis at which surgery for FAI can offer clinical benefits is still uncertain. QUESTIONS/PURPOSES: (1) How does the survivorship free from conversion to THA and survivorship free from revision differ between patients with preexisting Tönnis Grades 2 or 3 changes and those without advanced degenerative changes (Tönnis Grade 0 or 1) after mini-open femoroacetabular osteoplasty? (2) What are the differences in hip-specific and general-health outcome scores between the two groups after mini-open femoroacetabular osteoplasty? METHODS: From December 2003 to April 2019, we treated 901 patients for FAI, and their clinical data were systematically recorded in a longitudinally maintained database. Mini-open femoroacetabular osteoplasty was our preferred surgical approach because of the surgeon's extensive experience with the technique. Among the entire dataset, 6% of patients (51 individuals) had Tönnis Grade 2 or higher hip osteoarthritis, while the remaining 94% (850 patients) had no or mild degenerative changes (Tönnis Grade 0 or 1). In the Tönnis Grade 2 or 3 group, three patients were lost before the minimum 2-year follow-up duration, leaving 4% (48 patients) who qualified for inclusion in the study. For the matched group with Tönnis Grade 0 or 1, 5% (45 patients) were excluded because of incomplete data, and a further 7% (58 patients) were excluded because they did not have 2 years of follow-up, leaving 83% (747 patients) who were eligible for the matching process. Matching was based on patient age (within 1 year), gender, and BMI (within one unit). Matching resulted in the inclusion of 144 randomly selected control patients in this retrospective, comparative study. General indications for femoroacetabular osteoplasty included symptoms of pain and restricted hip motion in young, active patients with signs of FAI evident on physical examination and radiographs. Patient demographics, medical history, radiographic parameters, and intraoperative findings were compared between the two groups to establish baseline differences and identify potential confounding variables. There was no difference in the mean ± standard deviation age between the cohort of interest and control group (39 ± 10 years and 38 ± 11 years, respectively; p = 0.67). There was no difference in the mean follow-up duration (7 ± 3 years versus 8 ± 2 years; p = 0.25) or the preoperative symptomatic period between the study and control groups (2 ± 2 years versus 3 ± 6 years; p = 0.09). There was no difference in the prevalence of dysplasia, slipped capital femoral epiphysis, Perthes disease, or avascular necrosis of the hip between the two groups. Intraoperatively, the groups did not differ in terms of labral repair (65% [31 of 48] versus 78% [113 of 144]; p = 0.08) and labral transplantation (2%; p > 0.99 for both); however, labral resection was performed more frequently in the study group (63% [30 of 48] versus 42% [60 of 144]; p = 0.002). At a minimum of 2 years of follow-up, survivorship free from conversion to THA and survivorship free from revision surgeries, as well as the latest clinical and functional outcome scores (SF-36, Hip Disability and Osteoarthritis Outcome Score, and modified Harris hip score), were compared between groups. RESULTS: Survivorship free from conversion to THA at 5 years was lower among patients with preexisting Tönnis Grades 2 or 3 changes than it was among patients matched for age, gender, and BMI who did not have advanced degenerative changes (Tönnis Grade 0 or 1) after mini-open femoroacetabular osteoplasty (75% [95% confidence interval 64% to 88%] versus 92% [95% CI 87% to 96%]; p < 0.001). No patients in either group underwent reoperation other than conversion to THA. Although the groups did not differ at baseline in terms of their outcomes scores, the group with more visible arthritis had lower postoperative Hip Disability and Osteoarthritis Outcome Scores than the control group (60 ± 21 points versus 86 ± 11 points, mean difference 26 points [95% CI 10 to 41]; p =0.004). There were no other between-group differences in outcome scores after surgery. CONCLUSION: In our study, approximately 25% of patients undergoing mini-open femoroacetabular osteoplasty with Tönnis Grade 2 or higher osteoarthritis underwent conversion to THA within 5 years. Some postoperative functional scores were lower in patients with advanced arthritis than in matched patients with no or mild arthritis. We emphasize the importance of exercising caution when considering femoroacetabular osteoplasty in patients in whom advanced arthritis is already evident at the time of presentation. LEVEL OF EVIDENCE: Level III, therapeutic study.

Return to Sport After Unicompartmental Knee Arthroplasty and Patello-Femoral Arthroplasty.

BACKGROUND: Data on sports/physical activity participation following unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty (PFA) is variable and limited. The purpose of this study was to assess participations, outcomes, and limitations in sports following UKA and PFA. METHODS: Patients who underwent UKA and PFA at a single institution from 2015 to 2020 were surveyed on sports participation before and after surgery. Data was correlated with perioperative patient characteristics and outcome scores. Among 776 patients surveyed, 356 (50%) patients responded. Of respondents, 296 (83.1%) underwent UKA, 44 (12.6%) underwent PFA, and 16 (4.5%) underwent both UKA/PFA. RESULTS: Activity participation rates were 86.5, 77.3, and 87.5% five years prior, and 70.9, 61.4, and 75% at one year prior to UKA, PFA, and UKA/PFA, respectively. Return to sports rates were 81.6, 64.7, and 62.3% at mean 4.6 years postoperatively, respectively. The most common activities were recreational walking, swimming, cycling, and golf. Patients returned to a similar participation level for low-impact activities, whereas participation decreased for intermediate- and high-impact activities. Patients participating in activities had higher postoperative Knee Injury and Osteoarthritis Outcome Score Joint Replacement (P < .001), 12-Item Short Form Physical Component Score (P = .045) and Mental Component Score (P = .012). Activity restrictions were reported among 25, 36.4, and 25% of UKA, PFA, and UKA/PFA patients, respectively, and were more commonly self-imposed than surgeon-directed. CONCLUSIONS: Though UKA patients' postoperative sports participation may improve compared to one year preoperatively, participation for patients surgically treated for isolated osteoarthritis is decreased compared to 5 years preoperatively and varies among patient subsets.

Joint line position change in primary total knee arthroplasty: a radiographic analysis comparing conventional and robotic techniques.

PURPOSE: Joint line (JL) position change in total knee arthroplasty (TKA) may alter knee biomechanics and impact function. The purpose of this study was to compare the change in JL position between robotic-assisted TKA (RA-TKA) and conventional TKA (C-TKA). METHODS: A retrospective, radiographic analysis was conducted of patients who underwent RA-TKA and C-TKA to compare JL position change. JL position was measured in consecutive RA-TKAs and C-TKAs performed by four fellowship-trained arthroplasty surgeons. Statistical analysis was done utilizing t-tests and Mann Whitney U tests, with statistical significance being defined as a p value < 0.05. RESULTS: Six hundred total RA-TKAs and 400 total C-TKAs were included in the analysis. There were no significant differences in patient baseline characteristics such as body mass index, range of motion, and tibiofemoral coronal alignment. RA-TKAs were associated with an average of 0.04 (2.2) mm JL position change, and C-TKAs were associated with an average 0.5 (3.2) mm JL position change (p = 0.030). There were inter-surgeon differences when comparing the change in JL position for RA-TKAs and C-TKAs between the four participating surgeons. CONCLUSION: RA-TKA leads to better preservation of the JL position than C-TKA, and this seems to be dependent on the arthroplasty surgeon's preferences and techniques during TKA. Whether this statistically significant difference is clinically relevant needs to be further investigated.

Distressed communities demonstrate increased readmission and health care utilization following shoulder arthroplasty.

BACKGROUND: Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty. METHODS: A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits. RESULTS: Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities. CONCLUSIONS: Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike.

Routine Use of Closed Suction Drains Following Revision Arthroplasty May Not be Necessary.

BACKGROUND: There are numerous studies demonstrating that closed suction drainage (CSD) usage after primary total joint arthroplasty (TJA) has little to no benefit. There are little data on the role of CSDs after revision TJA. The purpose of our study was to evaluate whether there is any clinical advantage to CSD usage after revision TJA. METHODS: This retrospective study evaluated the clinical records of 2,030 patients undergoing revision TJA between 2007 and 2021. CSD was used in 472 patients and not used in 1,558 patients. Primary outcome was blood transfusion rate and secondary outcomes included total blood loss (TBL), as determined by Gross formula, wound complications (hematoma, infection, and dehiscence), and length of hospital stay. Patients undergoing revision TJA for oncologic reasons or those with incomplete datasets were excluded. RESULTS: There were no statistically significant differences in rates of allogeneic blood transfusion, TBL, and wound complications (hematoma, infection, and dehiscence) between the two groups (P = .159, .983, .192, .334, and .548, respectively). When adjusted for demographic and surgical confounders, there was no difference in transfusion and TBL rates between groups (Odds Ratio 1.04, 95% Confidence Interval 0.78-1.38, P = .780 and estimate -105.71 mL, 95% confidence interval -333.96 to 122.55, P = .364, respectively). CSD cohort had a shorter length of stay (4.30 versus 5.82 days, P < .001). CONCLUSION: We acknowledge that there is a role for CSD usage in a selected group of patients. Nevertheless, our study revealed that routine use of CSD after revision TJA does not provide an additional clinical benefit.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery.

BACKGROUND: Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA. METHODS: Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications. RESULTS: Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar. CONCLUSION: Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

For Patients With Acute PJI Treated With Debridement, Antibiotics, and Implant Retention, What Factors Are Associated With Systemic Sepsis and Recurrent or Persistent Infection in Septic Patients?

BACKGROUND: Periprosthetic joint infection (PJI) can lead to a severe systemic inflammatory response and may result in systemic sepsis. However, little is known about how often systemic sepsis may occur in patients with PJI, and whether sepsis is associated with a greater likelihood of persistent or recurrent PJI. QUESTIONS/PURPOSES: (1) Among patients who present with acute or acute hematogenous PJI and who were treated with debridement, antibiotics, and implant retention (DAIR), what proportion have sepsis and what factors are associated with a presentation with sepsis? (2) For patients presenting with sepsis, what factors are associated with persistent or recurrent PJI? METHODS: In all, 320 patients who underwent DAIR for the treatment of acute postoperative or acute hematogenous PJI between January 2000 and December 2019 were included in this study. Exclusion criteria were patients with other known sources of infection, such as pneumonia or urinary tract infections, which could contribute to systemic sepsis (6% [18 of 320]), patients with chronic PJI, and those with less than 6 months of follow-up (21% [66 of 320]). Our final cohort consisted of 236 patients presenting with an acute postoperative or acute hematogenous PJI who underwent an irrigation and debridement procedure. Sepsis was defined by the criteria for systemic inflammatory response syndrome (SIRS) or bacteria-positive blood culture results. Inclusion of patients with positive blood culture by organisms that caused their joint infection was important as all patients presented with fulminant acute infection of a prosthetic joint. Data, including vital signs, surgical variables, and treatment outcomes, were collected retrospectively through a chart review of an electronic medical record system. The statistical analysis comparing patients with sepsis versus patients without sepsis consisted of logistic regression to identify factors associated with sepsis. After confirming its ability to identify patients with a higher association with the development of sepsis through area under the curve models, a nomogram was generated to standardize our results from the regression, which was supported by the area under the curve model, to help readers better identify patients who are more likely to develop sepsis. RESULTS: A total of 44% (103 of 236) of patients had infections that met the criteria for sepsis. After controlling for confounding variables, including congestive heart failure, anemia, serum C-reactive protein (CRP), and the male sex, it was revealed that serum CRP (odds ratio 1.07 [95% confidence interval 1.04 to 1.11]; p < 0.001) and male sex (OR 1.96 [95% CI 1.03 to 3.81]; p = 0.04) were associated with the development of systemic sepsis. For patients presenting with sepsis, persistent or recurrent PJI were associated with an increased CRP level (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.01) and number of prior surgical procedures on the joint (OR 2.30 [95% CI 1.21 to 4.89]; p = 0.02). CONCLUSION: Overall, our findings support that patients with systematic sepsis may benefit from two-stage revision rather than DAIR to decrease the bioburden more effectively, especially in those with methicillin-resistant Staphylococcus aureus and polymicrobial infections. High serum CRP levels and a history of prior surgical procedures on the involved joint should trigger prompt, aggressive surgical treatment if the patient's overall clinical status can tolerate such an intervention. LEVEL OF EVIDENCE: Level III, therapeutic study.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty.

BACKGROUND: While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA. METHODS: This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections. RESULTS: 648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI. DISCUSSION: A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

Routine Laboratory Tests are not Necessary After Primary Total Joint Arthroplasty: A Prospective Study Utilizing a Selective Algorithmic Approach.

BACKGROUND: Laboratory tests are obtained following total joint arthroplasty (TJA) despite a lack of supporting evidence. No prior study has prospectively analyzed the effect of discontinuing routine laboratory tests. This study aimed to determine whether discontinuing routine laboratory tests in TJA patients resulted in a difference in 90-day complications. METHODS: This was a prospective protocol change study at a high-volume center. Prior to protocol change, patients underwent routine laboratory tests following primary unilateral TJA (control group). After the change, an algorithmic approach was used to selectively order laboratory tests (protocol group). Patients with bleeding disorders, chronic obstructive pulmonary disease, arrhythmia, coronary artery disease, congestive heart failure, chronic renal failure, dementia, abnormal preoperative sodium, potassium, or hemoglobin <10 g/dL were excluded. In-hospital and 90-day data were collected. Student's t-test was used to analyze continuous variables and chi-squared test was used for categorical variables. A pre-hoc analysis examining the primary outcome required 607 patients per group to achieve 80% power. RESULTS: The protocol group included 937 patients, whereas the control group included 891 patients. The protocol group had fewer females and total hip arthroplasties. There were no differences in age, body mass index, American Society of Anesthesiologists classification, tranexamic acid administration, or estimated blood loss between the protocol and control groups. There were also no differences in transfusions, electrolyte corrections, unplanned consults, length of stay, or transfers. The protocol cohort had more fluid boluses and home discharges. There was no difference in 90-day complications between the 2 groups. CONCLUSIONS: This study utilizing an algorithmic approach to laboratory collection demonstrates that discontinuing routine laboratory tests following TJA is safe and effective. We believe this protocol can be implemented for most patients undergoing primary unilateral TJA.

Short Interval Staged Bilateral Total Knee Arthroplasty: Safety Compared to Simultaneous and Later Staged Bilateral Total Knee Arthroplasty.

BACKGROUND: Simultaneous bilateral total knee arthroplasty (sim-BTKA) is reported to be safe in a select group of patients. Patients with symptomatic bilateral knee arthritis who are not candidates for sim-BTKA require staged surgery (stag-BTKA). This study aimed to compare the safety and complications associated with sim-BTKA with stag-BTKA performed at 2 time intervals. METHODS: This retrospective study of prospectively collected data includes bilateral TKA cases performed between 2001 and 2019. A cohort of sim-BTKA (n = 2728) was compared to a cohort of stag-BTKA (n = 1658). The staged group was subdivided according to the interval between surgeries: ≤90 days (early) and ≥91 days (later). Multivariate logistic regression analyses were used to adjust for confounding variables. RESULTS: In-hospital complication rates were lower in both arms of the stag-BTKA groups vs the sim-BTKA. The sim-BTKA group had higher odds ratio of anemia, electrolyte disturbances, pulmonary embolism, and respiratory, urinary, gastrointestinal, and neurological complications. Lower rates of all-cause revision were found in stag-BTKA vs sim-BTKA groups. There was a trend toward revision due to deep infection when increasing the interim before the second stag-BTKA procedure. No differences in complication rates after the second surgery were detected between the early and later stag-BTKA. CONCLUSION: This study demonstrates that sim-BTKA is associated with more complications and revisions when compared to stag-BTKA. Performing the second-stage TKA at 90 days or less after the first TKA is not associated with increased risk of complications. Performing sim-BTKA, simply for convenience, is not warranted and should be reserved for a select group of patient matching specific criteria.

Low-Dose Aspirin Administered for Venous Thromboembolism Prophylaxis Reduces the Incidence of Heterotopic Ossification in Total Joint Arthroplasty.

BACKGROUND: Heterotopic ossification (HO) is a common complication following total joint arthroplasty (TJA). However, the pathophysiology of HO is not entirely understood. Inflammation may play a significant role in the pathogenesis of HO as nonsteroidal anti-inflammatory drugs are effective in the prevention of HO. The purpose of this study is to examine if aspirin (ASA), when used as venous thromboembolism (VTE) prophylaxis, influenced the rate of HO formation following TJA. METHODS: We queried our longitudinally maintained database to identify all patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) for osteoarthritis between January 2016 and June 2018 with at least 3-month radiographic follow-up. In total, 1238 THAs and 1051 TKAs were included for analysis. Radiographs were reviewed and HO formation graded according to the Brooker classification. Patient demographic and VTE prophylaxis data were collected and reviewed for accuracy. Univariate and multivariate analysis was performed to evaluate the effect of ASA on HO formation. RESULTS: The overall rate of HO was 37.5% after THA and 17.4% after TKA. Patients receiving ASA were less likely to develop HO after THA (34.8% vs 45.5%; P < .001), as well as HO after TKA (13.4% vs 18.4%; P = .047) compared to patients receiving non-ASA VTE prophylaxis. The rate of HO formation trended to be lower, albeit not statistically significantly, in patients receiving low-dose ASA (81 mg) vs high-dose ASA (325 mg). CONCLUSION: Patients undergoing primary TJA receiving ASA for VTE prophylaxis were less likely to develop HO compared to patients who were administered non-ASA VTE prophylaxis.

High Bundled Payment Costs Following Total Hip and Knee Arthroplasty in African Americans.

BACKGROUND: Concerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients. METHODS: We queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs. RESULTS: Compared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001). CONCLUSION: African American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.

Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty.

BACKGROUND: Despite improved surgical and anesthesia techniques, as well as advances in perioperative protocols, a number of patients undergoing total joint arthroplasty (TJA) are at risk of serious medical complications that require intensive care unit (ICU) admission. With the recent move toward performing TJA in ambulatory surgical centers and on an outpatient basis, it is important to recognize patients that may require intensive care in the postoperative period. This study aimed to identify risk factors for ICU admission following elective total hip (THA) and knee (TKA) arthroplasty. METHODS: We evaluated 12,342 THA procedures, with 132 ICU admissions, and 10,976 TKA procedures, with 114 ICU admissions from 2005 to 2017. Demographic, preoperative, and surgical variables were collected and compared between cohorts using both univariate and logistic regression analysis. RESULTS: For THA, logistic regression analysis demonstrated older age, bilateral procedure, revision surgery, increased Charlson comorbidity index, general anesthesia, increased estimated blood loss, decreased preoperative hemoglobin, and increased preoperative glucose level were independently associated factors for increased risk of ICU admission. For TKA, increased age, increased body mass index, bilateral procedure, revision surgery, increased Charlson comorbidity index, increased estimated blood loss, general anesthesia, and increased preoperative glucose were independently significantly associated with ICU admission. CONCLUSION: In this study, we identify a number of critical independent risk factors which may place patients at increased risk of ICU admission following THA and TKA. Identification of these risk factors may help surgeons safely select those TJA candidates appropriate for surgery at facilities that do not have ICUs readily available.

Association Between Draft Order and Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers: An 18-Year Study.

BACKGROUND: The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow. PURPOSE: To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available. RESULTS: Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P = .932), relative laxity (P = .996), or presence of pathology detectable on SUS (P = .642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P < .001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology. CONCLUSION: Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound.

Impact of Climate on Stress Ultrasound Findings of the Elbow Ulnar Collateral Ligament in Professional Baseball Pitchers: An 18-Year Study.

Background: The ulnar collateral ligament (UCL) is the primary soft tissue stabilizer to valgus stress in the elbow and is placed under this valgus stress during the throwing motion. Although there are known risk factors for UCL injury, it is unknown whether the UCL undergoes adaptive changes in athletes from different climates. Purpose: To compare elbow stress ultrasound (SUS) findings between professional baseball pitchers from warm climates versus cold climates and assess significant differences in adaptive and morphologic changes in the UCL. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Dynamic SUS evaluations were performed over 18 years on the dominant and nondominant arms of 643 professional pitchers from warm and cold climates as determined by the player's country/state of origin. Studies were compared with respect to relative UCL thickness (dominant arm vs nondominant arm), relative glenohumeral joint laxity (joint space distance under stress vs joint space distance at rest), and the presence of morphologic changes such as tears or calcifications. In addition, a subgroup analysis was performed to compare the progression of SUS findings over 3 years in players with sequential yearly data. Results: Players from warmer climates had significantly greater relative UCL thicknesses than players from colder climates (1.75 vs 1.50 mm, respectively; P = .047). There were no differences between these 2 groups in terms of relative ulnohumeral joint laxity (P = .201), presence of morphologic changes (P = .433), 3-year progression of relative UCL thickness (P = .748), or relative joint laxity (P = .904). Conclusion: Professional pitchers from warm climates had a greater side-to-side difference in UCL thickness between the dominant and nondominant arms. This may be due to the potential for year-round throwing among baseball players from warm climates. There was no difference in laxity, thickness progression, laxity progression, or the presence of additional morphologic changes.

Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study.

Background: Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery. Purpose: To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries. Study Design: Case series; Level of evidence, 4. Methods: Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs). Results: Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use. Conclusion: The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. SUMMARY OF BACKGROUND DATA: As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. MATERIALS/METHODS: We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. RESULTS: A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75). CONCLUSION: Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement. LEVEL OF EVIDENCE: 3.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury.

INTRODUCTION: Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS: All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS: We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION: Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.

Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty.

Venous thromboembolism (VTE) and major bleeding (MBE) are feared complications that are influenced by numerous host and surgical related factors. Using machine learning on contemporary data, our aim was to develop and validate a practical, easy-to-use algorithm to predict risk for VTE and MBE following total joint arthroplasty (TJA). This was a single institutional study of 35,963 primary and revision total hip (THA) and knee arthroplasty (TKA) patients operated between 2009 and 2020. Fifty-six variables related to demographics, comorbidities, operative factors as well as chemoprophylaxis were included in the analysis. The cohort was divided to training (70%) and test (30%) sets. Four machine learning models were developed for each of the outcomes assessed (VTE and MBE). Models were created for all VTE grouped together as well as for pulmonary emboli (PE) and deep vein thrombosis (DVT) individually to examine the need for distinct algorithms. For each outcome, the model that best performed using repeated cross validation was chosen for algorithm development, and predicted versus observed incidences were evaluated. Of the 35,963 patients included, 308 (0.86%) developed VTE (170 PE's, 176 DVT's) and 293 (0.81%) developed MBE. Separate models were created for PE and DVT as they were found to outperform the prediction of VTE. Gradient boosting trees had the highest performance for both PE (AUC-ROC 0.774 [SD 0.055]) and DVT (AUC-ROC 0.759 [SD 0.039]). For MBE, least absolute shrinkage and selection operator (Lasso) analysis had the highest AUC (AUC-ROC 0.803 [SD 0.035]). An algorithm that provides the probability for PE, DVT and MBE for each specific patient was created. All 3 algorithms had good discriminatory capability and cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model. We successfully developed and validated an easy-to-use algorithm that accurately predicts VTE and MBE following TJA. This tool can be used in every-day clinical decision making and patient counseling.

Hyponatremia Is an Overlooked Sign of Trouble Following Total Joint Arthroplasty.

BACKGROUND: Hyponatremia is a common electrolyte abnormality in arthroplasty patients. This issue, underrecognized by surgeons, can impact the postoperative course of patients. There are, however, little data on the implications of sodium disturbances following total joint arthroplasty (TJA). The primary aims of this study were to (1) report the rate of hyponatremia following TJA, and (2) examine the impact of hyponatremia on the perioperative course of TJA patients. METHODS: This was a retrospective analysis of 3,071 primary and revision TJAs performed between 2015 and 2017. Based on preoperative and postoperative sodium values (pre-post), patients were classified into 4 groups: normonatremic-normonatremic (Group 1), normonatremic-hyponatremic (Group 2), hyponatremic-normonatremic (Group 3), and hyponatremic-hyponatremic (Group 4). Primary end points were length of stay (LOS), postoperative discharge, in-hospital complications, and 90-day readmissions. RESULTS: The distribution of cases was 84.6% Group 1, 9.4% Group 2, 2.1% Group 3, and 3.8% Group 4. Overall, 13.2% of patients had hyponatremia after TJA. Older age, hip arthroplasty, general anesthesia, higher Charlson Comorbidity Index, congestive heart failure, revision surgery, and history of stroke, liver disease, and chronic kidney disease were risk factors for postoperative hyponatremia. Patients with postoperative hyponatremia (Groups 2 and 4) had greater likelihoods of having a 90-day complication and non-home discharge and greater LOS. CONCLUSIONS: Postoperative hyponatremia was a relatively common occurrence in patients undergoing TJA, and was associated with greater LOS, complications, and non-home discharge. Surgeons should identify patients at risk for developing sodium abnormalities in order to optimize these patients and avoid increased resource utilization. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.