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Background: Tranexamic acid (TXA) is a regally excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty (HA)., Methods: Through a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or HA (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; non-elective or HA: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (intravenous and topical), were extracted. Pre and postoperative (≤ seven days) creatinine, perioperative transfusions, revisions, and 90-day emergency department visits, readmissions, and mortalities were recorded and compared between TXA groups., Results: In the total sample and all cohorts, change in pre to postoperative creatinine and incidence of postoperative acute kidney injury, per Kidney Disease Improving Global Outcomes guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or route of administration (P values ≥ 0.256). There were no statistically significant differences in 90-day emergency department visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA and three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA and one no TXA, P = 0.882) in the nonelective or HA cohort, with none in the elective cohorts., Conclusions: The administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or HA for fracture, suggesting TXA should not be contraindicated in this population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Discharge disposition after total joint arthroplasty may be predictable. Previous literature has attempted to improve upon models such as the Risk Assessment and Prediction Tool (RAPT) in an effort to optimize postoperative planning. The purpose of this study was to determine whether preoperative laboratory values and other previously unstudied demographic factors could improve the predictive accuracy of the RAPT., Methods: All patients included had RAPT scores in addition to the following preoperative laboratory values: red blood cell count, albumin, and vitamin D. All values were recorded within 90 days of surgery. Demographic variables including marital status, American Society of Anesthesiologists (ASA) scores, body mass index, Charlson Comorbidity Index, and depression were also evaluated. Binary logistic regression was used to determine the significance of each factor in association with discharge disposition., Results: Univariate logistic regression found significant associations between discharge disposition and all original RAPT factors as well as nonmarried patients ( P < 0.001), ASA class 3 to 4 ( P < 0.001), body mass index >30 kg/m 2 ( P = 0.065), red blood cell count <4 million/mm 3 ( P < 0.001), albumin <3.5 g/dL ( P < 0.001), Charlson Comorbidity Index ( P < 0.001), and a history of depression ( P < 0.001). All notable univariate models were used to create a multivariate model with an overall predictive accuracy of 90.1%., Conclusions: The addition of preoperative laboratory values and additional demographic data to the RAPT may improve its PA. Orthopaedic surgeons could benefit from incorporating these values as part of their discharge planning in THA. Machine learning may be able to identify other factors to make the model even more predictive., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Objective: The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up., Design: Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures., Results: Thirty-nine patients with a mean lesion size was 122.3 ± 64.1 mm 2 and mean follow-up time of 138.9 ± 16.9 months were included. The mean FAOS scores improved from a preoperative score of 51.9 ± 16.0 to 75.3 ± 21.9 ( P < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R 2 = 0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9 ± 5.2 ms) compared to the superficial layer of the adjacent native cartilage (35.8 ± 3.8 ms) ( P < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI., Conclusion: This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.G.K. is a consultant for Arteriocyte, In2Bones, and Arthrex. J.G.K. receives financial support from the Ohnell Family Foundation, Mr. Winston Fischer and Tatiana Rybak.

Background: Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF., Methods: We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk., Results: There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095)., Conclusions: The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: There has been much debate on use of bipolar or unipolar femoral heads in hemiarthroplasty for the treatment of femoral neck fractures. The outcome of these implants should be studied in the America Joint Replacement Registry (AJRR)., Methods: All primary femoral neck fractures treated with hemiarthroplasty between January 2012 and June 2020 were searched in the AJRR. All cause-revision of unipolar and bipolar hemiarthroplasty and reasons for revision were assessed for these patients until June of 2023., Results: There were no differences in number and reason for all cause revisions between unipolar and bipolar hemiarthroplasty ( p   =  0.41). Bipolar hemiarthroplasty had more revisons at 6 months postoperatively ( p   =  0.0281), but unipolar hemiarthroplasty had more revisions between 2 and 3 years ( p   =  0.0003), and after 3-years ( p   =  0.0085), as analysed with a Cox model. Patients with older age (HR = 0.999; 95% CI, 0.998-0.999; p   =  0.0006) and higher Charlson Comorbidity Index (HR = 0.996; 95% CI, 0.992- 0.999; p   =  0.0192) had a significant increase in revision risk., Conclusions: We suggest that surgeons should consider using bipolar prosthesis when performing hemiarthroplasty for femoral neck fracture in patients expected to live >2 years post injury., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Total knee arthroplasty (TKA) is one of the most popular and successful procedures of the past century. However, as the number of TKAs continues to increase, the volume of revision surgeries also will increase. Although revision TKAs are often successful, adult reconstruction surgeons will likely continue to see patients with limited arthroplasty options after multiple failed revision TKAs. This raises the question of limb salvage versus transfemoral amputation as the final procedure option. It is important to review modern techniques for the patient who has undergone multiple revision TKAs with significant bone loss or chronic infection. These techniques include distal femur replacement, total femur arthroplasty, knee arthrodesis, and transfemoral amputation.

Background: The use of a cemented monoblock dual-mobility implant into a fully porous cup is indicated for patients with acetabular bone loss who have a high risk of postoperative hip instability. Patients undergoing lumbar fusion for sagittal spinal deformities have an increased risk of hip dislocation (7.1%) and should be assessed on sitting and standing radiographs 1 . Gabor et al. conducted a multicenter, retrospective study assessing the use of a cemented monoblock dual-mobility bearing in a porous acetabular shell in patients with acetabular bone loss and a high risk of hip instability 2 . Of the 38 patients, 1 (2.6%) experienced a postoperative dislocation that was subsequently treated with closed reduction without further dislocation. This surgical technique represents a favorable surgical option for patients with acetabular bone loss who are at risk for hip instability. In the example case described in the present video article, the patients had a history of dislocations, lumbar fusion, and evidence of Paprosky 3B acetabular defect; as such, the decision was made to revise to a porous shell and cement a monoblock dual-mobility implant., Description: With use of the surgeon's preferred approach, the soft tissue is dissected and the hip is aspirated. The hip is dislocated and a subgluteal pocket is made with use of electrocautery to mobilize the trunnion of the femoral stem to aid in acetabular exposure. The femoral component is assessed to ensure appropriate positioning with adequate anteversion. The acetabular component and any acetabular screws are removed. A "ream to fit" technique is performed in the acetabulum until bleeding bone is encountered, with minimal reaming performed in healthy bone from the posterior column. A trial prosthesis is placed within the acetabulum to evaluate if there is satisfactory fixation and if any augment is necessary. Care must be taken during reaming to ensure that enough bone is reamed to accommodate a porous shell that can fit the monoblock dual-mobility implant with a 2-mm cement mantle. Smaller porous shells measuring 56 mm are available for smaller defects but are often not utilized in cases of substantial acetabular bone loss. Fresh-frozen cancellous allograft is utilized to fill any contained defects. The revision porous shell with circumferential screw holes is utilized to allow for screw fixation posterosuperior and anterior toward the pubis. The implants are dried prior to placement of the cement. The cement is applied to the shell and the monoblock dual-mobility implant to ensure adequate coverage. Antibiotic-loaded cement can be utilized according to surgeon preference. Excess cement is removed under direct visualization while the cement is drying, and the position of the dual-mobility implant is adjusted in approximately 20° anteversion and 40° inclination. Stability is assessed after the cement cures, and intraoperative radiography can be performed to confirm cup positioning prior to closure. Any remaining capsule is closed, followed by closure of the remaining soft tissue in a layered fashion., Alternatives: A fully porous multi-hole jumbo cup with conventional polyethylene liner and femoral head can be utilized to increase the jump distance of the femoral head. Constrained, lipped, or offset polyethylene liners can be utilized if the shell is well fixed and a dual-mobility implant cannot be inserted. A cemented dual-mobility implant can be utilized in a well-fixed acetabular shell without evidence of loosening or osteolysis., Rationale: Dual-mobility implants have become increasingly utilized because of their advantages: (1) ability to decrease dislocation rate without increasing constraint and (2) increasing range of motion with reduced impingement risk 2-8 . These implants are particularly useful in the setting of revision cases with large acetabular bone defects. In a study of 76 patients with dual-mobility implants cemented into porous acetabular shells, Muthusamy et al. found that only 3.3% of patients experienced postoperative dislocations 9 . Moreover, acetabular cup survival was excellent, with 100% survival at 1 year and 96.2% at 2 years., Expected Outcomes: The use of a dual-mobility implant is a viable treatment option in cases of revision total hip arthroplasty, particularly those in which postoperative stability is a concern; monoblock dual-mobility implants cemented into porous shells are particularly useful in this setting 2-8 . These trends are similarly seen in patients treated with monoblock dual-mobility implants cemented into porous shells. Muthusamy et al. evaluated the use of this construct to treat instability or risk of hip dislocation in 76 hips, reporting a dislocation rate of 3.3% at 2 years. Additionally, the authors reported rates of all-cause acetabular survival from re-revision of 96.7% at 6 months, 93.3% at 1 year, and 89.7% at 2 years 9 . Physicians should be aware of the possibility for intra-prosthetic dislocations, as although this complication is rare, it has been reported in the literature 7,10 ., Important Tips: In order to allow for circumferential coverage for fixation and ingrowth potential in cases with acetabular defects, the shell is typically impacted slightly vertical (45° to 50° of inclination) and in neutral version (0° to 5° of anteversion). Positioning can be adjusted to improve osseous contact and ingrowth as determined by the size and shape of the defect.The use of a drill guide for the locking screws allows limited degrees of variable screw angulation. In the revision setting, longer screws may be placed posterosuperior toward the sciatic notch or anteroinferior into the pubis. Surgeons should be aware of the anatomy and should predrill holes to reduce the risk of injury to surrounding neurovascular structures such as the obturator artery anteriorly.Any screw holes that are not filled should be covered with plastic hole covers in order to prevent cement from migrating behind the cup. Implants should be dried prior to the placement of the cement, and the cement should be applied to the shell and the dual-mobility implant to ensure adequate coverage.Utilize a monoblock dual-mobility implant that is designed for cementation in order to avoid implant dissociation from the acetabular shell.Remove all fibrous tissue that may hinder bony integration.Assess for pelvis discontinuity; pelvis discontinuity and acetabular bone loss are risk factors in the setting of any revision and should be properly assessed preoperatively and intraoperatively and managed accordingly.Avoid over-reaming and damage of the posterior column.Utilize a reamer or trial to assess defect size and need for augments.Place a compression screw where the cup is in contact with the bone in order to avoid tilting.Cover unused screw holes., Acronyms and Abbreviations: THA = total hip arthroplastyS/P = status postTKA = total knee arthroplastyCT = computed tomographyKM = Kaplan MeierDMC = dual-mobility cupPE = polyethylene., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

The process of giving and receiving feedback in orthopaedic surgery training programs is distinctly unique from any other job. Trainees are required to meet certain milestones, and faculty are responsible for the caliber of surgical skills of their graduating trainees, yet there are rarely standardized practices and guidance for providing real-time feedback. Furthermore, institutional educational programs for faculty on giving meaningful feedback are lacking. The purpose of this article was to understand how feedback is defined, how to appropriately involve the learner in the process to foster active engagement rather than destructive thinking, and to characterize important principles that can elevate one's learning and self-reflection to the fullest potential., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Total knee arthroplasty (TKA) procedures are expected to grow exponentially in the upcoming years, highlighting the importance of identifying preoperative risk factors that predispose patients to poor outcomes. The present study sought to determine if preoperative healthcare events (PHEs) influenced outcomes following TKA., Methods: This was a retrospective review of all patients who underwent TKA at a single institution from June 2011 to April 2022. Patients who had a PHE within 90 days of surgery, defined as an emergency department visit or hospital admission, were compared to patients with no history of PHE. Patients who underwent revision, nonelective, and/or bilateral TKA were excluded. Chi-squared analysis and independent sample t-tests were used to determine significant differences between demographic variables. All significant covariates were included in binary logistic regressions used to predict discharge disposition, 90-day readmission, and 1-year revision., Results: Of the 10,869 patients who underwent TKA, 265 had ≥1 PHE. Patients who had a PHE were significantly more likely to require facility discharge (odds ratio [OR]: 1.662; P  = .001) than patients who did not have a PHE. Any PHE predisposed patients to significantly higher 90-day readmission rates (OR: 2.173; P  = .002). Patients with ≥2 PHEs were at a significantly higher risk of 1-year revision (OR: 5.870; P  = .004) compared to patients without a PHE., Conclusions: Our results demonstrate that PHEs put patients at significantly greater risk of facility discharge, 90-day readmission, and 1-year revision. Moving forward, consideration of elective surgery scheduling in the context of a recent PHE may lead to improved postoperative outcomes., Level Iii Evidence: Retrospective Cohort Study., (© 2023 The Authors.)

Purposeof Review: The purpose of this review is to summarize the available literature on the epidemiology, biomechanics, clinical outcomes, and complications of return to sport after TJA, as well as provide guidelines for patients' safe return to athletic activity., Recent Findings: As volume and indications for total joint arthroplasty (TJA) expand, arthroplasty candidates today are demographically younger, more physically active, and have higher expectations for postoperative function. Many TJA patients wish to resume sports activity that may theoretically place their reconstruction under more biomechanical stress and risk for early wear or failure. Recommendations for postoperative patient activity following TJA have historically largely been surgeon-dependent and in the context of evolving prosthetic design and surgical techniques. We endorse a three-tiered framework for return to sporting activities: (1) low-impact sports are generally recommended, (2) intermediate-impact sports are generally recommended with experience, and (3) high-impact sports are generally not recommended though activity-specific joint decisions between patient and surgeon can be made., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Mucopolysaccharidosis encompasses multiple lysosomal storage disorders that are relevant to the orthopedic surgeon as they lead to disruption in bone and cartilage development. These patients may present with early-onset joint pain, including end-stage hip arthritis warranting total hip replacement. The altered hip anatomy in this disorder is of specific importance to the arthroplasty surgeon as it presents challenges when reconstructing the proximal femur and acetabulum and informs implant choice. We present a 17-year-old patient with end-stage bilateral hip arthritis who underwent staged bilateral total hip arthroplasty. We discuss technical considerations in surgical technique and the consequences of acetabular and femoral deformity on implant selection., (© 2022 The Authors.)

Background: Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA., Methods: We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011 to 2020. Patients were separated into 2 cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss, change in hemoglobin, surgical time, length of stay, reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores., Results: Of the 1212 patients included, 1007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (standard deviation 33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through estimated blood loss (224.1 vs 325.1 mL, P < .001) and change in preoperative to postoperative hemoglobin (1.75 vs 2.04 g/dL, P < .001). There were no statistical differences in surgical time (P = .267) and length of stay (P = .206) between the 2 groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5% vs 15.0%, P = .038). Delta improvement in KOOS, JR scores from baseline to 3 months postoperatively did not statistically differ between the 2 cohorts (P = .560)., Conclusion: Although delta improvements in KOOS, JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did., Level Iii Evidence: Retrospective Cohort Study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aims: Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits., Methods: We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables., Results: Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001)., Conclusion: ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA. Cite this article: Bone Jt Open  2022;3(7):543-548.

Purpose: Back pain may both decrease patient satisfaction after TKA and confound outcome assessment in satisfied patients. Our primary objective was to determine whether preoperative back pain is associated with differences in postoperative patient-reported outcome measures (PROMs)., Methods: We retrospectively reviewed 234 primary TKA patients who completed PROMs preoperatively and 12 weeks postoperatively, which included a back pain questionnaire, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the Forgotten Joint Score-12 (FJS-12). Cohorts were defined based on the severity of preoperative back pain (none, mild, moderate and severe) and compared. Demographics were compared using ANOVA and Chi-square analysis. Univariate ANCOVA analysis was utilized to compare PROMs while accounting for significant demographic differences., Results: Both preoperative KOOS JR scores (none: 47.90, mild: 47.61, moderate: 44.61 and severe: 38.70; p = 0.013) and 12-week postoperative KOOS JR scores (none: 61.24, mild: 64.94, moderate: 57.48 and severe: 57.01; p = 0.012) had a statistically significant inverse relationship with regard to the intensity of preoperative back pain. Although FJS-12 scores at the 12-week postoperative period trended lower with increasing levels of preoperative back pain (p = 0.362), it did not reach statistical significance. Patients who reported severe back pain preoperatively achieved the largest delta improvement from baseline compared to those with lesser pain intensity (p = 0.003). Patients who had a 2-grade improvement in their back pain achieved significantly higher KOOS JR scores 12 weeks postoperatively compared to patients with either 1-grade or no improvement (63.53 vs. 55.98; p = 0.042). Both preoperative (47.99 vs. 41.11; p = 0.003) and 12-week postoperative (64.06 vs. 55.73; p < 0.001) KOOS JR scores were statistically higher for those who reported mild or no back pain pre-and postoperatively than those who reported moderate or severe back pain pre-and postoperatively., Conclusion: Knee pain and back pain both exert negative effects on outcome instruments designed to measure pain and function. Although mean improvement from pre- to postoperative KOOS JR scores for patients with severe pre-existing back pain was higher than their counterparts, this statistical difference is likely not clinically significant. This implies that all patients may experience similar benefits from TKA despite the presence or absence of back pain. Attempts to measure TKA outcomes using PROMs should seek to control for lumbago and other sources of body pain. Level of Evidence IIIRetrospective Cohort Study., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons., (© 2022. The Author(s).)

The prosperous financial relationship between physicians and industry remains a highly scrutinized topic. Recently, a publicly available website was developed in conjunction with the U.S. Affordable Care Act to shed light on payments from industry to physicians with the goal of increasing transparency. The purpose of this study was to assess possible relationships between industry payments and orthopaedic surgeon gender, subspecialty training, and practice settings., Methods: A retrospective analysis was performed using publicly available information from the Centers for Medicare & Medicaid Services (CMS) to identify the 25 orthopaedic surgeons with the highest compensation from each of the 10 largest orthopaedic companies from 2013 to 2017. Statistical analyses were conducted to investigate the factors that contributed to payment differences., Results: Among the 347 highest-compensated orthopaedic surgeons, only 1 woman (0.29%) was identified. Orthopaedic surgeons in the subspecialties of spine (32.9%), adult reconstruction (27.9%), and sports medicine (14.5%) made up a majority of the 25 highest earners. A larger proportion of the physicians in this study worked in private practice (57.6%) compared with an academic setting (42.4%). Orthopaedic surgeons who subspecialize in sports medicine had significantly higher total mean payment amounts when compared with all other specialties. The primary method of compensation was found to be through licensing or royalty payments., Conclusions: The large majority of orthopaedic surgeons who are highly compensated from industry are men. Among these, the greatest number specialize in the spine, while sports medicine surgeons receive significantly higher total mean payment amounts. Additional studies are warranted to evaluate the disparities between men and women and encourage policies to promote gender equality., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A347)., (Copyright © 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: The novel coronavirus disease (COVID-19) has had a significant impact on orthopedic surgery practice, but there has been little investigation of the effects of COVID-19 on the orthopedic surgery literature. Additionally, because orthopedic research plays a vital role in physician education, changes to the characteristics and content of published literature can have lasting impacts on future teaching and learning. This paper represents the first known analysis of the COVID-19 pandemic's impact on peer-reviewed articles published in orthopedic surgery journals., Methods: The 20 orthopedic journals with the highest impact factors in 2019, according to the Journal Citation Reports , were included in this study. Using PubMed and COVID-19 related keywords as well as manual screening, a final count of 199 articles were assessed for this study and subsequently sorted by country of origin, orthopedic subspecialty, article type, and general theme. Kruskal Wallis and Pearson's Chi-squared tests were used to analyze continuous and categorical variables, respectively., Results: Fourteen journals published articles relating to COVID-19, representing 26 countries with the United States (37%) and United Kingdom (13%) publishing the greatest proportion of all COVID-19 articles. Sixty percent of publications discussed COVID-19's impact on the overall field of orthopedic surgery, with the remainder focusing on specific subspecialties. Forty-seven percent of publications were original research articles while 46% were editorials or commentaries. The median time to publication for all COVID-19 related articles was 24.5 days, compared to the 129 days reported for orthopedic journals prior to the COVID-19 pandemic (p < 0.001). In the first 100 articles published, 49% (n = 49) originated exclusively from United States institutions, whereas only 25% (n = 25) of the next ninety-nine articles had US-only institutions (p < 0.001)., Conclusions: The COVID-19 pandemic has significantly impacted the characteristics, content, and time to publication of the orthopedic surgery literature. The data and ideas presented in this paper should help streamline future, formal analysis on the lasting implications of COVID-19 on orthopedic surgery practice, teaching, and learning., Competing Interests: None., (© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: The Sunshine Act aims to increase the transparency of physicians receiving compensation from pharmaceutical and medical device companies. Nine states have supplementary legislation in addition to the Federal Sunshine Act. The purpose of this study is to assess the characteristics of financial compensation to orthopaedic residents on the Centers for Medicare and Medicaid Services (CMS) Open Payments Database in states with more restrictive regulations compared with those without additional restrictions., Methods: A complete list of accredited orthopaedic residency programs in the United States was compiled using the Accreditation Council for Graduate Medical Education and American Osteopathic Academy of Orthopedics websites. The website of each orthopaedic residency program was searched to compile a list of residents who attended their program from 2014 to 2016. The CMS Open Payments Database was used to search the residents identified for the corresponding years. All data available on the CMS Open Payments Database were recorded., Results: Over the 3-year period, 3,622 residents were identified from 151 programs. A total of 41% of the residents were reported as receiving compensation from the industry. The percent of residents reported from programs in less restrictive states was 45% versus 28% in more restrictive states (P < 0.001). Residents had a mean of 5.3 transactions per year in less restrictive states and 2.4 transactions per year in more restrictive states (P < 0.001). The mean compensation per resident reported was $2,730 for less restrictive sates versus $1,937 for more restrictive states (P < 0.001)., Discussion: Overall, 41% of orthopaedic residents were reported on the CMS Open Payments Database with fewer transactions and less compensation going to residents in states with more restrictive legislature. Potential implications on resident education remain unknown.

Objectives: Residents receiving industry payments are not legally required to be reported on the Centers for Medicare & Medicaid Services (CMS) Open Payments Database. The purpose of this study is to review reporting of orthopedic surgery residents and identify the trends for which payments or transfers in value were received., Design: The CMS Open Payments Database was used to search for all available orthopedic residents from 2014 to 2016. All data available on the CMS Open Payments Database was recorded., Setting/participants: This is a database study. Participants are residents reported in the CMS Open Payments Database., Results: Over the 3-year period, 6832 resident "entities" were identified from 151 programs. A total of 3217 entities (47%) were reported as receiving payments from industry during this time period. This totaled $3,786,754 over the 3 year study period. The largest itemized categories for payment were education (32.5%) and grants (30.9%) totaling more than $2.4 million. Other areas of payment included travel (17.0%), food (16.0%), consultation fee (1.7%), research (0.8%), speaker fee (0.7%), gift (0.1%), honoraria (0.1%), and other (0.02%)., Conclusion: Overall, 47% of orthopedic resident entities were reported on the CMS Open Payments Database. The vast majority of payments were related to education and grants. Residents should become familiar with how to navigate the Open Payments Database and be educated on maintaining appropriate relationships with industry., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Isolated greater tuberosity fractures account for up to a fifth of all proximal humeral fractures. There have been several retrospective cohort studies and case series reporting outcomes after treatment of this pathology. This study aims to report on the clinical outcomes of surgically treated isolated greater tuberosity fractures, as well as diagnostic workup and complications associated with fracture fixation., Methods: A systematic review was performed under PRISMA guidelines to identify studies that reported the results or clinical outcomes of isolated greater tuberosity fracture. The searches were performed using MEDLINE through PubMed, the Elsevier Embase database, and the Cochrane Database of Systematic Reviews., Results: Sixteen studies met inclusion criteria comprising 345 patients and 345 shoulders. The mean age was 52.9 years and mean follow-up was 3.4 months. The mean postoperative American Shoulder and Elbow Surgeon Score, the most frequently utilized patient reported outcome measure across studies, was 90.1% of ideal maximum. All studies used standard shoulder radiographs in their initial workup and most commonly referred to a minimum of 5mm displacement as an indication for surgery. Fifty five percent of patients were treated using open fixation and 35.9 with arthroscopic fixation. Ninety three percent of patients were able to return to work. A total of fifty-two (15.1%) complications were reported in the included studies., Conclusions: The current literature describes overall satisfactory functional outcomes and minimal occupational morbidity following either open or arthroscopic fixation of isolated greater tuberosity fractures despite a notable rate of complications., Level of Evidence: IV, systematic review., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Arthrofibrosis is a common complication following total knee arthroplasty caused by pathologic fibroblast activation and excessive collagen deposition around a synovial joint leading to debilitating loss of motion. Treatment options are limited because the pathologic mechanisms remain to be characterized. Dysregulation of the inflammatory cascade may lead to communication between myofibroblasts and immune cells triggering tissue metaplasia, and excessive collagen deposition described clinically as arthrofibrosis. We explored the novel use of celecoxib (selective cyclooxygenase-2 [COX-2] inhibitor) to disrupt the downstream effects of the post-traumatic inflammatory cascade and inhibit scar tissue formation in a validated rabbit model of arthrofibrosis combined with new parameters for quantifying the stiffness of the posterior capsule. Biomechanical and molecular analyses, of contracted rabbit knee posterior capsule tissue after COX-2 inhibition revealed increased maximal passive extension and down-regulation of collagen messenger RNA compared with controls. Histopathologic examination suggested a trend of decreased quantities of dense fibrous connective tissue with COX-2 inhibition. These data may suggest that inhibiting the inflammatory cascade could potentially reduce pathologic myofibroblast activation, thereby reducing scar tissue formation and increasing the range of motion in arthrofibrotic joints. Implementing a multi-modal pharmacologic approach may simultaneously target numerous cellular components contributing to the complex process of arthrofibrogenesis. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2609-2620, 2019., (© 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Total hip arthroplasty (THA) alleviates hip pain and improves joint function. Current implant design permits long-term survivorship of THAs, but certain metal-on-metal (MoM) articulations can portend catastrophic failure due to adverse local tissue reactions (ALTR). Here, we identified biological and molecular differences between periacetabular synovial tissues of patients with MoM THA failure undergoing revision THA compared to patients undergoing primary THA for routine osteoarthritis (OA). Analysis of tissue biopsies by RNA-sequencing (RNA-seq) revealed that MoM patient samples exhibit significantly increased expression of immune response genes but decreased expression of genes related to extracellular matrix (ECM) remodeling. Thus, interplay between local tissue inflammation and ECM degradation may account for the pathology and compromised clinical outcomes in select patients with MoM implants. We conclude that adverse responses of host tissues to implant materials result in transcriptomic modifications in patients with MoM implants that permit consideration of strategies that could mitigate ECM damage., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Total knee arthroplasty (TKA) is a durable and reliable procedure to alleviate pain and improve joint function. However, failures related to flexion instability sometimes occur. The goal of this study was to define biological differences between tissues from patients with and without flexion instability of the knee after TKA. Human knee joint capsule tissues were collected at the time of primary or revision TKAs and analyzed by RT-qPCR and RNA-seq, revealing novel patterns of differential gene expression between the two groups. Interestingly, genes related to collagen production and extracellular matrix (ECM) degradation were higher in samples from patients with flexion instability. Partitioned clustering analyses further emphasized differential gene expression patterns between sample types that may help guide clinical interpretations of this complication. Future efforts to disentangle the effects of physical and biological (e.g., transcriptomic modifications) risk factors will aid in further characterizing and avoiding flexion instability after TKA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Tonic receptors convey stimulus duration and intensity and are implicated in homeostatic control. However, how tonic homeostatic signals are generated and how they reconfigure neural circuits and modify animal behavior is poorly understood. Here we show that Caenorhabditis elegans O(2)-sensing neurons are tonic receptors that continuously signal ambient [O(2)] to set the animal's behavioral state. Sustained signaling relied on a Ca(2+) relay involving L-type voltage-gated Ca(2+) channels, the ryanodine and the inositol-1,4,5-trisphosphate receptors. Tonic activity evoked continuous neuropeptide release, which helps elicit the enduring behavioral state associated with high [O(2)]. Sustained O(2) receptor signaling was propagated to downstream neural circuits, including the hub interneuron RMG. O(2) receptors evoked similar locomotory states at particular O(2) concentrations, regardless of previous d[O(2)]/dt. However, a phasic component of the URX receptors' response to high d[O(2)]/dt, as well as tonic-to-phasic transformations in downstream interneurons, enabled transient reorientation movements shaped by d[O(2)]/dt. Our results highlight how tonic homeostatic signals can generate both transient and enduring behavioral change.

Variation in food quality and abundance requires animals to decide whether to stay on a poor food patch or leave in search of better food. An important question in behavioral ecology asks when is it optimal for an animal to leave a food patch it is depleting. Although optimal foraging is central to evolutionary success, the neural and molecular mechanisms underlying it are poorly understood. Here we investigate the neuronal basis for adaptive food-leaving behavior in response to resource depletion in Caenorhabditis elegans, and identify several of the signaling pathways involved. The ASE neurons, previously implicated in salt chemoattraction, promote food-leaving behavior via a cGMP pathway as food becomes limited. High ambient O(2) promotes food-leaving via the O(2)-sensing neurons AQR, PQR, and URX. Ectopic activation of these neurons using channelrhodopsin is sufficient to induce high food-leaving behavior. In contrast, the neuropeptide receptor NPR-1, which regulates social behavior on food, acts in the ASE neurons, the nociceptive ASH neurons, and in the RMG interneuron to repress food-leaving. Finally, we show that neuroendocrine signaling by TGF-β/DAF-7 and neuronal insulin signaling are necessary for adaptive food-leaving behavior. We suggest that animals integrate information about their nutritional state with ambient oxygen and gustatory stimuli to formulate optimal foraging strategies.

Homeostatic control of body fluid CO(2) is essential in animals but is poorly understood. C. elegans relies on diffusion for gas exchange and avoids environments with elevated CO(2). We show that C. elegans temperature, O(2), and salt-sensing neurons are also CO(2) sensors mediating CO(2) avoidance. AFD thermosensors respond to increasing CO(2) by a fall and then rise in Ca(2+) and show a Ca(2+) spike when CO(2) decreases. BAG O(2) sensors and ASE salt sensors are both activated by CO(2) and remain tonically active while high CO(2) persists. CO(2)-evoked Ca(2+) responses in AFD and BAG neurons require cGMP-gated ion channels. Atypical soluble guanylate cyclases mediating O(2) responses also contribute to BAG CO(2) responses. AFD and BAG neurons together stimulate turning when CO(2) rises and inhibit turning when CO(2) falls. Our results show that C. elegans senses CO(2) using functionally diverse sensory neurons acting homeostatically to minimize exposure to elevated CO(2)., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Dislocation is a rare complication of hip resurfacing in young people. This is thought to be due to the stability imposed by a large-diameter head [Stulberg BN, Trier KK, Naughton M, et al. Results and Lessons Learned from a United States Hip Resurfacing Investigational Device Exemption Trial. J Bone Joint Surg Am 2008;90:21]. We report an isolated case 1 week post-Birmingham hip resurfacing in a 44-year-old man without any history of trauma or infection. We note that due to massive periacetabular and femoral neck osteophyte formation and loss of normal bony anatomical landmarks, the version of the acetabular component may have been slightly retroverted. Due to marked narrowing of the femoral neck and head proximally, a cone-shaped proximal femur was found and felt to be unsuitable for direct resurfacing without prior shortening to allow fitting of the appropriate-sized Birmingham hip resurfacing femoral component. This was done successfully, but resulted in slightly reduced femoral neck offset of approximately 10 mm, compared to the native hip. We suspect this reduced offset contributed significantly to the 2 dislocations. We recommend careful preoperative planning and case selection to avoid this complication in similar patients., (Copyright 2010 Elsevier Inc. All rights reserved.)