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Background: With the expansion of the Affordable Care Act in 2014, there has been a growing interest in how the Medicaid population will affect postoperative outcomes following total knee arthroplasty (TKA). Studies have shown that lower socioeconomic status, non-Caucasian race, women, cardiac and renal disorders, and younger age have been associated with increased lengths of stay (LOS) after TKA. The primary purpose of our study was to compare the total complications and LOS among patients undergoing TKA who have cash, commercial, government, Medicaid, and Medicare insurances., Methods: We queried a national, all-payer administrative claims database from 2016 to 2022 among patients undergoing TKA who had cash (n = 3,923), commercial (n = 966,169), government (n = 25,644), Medicaid (n = 56,184), and Medicare (n = 524,034) insurances. We compared and analyzed various baseline demographics, total complications, and LOS (<1 day, 1 to 2 days, 3 to 4 days, and >4 days), between the insurance types., Results: Medicaid and Medicaid insurance types had patients who had the most comorbidities at baseline, including a comorbidity index >3 (P < 0.0001), women, alcohol abuse, diabetes, obesity, tobacco use, chronic kidney disease, and congestive heart disease (all P < 0.0001). In accounting for comorbidities, Medicaid was the biggest risk factor for total complications (P < 0.001) as well as increased LOS after TKA at 4 to 6 days, 7 to 9 days, and >9 days (P < 0.0001)., Conclusions: Medicaid insurance is a risk factor for increased total complications and LOS following TKA. Appropriate preoperative and perioperative management of these patients is essential in order to mitigate the risk and burden on the health care system in this population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Relative value units (RVUs) were first introduced by the Omnibus Budget Reconciliation Act of 1989 to standardize physician compensation based on the effort, skill, and resources required for medical services. This methodology replaced the "usual, customary, and reasonable" standard, which reduced variability in payments across providers. RVUs are comprised of physician work, practice expenses, and malpractice costs. In arthroplasty, declining inflation-adjusted reimbursements for total hip and knee replacements are primarily due to a lack of inflation adjustments, rather than nominal decreases values of RVUs values or the Medicare Conversion Factor. While value-based care models like the Comprehensive Care for Joint Replacement initiative and the Merit-Based Incentive Payment System aim to link RVU-based payments with quality and cost metrics, compensation remains largely tied to fee-for-service models. Major challenges include inadequate compensation for revision arthroplasty and the administrative burden of RVU management. Despite its limitations, the RVU system has enhanced transparency in physician reimbursement, though improvements are needed to better align financial incentives with value-based care principles in orthopaedics., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Value-based care models are health care economic frameworks that aim to prioritize and financially incentivize quality of care, provider performance, and patient experience. The focus on value-based care metrics will undoubtedly lead to a greater weight placed on economic analyses in arthroplasty. Authors of cost analyses in arthroplasty often use the term "cost" in ways that have vastly different underlying meanings. It is imperative that surgeons understand the different characteristics of cost data, where they come from, and how to interpret them. There are three types of costs: 1) costs to the health care providers; 2) costs to the payer; and 3) costs to society. In this review, we evaluate where each type of cost data comes from, what are the appropriate conclusions to be drawn from them, and examples of how they are used in the literature., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Health care delivery systems throughout the United States have transitioned to a value-based care model, shifting away from a fee-for-service model to instead emphasize patient health outcomes and the quality of medical care. Social determinants of health (SDOH) have been shown to have a large impact on patient health outcomes and thus, must play an integral role in the implementation of a value-based model. This is of particular interest in the field of lower extremity joint arthroplasty, where demand is rising in conjunction with expanded access to care. This article intends to address the following: (1) provide background on SDOH in the setting of value-based arthroplasty care; (2) explore the impact of SDOH on patient outcomes and costs following total joint arthroplasty; and (3) provide strategies for recognizing and addressing SDOH in practice., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis., Methods: Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM., Results: The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision., Conclusions: The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange., (Copyright © 2024. Published by Elsevier Inc.)

Background: A consumer-focused health care model not only allows unprecedented access to information, but equally warrants consideration of the appropriateness of providing accurate patient health information. Nurses play a large role in influencing patient satisfaction following total knee arthroplasty (TKA), but they come at a cost. A specific natural language artificial intelligence (AI) model, ChatGPT (Chat Generative Pre-trained Transformer), has accumulated over 100 million users within months of launching. As such, we aimed to compare: (1) orthopaedic surgeons' evaluation of the appropriateness of the answers to the most frequently asked patient questions after TKA; and (2) patients' comfort level in answering their postoperative questions by using answers provided by arthroplasty-trained nurses and ChatGPT., Methods: We prospectively created 60 questions based on the most commonly asked patient questions following TKA. There were 3 fellowship-trained surgeons who assessed the answers provided by arthroplasty-trained nurses and ChatGPT-4 to each of the questions. The surgeons graded each set of responses based on clinical judgment as: (1) "appropriate," (2) "inappropriate" if the response contained inappropriate information, or (3) "unreliable," if the responses provided inconsistent content. Patients' comfort level and trust in AI were assessed using Research Electronic Data Capture (REDCap) hosted at our local hospital., Results: The surgeons graded 44 out of 60 (73.3%) responses for the arthroplasty-trained nurses and 44 out of 60 (73.3%) for ChatGPT to be "appropriate." There were 4 responses graded "inappropriate" and one response graded "unreliable" provided by the nurses. For the ChatGPT response, there were 5 responses graded "inappropriate" and no responses graded "unreliable." There were 136 patients (53.8%) who were more comfortable with the answers provided by ChatGPT compared to 86 patients (34.0%) who preferred the answers from arthroplasty-trained nurses. Of the 253 patients, 233 (92.1%) were uncertain if they would trust AI to answer their postoperative questions. There were 127 patients (50.2%) who answered that if they knew the previous answer was provided by ChatGPT, their comfort level in trusting the answer would change., Conclusions: One potential use of ChatGPT can be found in providing appropriate answers to patient questions after TKA. At our institution, cost expenditures can potentially be minimized while maintaining patient satisfaction. Inevitably, successful implementation is dependent on the ability to provide information that is credible and in accordance with the objectives of both physicians and patients., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The use of ChatGPT (Generative Pretrained Transformer), which is a natural language artificial intelligence model, has gained unparalleled attention with the accumulation of over 100 million users within months of launching. As such, we aimed to compare the following: 1) orthopaedic surgeons' evaluation of the appropriateness of the answers to the most frequently asked patient questions after total hip arthroplasty; and 2) patients' evaluation of ChatGPT and arthroplasty-trained nurses responses to answer their postoperative questions., Methods: We prospectively created 60 questions to address the most commonly asked patient questions following total hip arthroplasty. We obtained answers from arthroplasty-trained nurses and from the ChatGPT-3.5 version for each of the questions. Surgeons graded each set of responses based on clinical judgment as 1) "appropriate," 2) "inappropriate" if the response contained inappropriate information, or 3) "unreliable" if the responses provided inconsistent content. Each patient was given a randomly selected question from the 60 aforementioned questions, with responses provided by ChatGPT and arthroplasty-trained nurses, using a Research Electronic Data Capture survey hosted at our local hospital., Results: The 3 fellowship-trained surgeons graded 56 out of 60 (93.3%) responses for the arthroplasty-trained nurses and 57 out of 60 (95.0%) for ChatGPT to be "appropriate." There were 175 out of 252 (69.4%) patients who were more comfortable following the ChatGPT responses and 77 out of 252 (30.6%) who preferred arthroplasty-trained nurses' responses. However, 199 out of 252 patients (79.0%) responded that they were "uncertain" with regard to trusting AI to answer their postoperative questions., Conclusions: ChatGPT provided appropriate answers from a physician perspective. Patients were also more comfortable with the ChatGPT responses than those from arthroplasty-trained nurses. Inevitably, its successful implementation is dependent on its ability to provide credible information that is consistent with the goals of the physician and patient alike., (Copyright © 2024 Elsevier Inc. All rights reserved.)

At the top of the evidence-based pyramid, systematic reviews stand out as the most powerful, synthesizing findings from numerous primary studies. Specifically, a quantitative systematic review, known as a meta-analysis, combines results from various studies to address a specific research question. This review serves as a guide on how to: (1) design; (2) perform; and (3) publish an orthopedic arthroplasty systematic review. In Part III, we focus on how to design and perform a meta-analysis. We delineate the advantages and disadvantages of meta-analyses compared to systematic reviews, acknowledging their potential challenges due to time constraints and the complexities posed by study heterogeneity and data availability. Despite these obstacles, a well-executed meta-analysis contributes precision and heightened statistical power, standing at the apex of the evidence-based pyramid. The design of a meta-analysis closely mirrors that of a systematic review, but necessitates the inclusion of effect sizes, variability measures, sample sizes, outcome measures, and overall study characteristics. Effective data presentation involves the use of forest plots, along with analyses for heterogeneities and subgroups. Widely-used software tools are common in this domain, and there is a growing trend toward incorporating artificial intelligence software. Ultimately, the intention is for these papers to act as foundational resources for individuals interested in conducting systematic reviews and meta-analyses in the context of orthopaedic arthroplasty, where applicable., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA)., Methods: Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area., Results: When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively., Conclusions: The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin., Methods: Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA., Results: From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days., Conclusions: An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older., Methods: We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance., Results: The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries., Conclusions: This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Systematic reviews are conducted through a consistent and reproducible method to search, appraise, and summarize information. Within the evidence-based pyramid, systematic reviews can be at the apex when incorporating high-quality studies, presenting the strongest form of evidence given their synthesis of results from multiple primary studies to level IV evidence, depending on the studies they incorporate. When combined and supplemented with a meta-analysis using statistical methods to pool the results of 3 or more studies, systematic reviews are powerful tools to help answer research questions. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic arthroplasty systematic review and meta-analysis. In Part I, we discuss how to develop an appropriate research question as well as source and screen databases. To date, commonly used databases to source studies include PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science. Although not all-encompassing, this paper serves as a starting point for those interested in performing and/or critically reviewing lower extremity arthroplasty systematic reviews and meta-analyses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The mode of femoral fixation for primary total hip arthroplasty (THA) is undetermined, with reported outcomes favoring different fixation methods. This study aimed to compare postoperative complications between cemented and cementless fixation at 90 days, 1 year, and 2 years in patients aged 65 years of age and older undergoing THA for osteoarthritis., Methods: Using an all-payer, national database, patients 65 years and older undergoing primary THA, either with cementless (n = 56,701) or cemented (n = 6,283) femoral fixation for osteoarthritis were identified. A 1:1 propensity-matched analysis for age, sex, comorbidity index, alcohol abuse, tobacco use, obesity, and diabetes was performed, resulting in n = 6,283 patients in each cohort. Postoperative outcomes, including postoperative periprosthetic joint infection, aseptic revision, surgical site infection, pulmonary embolism, venous thromboembolism, wound complications, dislocation, periprosthetic fracture, and aseptic loosening were assessed., Results: The cemented cohort had higher rates of infection (4.5 versus 0.8%, odds ratio [OR] 5.9, 95% confidence interval [CI] 4.33 to 7.93, P < .001), aseptic revision (2.9 versus 2.0%, OR 1.47, 95% CI 1.17 to 1.85, P = .001), venous thromboembolism (1.8 versus 1.3%, OR 1.40, 95% CI 1.05 to 1.87, P < .001), and aseptic loosening (1.5 versus 0.7%, OR 2.31, 95% CI 1.60 to 3.32, P < .001) at 90-days. At 1 and 2 years, the cemented cohort had higher rates of infection, aseptic revision, and aseptic loosening (all P < .001). Rates of periprosthetic fracture were similar at all time points (all P < .001)., Conclusions: Cemented fixation had higher rates of infection, aseptic loosening, and aseptic revision. This finding supports the current use of cementless fixation, but the ultimate decision regarding fixation type should be based on the proper optimization of the patient's comorbidities and bone quality., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence., Methods: The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published)., Results: The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05)., Conclusions: Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Influence of factors like reporting outcomes, conflicts of interest, and funding sources on study outcomes, particularly positive outcomes in orthopedics, remains underexplored. As transparency of partnerships in orthopaedic surgery through conflicts of interest statements has increased over the years, there has been a lack of focus on the value of these partnerships in influencing study outcomes. We aimed to investigate the associations between reporting outcomes, conflicts of interest, and sources of funding on study outcomes., Methods: We reviewed articles published in 1 year in The Journal of Bone and Joint Surgery, The American Journal of Sports Medicine, and The Journal of Arthroplasty. The abstracts were examined for appropriate inclusion, while the authors' names, academic degrees, funding disclosures, and departmental and institutional affiliations were redacted. There were a total of 1,351 publications reviewed from January 1, 2021 to December 31, 2021., Results: A significant association was found between positive outcomes and reported conflicts of interest (75% versus 25%, P < .001). Likewise, conflicts of interest showed significant association with industry-sponsored studies (88% versus 12%, P < .001) and evidence level > II (72% versus 28%, P < .001). Industry-sponsored research accounted for the highest percentage of studies involving a conflict of interest (88%) and level I studies (12%)., Conclusions: Conflicts of interest are significantly associated with positive outcomes in orthopaedics. Sponsored studies were more inclined to have conflicts of interest and accounted for the majority of level I studies., (Copyright © 2023. Published by Elsevier Inc.)

Background: A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors., Methods: A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI)., Results: The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067)., Conclusions: Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner., Methods: We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points., Results: Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001)., Conclusions: There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The number of revision total knee arthroplasties (TKAs) is projected to reach 268,200 cases annually by 2030 in the United States. The growing demand for revision TKA can be attributed to the successes of primary TKAs combined with an aging population, patient desires to remain active, as well as expanded indications for younger patients. Given the evolving nature of revision TKAs, an epidemiological analysis of: (1) etiologies; (2) demographics, including age and region; as well as (3) lengths of stay (LOS) offers a way to minimize the gap between appropriate understanding and effective intervention., Methods: From 2016 to 2022, a national, all-payer database was queried. Incidences and indications were analyzed for a total of 135,983 patients who had revision TKA procedures., Results: The most common etiologies for revision TKA procedures were infection (19.3%) and aseptic loosening (12.8%), followed by mechanical complications (7.9%). The largest age group was 65 to 74 years (34.9%) followed by 55 to 64 years (32.2%), then age >75 years (20.5%). The South had the largest total procedure cohort (39.8%), followed by the Midwest (28.6%), then the Northeast (18.6%), and the West (13.0%). The mean length of stay was 3.86 days (range, 1.0 to 15.0)., Conclusions: Our study details the current status of revision TKA through 2022. While infection and aseptic loosening remain leading causes, we found a low aseptic loosening rate of 12.8%., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The promise of controlling spending and improving the quality of care incentivizes health care providers to prioritize value through alternative payment models. Findings regarding improved value and cost savings of the Comprehensive Care for Joint Replacement (CJR) redesign are consistent throughout selected metropolitan hospitals. Before refinement can take place, reporting on baseline financial status is a necessity to ensure the starting point of hospitals before CJR takes effect. Evidence-based protocols, outcomes-based measures to evaluate results, and cooperation across specialties to deliver high quality care will be necessary to insure improved care throughout the episode. This commentary reviews the CJR program and provides recommendations for the near future in order to best serve the needs of patients as we move forward in the bundled payments direction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications., Methods: A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients., Results: The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455)., Conclusion: Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Studies suggest an increase in the number of combined users of tobacco and cannabis. Therefore, we specifically assessed tobacco, cannabis, and combined users who underwent primary total knee arthroplasty (TKA) to determine 90-day to 2-year: (1) odds of periprosthetic joint infection; (2) odds of revision; and (3) medical complications., Methods: We queried a national, all payer database of patients undergoing primary TKA between 2010 and 2020. Patients were stratified according to current use of tobacco products (n = 30,000), cannabis (n = 400), or a combination (n = 3,526). These were defined according to International Classification of Disease codes, Ninth and Tenth Editions. Patients were tracked from the 2 years before TKA through 2 years afterwards. A fourth group of TKA recipients who did not have tobacco nor cannabis use was used as a matching cohort. Periprosthetic joint infections (PJIs), revisions, and other medical/surgical complications from 90 days through 2 years were evaluated between these cohorts using bivariate analyses. Multivariate analyses assessed independent risk factors for PJI at 90 days through 2 years, adjusted for patient demographics and health metrics., Results: Combined tobacco and cannabis use were associated with the highest rates of PJI following TKA. The odds of 90-day PJI risk among cannabis, tobacco, and combined users was 1.60, 2.14, and 3.39, respectively, as compared to the matched cohort (P < .001). Co-users had the highest and significantly increased revision odds at 2 years following TKA (odds ratio = 1.52, 95% confidence interval, 1.15 to 2.00). At 1 and 2 years following TKA, cannabis, tobacco, and co-users had higher rates of myocardial infarctions, respiratory failures, surgical site infections, and manipulations under anesthesia when compared to the matched cohort (all P < .001)., Conclusion: Tobacco and cannabis use before primary TKA demonstrated a synergistic association on PJI risk from 90 days through 2 years. Although the harms of tobacco use are well-known, this additional knowledge about cannabis should be incorporated in the shared decision-making discussions in the pre-operative setting to best prepare for expected risks following primary TKA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Rapid technological advancements have laid the foundations for the use of artificial intelligence in medicine. The promise of machine learning (ML) lies in its potential ability to improve treatment decision making, predict adverse outcomes, and streamline the management of perioperative healthcare. In an increasing consumer-focused health care model, unprecedented access to information may extend to patients using ChatGPT to gain insight into medical questions. The main objective of our study was to replicate a patient's internet search in order to assess the appropriateness of ChatGPT, a novel machine learning tool released in 2022 that provides dialogue responses to queries, in comparison to Google Web Search, the most widely used search engine in the United States today, as a resource for patients for online health information. For the 2 different search engines, we compared i) the most frequently asked questions (FAQs) associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA) by question type and topic; ii) the answers to the most frequently asked questions; as well as iii) the FAQs yielding a numerical response., Methods: A Google web search was performed with the following search terms: "total knee replacement" and "total hip replacement." These terms were individually entered and the first 10 FAQs were extracted along with the source of the associated website for each question. The following statements were inputted into ChatGPT: 1) "Perform a google search with the search term 'total knee replacement' and record the 10 most FAQs related to the search term" as well as 2) "Perform a google search with the search term 'total hip replacement' and record the 10 most FAQs related to the search term." A Google web search was repeated with the same search terms to identify the first 10 FAQs that included a numerical response for both "total knee replacement" and "total hip replacement." These questions were then inputted into ChatGPT and the questions and answers were recorded., Results: There were 5 of 20 (25%) questions that were similar when performing a Google web search and a search of ChatGPT for all search terms. Of the 20 questions asked for the Google Web Search, 13 of 20 were provided by commercial websites. For ChatGPT, 15 of 20 (75%) questions were answered by government websites, with the most frequent one being PubMed. In terms of numerical questions, 11 of 20 (55%) of the most FAQs provided different responses between a Google web search and ChatGPT., Conclusion: A comparison of the FAQs by a Google web search with attempted replication by ChatGPT revealed heterogenous questions and responses for open and discrete questions. ChatGPT should remain a trending use as a potential resource to patients that needs further corroboration until its ability to provide credible information is verified and concordant with the goals of the physician and the patient alike., (Copyright © 2023. Published by Elsevier Inc.)

Background: Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures)., Methods: We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated., Results: The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies., Conclusion: The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Incidence of bacteremia following screening colonoscopy is low, but risk of hematogenous spread causing prosthetic joint infection (PJI) may exist in total knee arthroplasty (TKA) patients. In multivariate analyses, we examined PJI risk among 3 TKA cohorts: (1) colonoscopy recipients given antibiotic prophylaxis; (2) colonoscopy recipients not given antibiotic prophylaxis; and (3) no colonoscopy. We assessed 90-day to 1-year (A) PJI risk and (B) risk factors for postcolonoscopy PJI., Methods: We queried a national, all-payer database for primary TKA recipients from 2010 to 2020. Patients who had colonoscopies and who did (n = 2,558) or did not have antibiotic prophylaxis (n = 20,000) were identified. These were compared those who did not undergo colonoscopy (n = 20,000). The 20,000 patients were randomly selected to mitigate type-1 errors. Multivariate regressions compared PJI risk factors, such as alcohol abuse (AA), rheumatoid arthritis (RA), and diabetes., Results: Both colonoscopy cohorts had no increased PJI risk compared to noncolonoscopy (odds ratio (OR) ≤ 2.20, P ≥ .064). Alcohol abuse, diabetes, and RA were found to be risk factors further enhancing likelihood of PJI for TKA patients not receiving antibiotics undergoing colonoscopies (OR ≥ 1.35, P ≤ .044)., Conclusion: Overall, antibiotic prophylaxis does not decrease PJI risk following colonoscopy TKA recipients. After adjusting for known risk factors, both colonoscopy cohorts demonstrated similar PJI risks compared to the noncolonoscopy cohort. However, AA, diabetes, and RA were associated with further increased PJI risk for TKA patients undergoing colonoscopies compared to those who did not. Therefore, if undergoing colonoscopy after TKA, our findings suggest that most patients do not need to have antibiotics except for these high-risk patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Approximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years., Methods: A national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models., Results: The septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history., Conclusion: Less than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: A prior history of a septic knee may predispose patients to a periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We performed multivariate analyses of known risk factors that portend a periprosthetic infection for patients who have a history of septic arthritis (SA). The focus of the study was an assessment of the incidence of TKA PJIs at various time intervals after the onset of a septic knee (0 to 3 months, 3 to 6 months, 6 to 9 months, and 9 months to 1-year)., Methods: We queried a national database to identify patients who underwent a primary TKA between 2010 and 2021 (n = 1.9 million). Patients who had a prior septic knee ipsilateral to the primary TKA were characterized (n = 4,251) and were put into four specific cohorts based on the interval between the SA diagnosis and TKA: less than 3 months; 3 to 6 months; 6 to 9 months; and 9 to 12 months. A cohort of patients who did not have history of septic knee were used for comparison (n = 5,000). The incidence of PJIs from 90 days to 1 year was identified and compared using multivariate analyses., Results: All time cohorts were more likely to require revisions due to PJI, as compared to the comparison group. Significant differences were demonstrated among all time cohorts who had prior SA compared to patients who did not have a history of SA (odds ratio [OR] range, 90.0 to 113.0, P < .001)., Conclusion: This study has shown an increased PJI risk in the first year after SA (P < .05). The surgeon should be aware of the increased PJI risk after SA within the first year after TKA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In recent years, the use of national databases in orthopaedic surgery research has grown substantially with database studies comprising an estimated ∼10% of all published lower extremity arthroplasty research. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic database arthroplasty project. In part II, we discuss how to collect data, propose a novel checklist/standards for presenting orthopaedic database information (SOPOD), discuss methods for appropriate data interpretation/analysis, and summarize how to convert findings to a manuscript (providing a previously published example study). Data collection can be divided into two stages: baseline patient demographics and primary/secondary outcomes of interest. Our proposed SOPOD is more orthopaedic-centered and builds upon previous standards for observational studies from the EQUATOR network. There are a host of statistical methods available to analyze data to compare baseline demographics, primary/secondary outcomes, and reduce type 1 errors seen in large datasets. When drafting a manuscript, it is important to consider and discuss the limitations of database studies, including their retrospective nature, issues with coding/billing, differences in statistical versus clinical significance (or relevance), lack of surgery details (approach, laterality, and implants), and limited sampling or follow-up. We hope this paper will serve as a starting point for those interested in conducting lower extremity arthroplasty database studies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Use of clinical and administrative databases in orthopaedic surgery research has grown substantially in recent years. It is estimated that approximately 10% of all published lower extremity arthroplasty research have been database studies. The aim of this review is to serve as a guide on how to (1) design, (2) execute, and (3) publish an orthopaedic administrative database arthroplasty project., Methods: In part I, we discuss how to develop a research question and choose a database (when databases should/should not be used), detailing advantages/disadvantages of those most commonly used. To date, the most commonly published databases in orthopaedic research have been the National Inpatient Sample, Medicare, National Surgical Quality Improvement Program, and those provided by PearlDiver. General advantages of most database studies include accessibility, affordability compared to prospective research studies, ease of use, large sample sizes, and the ability to identify trends and aggregate outcomes of multiple health care systems/providers., Results: Disadvantages of most databases include their retrospective observational nature, limitations of procedural/billing coding, relatively short follow-up, limited ability to control for confounding variables, and lack of functional/patient-reported outcomes., Conclusion: Although this study is not all-encompassing, we hope it will serve as a starting point for those interested in conducting and critically reviewing lower extremity arthroplasty database studies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Use of "orthobiologics" continues to expand for patients who have knee osteoarthritis (OA). We sought to perform a systemic review of biologic therapies relative to comparative groups, including the following: (1) platelet-rich plasma (PRP); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amniotic-derived mesenchymal stem cells (AMSCs). We assessed the following: (1) study methodologies; (2) cell preparations and formulations; (3) patient-reported outcome scores (PROMs); and (4) structural changes., Methods: PubMed, Cochrane Library, and Embase databases were queried (2013-2021) to conduct a systematic review of biologic therapies for knee OA, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighty-two studies were included: PRP (51); BMSC (15); ADSC (11); and AMSC (5). Study evaluations were made using the Modified Coleman Methodology Score. PROMs included the Western Ontario and McMaster Universities Arthritis Index and the Visual Analog Scale. Structural change evaluations included ultrasounds, radiographs, or magnetic resonance imaging., Results: PRP comprised a majority of the studies (n = 51), most with "fair" to "good" Modified Coleman Methodology Score. Studies had variable cell preparations and formulations, with comparison study results leading to inconsistent PROMs, and structural changes. A limited number of studies were included for BMSC, ADSC, and AMSC, all with similar findings to PRP., Conclusion: Available literature evaluating "orthobiologics" for knee OA remain nonsuperior to comparison cohorts. Higher level studies with larger sample sizes and improved methodologies are warranted to suggest differences. Despite a growth of "orthobiologics" in clinics, this updated systematic review highlights the uncertain efficacy for use in knee OA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Platelet-rich plasma (PRP) usage in orthopedics continues to rise, despite guidelines suggesting non-superiority to comparative cohorts. Therefore, we performed a systematic review and meta-analysis on PRP efficacy using two clinical assessments: (1) Visual Analog Scale and (2) Western Ontario and McMaster Universities Osteoarthritis Index. We assessed consistency and clinical relevancy by determining study heterogeneity (eg, sample sizes, ages, body mass index, arthritic severities, etc.). Comparative cohorts were: (A) hyaluronic acid (HA); (B) corticosteroid (CS); (C) normal saline (NS); and (D) exercise therapy. We performed sub-analyses of structural changes assessed on ultrasound, radiograph, or magnetic resonance imaging ., Methods: We utilized PubMed, Cochrane Library, and Embase databases up to December 1, 2021, according to Preferred Reporting Items for Systematic-Reviews and Meta-Analyses guidelines. Twenty-four studies met criteria, with comparisons to: HA (n = 11); CS (n = 6); NS (n = 5); and exercise therapy (n = 3). Seven studies assessed structural changes. Evaluations utilized a methodological scoring system. I 2 statistics and forest plots pooled analyses and delineated study results., Results: PRP led to Visual Analog Scale and Western Ontario and McMaster Universities Osteoarthritis Index improvements in most studies when compared to HA, CS, and NS (P ≤ .05). Comparison to exercise therapy resulted in inconclusive findings (P ≥ .05). However, substantial heterogeneity (I 2 ≥ 76%) was reported due to study variability. No differences were found when assessing structural changes or cartilage thickness by magnetic resonance imaging (standardized mean difference -0.01 [-0.19, 0.18], P = .91)., Conclusions: PRP may be associated with pain and functional improvements but was not clinically relevant (inconsistent study- and patient-metrics). In addition, PRP did not confer superiority when assessing knee-related structural changes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: No consensus exists regarding the appropriate timing of bariatric surgery (BS) or the complication profiles between Roux-en-Y Gastric Bypass (RYGB) and sleeve gastrectomy (SG) prior to total knee arthroplasty (TKA). We sought to compare 90-day medical and up to two-year surgical complications and revisions among (1) BS performed 6 months and 1 year prior to TKA; (2) between BS types (RYGB and SG) prior to TKA; and (3) with comparison to 2 non-BS cohorts of morbidly and nonmorbidly obese patients., Methods: We queried a national database to identify patients undergoing BS (RYGB and SG) prior to TKA from 2010 to 2020. Timing (six-month and one-year intervals) and type of BS (RYGB and SG) were identified. Cohorts without prior BS served as comparators: BMI, kg/m 2 > 40 and 20-35. Ninety-day to two-year medical/surgical complications and revisions were assessed. Multivariate regression analyses examined the risk factors for prosthetic joint infections (PJIs) and revisions., Results: The timing of BS (6 months and 1 year) had similar incidences of medical/surgical complications and revisions, with both lower than the BMI > 40 cohort (P < .001). Differences between types of BS were also lower than the BMI > 40 cohort (P < .001). The BMI 20-35 had lower complications and revisions among all cohorts. No differences were observed between BS timing or type as risk-factors for PJIs and revisions., Conclusion: Timing (6 months or 1 year prior to TKA) and type of BS shared similar complication profiles, lower than BMI > 40 and higher than BMI 20-35. These findings support a surgeon's decision to proceed with TKA at six months post-BS if indicated., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Social determinants of health (SDOH) may play a larger role in predicting patient outcomes as outpatient total hip arthroplasty (THA) expands. We specifically examined the association between SDOH and patient metrics (demographics and comorbidities) for: (1) 30-day post-discharge costs of care; (2) lengths of stay (LOS); and (3) patient-reported outcomes (Hip Disability and Osteoarthritis Outcomes Score for Joints Replacement (HOOS JR))., Methods: Medicare patients who underwent primary THA between 2018 and 2019 were identified. Those who had complete social determinant data were included (n = 136). Data elements were drawn from institutional, regional, and government databases, as well as the Social Vulnerability Index (SVI). Multiple regression analyses were performed to determine SDOH and baseline comorbidities associations with costs, LOS, and HOOS JR scores., Results: Various SDOH factors were associated with higher 30-day costs, including residing in a food desert ($53,695 ± 15,485; P < .001) and the following SVI themes: 'Minority Status and Language' ($24,075 ± 9845; P = .01) and 'Housing and Transportation' ($16,190 ± 8501; P = .06), although the latter did not meet statistical significance. Baseline depression was associated with longer LOS (P = .02), while none of the other SDOH or patient metrics affected LOS. No relationships were observed between SDOH and HOOS JR changes from baseline., Conclusion: Patients who live in food deserts and have minority status had higher costs of care after primary THA. Poor housing and transportation may also increase costs, albeit insignificantly. These results highlight the utility of assessing SDOH-related risk factors to optimize post-operative outcomes, with potential implications for bundled care., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Characterizations and factors influencing longer term performance of second-generation sequentially irradiated and annealed highly cross-linked polyethylene (HXLPE) are lacking. We evaluated patients who underwent total hip arthroplasty with HXLPE at mean 10-year follow-up for (1) linear and volumetric wear rates, (2) patient and implant characteristics, (3) implant survivorships, and (4) functional scores., Methods: We evaluated 130 hips (110 patients) that received HXLPE acetabular liners at a single center. The mean age was 56 years (range, 20-79 years), with a mean follow-up of 10 years (range, 8-15). Radiographic linear (millimeters/year) and volumetric (cubic millimeters/year) wear rates were quantified using radiographic analysis. Survivorship was assessed by all-cause and wear-related revision rates. Functional outcomes were assessed by Short Form 12 and modified Harris Hip Scores., Results: The mean linear wear rate was 0.02 ± 0.03 mm/y, and the mean volumetric wear rate was 12.6 ± 5.3 mm 3 /y. Younger age had higher volumetric wear (total and yearly, P = .01). Increasing body mass index trended toward higher total and yearly linear (both, P ≤ .09) and volumetric wear (both, P ≤ .07). Ten patients required revisions, with an all-cause survivorship of 92% and a wear survivorship of 100%. The mean modified Harris Hip Scores was 84, and the mean Short Form 12 scores were 46 (physical) and 55 (mental)., Conclusion: We observed low linear and volumetric wear rates for HXLPE at 10-year mean follow-up. Younger age and higher body mass index at the time of surgery may be important patient characteristics influencing long-term wear. These results illustrate the potential for this second-generation HXLPE to be an appropriate long-term total hip arthroplasty interface., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Traditional management of prosthetic joint infection following total knee arthroplasty (TKA) consists of a 2-stage approach. However, 1.5-stage exchange has seen preliminary success, whereby metal femoral and all-polyethylene tibia components are placed without intention for subsequent second stage. We sought to examine all patients who underwent a 1.5-stage exchange TKA at a single institution compared to historical 2-stage controls. We assessed the following: (1) infection-free survivorship and risk factors for reinfection; (2) 1-year surgical/medical outcomes; (3) patient-reported outcomes (ie, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS JR]); and (4) radiographic outcomes., Methods: We reviewed all patients undergoing a 1.5-stage (between 2015 and 2019) and 2-stage exchange TKA (between 2011 and 2016) at a single institution. A total of 162 knees were included (1.5-stage: 114; 2-stage: 48) with mean clinical follow-up of 2.6 years. KOOS JR scores and radiographic outcomes were evaluated at last clinical follow-up., Results: The 1.5-stage exchange TKA resulted in a 10.1% difference in infection-free survival (85.1% vs 75.0%, P = .158), compared to 2-stage exchange. Prior prosthetic joint infection was found to be an independent risk factor for reinfection (P = .030). Overall, postoperative complications were lower among 1.5-stage exchanges (8.8% vs 31.3%, P < .001). KOOS JR scores improved more from baseline among 1.5-staged (Δ24.7 vs Δ16.6, P < .001). Radiographic review did not demonstrate any progressive radiolucent lines, subsidences, or failures in either group., Conclusion: A 1.5-stage exchange TKA is an effective alternative to the traditional 2-stage protocols with noninferior infection eradication and absence of radiographic complications at over 2 years of mean follow-up., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Two common diagnoses for patients undergoing total hip arthroplasty (THA) are osteoarthritis (OA) and osteonecrosis (ON), pathologically different diseases that affect postoperative complication rates. The underlying pathology of ON may predispose patients to a higher rate of certain complications. Previous research has linked ON with higher mortality and revisions, but a comparison of costs and complication rates may help elucidate further risks. This study reports 90-day costs, lengths of stay (LOS), readmission rates, and complication rates between patients undergoing THA for OA and ON., Methods: The Nationwide Readmissions Database was retrospectively reviewed for primary THAs, with 90-day readmissions assessed from the index procedure. Patients diagnosed with OA (n = 1,577,991) and ON (n = 55,034) were identified. Costs, LOS, and any readmission within 90 days for complications were recorded and analyzed with the chi-square and t-tests., Results: Patients with ON had higher 90-day costs ($20,110.80 vs. 22,462.79, P < .01) and longer average LOS (3.48 vs. 4.49 days, P < .01). Readmission rates within 90 days of index THA were significantly higher among patients with ON (7.7% vs. 13.1%, P < .01). Patients with OA had a lower incidence of 90-day overall complications (4.1 vs. 6.4%, P < .01)., Conclusions: Patients undergoing THA for ON incur higher readmission-related costs and complication rates. Understanding the predisposing factors for increased complications in ON may improve patient outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recent institutional evidence suggests that conversion total hip arthroplasty (THA) incurs higher complication rates and costs when compared to primary THA. These findings contrast with the current reimbursement system as conversion and primary THAs are classified under the same diagnosis-related group. Thus, a national all-payer database was utilized to compare complication rates up to 2 years, 30-day readmission rates, and 90-day costs between conversion THA and matched primary THA patients., Methods: A retrospective review of the PearlDiver database between 2010 and second quarter of 2018 was performed using Current Procedural Terminology (CPT) codes to compare conversion THA (CPT 27132) to primary THA (CPT 27130). Patients were matched at a 1:3 ratio based on age, gender, Charlson Comorbidity Index, body mass index, tobacco use, and diabetes (conversion = 8369; primary = 25,081 patients)., Results: Conversion THA had higher rates of periprosthetic joint infections (conversion: 7.7% vs primary: 1.4%), hip dislocations (4.5% vs 2.0%), blood transfusions (2.0% vs 1.0%), mechanical complications (5.5% vs 1.0%), and revision surgeries (4.0% vs 1.5%) (P < .001 for all) by 90 days. The 30-day readmission rate for conversion THA was significantly higher compared to the primary group (7.3% vs 3.3%) (P < .001). Median cost at 90 days for conversion THA was significantly higher compared to primary THA ($18,800 vs $13,611, P < .001)., Conclusion: This study revealed increased complication rates, revisions, readmissions, and costs among conversion THA patients compared to matched primary THA patients. These results support the reclassification of conversion into a diagnosis-related group separate from primary THA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Maryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.)., Methods: We identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods., Results: After GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (-4.2% vs -1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (-3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (-$1780.80 vs -$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P < .001 for both)., Conclusion: Maryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: This review summarizes single vs dual antibiotic cement literature, evaluating for synergistic activity with dual antibiotics., Methods: A systematic review was performed for literature regarding dual antibiotics in cement, identifying 13 studies to include for review., Results: Many in vitro studies reported higher elution from cement and/or improved bacteria inhibition with dual antibiotics, typically at higher dosages with a manual mixing technique. Limited clinical data from hip hemiarthroplasties and spacers demonstrated that dual antibiotics were associated with improved infection prevention and higher intra-articular antibiotic concentrations., Conclusion: In addition to broader pathogen coverage, several studies document synergy of elution and increased antibacterial activity when dual antibiotics are added to cement. Limited clinical evidence suggests that dual antibiotic cement may be associated with reduced infection rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)