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Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, carrying significant economic and personal burden. The goal of this study is to use an established database to analyze socioeconomic variables and assess their relationship to PJI. Additionally, we sought to evaluate whether socioeconomic factors, along with other known risk factors of PJI, when controlled for in a statistical model affected the familial risk of PJI.With approval from our Institutional Review Board we performed a population-based retrospective cohort study on all primary total joint arthroplasty cases of the hip or knee (n = 85,332), within a statewide database, between January 1996 and December 2013. We excluded 9854 patients due to age18 years, missing data, history of PJI prior to index procedure, and no evidence of 2-year follow-up (excluding those with PJI). Cases that developed PJI following the index procedure (n = 2282) were compared to those that did not (n = 73,196).After adjusting for covariates, patients with Medicaid as a primary payer were at greater risk for experiencing PJI (relative risk 1.40, 95% confidence interval [CI] 1.08-1.82, P = .01). There was no difference in risk between the groups associated with education level or median household income (all, P.05). First-degree relatives of patients who develop PJI (hazard ratio 1.66, 95% CI 1.23-2.24, P = .001) and first-degree and second-degree relatives combined (hazard ratio 1.39, 95% CI 1.09-1.77, P = .007) were at greater risk despite controlling for the above socioeconomic factors.Our study provides further support that genetic factors may underlie PJI as we did observe significant familial risk even after accounting for socioeconomic factors and payer status. We did not find a correlation between education level or household income and PJI; however, Medicaid payees were at increased risk. Continued study is needed to define a possible heritable disposition to PJI in an effort to optimize treatment and possibly prevent this complication.

Background We sought to determine the 10-year survivorship and reasons for revision for a fixed-bearing unicompartmental knee arthroplasty (UKA) design. In addition, we report on patient-reported outcomes and satisfaction and compare results of medial vs lateral compartment UKA and cemented vs cementless UKA with the same design. Methods We performed a retrospective cohort study on a single-surgeon case series using a single fixed-bearing UKA design in 158 consecutive patients who underwent 177 UKA procedures between July 2000 and December 2010. Cases missing follow-up within the last year, clinically or via telephone, were excluded (n = 17, 10%). A cumulative incidence competing risk model was used to evaluate the cumulative incidence of failure. Results Cumulative incidence of revision at a mean follow-up of 10 years was 13%. The majority of revisions (43%, 10/23) were for aseptic tibial component loosening, followed by progression of osteoarthritis (5/23, 22%). All Patient Reported Outcomes Measurement Information System measures demonstrated mean T-scores within one standard deviation from the US population norm. The mean Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was 96.9 (range, 40-100). The mean pain score was 3.8 (range, 0-8). Eighty-six percent of patients were satisfied with the UKA. Conclusions At 10-year follow-up, the most common causes for revision were aseptic tibial loosening and adjacent compartment knee arthroplasty, and similar results were found for medial vs lateral compartment and for cemented vs cementless UKA. Surgeons should consider these findings for future UKA designs, and this represents the first study reporting on survivorship and outcomes of this specific UKA design.

Background Controversy continues to exist regarding the advisability of isolated polyethylene exchange (IPE) following total knee arthroplasty (TKA) for aseptic indications. We sought to compare the difference in the cumulative incidence of reoperation after IPE specifically for aseptic failure and to evaluate risk factors for failure. Methods We performed a retrospective cohort study of 122 knees revised for aseptic failure. Reasons for IPE in aseptic knees included: instability, polyethylene wear, arthrofibrosis, patella fracture, patellar resurfacing, patellar maltracking, extensor mechanism failure, patellectomy, and a custom polyethylene for correction of valgus deformity. The relatively high rate of mortality warranted a competing risk model to evaluate the cumulative incidence reoperation. Follow-up time was defined by years from IPE to date of reoperation or last follow-up. Generalized estimating equations were used for comparisons. Results Our analysis demonstrated an 87% (95% CI, 78–92%) survivorship free of reoperation at five years. Re-revision was secondary to aseptic failure, infection, and patellar malalignment. IPE for polyethylene wear was found to be protective and less likely to require reoperation (SHR 0.121 95% CI: 0.016–0.896, p = 0.039). Conclusions The current study suggests that when done for carefully selected indications, IPE may be an acceptable procedure and helpful alternative for aseptic TKA revisions, particularly when the pre-operative diagnosis is polyethylene wear. This is in contrast to prior reports and may represent a need to re-visit the role of isolated polyethylene exchange.

Background Enthusiasm for anterior-based approaches for total hip arthroplasty (THA) continues to increase but there is concern for increased complications during the learning curve period associated. This study aimed to investigate if there was a difference in perioperative variables, intraoperative and immediate postoperative complications, or patient-reported outcomes when transitioning from a mini-posterior approach (mPA) to an anterior-based muscle-sparing (ABMS) approach for THA. Methods Retrospective cohort study on the first 100 primary THA cases (n = 96 patients) of the senior author (August 2016 to August 2017) using the ABMS approach. These cases were compared to primary THA cases done the year prior (July 2015 to July 2016, n = 91 cases in 89 patients) using an mPA. Data were extracted and analyzed via gamma regression with robust standard errors and using generalized estimating equation regression. Results We found no difference in the estimated blood loss (P = .452) and surgical time (P = .564) between the cohorts. The ABMS cases had a slightly shorter length of stay (P = .001) with an adjusted mean length of stay of 1.53 days (95% confidence interval 1.4-1.6) compared to 1.85 days (95% confidence interval 1.8-1.9) in the mPA cases. There was no difference in the frequency of immediate postoperative complications (all, P > .05). There was no difference in the adjusted mean change in patient-reported outcomes (all P > .05). In the ABMS group, there was no difference in surgical time or physical function computerized adaptive test between the first 20 cases (reference) and each subsequent group of 20 cases (all P > .05). Conclusion This study demonstrates no associated learning curve for an experienced senior surgeon when switching routine THA approach from mPA to ABMS. We advise careful interpretation of our results, as they may not apply to all surgeons and practices. Level of Evidence Level III Therapeutic Study: retrospective comparative study.

We describe 3 cases of DePuy Pinnacle polyethylene dissociations, their presentations, and treatment. A 34-year-old female with arthritis secondary to dysplasia, a 51-year-old male with avascular necrosis of the femoral head, and a 57-year-old female with osteoarthritis were treated with total hip arthroplasty. Acute nontraumatic polyethylene liner dissociations occurred at 31, 42, and 2 months postoperatively. They were treated with component retention and modular femoral head and liner revision. The 51-year-old male subsequently developed a prosthetic joint infection requiring explant of his components. Although dissociation of polyethylene liners from the DePuy Pinnacle acetabular components is an uncommon complication, this problem may increase in prevalence with longer term follow-up, and vigilance is recommended. Keywords: Modular acetabular components, Polyethylene liner dissociation, DePuy, Pinnacle

Background Patient delivery of care satisfaction surveys have emerged as instruments to assess the quality of health care at both the hospital and provider levels. We evaluated the correlation between these care satisfaction surveys and patient-reported outcomes (PROs). Methods We reviewed secondary data on 540 patients with 540 random visits who underwent primary total joint arthroplasty between January 2014 and February 2017. The Press Ganey Outpatient Medical Practice Survey was collected from outpatient clinical encounters to measure patient satisfaction with their experience and matched to PRO measures from the same encounter. The PROs evaluated included the Patient-Reported Outcomes Measurement Information System physical function computerized adaptive test, v1.2, and the Patient-Reported Outcomes Measurement Information System Global 10 health survey. In addition to the random selection, we reviewed separate cross-sections of the data including preoperative visits within 90 days of the index procedure, all postoperative visits at least 1 year from the index procedure, and the magnitude of change in PRO scores from preoperative to a minimum 1-year postoperative visit. Data were evaluated using the Spearman correlation coefficient (rs). Results There was little if any correlation between the Press Ganey scores and PROs at all time points evaluated (all, rs: −0.13 to 0.14). When evaluating knee and hip arthroplasty cases separately, the data demonstrated similar results (all, rs: −0.33 to 0.18). Conclusion We found little, if any, correlation between a patient’s satisfaction with their care experience and their own perception of physical function and global health measures at all time points evaluated. These data question the utility of these scores as surrogate measures of health care quality, especially when reimbursements become tied to these metrics.

Background To determine if there was a difference in the change in patient-reported physical function (PF) between nondepressed and medically treated depressed or untreated depressed total joint arthroplasty (TJA) patients. Methods This is an Institutional Review Board exempt retrospective review of 280 TJA cases from March 2014 to May 2016. Patient-reported PF was measured as part of the routine care via the Patient Reported Outcomes Measurement Information System PF computerized adaptive test. Linear generalized estimating equation regression analyses were used. Results Untreated depressed cases demonstrated much smaller gains in PF scores compared to nondepressed patients (P = .020). Additionally, although treated and untreated depressed patients had statistically similar preoperative and postoperative PF scores (P > .05), untreated depressed cases experienced a lower magnitude of change (P = .015). Conclusion Medically treated depressed patients may have similar PF gains as nondepressed patients. Larger prospective studies may help identify whether screening for untreated depression and subsequent treatment leads to improved outcomes.

Background Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force. Methods To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described. Results Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements. Conclusion Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.

A step-by-step approach to creating a comprehensive patient education, expectation, and management program is described with the aim of reducing discharges to post-acute care centers (PACs) following total joint arthroplasty (TJA). We hypothesized that by lowering discharges to PACs, readmissions and reoperations would also decrease.Following the implementation of a multi-faceted patient education and management program, we retrospectively reviewed 927 TJAs who underwent surgery 12 months before (n = 465) and after (n = 462) the program was implemented. To assess the exposure of the pathway on discharge disposition as well as institutional 30-day and 90-day readmissions and reoperations, a modified Poisson regression was used.There was a 20% absolute reduction in discharges to PACs (0.001). The frequency of 30-day readmissions was greater in patients who underwent TJA before implementation (incidence rate ratio [IRR] 1.93, 95% confidence interval [CI] 1.01-3.69). The risk for 90-day readmissions (IRR 1.70, 95% CI 1.20-2.40) and reoperations (IRR 1.67, 95% CI 1.12-2.53) was greater prior to implementation. Discharge to PACs was associated with 2.4 and 3.10 times greater risk for 30-day readmissions (95% CI 1.28-4.56) and 30-day reoperations (95% CI 1.40-7.0), respectively. Patients discharged to PACs were also at greater risk for both 90-day readmissions (IRR 1.59, 95% CI 1.08-2.32) and 90-day reoperations (IRR 1.75, 95% CI 1.12-2.73).Our program led to a reduction in the number of patients being discharged to PACs following TJA, while also demonstrating a reduction in readmission and reoperations. Additionally, discharge to these facilities was an independent risk factor for these complications.

Background Developmental dysplasia of the hip (DDH) is a recognized cause of secondary arthritis, which may eventually lead to total hip arthroplasty (THA). An understanding of the common acetabular and femoral morphologic abnormalities will aid the surgeon in preparing for the complexity of the surgical case. Methods We present the challenges associated with acetabular and femoral morphologies that may be present in the dysplastic hip and discuss surgical options to consider when performing THA. In addition, common complications associated with this population are reviewed. Results The complexity of THA in the DDH patient is due to a broad range of pathomorphologic changes of the acetabulum and femur, as well as the diverse and often younger age of these patients. As such, THA in the DDH patient may offer a typical primary hip arthroplasty or be a highly complex reconstruction. It is important to be familiar with all the subtleties associated with DDH in the THA population. The surgeon must be prepared for bone deficiency when reconstructing the acetabulum and should place the component low and medial (at the anatomic hip center), and avoid oversizing the acetabular component. Femoral dysplasia is also complex and variable, and the surgeon must be prepared for different stem choices that allow for decoupling of the metaphyseal stem fit from the implanted stem version. In Crowe III and IV dysplasia, femoral derotation/shortening osteotomy may be required. Many complications associated with THA in the DDH patient may be mitigated with careful planning and surgical technique. Conclusion Performed correctly, THA can yield excellent results in this complex patient population.

To evaluate the convergent validity, precision, and completion times for the Physical Function Computerized Adaptive Test (PF-CAT) in a sports medicine patient population relative to standard measures of knee and shoulder function.We reviewed all patient visits from April through September 2014 with either knee or shoulder complaints from a university-based sports medicine clinic, during which PF-CAT, Single Assessment Numerical Evaluation (SANE), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) outcome scores for shoulder patients and PF-CAT, SANE, and International Knee Documentation Committee (IKDC) scores for knee patients were obtained, with an initial visit or one follow-up visit included in the study. Spearman correlation was used to evaluate pairwise agreement among scores. The McNemar χIn total, 415 shoulder and 450 knee clinical evaluations qualified for inclusion in the study. A high correlation was found between IKDC and PF-CAT scores (r = 0.75, P.0001), and a moderately high correlation was found between PF-CAT and both SST (r = 0.68, P.0001) and ASES (r = 0.63, P.0001) scores. Maximum differences in the sum of floor-ceiling values versus the PF-CAT were 15% for the SST (P.0001), 2.5% for the ASES (ceiling only, P = .0133), and 5.8% for the shoulder SANE (floor P = .0012, ceiling P = .0269). The PF-CAT had values of 0.4% for the shoulder and 0.6% for the knee. Zero percent of IKDC scores but 6.9% of knee SANE scores hit floor or ceiling values (floor P = .0019, ceiling P = .0007). The PF-CAT median completion time was lower at 55 seconds versus 268 seconds for the IKDC assessment (P.0001), whereas shoulder patients' times were 61, 139, and 116 seconds for the PF-CAT, SST, and ASES evaluation, respectively (P.0001).The PF-CAT showed a high correlation with IKDC scores and a moderately high correlation with ASES and SST outcomes. The PF-CAT takes significantly less time to complete and exhibits improved or similar floor and ceiling effects in comparison to IKDC, SST, and ASES scores. The PF-CAT can be used in evaluating sports medicine knee and shoulder patients.Level III, cross-sectional study.

Background We sought to assess the prevalence of soft tissue changes seen on magnetic resonance imaging (MRI) after metal-on-metal (MOM) total hip arthroplasty (THA) and determine if the presence of pseudotumors was associated with metal ion levels, acetabular cup position, outcomes scores, and femoral head size. Methods After receiving an institutional review board exemption for secondary data analysis, we performed a cross-sectional study identifying 55 patients (55 hips) that underwent primary THA with a MOM articulation and had subsequent MRI imaging between February 2013 and February 2014 at a single academic medical center. Results Twenty-four patients (44%) had no evidence of pseudotumors, 27 (49%) had type I pseudotumors, and 4 (7%) were classified as having type II pseudotumors. The presence and severity of pseudotumors were associated with higher serum chromium levels ( P = .043). Neither acetabular inclination nor acetabular version was associated with the presence of pseudotumors, the severity of pseudotumors, or elevated serum metal ion levels (all P > .05). Increased metal ion levels were associated with lower Harris Hip Score and higher Harris Hip Score pain subscores (all P Conclusion In conclusion, pseudotumors on metal artifact reduction sequencing MRI may be present in both symptomatic and asymptomatic MOM THAs. Surgeons should therefore exercise caution in placing too much emphasis on isolated studies such as cross-sectional imaging. Instead, a structured approach to evaluation of MOM arthroplasty should be followed.

Using THA as a proxy for underlying osteoarthritis, we describe population-based familial clustering of osteoarthritis of the hip. The GIF test for excess relatedness on 1049 patients that underwent THA (and do not have a diagnostic code for other conditions leading to THA) showed excess relatedness (P0.001). Even when close relationships were ignored (closer than third-degree relationships), excess relatedness was observed (P=0.020). Relative risk was elevated in first-degree (RR 2.59; 95% CI 1.84-3.53, P=2.0e(-7)), second-degree (RR 1.66; 95% CI 1.11-2.39; P=0.0075) and third-degree relatives (RR 1.46; 95% CI 1.17-1.81; P=5.7e(-4)). Excess relatedness of individuals who had undergone THA for osteoarthritis and elevated risks to both near and distant relatives were observed.

We sought to determine if HbA1c and perioperative hyperglycemia were positively associated with the incidence of PJI. We retrospectively reviewed the VA VINCI database on patients who underwent primary joint arthroplasty between 2001 and 2011 and had HbA1c and perioperative blood glucose levels. Of 13,272 patients, 38% (n=5035) had an elevated perioperative HbA1c ≥7%. While there was no increased risk of infection associated with elevated HbA1c (HR 0.86, P =0.23), mortality was increased (HR 1.3, P =0.01). Preoperative hyperglycemia was associated with an increased incidence of PJI (HR 1.44, P =0.008). While HbA1c did not perfectly correlate with the risk of PJI, perioperative hyperglycemia did, and may be a target for optimization to decrease the burden of PJI.

A femoral nerve catheter (FNC) is often used to minimize pain following total knee arthroplasty (TKA), but complications including inpatient falls, may increase as a result, despite fall prevention protocols. We evaluated the rate of falls in 707 primary TKAs performed with an FNC at a major academic center from May 2009 to September 2012. Despite a formalized fall prevention protocol, we found 19 falls (2.7%). Three patients required further operative intervention. At a rate of 2.7%, postoperative fall is one of the most common complications of TKA at our institution. While pain control may be good with the use of FNCs following primary TKA, improvements in fall prevention strategies or the use of alternative postoperative pain control modalities may need to be considered.