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Background: With the advent of outpatient total joint arthroplasty (TJA), the days of routinely drawing postoperative labs (complete blood counts [CBCs] and metabolic panels [CMPs/BMPs]) to monitor for complications are behind us. However, there does exist a subset of at-risk patients that may benefit from diligent postoperative monitoring, though the circumstances under which labs should be ordered remains unclear and subject to surgeon discretion. A systematic review of the literature was therefore conducted to evaluate the utility of postoperative laboratory testing, approaches to targeted patient selection and associated cost-savings., Methods: The PubMed, MEDLINE, EBSCOhost, and Google Scholar electronic databases were searched on August 17, 2023, to identify all studies published since January 1, 2000, that evaluated the role of postoperative lab testing in TJA. (PROSPERO study protocol registration: CRD42023437334). Articles were included if a full-text English manuscript was available and the study assessed the utility of routine postoperative labs in TJA. 19 studies were included comprising 34,166 procedures. The mean Methodological index for Nonrandomized Studies score was 18.2 ± 1.5., Results: Abnormal postoperative lab results were common and infrequently required clinical intervention. Among several identified risk factors for patients that may benefit from postoperative laboratory monitoring, preoperative lab values proved excellent discriminators of transfusion requirement and metabolite-associated intervention. Selective testing demonstrated the ability to generate substantial cost-savings., Conclusion: Routine postoperative laboratory testing offers little clinical utility and produces unnecessary expenditures. Preoperative lab values offer the greatest predictive utility for postoperative transfusion requirement and metabolite-associated clinical intervention, with a preoperative hemoglobin threshold of 111.5 g/L offering an area under the curve (AUC) of 0.93 for predicting postoperative transfusion. Further investigations are needed for metabolic panel predictive models and should incorporate preoperative lab values. The refinement of such models can enable targeted patient selection to avoid unnecessary labs and generate substantial cost savings without compromising patient safety., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Serving as a principal investigator for a clinical trial can bring national visibility and recognition to physicians, and it can have a substantial impact on their promotion and tenure. In the field of orthopaedics, there is a well-known gender gap in terms of representation and leadership. Examining the representation of women in clinical trial leadership may help to inform and enable the design of targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership., Questions/purposes: (1) What is the proportion of women principal investigators in orthopaedic clinical trials, and has this changed over time? (2) Are there trial characteristics (trial phase, status, funding source, and intervention) associated with women principal investigators? (3) What is the geographic distribution globally and regionally within the United States of clinical trials led by women principal investigators?, Methods: A cross-sectional survey of clinical trials using the ClinialTrials.gov registry and results database provided by the NIH was performed on August 22, 2022. Trial characteristics included principal investigator names and gender, trial phase, type, funding source, intervention, and location (defined by continent and US Census region). Our primary outcome was the overall proportion of women orthopaedic principal investigators over time. We assessed this by comparing the proportion of women principal investigators from 2007 to 2022. Our secondary outcomes were trial characteristics (trial phase, status, funding source, and intervention) and geographic distribution (globally and within the United States) associated with women principal investigators. Baseline characteristics of the clinical trials were calculated using frequencies and percentages for categorical variables. Fisher exact tests were conducted to evaluate differences in gender proportions based on the included clinical trial characteristics. Univariate linear regression was applied to analyze trends in the annual proportion of women principal investigators over time., Results: The overall proportion of women principal investigators was 18% (592 of 3246), and this proportion increased over the study period. Specifically, the proportion of women leading clinical trials was 13% (16 of 121) in 2007 and 22% (53 of 242) in 2022 (r 2 = 0.68; p < 0.001). This trend was also observed when evaluating only US women principal investigators (r 2 = 0.47; p = 0.003) and non-US women principal investigators over the study period (r 2 = 0.298; p = 0.03). There was no difference in the distribution of trial phases between men and women principal investigators. Most men and women were involved in "not applicable" or Phase IV trials. Similarly, there was no difference in trial status or funding source. However, women principal investigators had a higher proportion of studies involving behavioral interventions (11% [67 of 592]) compared with men principal investigators (3% [74 of 2654]; p = 0.03). The proportion of women principal investigators over the study period by world region revealed a higher proportion of women principal investigators in Asia (23% [88 of 391]), followed by South America (24% [12 of 49]), North America (18% [306 of 1746]), and Europe (16% [136 of 833]). Among all US trials over the study period, the proportion of women principal investigators across the US Census region was Northeast (19% [62 of 329]), South (18% [90 of 488]), West (20% [97 of 492]), and Midwest (13% [22 of 168])., Conclusion: Although there has been a notable increase in the proportion of women principal investigators over time, the overall representation remains relatively low. The disparities observed in trial characteristics and geographic distribution of women principal investigators further emphasize the need for targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership., Clinical Relevance: These results underscore the importance of adopting practices and strategies that foster gender equity in the leadership of orthopaedic clinical trials. By establishing mentorship and sponsorship programs, early-career women surgeons can be connected with experienced leaders, cultivating a supportive network and offering valuable career guidance. Additionally, addressing geographic disparities in the representation of women principal investigators can involve the implementation of mentorship and sponsorship programs in regions with lower representation., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background: Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized., Questions/purposes: (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states?, Methods: We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions., Results: A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08)., Conclusion: As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately., Clinical Relevance: To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background: Because research experience is increasingly important in ranking orthopaedic residency and fellowship applicants, determining the accuracy of candidates reporting their scholarly activity is essential. However, disparate and inconsistent findings have made it difficult to draw meaningful conclusions from individual studies., Questions/purposes: In this systematic review, we asked: (1) What percentage of research publications are misrepresented among orthopaedic residency and fellowship applicants? (2) What percentage of applications contain one or more example of academic misrepresentation? (3) Is research misrepresentation associated with any individual applicant characteristics? (4) What is the publication status of articles listed by applicants as having been submitted to journals?, Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were searched on March 10, 2022, to identify all studies that evaluated research misrepresentation in orthopaedic residency and fellowship applications between January 1, 1995, and March 1, 2022. Articles were included if full-text articles in English were available and the study reported on research misrepresentation among orthopaedic residency or fellowship applicants. Studies investigating nonorthopaedic publications, systematic reviews, case studies, duplicate studies among databases, and gray literature were excluded. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. This is a validated assessment tool that grades noncomparative studies from 0 to 16 and studies with control groups from 0 to 24, based on eight criteria related to study design, outcomes assessed, and follow-up. All included articles were noncomparative studies, so the maximum score here was 16, with higher scores indicating better study quality. The mean MINORS score was 13 ± 1 in the studies we included. The final analysis included 10 studies with 5119 applicants. Eight studies evaluated orthopaedic residency applicants and two evaluated fellowship applicants. The applicant classes ranged from 1996 to 2019. Research misrepresentation was defined among studies as nonauthorship of an existing article, claimed authorship of a nonexistent article, or incorrect listing of authorship order for an existing article. Each study's findings and definition of research misrepresentation were considered to allow for a discussion of overall trends. The percentage of misrepresentation was further broken down by the misrepresentation type. Applicant characteristics and destination of submitted articles were also evaluated. Given the potential overlap between applicants among the studies, no pooled analysis was conducted, and results are presented as a narrative summary., Results: The percentage of overall publication misrepresentation was estimated to range between 1% (13 of 1100) and 21% (27 of 131), with more-recent studies reporting a lower proportion of overall articles misrepresented. Most studies we found claimed that authorship of a nonexistent article was the most common type of misrepresentation. Nonauthorship of an existing article and incorrect authorship order were less common. The percentage of applications with at least one misrepresentation was approximately 20% between 1998 and 2017. Most studies found no applicant characteristics, such as match outcomes, demographic markers, or academic records, that were consistently associated with a higher odds of the candidate misrepresenting his or her research credentials. Finally, approximately half of the articles listed as submitted to journals went on to publication, with one-third going to a different journal with a lower Impact Factor., Conclusions: Our systematic review found that the percentage of overall publication misrepresentations among orthopaedic residency and fellowship applicants has generally been low over the past 20 years. However, approximately one-fifth of applications had at least one research misrepresentation, with 2% having multiple misrepresentations on reported publications. There were no consistent applicant characteristics associated with higher odds of research misrepresentation. Additionally, most of the articles listed as submitted to journals for publication were ultimately published., Clinical Relevance: Although the decrease in overall publication misrepresentation is encouraging, our finding that one-fifth of applicants have research misrepresentation is a cause for concern. In light of a continually evolving application process, orthopaedic residency and fellowship programs must ensure there is integrity related to information that is self-reported by applicants. These findings also serve to encourage faculty members involved in the application screening and decision process to limit biases related to applicant demographics perceived to be associated with a high odds of misrepresentation. Furthermore, governing agencies and program leadership should evaluate methods of verifying unpublished work and provide opportunities for applicants to give publication updates throughout the application cycle., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background: Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary., Question/purpose: Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?, Methods: The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively., Results: Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness., Conclusion: Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity., Questions/purposes: We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?, Methods: A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively., Results: Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles., Conclusion: These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: The Centers for Medicare and Medicaid Services (CMS) recently implemented price transparency legislation. As total joint arthroplasty (TJA) procedures are widely used, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures are a proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, cost estimates for TJA procedures represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population., Questions/purposes: We asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes?, Methods: Our cross-sectional retrospective analysis used the CMS's Hospital Compare database. This database includes information for 5326 Medicare hospitals nationally. We excluded children's, psychiatric, Veterans Affairs, and active military base hospitals as well as hospitals performing fewer than 100 TJAs annually. A total of 1719 hospitals remained after this selection process. Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 facilities for our final analysis. Included hospitals were located predominately in urban areas (79% [317 of 400]) and were mostly medium-sized facilities (43% [171 of 400]). Most hospitals were classified as acute care (98% [392 of 400]) versus critical access. Three reviewers thoroughly searched each hospital website for a machine-readable file providing the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals with any gross price information pseudocompliant. The consumer-friendliness of the website was assessed based on the following criteria: (1) languages other than English were offered, (2) it took less than 15 minutes to locate pricing information, (3) a phone number or email address was provided for questions, and (4) there was a description of procedure in common terms. Pricing information was recorded and compared for CPT codes 27447 and 27130 and DRG codes 469 and 470. Data were sourced from December 1 through 20, 2021, to assess compliance in the first year since the legislation was implemented., Results: Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing. When segregating by individual procedures, 21% (84 of 400), 18% (72 of 400), 18% (71 of 400), and 19% (74 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130 and DRG codes 469 and 470, respectively. For each code, rates of pseudocompliance were 36% (143 of 400), 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400) for the included codes, respectively. Most included hospitals provided at least some of their pricing data in a user-friendly format. Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code., Conclusion: Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures., Clinical Relevance: Given the potential influence compliance and price sharing may have on empowering patients' healthcare decisions and reducing healthcare expenditures, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available to their patients. In addition to ensuring that all six CMS mandates are met, this should include providing information in easy-to-understand formats and making related services identifiable across all levels of health literacy. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Introduction: Despite high rates of transfusion reported among hip fracture patients in the perioperative period, the relationship between perioperative transfusions and VTE has not been thoroughly explored. Therefore, we used a national database to evaluate how perioperative transfusions among patients undergoing surgical management of hip fractures impacted 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE) risk., Methods: The Targeted Hip Fracture Database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients undergoing surgical management of hip fractures from 2016 to 2019. A multivariate logistic regression was conducted using various patient-specific variables to identify risk factors for DVT and PE. A nearest-neighbor propensity score matched (PSM) comparison between patients receiving and not receiving perioperative blood transfusions (1:1) was additionally conducted., Results: Prior to our PSM, preoperative transfusions were not associated with DVT incidence (OR: 1.48, 95% CI: 0.80-2.50; p  = 0.2). However, intra-operative/post-operative transfusions (OR: 1.26, 95% CI: 1.02-1.56; p  = 0.00.30) as well as the receipt of both transfusion types (OR: 1.81, 95% CI: 1.10-2.81; p  = 0.012) were associated with an increased risk of DVT. The latter of these findings remained significant following PSM (OR: 1.73, 95% CI: 1.04-2.73; p  = 0.025) . No relationship was demonstrated between PE risk and perioperative transfusion receipt., Conclusion: Our findings emphasize the importance of perioperative blood management strategies among patients undergoing surgical repair of hip fracture. Specifically, orthopaedic surgeons should aim to optimize hip fracture patients prior to surgical intervention as well as intra-operatively to reduce transfusion incidence., Competing Interests: A.F.K. reports the following disclosures: research support (Signature Orthopaedics), paid presenter or speaker (DePuy Synthes and Zimmer Biomet), paid consultant (DePuy Synthes and Zimmer Biomet), stock or stock options (Zimmer Biomet, Johnson & Johnson, and Procter & Gamble), IP royalties (Innomed), and board or committee member (AAOS, AAHKS, and Anterior Hip Foundation). The other authors have nothing to disclose., (© 2022 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: The Merit-based Incentive Payment System (MIPS) is the latest value-based payment program implemented by the Centers for Medicare & Medicaid Services. As performance-based bonuses and penalties continue to rise in magnitude, it is essential to evaluate this program's ability to achieve its core objectives of quality improvement, cost reduction, and competition around clinically meaningful outcomes., Questions/purposes: We asked the following: (1) How do orthopaedic surgeons differ on the MIPS compared with surgeons in other specialties, both in terms of the MIPS scores and bonuses that derive from them? (2) What features of surgeons and practices are associated with receiving penalties based on the MIPS? (3) What features of surgeons and practices are associated with receiving a perfect score of 100 based on the MIPS?, Methods: Scores from the 2018 MIPS reporting period were linked to physician demographic and practice-based information using the Medicare Part B Provider Utilization and Payment File, the National Plan and Provider Enumeration System Data (NPPES), and National Physician Compare Database. For all orthopaedic surgeons identified within the Physician Compare Database, there were 15,210 MIPS scores identified, representing a 72% (15,210 of 21,124) participation rate in the 2018 MIPS. Those participating in the MIPS receive a final score (0 to 100, with 100 being a perfect score) based on a weighted calculation of performance metrics across four domains: quality, promoting interoperability, improvement activities, and costs. In 2018, orthopaedic surgeons had an overall mean ± SD score of 87 ± 21. From these scores, payment adjustments are determined in the following manner: scores less than 15 received a maximum penalty adjustment of -5% ("penalty"), scores equal to 15 did not receive an adjustment ("neutral"), scores between 15 and 70 received a positive adjustment ("positive"), and scores above 70 (maximum 100) received both a positive adjustment and an additional exceptional performance adjustment with a maximum adjustment of +5% ("bonus"). Adjustments among orthopaedic surgeons were compared across various demographic and practice characteristics. Both the mean MIPS score and the resulting payment adjustments were compared with a group of surgeons in other subspecialties. Finally, multivariable logistic regression models were generated to identify which variables were associated with increased odds of receiving a penalty as well as a perfect score of 100., Results: Compared with surgeons in other specialties, orthopaedic surgeons' mean MIPS score was 4.8 (95% CI 4.3 to 5.2; p < 0.001) points lower. From this difference, a lower proportion of orthopaedic surgeons received bonuses (-5.0% [95% CI -5.6 to -4.3]; p < 0.001), and a greater proportion received penalties (+0.5% [95% CI 0.2 to 0.8]; p < 0.001) and positive adjustments (+4.6% [95% CI 6.1 to 10.7]; p < 0.001) compared with surgeons in other specialties. After controlling for potentially confounding variables such as gender, years in practice, and practice setting, small (1 to 49 members) group size (adjusted odds ratio 22.2 [95% CI 8.17 to 60.3]; p < 0.001) and higher Hierarchical Condition Category (HCC) scores (aOR 2.32 [95% CI 1.35 to 4.01]; p = 0.002) were associated with increased odds of a penalty. Also, after controlling for potential confounding, we found that reporting through an alternative payment model (aOR 28.7 [95% CI 24.0 to 34.3]; p < 0.001) was associated with increased odds of a perfect score, whereas small practice size (1 to 49 members) (aOR 0.35 [95% CI 0.31 to 0.39]; p < 0.001), a high patient volume (greater than 500 Medicare patients) (aOR 0.82 [95% CI 0.70 to 0.95]; p = 0.01), and higher HCC score (aOR 0.79 [95% Cl 0.66 to 0.93]; p = 0.006) were associated with decreased odds of a perfect MIPS score., Conclusion: Collectively, orthopaedic surgeons performed well in the second year of the MIPS, with 87% earning bonus payments. Among participating orthopaedic surgeons, individual reporting affiliation, small practice size, and more medically complex patient populations were associated with higher odds of receiving penalties and lower odds of earning a perfect score. Based on these findings, we recommend that individuals and orthopaedic surgeons in small group practices strive to forge partnerships with larger hospital practices with adequate ancillary staff to support quality reporting initiatives. Such partnerships may help relieve surgeons of growing administrative obligations and allow for maintained focus on direct patient care activities. Policymakers should aim to produce a shortened panel of performance measures to ensure more standardized comparison and less time and energy diverted from established clinical workflows. The current MIPS scoring methodology should also be amended with a complexity modifier to ensure fair evaluation of surgeons practicing in the safety net setting, or those treating patients with a high comorbidity burden., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions., Question/purpose: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States?, Methods: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively., Results: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth., Conclusion: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains., Clinical Relevance: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Introduction: As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees., Methods: The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age., Results: We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05)., Conclusion: Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power., Questions/purposes: Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as "non-elective" were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients' transfusion status. Significance was determined at a p value < 0.05., Results: Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching., Conclusion: After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team., Level of Evidence: Level III, therapeutic study., Competing Interests: Each remaining author certifies that neither he, nor any member of immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

Background: Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular., Questions/purposes: Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder?, Methods: All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder., Results: Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001)., Conclusions: After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure., Level of Evidence: Level III, therapeutic study.

Background: Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA., Questions/purposes: In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA., Methods: All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant., Results: For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort., Conclusions: These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles., Level of Evidence: Level III, therapeutic study.

Introduction: Osteoarthritis of the hip is one of the leading causes of disability worldwide. There is lack of agreement among providers and governing agencies regarding the efficacy of hyaluronic acid (HA) for the management of hip osteoarthritis (OA). Therefore, the purpose of this systematic review was to determine how HA administration impacts 1) patient reported outcome measures (PROMs) and 2) rates of conversion to THA., Methods: The PubMed, EBSCO host, and Google Scholar electronic databases were queried for all studies published between January 1st, 2000 and January 1st, 2020 that reported on outcomes following HA administration for treatment of hip OA. The following keywords were implemented with AND and OR Boolean operators: "hip"; "osteoarthritis"; "arthritis"; "viscosupplementation"; "hyaluronic acid." Our final analysis included 39 studies and reported on a total of 5,864 patients receiving injections of HA., Results: All studies reporting on visual analog scale (VAS), patient global assessment, and total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores demonstrated improvements following HA administration. For the Lequesne Index (LI), WOMAC pain, WOMAC function, and Harris Hip Score (HHS) values, a majority of studies reported that HA would prove beneficial, with one analysis suggesting a lack of improvement. There was inconsistent evidence across studies regarding the effectiveness of HA compared to other intra-articular injections. The formulation of the administered viscosupplementation did not appear to influence outcomes. Furthermore, rates of conversion to THA were relatively low when evaluating 1- to 4-year follow-up intervals., Discussion: Non-comparative studies consistently demonstrated that HA can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether HA is superior to placebo or other types of intra-articular injections. Future studies should continue to compare HA to other treatment modalities in randomized controlled trials with larger sample sizes., Competing Interests: A.F.K. reports the following disclosures: research support (Zimmer Biomet, DePuy Synthes), paid presenter or speaker (Corin, DePuy Synthes, Heraeus Medical, and Zimmer Biomet), paid consultant (Pacira Pharmaceuticals, Heraeus Medical, DePuy Synthes, and Zimmer Biomet), stock or stock options (Zimmer Biomet, Johnson & Johnson, and Procter & Gamble), IP royalties (Innomed), board or committee member (AAOS and AAHKS), and editorial or governing board (BMC Musculoskeletal Disorders). A.J.A., L.T.S., A.K.E., and S.H.J. have nothing to disclose., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Purpose: To objectively evaluate the effect different management strategies have on the following post-surgical outcomes., Methods: The PubMed, Embase and Cochrane Library databases were reviewed for articles published between January 1st, 2000 to September 18, 2019 that reported on studies comparing techniques for handling the capsule during hip arthroscopy. After applying the inclusion and exclusion criteria, our final analysis included 10 studies. In total, these articles included 1556 hips. The following capsular management strategies were implemented: complete repair (n = 444; 28.53%), partial repair (n = 32; 2.06%), plication (n = 223; 14.33%) and release/no-repair (n = 857; 55.08%). A meta-analysis was performed on outcomes presented in three or more studies using sufficient pooled statistical analysis data., Results: Our meta-analysis demonstrated an improvement in the HOS-SS with capsular repair without being statistically significant (95%CI [-6.71, 8.21], p  = 0.06). However, a significant improvement in the mHHS was detected with capsular repair (95%CI [-1.37, 9.39], p  = 0.03). Of the Four studies evaluating HOS-ADL, two reported improved outcomes with capsular repair ( p  < 0.05 for both) while the other two reported no significant difference. While mixed results were demonstrated for reoperation rates, no difference was found across capsular management strategies regarding radiological outcomes, NAHS (all p -values >0.05) pain ( p  > 0.05), flexion ( p  > 0.05), and patient satisfaction ( p  > 0.05)., Conclusion: Capsular repair has the potential to improve patient reported outcomes after hip arthroscopy. While there was no consensus in literature, studies consistently reported similar or superior outcomes in the capsular repair cohorts compared to capsular release. Further randomized controlled studies need to be conducted for better evaluation of outcomes., Competing Interests: A.F.K. reports the following disclosures: research support (Zimmer Biomet, DePuy Synthes), paid presenter or speaker (Corin, DePuy Synthes, Heraeus Medical, and Zimmer Biomet), paid consultant (Pacira Pharmaceuticals, Heraeus Medical, DePuy Synthes, and Zimmer Biomet), stock or stock options (Zimmer Biomet, Johnson & Johnson, and Procter & Gamble), IP royalties (Innomed), board or committee member (AAOS and AAHKS), and editorial or governing board (BMC Musculoskeletal Disorders). A.J.A., L.T.S., A.K.E., and A.R. have nothing to disclose., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period., Methods: The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were "operative," "time," and "total hip arthroplasty." An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria., Results: The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee., Conclusions: The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost., (Copyright © 2019 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Although the anterior approach for total hip arthroplasty has gained increasing utilization, some studies have suggested a higher risk of femoral complications, as well as difficulty with femoral exposure. Techniques of soft tissue releases have been described to offer better femoral exposure, and to help mitigate complications. The purpose of the study is to describe an algorithmic soft tissue femoral release in direct anterior approach total hip arthroplasty and to assess the clinical outcomes of patients upon which this algorithm of femoral soft tissue releases was utilized. Clinical outcomes with the Harris Hip Score, reoperation rates, component survivorship, and complications were analyzed., (© 2019 The Authors.)

Acetabular dysplasia, related to developmental dysplasia of the hip, causes the abnormal distribution of hip joint forces. Surgical correction of acetabular dysplasia involves repositioning the acetabulum to achieve improved coverage of the femoral head. However, ideal placement of the acetabular fragment is challenging, and has led to an increased interest in pre-operative planning modalities. In this study, we used the PubMed and EBSCO host databases to systematically review all the modalities for pre-operative planning of acetabular dysplasia proposed in the current literature. We included all case-series, English, full-text manuscripts pertaining to pre-operative planning for congenital acetabular dysplasia. Exclusion criteria included: total hip arthroplasty (THA) planning, patient population mean age >35, and double/single case studies. A total of 12 manuscripts met our criteria for a total of 186 hips. Pre-operative planning modalities described were: Amira (Thermo Fischer Scientific; Waltham, MA, USA) 12.9%, OrthoMap (Stryker Orthopaedics; Mahwah, NJ, USA) 36.5%, Amira + Biomechanical Guidance System 5.9%, Mills et al. method 16.1%, Klaue et al. method 16.1%, Armand et al. method 6.5%, Tsumura et al. method 3.8% and Morrita et al. method 2.2%. As a whole, there was a notable lack of prospective studies demonstrating these modalities' efficacy, with small sample sizes and lack of commercial availability diminishing their applicability. Future studies are needed to comprehensively compare computer-assisted planning with traditional radiographic assessment of ideal osteotomy orientation., (© The Author(s) 2019. Published by Oxford University Press.)

The Bernese periacetabular osteotomy (PAO) is a well-established procedure for the management of symptomatic hip dysplasia. The associated Smith-Petersen exposure offers excellent visualization of the acetabulum and control of acetabular osteotomy and mobilization. The traditional exposure of the true pelvis involves osteotomy of the iliac wing in order to mobilize the sartorial and inguinal ligament insertion. However, full osteotomy of the iliac spine may necessitate screw fixation if a relatively large segment of bone is included. A known complication with screw fixation of the iliac wing osteotomy involves failure of fixation and screw back out. Moreover, the screw may irritate the patient even in the setting of adequate fixation. A larger osteotomy may also injure the lateral femoral cutaneous nerve (LFCN) as it travels near the anterior-superior spine. To minimize the risk of these potential complications, a wafer osteotomy may be used to develop a sleeve of tissue involving the sartorial insertion. This sleeve also mobilizes the entirety of the LFCN medially and affords protection throughout the procedure. Furthermore, the wafer osteotomy may be re-fixed to the stable pelvis during closure with simple heavy suture fixation alone, avoiding screw insertion or associated removal. Because only a wafer or bone is taken during the spine osteotomy, more bone is available at the anterior-superior iliac spine for fixation of the mobile fragment after repositioning. In this technical note, we describe the wafer osteotomy technique in further detail., (© The Author(s) 2019. Published by Oxford University Press.)