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Background: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures., Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures ( n  = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes., Results: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality., Discussion: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RM: Paid consultant/presenter/speaker: Stryker; research support: Stryker, Zimmer, all outside of the submitted work.VK: Receives publishing royalties (Journal of Arthroplasty); Receives IP royalties: Stryker; Paid consultant: Stryker, all outside of the submitted work.NP: Paid consultant: Stryker; Receives research support: Osteal Therapeutics, RegenLab, Signature Orthopaedics, Zimmer. all outside of the submitted work.All other authors declare that there is no conflict of interest.

Background: It is crucial to understand weight trends in patients undergoing total hip arthroplasty (THA)., Objective: To evaluate preoperative and postoperative weight trends for patients undergoing primary THA and factors associated with clinically significant weight change., Methods: A prospective cohort who underwent primary unilateral THA (n= 3,011) at a tertiary healthcare system (January 2016 to December 2019) were included in the study. The primary outcomes were clinically significant weight change (> 5% change in body mass index [BMI]) during the one-year preoperative and one-year postoperative periods., Results: Preoperatively, 66.6% maintained a stable weight, 16.0% gained and 17.4% lost weight, respectively. Postoperatively, 64.0% maintained a stable weight, while 22.6% gained and 13.4% lost weight, respectively. Female sex, Black race, obesity, higher Charlson Comorbidity Index (CCI) scores, and older age were associated with preoperative weight loss. Female sex, obesity, higher CCI scores, and Medicare insurance were associated with postoperative weight loss. Preoperative weight loss was associated with postoperative weight gain (OR = 3.37 [CI: 2.67 to 4.25]; p< 0.001), and preoperative weight gain was associated with postoperative weight loss (OR = 1.74 [CI: 1.30 to 2.3]; p< 0.001)., Conclusion: Most patients maintained a stable BMI one-year before and one-year after THA. Several factors are associated with weight loss before and after THA. Preoperative weight changes were associated with a reciprocal rebound in BMI post-operatively.

Background: The value of robotic-assisted total hip arthroplasty (rTHA) has yet to be determined compared to conventional manual THA (mTHA)., Objective: Evaluate 90-day inpatient readmission rates, rates of reoperation, and clinically significant improvement of patient-reported outcome measures (PROMs) at 1-year in a cohort of patients who underwent mTHA or rTHA through a direct anterior (DA) approach., Methods: A single-surgeon, prospective institutional cohort of 362 patients who underwent primary THA for osteoarthritis via the DA approach between February 2019 and November 2020 were included. Patient demographics, surgical time, discharge disposition, length of stay, acetabular cup size, 90-day inpatient readmission, 1-year reoperation, and 1-year PROMs were collected for 148 manual and 214 robotic THAs, respectively., Results: Patients undergoing rTHA had lower 90-day readmission (3.74% vs 9.46%, p= 0.04) and lower 1-year reoperation (0.93% vs 4.73% mTHA, p= 0.04). rTHA acetabular cup sizes were smaller (rTHA median 52, interquartile range [IQR] 50; 54, mTHA median 54, IQR 52; 58, p< 0.001). Surgical time was longer for rTHA (114 minutes vs 101 minutes, p< 0.001). At 1-year post-operatively, there was no difference in any of the PROMs evaluated., Conclusion: Robotic THA demonstrated lower 90-day readmissions and 1-year reoperation rates than manual THA via the DA approach. PROMs were not significantly different between the two groups at one year.

Background: Mortality after total hip arthroplasty (THA) is a rare but devastating complication. This meta-analysis aimed to: (1) determine the mortality rates at 30 days, 90 days, 1 year, 5 years and 10 years after THA; (2) identify risk factors and causes of mortality after THA., Methods: Pubmed, MEDLINE, Cochrane, EBSCO Host, and Google Scholar databases were queried for studies reporting mortality rates after primary elective, unilateral THA. Inverse-proportion models were constructed to quantify the incidence of all-cause mortality at 30 days, 90 days, 1 year, 5 years and 10 years after THA. Random-effects multiple regression was performed to investigate the potential effect modifiers of age (at time of THA), body mass index, and gender., Results: A total of 53 studies (3,297,363 patients) were included. The overall mortality rate was 3.9%. The 30-day mortality was 0.49% (95% CI; 0.23-0.84). Mortality at 90 days was 0.47% (95% CI, 0.38-0.57). Mortality increased exponentially between 90 days and 5 years, with a 1-year mortality rate of 1.90% (95% CI, 1.22-2.73) and a 5-year mortality rate of 9.85% (95% CI, 5.53-15.22). At 10-year follow-up, the mortality rate was 16.43% (95% CI, 1.17-22.48). Increasing comorbidity indices, socioeconomic disadvantage, age, anaemia, and smoking were found to be risk factors for mortality. The most commonly reported causes of death were ischaemic heart disease, malignancy, and pulmonary disease., Conclusions: All-cause mortality remains low after contemporary THA. However, 1 out of 10 patients and 1 out of 6 patients were deceased after 5 years and 10 years of THA, respectively. As expected, age, but not BMI or gender, was significantly associated with mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RM: paid speaker at Stryker; paid consultant at Stryker; Research support from: Stryker, Zimmer.NS: paid consultant for Stryker; Research support from: RegenLab, Zimmer, Signature Orthopaedics, Osteal Therapeutics.All other authors declare that there is no conflict of interest.

Case: This is a case of a 71-year-old female patient with recurrent instability and complex hip abductor deficiency after total hip arthroplasty (THA) who was treated successfully with an abductor reconstruction with gluteal transfer with mesh reconstruction. The patient returned to nonassisted ambulation with no further THA dislocations at the 1-year follow-up., Conclusion: Abductor deficiencies after THA are complex and have a high potential for long-term disability if not properly diagnosed and treated. A modified gluteal transfer with mesh reconstruction and distal fixation with cerclage cable allowed for sustained restoration of functional hip abduction and stability after revision THA., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C208)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: An 84-year-old woman presented 6 years after revision total hip arthroplasty (rTHA) with worsening hip pain and a Paprosky classification IIIB femoral defect. rTHA was performed using a proximal femur replacement. Given her osteoporosis and poor bone stock, a tibial cone and impaction grafting (IG) were used for megaprosthesis fixation. At the 33-month follow-up, the patient was pain-free and radiographs demonstrated a well-fixed implant., Conclusion: In the setting of massive defects of poor-quality bone, novel use of a tibial cone and IG can be implemented to achieve implant fixation and maximize patient outcomes., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C174)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Revision total hip arthroplasty (THA) is a challenging procedure that burdens the healthcare system. Despite being associated with worse outcomes relative to its primary counterpart, postoperative mortality after revision THA remains ill-defined. The present study aimed to (1) establish the overall 30-day mortality rate after revision THA and (2) explore the mortality rate stratified by age, comorbidity burden, and aseptic versus septic failure., Methods: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent revision THA from 2011 to 2019. A total of 23,501 patients were identified and grouped into mortality ( n   =  161) and mortality-free ( n   =  23,340) cohorts. Patient demographics, comorbidities, and aseptic/septic failure were evaluated., Results: The overall 30-day mortality was 0.69%. The mortality rate by age group (normalised per 1000 patients) was 0 (18-39 years [Y]), 0.67 (40-49 Y), 1.10 (50-59 Y), 2.58 (60-69 Y), 6.15 (70-79 Y) 19.32 (80-89 Y), and 58.22 (90+Y) ( p   <  0.001). The mortality rate by ASA classification (normalised per 1000 patients) was 0 (ASA I), 1.47 (ASA II), 6.94 (ASA III), 45.42 (ASA IV), and 200 (ASA V) ( p   <  0.001). The 30-day mortality rate for the septic and aseptic cohorts was 1.03% and 0.65%, respectively ( p   =  0.038). CCI scores ( p   <  0.001), diabetes ( p   <  0.001), systematic sepsis ( p   <  0.001), poor functional status ( p   <  0.001), BMI < 24.9 kg/m 2 ( p   <  0.001), and dirty/infected wounds ( p   <  0.001) were all associated with increased mortality risk., Conclusions: 1 in 145 patients will suffer mortality during the 30 days after revision THA. PJI-related revision THA was associated with 1.5-fold increase in 30-day mortality rate compared to its aseptic counterpart. Certain patient determinants and baseline comorbidities, as measured by ASA and CCI scores, were associated with higher 30-day mortality rates. Therefore, it is imperative to identify such risk factors and implement perioperative patient optimisation pathways to mitigate the risk among vulnerable patients.

Background: The present study aimed to determine the distribution of Veterans RAND 12-Item health survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher health care utilizations and 1-year patient-reported outcome measures (PROMs)., Methods: A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (nonhome discharge, prolonged length of stay [LOS](ie, ≥3 days), all-cause readmission), attainment of patient acceptable symptom state (PASS) at 1-year postoperative and substantial clinical benefit (SCB) in the hip disability osteoarthritis outcome score (HOOS)-pain and HOOS-physical short form., Results: Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all P < .001). Preoperative VR-12 MCS<20 was associated with more than twice the odds of nonhome discharge (odds ratio [OR]:2.31) and prolonged LOS (OR: 3.46). VR-12 MCS >60 was associated with higher odds of achieving PASS (OR: 2.00) and SCB in HOOS-joint related (JR) (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes., Conclusion: Low preoperative VR-12 MCS, specifically less than 40, may predict increased health care utilization. Furthermore, preoperative VR-12 MCS>60 predicts greater satisfaction at 1 year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared decision-making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA., Level of Evidence: II., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon., Methods: A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs., Results: Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS., Conclusions: Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

Background: Decreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days., Results: When comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD., Conclusion: The unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA., Level of Evidence: III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address., Questions/purposes: The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes., Methods: Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI., Results: In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 [95% confidence interval (CI) 0.31 to 0.59]; p < 0.001) and nonhome discharge (OR 0.39 [95% CI 0.27 to 0.56]; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 [95% CI -0.063 to -0.026]; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 [95% CI 0.024 to 0.059]; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 [95% CI -0.13 to -0.024]; p = 0.004; nonhome discharge: 0.060 [95% CI 0.016 to 0.11]; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 [95% CI 0.32 to 0.54]; p < 0.001), nonhome discharge (OR 0.44 [95% CI 0.33 to 0.60]; p < 0.001), 90-day readmission (OR 0.54 [95% CI 0.39 to 0.77]; p < 0.001), and 90-day ED admission (OR 0.60 [95% CI 0.45 to 0.79]; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 [95% CI -0.035 to -0.007]; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 [95% CI -0.016 to 0.040]; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 [95% CI -0.13 to -0.049]; p < 0.001; nonhome discharge: 0.046 [95% CI 0.014 to 0.078]; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group., Conclusion: Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage., Level of Evidence: Level III, therapeutic study., Competing Interests: The authors certify 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: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches., Methods: A prospective consecutive series of primary THA for osteoarthritis ( n  = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA ( n  = 913; 38%), AL/DL ( n  = 505; 21%), or PL ( n  = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed., Results: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain ( p  = 0.002). Approach was not a significant factor for 1-year HOOS-PS ( p  = 0.16) or 1-year UCLA activity ( p  = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach ( p   >  0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively ( p   <  0.05)., Conclusions: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

➢: Periprosthetic acetabular fractures are uncommon and infrequently the focus of studies., ➢: Acetabular fractures are occasionally recognized postoperatively when patients report unremitting groin pain weeks after surgery., ➢: The widespread use of cementless acetabular cups might lead to a higher number of fractures than are clinically detectable., ➢: Appropriate recognition, including mindfulness of preoperative patient and surgical risk factors, is critical to the successful management of acetabular complications., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A850)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Evaluating trends and drivers of baseline patient-reported outcome measures (PROMs) is critical to understanding when patients and providers elect to undergo surgery. We aimed to assess the following: (1) 5-year trends in baseline PROMs pre-THA (total hip arthroplasty) stratified by patient determinants; (2) patient factor associated with poor preoperative hip pain/function; (3) phenotypes of combined pain/function PROMs at baseline; and (4) intersurgeon variability in PROM thresholds at surgery., Methods: A prospective cohort of 6,902 primary THAs was enrolled (January 2016 to December 2020). Patient/surgeon details and PROMs were collected at point of care preoperatively. Outcomes included trends (5 years; 20 quarters) in Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS-PS (Physical Function Short-Form), stratified by patient demographics. Patients were further classified into phenotype categories of above or equal to median pain/function (P+PS+); below median pain/function (P-PS-); above or equal to median pain but below median function (P+PS-); and below median pain but above or equal to median function (P-PS+)., Results: Baseline HOOS-Pain was consistent across the study period (P-trend = .166), while HOOS-PS demonstrated increasing function (P-trend = .015). Such trends were appreciable in males, females, and White (P-trend < .001, each) but not Black patients (P-trend = .67). Higher odds ratio (OR) of low baseline HOOS-Pain and HOOS-PS were detected among females (HOOS-Pain: OR 1.75, 95% confidence interval [CI] 1.55-1.98, P < .001; HOOS-PS: OR 1.56, 95% CI 1.38-1.77, P < .001), Black patients (HOOS-Pain: OR 1.64, 95% CI 1.35-2.82, P < .001; HOOS-PS: OR 1.59, 95% CI 1.34-1.89, P < .001), and smokers (HOOS-Pain: OR 1.56, 95% CI 1.29-1.89, P < .001; HOOS-PS: OR 1.52, 95% CI 1.25-1.85, P < .001). The P-PS- cohort (32.4%) had lowest age (65.2 ± 11.1 years), highest body mass index (31.6 ± 6.9 kg/m 2 ), females (64.8%), Black (15.8%), and current smokers (12.2%). There was significant intersurgeon preoperative PROM variation in HOOS-Pain and HOOS-PS (P < .001, each)., Conclusion: In contrast to the general population, Black patients have consistently received THA at lower functional levels throughout the 5-year period. Females, smokers, and Black patients were more likely to have poorer pain and function at THA. PROMs assessment as combined pain-function phenotypes may provide a more comprehensive interpretation of patient status preoperatively., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Venous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission., Methods: The Agency of Healthcare Research and Quality's National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities., Results: Higher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05)., Conclusion: One in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE complications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

»: As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function., »: Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise., »: Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function., »: Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status., »: Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A807)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Work relative value units (wRVUs) measure a surgeon's time and intensity required to perform the pre-service, intra-service, and post-service work of a surgical procedure and are commonly used to compare a physician's work between different procedures. Previous literature across multiple specialties report that longer, often revision, operations are undervalued when compared to primary procedures. Our study aims to analyze the differences in intra-operative time, and its corresponding wRVU/h between the Medicare benchmarks and real-world time-stamped data for total joint arthroplasty procedures., Methods: Thirteen primary and revision hip and knee arthroplasty procedures were identified, and intra-operative times were collected using the National Surgical Quality Improvement Program databases from 2014 to 2019. The Relative Value Scale Update Committee's (RUC) estimated median intra-operative times for each procedure was compared to the calculated median intra-operative times from National Surgical Quality Improvement Program, as were their corresponding wRVU/h. Procedures were additionally stratified by "long" (>110 minutes) and "short" (≤110 minutes) intra-operative times., Results: The RUC over-estimated intra-operative time by 35.24% on average and this overestimation was more profound in longer operations than shorter operations (47.75% vs 15.22%, P = .011). The RUC intensity per unit time values (wRVU/h) between "long" and "short" procedures were significantly different (P < .001) and showed the undervaluation of intensity for the longer procedures by an average of 3.47 wRVU/h., Conclusion: Our study provides further evidence that physician work is undervalued in revision total hip and knee surgeries., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: YouTube has become a popular platform for disseminating health-related information. However, the quality of such videos has never been assessed based on video source (author). Therefore, the current investigation aimed to quantitatively analyze the (1) accuracy, (2) reliability, (3) quality, and (4) content of total knee (TKA) and hip (THA) arthroplasty videos as a platform for patient information, based on video source., Methods: YouTube was queried (May 13, 2020) for TKA and THA videos. Top viewed 55 TKA and 50 THA relevant videos were stratified by source (ie, academic, physician, nonphysician/trainer, patient, and commercial). The Journal of the American Medical Association criteria were used to assess reliability, whereas DISCERN and TKA/THA content-specific scores assessed content quality. Two-sample t-tests and regression analyses assessed score variations based on video sources., Results: Mean TKA and THA video durations were 11.5 and 13.7 minutes, respectively. TKA and THA academic/physician videos demonstrated higher Journal of the American Medical Association scores relative to nonphysician videos (P < 0.001). Overall, TKA and THA mean DISCERN scores were 50.6 of 80 and 54.7 of 80 points, with significant differences between academic versus nonphysician videos (TKA: 59.9 versus 42.7, THA: 54.7 versus 31.5, P < 0.001). Regression analyses revealed that physician videos had higher odds ratio (OR) of excellent DISCERN score than nonphysician videos for TKA (OR: 8.8; 95% confidence interval: 1.4 to 55.6; P = 0.019) and THA (OR: 10.8; 95% confidence interval: 2.5 to 45.5; P = 0.001). TKA and THA mean content scores were 8.4 of 15 and 8.6 of 15, with significant differences between academic and nonphysician videos (TKA: 10.6 versus 5.8, THA: 8.6 versus 4.6; P < 0.001)., Conclusion: Reliability, quality, and content of YouTube TKA and THA videos demonstrate marked variation. Academic and physician videos demonstrated fair to good quality and were more likely to attain a good/excellent score. Healthcare providers may direct patients to view higher quality videos., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: This study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts?, Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis., Results: The 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001)., Conclusion: The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort., Level of Evidence: III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored., Questions/purposes: (1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes?, Methods: Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA., Results: After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02)., Conclusion: Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility., Level of Evidence: Level III, diagnostic study., Competing Interests: Each author certifies that neither he or she, nor any member of his or her 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 © 2021 by the Association of Bone and Joint Surgeons.)

Introduction: The broad aim of this study was to compare the safety and efficacy of using barbed sutures and running closure versus interrupted placement of standard of care sutures for closure of the arthrotomy during total hip arthroplasty (THA). Specifically, we compared duration of arthrotomy closure, the number of sutures utilised for arthrotomy closure, and 90-day outcomes including wound-related readmission, reoperation, and complications., Methods: A total of 60 patients undergoing 60 THAs were enrolled in a prospective, single-blinded trial and randomised to receive either running closure of the arthrotomy with barbed sutures ( n = 30) or interrupted closure with standard of care sutures ( n = 30). Patients were eligible if they were undergoing primary THA for osteoarthritis and excluded if they had a BMI > 45 kg/m 2 or age > 80 years or <18 years., Results: Arthrotomy closure duration was significantly shorter in the barbed suture group (3 minutes ± 9 seconds) versus the standard of care group (8 minutes ± 26 seconds, p < 0.001). The suture utilisation for arthrotomy closure was 1 suture in the barbed sutured group 28/30 (93%) patients versus 2-4 sutures in 27/30 (90%) in the standard of care group ( p < 0.001). The overall number of wound-related complications in the barbed suture group was 1/30 (3%) versus 1/30 (3%) in the standard of care group ( p = 1.00). The rate of suture abscesses was 1/30 (3%) in barbed suture group versus the standard of care ( p = 1.00). There was trochanter bursitis 1/30 (3%) in the standard of care group versus zero in the barbed suture group ( p = 1.00)., Conclusions: These results suggest that barbed suture utilisation may be faster and more resource efficient than use of standard of care sutures for arthrotomy closure in THA.ClinicalTrials.gov Identifier: NCT03285555.

Background: An overall assessment of how patient demographic characteristics and comorbidities are improving or worsening can allow better understanding of the value of revision total joint arthroplasty (TJA). Therefore, the purpose of this study was to identify patient demographic characteristics and comorbidities trends and episode-of-care outcome trends from 2008 to 2018 in patients undergoing revision TJA., Methods: The National Surgical Quality Improvement Program database was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes in patients undergoing revision TJA from 2008 to 2018 (n = 45,706). Pairwise t tests and pairwise chi-square tests were performed on consecutive years with Bonferroni correction. Trends were assessed using the 2-tailed Mann-Kendall test of the temporal trend., Results: Among patients undergoing revision TJA, there was no clinically important difference, from 2008 to 2018, in age, body mass index (BMI), percentages with >40 kg/m2 BMI, diabetes (18.8% to 19%), chronic obstructive pulmonary disease (4.1% to 5.4%), congestive heart failure within 30 days (0% to 1%), or acute renal failure (0% to 0.2%). However, modifiable comorbidities including smoking status (14.7% to 12.0%; p = 0.01), hypertension (66% to 26.0%; p = 0.02), anemia (34.5% to 26.3%; p < 0.001), malnutrition (10.4% to 9.3%; p = 0.004), and overall morbidity or mortality probability have improved, with a decrease in the hospital length of stay and 30-day readmission and a significant increase in home discharge (p < 0.001 for all)., Conclusions: Time-difference analysis demonstrated that the overall health status of patients undergoing revision TJA improved from 2008 to 2018. However, formal time-trend analysis demonstrated improvements to a lesser degree. The multidisciplinary effort to improve value-based metrics including patient comorbidity optimization and episode-of-care outcomes for primary TJA has been shown to potentially have an impact on revision TJA., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G522)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

»: Dressing choice following lower-extremity total joint arthroplasty has substantial ramifications for postoperative outcomes and should be carefully made to prevent complications such as periprosthetic joint infection., »: Patient risk factors are essential components in the selection of wound dressings in total joint arthroplasty., »: Traditional dressings are inexpensive per unit; nevertheless, the associated higher complication profile in patients at a high risk for poor wound healing and sequelae-associated costs may outweigh the up-front savings., »: Modern dressings have the potential to yield better safety outcomes and increased patient satisfaction; however, there is a paucity of evidence regarding the ideal interactive dressing., »: Active dressings, such as silver-ion dressings and closed-incisional negative-pressure wound therapy, have shown promising results to reduce surgical site and periprosthetic joint infection, especially in patients at a high risk for poor wound healing following hip and knee total joint arthroplasty., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A721)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The surgical management of complications surrounding patients who have undergone hip arthroplasty necessitates accurate identification of the femoral implant manufacturer and model. Failure to do so risks delays in care, increased morbidity, and further economic burden. Because few arthroplasty experts can confidently classify implants using plain radiographs, automated image processing using deep learning for implant identification may offer an opportunity to improve the value of care rendered., Methods: We trained, validated, and externally tested a deep-learning system to classify total hip arthroplasty and hip resurfacing arthroplasty femoral implants as one of 18 different manufacturer models from 1972 retrospectively collected anterior-posterior (AP) plain radiographs from 4 sites in one quaternary referral health system. From these radiographs, 1559 were used for training, 207 for validation, and 206 for external testing. Performance was evaluated by calculating the area under the receiver-operating characteristic curve, sensitivity, specificity, and accuracy, as compared with a reference standard of implant model from operative reports with implant serial numbers., Results: The training and validation data sets from 1715 patients and 1766 AP radiographs included 18 different femoral components across four leading implant manufacturers and 10 fellowship-trained arthroplasty surgeons. After 1000 training epochs by the deep-learning system, the system discriminated 18 implant models with an area under the receiver-operating characteristic curve of 0.999, accuracy of 99.6%, sensitivity of 94.3%, and specificity of 99.8% in the external-testing data set of 206 AP radiographs., Conclusions: A deep-learning system using AP plain radiographs accurately differentiated among 18 hip arthroplasty models from four industry leading manufacturers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Total hip and knee arthroplasty are common major orthopedic operations being performed on an increasing number of patients. Many patients undergoing total joint arthroplasty (TJA) are on chronic antithrombotic agents due to other medical conditions, such as atrial fibrillation or acute coronary syndrome. Given the risk of bleeding associated with TJAs, as well as the risk of thromboembolic events in the post-operative period, the management of chronic antithrombotic agents perioperatively is critical to achieving successful outcomes in arthroplasty. In this review, we provide a concise overview of society guidelines regarding the perioperative management of chronic antithrombotic agents in the setting of elective TJAs and summarize the recent literature that may inform future guidelines. Ultimately, antithrombotic regimen management should be patient-specific, in consultation with cardiology, internal medicine, hematology, and other physicians who play an essential role in perioperative care.

Patients undergoing total hip and knee arthroplasty are at high risk for venous thromboembolism (VTE) with an incidence of approximately 0.6-1.5%. Given the high volume of these operations, with approximately one million performed annually in the U.S., the rate of VTE represents a large absolute number of patients. The rate of VTE after total hip arthroplasty has been stable over the past decade, although there has been a slight reduction in the rate of deep venous thrombosis (DVT), but not pulmonary embolism (PE), after total knee arthroplasty. Over this time, there has been significant research into the optimal choice of pharmacologic VTE prophylaxis for individual patients, with the objective to reduce the rate of VTE while minimizing adverse side effects such as bleeding. Recently, aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents. However, there is no evidence to date that clearly demonstrates the superiority of any given prophylactic agent. Therefore, this review discusses (1) the current prevalence and trends in VTE after total hip and knee arthroplasty and (2) provides an update on pharmacologic VTE prophylaxis in regard to aspirin usage.

Aims: Thresholds for operative eligibility based on body mass index (BMI) alone may restrict patient access to the benefits of arthroplasty. The purpose of this study was to evaluate the relationship between BMI and improvements in patient-reported outcome measures (PROMs), and to determine how many patients would have been denied improvements in PROMs if BMI cut-offs were to be implemented., Methods: A prospective cohort of 3,449 primary total hip arthroplasties (THAs) performed between 2015 and 2018 were analyzed. The following one-year PROMs were evaluated: hip injury and osteoarthritis outcome score (HOOS) pain, HOOS Physical Function Shortform (PS), University of California, Los Angeles (UCLA) activity, Veterans Rand-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (VR-12 MCS). Positive predictive values for failure to improve and the number of patients denied surgery in order to avoid a failed improvement were calculated for each PROM at different BMI cut-offs., Results: There was a trend to improved outcomes in terms of pain and function improvements with higher BMI. Patients with BMI ≥ 40 kg/m 2 had median (Q1, Q3) HOOS pain improvements of 58 points (interquartile range (IQR) 41 to 70) and those with BMI 35 to 40 kg/m 2 had median improvements of 55 (IQR 40 to 68). With a BMI cut-off of 30 kg/m 2 , 21 patients would have been denied a meaningful improvement in HOOS pain score in order to avoid one failed improvement. At a 35 kg/m 2 cut-off, 18 patients would be denied improvement, at a 40 kg/m 2 cut-off 21 patients would be denied improvement, and at a 45 kg/m 2 cut-off 21 patients would be denied improvement. Similar findings were observed for HOOS-PS, UCLA, and VR-12 scores., Conclusion: Patients with higher BMIs show greater improvements in PROMs. Using BMI alone to determine eligibility criteria did not improve the rate of clinically meaningful improvements. BMI thresholds prevent patients who may benefit the most from surgery from undergoing THA. Surgeons should consider PROMs improvements in determining eligibility for THA while balancing traditional metrics of preoperative risk stratification. Cite this article: Bone Joint J 2020;102-B(6):683-692.

Background: Establishing an association between postoperative outcomes and the spectrum of renal function would allow for more informed decisions to manage surgical risks and improved patient-specific care. Estimated glomerular filtration rate (eGFR) can be calculated from standard prescreening measurements to gauge renal function. This work investigates the effect of eGFR, as a continuous and categorical variable, on mortality and major and minor complications in patients undergoing revision total knee and hip arthroplasty., Methods: 25,056 patients having undergone revision total hip and knee arthroplasty from 2013 to 2016 were identified using the National Quality Improvement Program database. The investigated outcomes included 30-day mortality, major complications, and minor complications. Multivariate regression models were created to evaluate the effect of eGFR on the outcomes of interest. Multivariate spline regressions were generated to assess for nonlinear relationships between eGFR as a continuous variable and the outcomes., Results: Our study revealed that as eGFR decreased <60 mL/min/1.73 m 2 , mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001) increased. Patients with eGFR 15-30 mL/min/1.73 m 2 had increased risk for mortality (P = .033). There was an increased risk for any major complication at an eGFR 30-60 and <15 mL/min/1.73 m 2 , (P < .05). There was an increased risk of minor complications for those with hyperfiltration and <60 mL/min/1.73 m 2 ., Conclusion: Patients with lower preoperative eGFR generally display an increased risk for complications after revision total hip and knee arthroplasty. Proper consideration should be given to this patient population before surgical intervention to allow for preventative measures to be taken to improve patient outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Chronic kidney disease (CKD) is a relatively common comorbidity that has been shown to adversely affect outcomes in total hip arthroplasty (THA), as well as to increase the procedure's total costs. However, the effect of different stages of kidney disease and the association of estimated glomerular filtration rate (eGFR) with perioperative THA complications are less understood. Therefore, the aims of this study were to investigate the relationships between eGFR, both as a categorical and continuous variable and 30-day outcomes and complications., Methods: The National Surgical Quality Improvement Program database was used to identify 101,925 primary THAs between January 1, 2008, and December 31, 2016. The following outcomes were assessed: 30-day mortality, 30-day major complications, 30-day minor complications, specific complications, and discharge disposition. To evaluate the effect of eGFR status on outcomes and complication, multivariate regression models were created to adjust for differences in patient demographics and comorbidities. In addition, multivariate spline regressions were developed to assess the nonlinear relationships between eGFR as a continuous variable and the outcomes of interest., Results: Our study revealed that as eGFR decreases to <30 mL/min/1.73 m 2 , there is an increased risk for mortality and nonhome discharge (P < .05). There was an increased risk for any major complication and any minor complication as well as several specific medical complications such as transfusion and myocardial infarction (P < .05) for an eGFR of <60 mL/min/1.73 m 2 . Patients' eGFR had a nonlinear relationship with mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001), as well as a number of other specific medical complications. Once the eGFR, <60 mL/min/1.73 m 2 the increase was exponential for mortality, major complications, and minor complications. For example, mortality increased of 900% for <15 mL/min/1.73 m 2 or on dialysis, 600% for 15 to 30 mL/min/1.73 m 2 and 50% for 30 to 60 mL/min/1.73 m 2 . Similarly, nonlinear relationships were discovered between eGFR and nonhome discharge (P < .001)., Conclusion: Patients with lower eGFR, and in particular those with <30 mL/min/1.73 m 2 , are more likely to sustain medical complications and have 6 to 9 times higher mortality than patients with normal eGFR. THA patients with CKD should be appropriately counseled and advised on the risk of postoperative complications by using eGFR as a screening tool., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis [DVT] and/or pulmonary embolism [PE] in the same patient), DVT, PE, and mortality in the 30-day period after rTKA and rTHA., Methods: We identified 30,406 rTKA and rTHA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest., Results: The overall incidences of 30-day VTE, DVT, PE, and mortality for rTKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in rTHA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period., Conclusion: Within 30 days of surgery, approximately 1 in 83 rTKA patients and 1 in 100 rTHA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in rTKA and rTHA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in rTHA and rTKA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience., Methods: A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores., Results: In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient., Conclusion: TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to identify factors affecting operative times and to evaluate the associations of operative times with prosthetic joint infections (PJIs) and surgical site infections (SSIs) in primary total knee arthroplasty., Methods: A total of 11,840 primary total knee arthroplasties with a mean 2-year post-operative follow-up were studied. Operative times were analyzed both as categorical and continuous variables. Associations with PJIs and SSIs were evaluated with univariate and multivariate analyses to adjust for gender, age, body mass index, Charlson Comorbidity Index, year of surgery, antibiotic cement use, and hospital/surgeon volume., Results: The longest cases (>121 minutes) were associated with patients who were younger (P < .001) and had a higher body mass index (P < .001). PJI rates were higher in cases >121 minutes (1.4%) compared to those <85 minutes (0.3%, P < .001). SSI rates were also highest (3.8%) in cases >121 minutes (P < .001). Cases complicated by PJIs (135 ± 47 minutes) had longer mean operative times compared to non-infected cases (105 ± 32 minutes, P < .001). Patients with subsequent SSIs also had longer mean operative times (P < .001). Multivariate analyses revealed an 18% increased risk for PJIs and an 11% increased risk for SSIs for every 15-minute increase in operative time., Conclusion: Identifying risk factors for infection that are as easily measurable and modifiable as procedure duration can aid in risk-stratifying post-operative surveillance. This study demonstrated that longer operative times were an independent predisposing factor for both PJIs and SSIs even after accounting for patient and procedure-related factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: It has been established by previous studies that longer operative times can lead to higher rates of complications and poorer outcomes after total hip arthroplasty (THA). However, these studies were heterogeneous, examined limited complications, and have not provided a clear time after which complications increase. The aims of this study were to (1) assess whether longer operative time increases risk of complications within 30 days of THA, (2) investigate the relationship between operative time and various complications after THA, and (3) identify possible operative times beyond which complication rates increase., Methods: The National Surgical Quality Improvement Project database was queried to identify 89,802 procedures that were included in the final analysis. The effect of operative time on complications within 30 days was evaluated using multivariate logistic regression models. Spline regression models were created to investigate the relationship between operative time and complications., Results: Longer operative times were associated with higher risk of readmissions (P < .001), reoperations (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), renal or systemic complications (P < .001), and blood transfusion (P < .001). A linear relationship was observed between operative time and readmission, reoperation, surgical site infection, and transfusions with increased rate of these complications when the operative time exceeded 75 to 80 minutes. Venous thromboembolic complications had a U-shaped relationship with operative time with the trough around 90 to 100 minutes., Conclusion: While our findings cannot establish a clear cause and effect relation, they do suggest strong correlation between increased operative time and perioperative complications. Additionally, this study suggests an optimal time of approximately 80 minutes, as a goal for surgeons, that may be associated with less risk of complications following THA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications., Methods: A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively., Results: The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 [23.8%] vs 8 [10.1%], P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 [23.8%] vs 16 [20.3%], P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 [12.5%] vs 2 [2.5%], P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68)., Conclusion: ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Thirty-day hospital readmissions following total hip arthroplasty (THA) have received increasing scrutiny by policy makers and hospitals. Emergency department (ED) visits may not necessarily result in an inpatient readmission but can be a measure of performance and can incur costs to the health system. The purpose of this study is to describe the following: (1) the frequency and subsequent disposition; (2) patient characteristics; (3) reasons; and (4) potential risk factors for ED visits that did not result in a readmission within 30 days of discharge after THA., Methods: All primary THAs performed at a large healthcare system between 2013 and 2015 were identified. Patients who received unplanned hospital services for complications within 30 days following surgery were identified and analyzed. A multiple regression analysis was utilized to identify risk factors predisposing for returning to the ED without readmission., Results: From a total of 6270 primary THAs, 440 patients (7%) had an unplanned return to the hospital within 30 days. Of those, 227 (3.6%) patients presented to the ED and were not readmitted. Higher percentage of African Americans was noted among patients who returned to the ED versus those who did not (20.2% vs 9.8%, P < .01). The most common medical diagnoses were nonspecific medical symptoms (24.8%) followed by minor gastrointestinal problems (10.5%). The most common surgery-related diagnoses were pain and swelling (35%), followed by wound complications (12%) and hip dislocations (7.3%). Nearly 50% of wound complications and 40% of hip dislocations were managed and discharged from the ED without a readmission. Both African Americans (odds ratio 2.28, 95% confidence interval 1.55-3.36) and home discharge (odds ratio 1.90, 95% confidence interval 1.28-2.82) were independent risk factors for return to the ED without readmission., Conclusion: ED visits that do not result in hospital readmissions, many of which may be due to serious complications, are more frequent than inpatient readmission. This is extremely relevant to policy makers and quality metrics, especially as comprehensive and bundled payment initiatives become more prevalent., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Multiple recent reports have indicated a rising awareness of trunnionosis-related implant failures, accounting for up to 3% of all total hip arthroplasty revisions. Moreover, aseptic loosening and osteolysis from local release of metal debris can be the presenting manifestations, and thus the true incidence of trunnionosis is thought to be underreported. Furthermore, the relatively unclear and multifactorial pathogenesis and the widely variable clinical presentations pose a diagnostic challenge. A consensus regarding the ideal intervention and its timing is also lacking. Because of the relative paucity of reports regarding the diagnosis and management of trunnionosis, we conducted this evidence-based review to evaluate the (1) incidence, (2) pathogenesis, (3) diagnosis, and (4) treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty. We then propose an algorithm for the diagnostic work-up and management of this condition., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: At the 2017 annual meeting of the American Association of Hip and Knee Surgeons (AAHKS), a survey was conducted to assess current practice management strategies by AAHKS members., Methods: During the annual AAHKS meeting, a survey was conducted using an audience response system. The moderator queried AAHKS members with respect to a variety of practice management issues. The survey included both multiple choice and yes or no questions. The answers were collected in a central database and provided to the audience in real time., Results: The survey responses provided valuable information with respect to the practice activity of AAHKS members. A total of 47% of AAHKS members are in private practice, and fee for service remains the major form of compensation for 39% of the membership. Participation in bundled-payment programs was 46%. A minority (22%) had performed a total joint arthroplasty in an outpatient surgery center., Conclusion: This survey of AAHKS members' practice patterns provided interesting data. Future surveys should determine potential changes in practice activity related to private practice, fee for service compensation, the use of outpatient surgery centers for total joint arthroplasty, and surgeon participation in bundled-payment programs., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA)., Methods: An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS., Results: Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001)., Conclusion: Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges., (Published by Elsevier Inc.)

Background: Periprosthetic joint infection is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of certain agents to prevent deep vein thrombosis after arthroplasty has been linked to an increased risk of adverse effects including wound drainage and infection. Adverse effects of one alternative, rivaroxaban, was studied in a single community hospital., Methods: International Classification of Diseases, Clinical Modification 9 codes were used to identify primary THAs and TKAs in an administrative database at one large-volume community hospital performed in 2012. Patients were divided into 2 groups: the study group received rivaroxaban, whereas the control group received another form of chemical thromboprophylaxis for at least 2 weeks postoperative. Demographics, risk factors, and illness severity scores were collected for each group. The primary measured outcome was the incidence of deep surgical site infection (SSI) within 30 days postoperative., Results: A total of 639 TKA or THA patients were included, with 159 patients who received rivaroxaban and 480 who received another form of chemical thromboprophylaxis. There were no significant differences between groups regarding demographics, risk factors, or illness severity scores. Incidence of early deep SSI in the rivaroxaban group was higher than in the control group (2.5% vs 0.2%; P < .015)., Conclusion: The use of rivaroxaban for thromboprophylaxis led to a significantly increased incidence of deep SSI in a continuous series of patients undergoing primary THA and TKA in a single institution., (Copyright © 2015 Elsevier Inc. All rights reserved.)