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

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

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

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

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

Introduction: The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060., Methods: A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI)., Results: The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%)., Conclusion: Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited., Methods: A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years., Results: The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years., Conclusion: Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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

Introduction: There is continued debate regarding the survivorship and revision rate of cementless versus cemented total knee arthroplasty (TKA) prostheses. This includes the assessment of early revision surgery due to aseptic loosenings and periprosthetic joint infections (PJIs). Studies have not always taken into account the impact of comorbidities, such as diabetes, obesity, and tobacco. Therefore, we compared revisions in a large population of patients undergoing cemented or cementless TKAs at 90 days, 1 year, and 2 years., Methods: A review of an administrative claims database was used to identify patients undergoing primary TKA, either cementless (n = 8,890) or cemented (n = 215,460), from October 1, 2015 to October 31, 2020. Revision surgery for PJI and aseptic loosening were identified with diagnosis and associated procedural codes at 90 days, 1 year, and 2 years and then compared between groups. A propensity matched-analysis was performed for age, sex, Charles Comorbidity Index (CCI) > 3, alcohol abuse, tobacco use, obesity, and diabetes. Chi square tests assessed statistical significance of differences in the matched cohorts using odds ratios (ORs) with 95% confidence intervals (CIs). A P < 0.05 was defined as statistically significant., Results: Cementless TKA was associated with similar revisions rates due to PJIs at 90 days (OR, 1.04, 95% CI 0.79-1.38, p = 0.83), 1 year (OR, 0.93, 95% CI 0.75-1.14, p = 0.53, and 2 years (OR, 0.87, 95% CI 0.73-1.05, p = 0.17) in comparison to the cemented TKA cohort. The odds ratio of revision due to aseptic loosening was similar as well at 90 days (OR, 0.67, 95% CI 0.34-1.31, 0.31), 1 year (OR, 1.09, 95% CI 0.73-1.61, p = 0.76), and 2 years (OR, 1.00, 95% CI 0.73-1.61, p = 0.99)., Conclusions: This study found a comparable risk of PJI and aseptic loosening in cementless and cemented TKA when controlling for several comorbidities, such as tobacco, diabetes, and alcohol. Therefore, with proper patient selection, cementless TKAs can be performed with expectation of low risks of infections and aseptic loosenings., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

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

A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA ( n  = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA ( n  = 6,027) and those experiencing CDIs ≤ 6 months before TKA ( n  = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p  < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p  < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION:  CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection., Competing Interests: Z.C. is a paid consultant for Johnson & Johnson. R.E.D. is a board or committee member of the Baltimore City Medical Society and receives research support from Biocomposites, Inc., CyMedica Orthopedics, DePuy Synthes Product, Inc., Flexion Therapeutics, Microport Orthopedics, Inc., Orthofix, Inc., Patient-Centered Outcomes Research Institute (PCORI), Smith & Nephew, Stryker, Tissue Gene, as well as United Orthopedic Corporation. The remaining authors have no conflict of interest to disclose., (Thieme. All rights reserved.)

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

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

Over 25% of patients with rheumatoid arthritis (RA) are expected to undergo a joint replacement during their lifetime. Current practice guidelines recommend withholding biologic therapy 1 week prior to total hip arthroplasty, given its immunosuppressive effects. Most patients are on a regimen including biologic and nonbiologic therapy; however, the individual influences of these therapies are not well understood in the setting of total knee arthroplasty (TKA). Therefore, we sought to compare biologic, nonbiologic, and recipients of both types of therapy in patients with RA undergoing TKA. We specifically assessed (1) medical complications at 90 days; (2) surgical complications up to 1 year; and (3) independent risk factors for prosthetic joint infections (PJIs).A retrospective review was conducted using a national, all-payer database for patients undergoing primary TKA from January 2010 to April 2020 ( n  = 1.97 million). Patients diagnosed with RA were then separated into at least 1-year users of biologic ( n  = 3,092), nonbiologic (28,299), or dual ( n  = 10,949) therapy. Bivariate analyses were utilized to assess for 90-day medical and up to 1-year surgical outcomes. Additionally, multivariate regression models were utilized to assess for independent risk factors.The incidence and odds ratio for medical/surgical outcomes were equivocal among the biologic, nonbiologic, and recipients receiving both types of therapy ( p  > 0.061). No differences were observed between the type of therapy as additional risk factors for infection ( p  > 0.505). However, glucocorticoids at 90 days and alcohol abuse, diabetes mellitus, obesity, as well as tobacco use were identified as additional risk factors for PJI( p  < 0.036).No appreciable differences in medical or surgical outcomes were associated with the independent use of biologic, nonbiologic, or recipients of both types of therapy in patients with RA. Additionally, alcohol abuse, diabetes mellitus, glucocorticoids, obesity, and tobacco use conferred an increased risk of PJI. These results can serve as an adjunct to current practice guidelines., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: The pleiotropic effects of statins extend beyond managing cardiovascular health and are suggested to modulate Staphylococcus aureus biofilm formation with prosthetic joint infection (PJI) reduction. However, a large analysis of statin use prior to total joint arthroplasty (TJA) to determine infection and revision risk is lacking. We specifically evaluated: 90-day to two-year (1) prosthetic joint infection (PJIs); (2) revisions; and (3) respective risk factors., Materials and Methods: We queried a national, all-payer database for patients undergoing either TKA or THA between 2010-2020. Chronic statin exposure was defined as >3 prescriptions filled within one-year prior to TJA (statin users). A control cohort of patients undergoing TJA without history of statin use prior was identified (statin naïve). Cohorts were matched 1:1 based on demographics and comorbidities (TKA: n=579,136; THA: n=202,092). Multivariate logistic regression was performed to evaluate risk factors for PJIs and revisions., Results: Among TKA recipients, statin users had lower incidence of PJIs at one year (0.36 vs. 0.39%) to two years (0.45 vs. 0.49%) compared to the statin naïve (all, p≤0.007). Similarly, statin users had lower incidence of one- to two-year revisions (all, p≤0.048). Among THA recipients, statin users had lower incidence of PJIs at 90 days (0.37 vs. 0.45%) to two years (2% vs. 2.14%) (all, p<0.001). Similar trends were observed for 90-day to two-year revisions (all, p≤0.022). Statin use was independently associated with decreased odds of PJIs and revisions by one year., Conclusions: Statin use is associated with a reduced risk of PJIs and revisions from one to two years following TJA. It may be worthwhile to ensure patients take statin therapy if indicated for previously established cardiovascular guidelines.

Introduction: Recent coronavirus disease 2019 (COVID-19) infection may pose increased risk of post-operative complications after total joint arthroplasty (TJA). Current recommendations suggest waiting four-weeks before elective surgery in asymptomatic patients. The purpose of this study was to propensity-score-match patients who had positive COVID-19-test between (1) 0-2 weeks and (2) 2-4 weeks before TJA with a matching group without COVID-19 history to determine rates of complications at 90-days and 1-year post-operatively., Materials and Methods: We queried a national-database for patients who tested positively for COVID-19 within 1-month (n = 1749) before TJA. A propensity-score-match analysis was conducted to limit influence of confounders. They were separated into mutually exclusive asymptomatic cohorts based on time of positive COVID-19-test before TJA: within 2-weeks (n = 1749) and between 2-to-4 weeks (n = 599). Asymptomatic patients were patients with positive test without symptoms of fever, shortness of breath, nausea, vomiting, diarrhea, loss of taste or smell, cough, bronchitis, pneumonia, lung infections, septic shock, and multiple-organ-dysfunction. Complications analyzed: 90-day and 1-year periprosthetic-joint infections (PJIs), surgical-site infections(SSIs), wound complications, cardiac complications, transfusions, and venous thromboembolisms., Results: Asymptomatic patients who have COVID-19 demonstrated increased incidence of PJI in patients who had TJA performed within two weeks from positive test at 90-days compared to patients who did not test positive for COVID-19 (3.0 vs. 1.5%; p = 0.023). Upon totaling all 90-day post-operative complications, no significant difference was found amongst asymptomatic patients who tested positive for COVID-19 for total complications at 90-days (p = 0.936)., Conclusions: Asymptomatic patients who test positive for COVID-19 don't have increased risk for post-operative complications after TJA. However, two-fold increased risk in PJI for patients who tested positive for COVID-19 in first 2-weeks cannot be ignored. These results should be taken into consideration when surgeons consider performing TJA. We recommend asymptomatic patients consider waiting two-weeks before TJA to mitigate risk of PJI. Nevertheless, there's reassurance these patients are not at increased total complication risk., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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

The purpose of this study is to examine patients undergoing primary total knee arthroplasty (TKA) with and without prior history of statin use. We specifically evaluated (1) 90-day to 2-year periprosthetic fractures, (2) revisions, and (3) respective risk factors. We queried a national, all-payer database for patients undergoing primary TKA between 2010 and 2020. Chronic statin exposure was then identified and defined as more than three prescriptions filled within 1 year prior to TKA (statin users). A control cohort of patients undergoing TKA without the prior history of statin use was then created (statin naïve). Cohorts were matched 1:1 based on age range, Charlson Comorbidity Index, sex, diabetes, obesity, and tobacco use, yielding 579,136 patients. Multivariate logistic regression was performed to evaluate the risk factors for periprosthetic fractures and revisions, adjusted for demographics and comorbidities. Statin users had a lower incidence of periprosthetic fractures from 90 days to 2 years compared with the statin naïve ( p  < 0.001). Similarly, statin users had a lower incidence of revisions at 90 days to 2 years ( p  < 0.001). Using the statin-naïve cohort as a reference, statin use was independently associated with decreased odds of periprosthetic fractures and revisions. Statin use was associated with a reduced risk of periprosthetic fractures and revisions. These results may mitigate postoperative risks though statin therapy is currently not recommended for fracture-related benefits alone., Competing Interests: None declared., (Thieme. All rights reserved.)

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

Conversion total knee arthroplasty (TKA) is suggested to incur similar complication rates to revision arthroplasties. However, current billing codes do not allow for the differentiation between this operation and primary TKAs. Therefore, the purpose of this study was to compare outcomes of these two surgeries, as well as revision TKAs. Specifically, we analyzed (1) medical complications, (2) surgical complications, and (3) revision rates at 90 days and 1 year. We queried a national, all-payer database to identify patients who underwent TKA without prior implants ( n  = 1,358,767), required conversion TKA ( n  = 15,378), and who underwent revision TKA ( n  = 33,966) between January 1, 2010, and April 30, 2020. Conversion TKA patients (prior implant removal) were identified using the Current Procedural Terminology (CPT) codes. Outcomes studied included 30-day readmission rates and 90-day, as well as 1-year, medical and surgical complications. Conversion TKAs had greater 30-day readmission rates and incidences of most of the complications studied when compared with primary TKAs. The majority of outcomes when comparing between primary, conversion, and revision TKAs were significantly different ( p  < 0.01). In contrast, conversion TKA complications were similar to revision TKA. Conversion TKAs have higher postoperative complications than primary TKAs and share more similarities with revision TKAs. Thus, the lack of billing codes differentiating conversion and primary TKAs creates a challenge for orthopaedic surgeons., Competing Interests: None declared., (Thieme. All rights reserved.)

Cartilage restoration procedures are effective for articular defects of the knee. However, studies suggest decreased clinical improvements after total knee arthroplasty (TKA). The purpose of this study was to compare patients who had a prior cartilage restoration undergoing TKA with patients who had TKA without a prior cartilage restoration procedure. We specifically assessed (1) 90-day and 1-year medical/surgical complications; (2) 90-day and 1-year revision rates; and (3) 90-day costs. A search using a national, all-payer database examined matched cohorts of patients who underwent cartilage restoration procedures prior to TKA (n=22,072) and controls who did not (n=220,364) between January 1, 2010, and April 30, 2020. Cartilage restoration procedures included autologous chondrocyte implantation, microfracture, osteochondral autograft transfer system operations, or open and arthroscopic osteochondral allograft transplantation. Outcomes studied included lengths of stay, 30-day readmission rates, 90-day costs, and medical and surgical complications to include 90-day and 1-year prosthetic joint infections, pathologic fractures, dislocations, knee manipulations, and revisions. Comparable rates of 90-day and 1-year medical and surgical complications were found for TKAs after cartilage restoration. Additionally, 90-day and 1-year revision surgery rates were similar. These patients were also found to have 90-day costs almost identical to those of patients who did not have cartilage restoration. This large analysis of patients with cartilage restoration procedures prior to TKA demonstrated that the complication rates may be similar to those of patients who do not have these operations before TKA. These findings provide valuable information to surgeons and patients when deciding to proceed with TKA after cartilage restoration. [ Orthopedics. 2023;46(4):250-255.].

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

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

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

Antibiotic prophylaxis before an invasive dental procedure (IDP) for patients with preexisting knee implants has been suggested, but its use has yet to reach consensus. Therefore, we sought to examine antibiotic prophylaxis before an IDP for patients who had undergone a total knee arthroplasty (TKA). We specifically assessed 90-day to 1-year (1) periprosthetic joint infection (PJI) and (2) revision. We queried a national, all-payer database for patients undergoing primary TKA between 2010 and 2020 (n=1,952,917). We identified IDP, as defined by any procedure that involves gingival manipulation, and stratified according to antibiotic prophylaxis. A control cohort of TKA recipients without subsequent IDP was then established. All 3 cohorts were matched according to demographic and health metrics (n=496). Chi-square testing generated the odds ratio (OR) with 95% CI for postoperative PJI and revision. The odds for PJI and revision at all time points were statistically similar between antibiotic prophylaxis and no antibiotic prophylaxis (PJI: OR, 0.62; 95% CI, 0.11-4.00; P ≥.479; revision: OR, ≥0.33; 95% CI, 0.03-4.00; P ≥.248). Additionally, both IDP cohorts and the control cohort had similar rates of postoperative PJI ( P ≥.367) and revision ( P ≥.173) at all time points. Antibiotic prophylaxis before an IDP for TKA recipients did not decrease the risk of PJI or revision up to 1 year after the index procedure. These results support the trend by dentists and orthopedic surgeons to refrain from antibiotic prophylaxis. However, it likely has utility in patients at high risk, as suggested by current guidelines. [ Orthopedics . 2023;46(2):76-81.].

Highly cross-linked polyethylene (HXLPE) has become the preferred bearing surface in total hip arthroplasty. However, its acceptance in total knee arthroplasty (TKA) has not been as robust because of concerns pertaining to wear and its impact on implant failure. Therefore, this multicenter study was purposed to evaluate the 10-year (1) radiographic outcomes; (2) complications; and (3) implant survivorship in patients with TKA receiving a sequentially irradiated and annealed HXLPE. A retrospective, multi-center study was performed on 139 patients (171 TKAs) who underwent primary TKA with HXLPE and possessed a minimum of 10-year follow-up. Radiographs were analyzed for radiolucencies along the implant-fixation interface using the Modern Knee Society Radiographic Evaluation System. Kaplan-Meier analysis determined implant survivorship when the end points were revision for polyethylene wear and polyethylene revision for any reason. Sixteen TKAs (9.9%) demonstrated periprosthetic linear radio-lucencies. Seventeen TKAs (9.9%) required additional surgeries, 9 (5.3%) of which were revisions, with 1 (0.6%) TKA requiring revision because of polyethylene wear. Other causes of revision included instability (1.8%), infection (1.6%), and arthrofibrosis (1.6%). The mean time to revision was 5.9 years (range, 0.1-11.1 years). Survivorship pertaining to polyethylene revision for wear was 99.4%, whereas all-cause polyethylene revision was 94.7%. This study in patients undergoing primary TKA using a second-generation HXLPE demonstrated excellent results with respect to polyethylene wear characteristics and strength with a 99.4% survivorship at 10 years. [ Orthopedics . 2023;46(2):e111-e117.].

To our knowledge, no studies have compared postoperative outcomes between patients who received a temporary short or long intramedullary (IM) nail in the setting of infected total knee arthroplasty (TKA). Therefore, the aim of this study was to compare short-term outcomes for patients who underwent long or short IM nail insertion for treatment of periprosthetic knee infection. Specifically, we compared: (1) success rates; (2) patient reported/functional outcomes; and (3) complications between patients implanted with a short or a long IM nail following PJI of the knee. A retrospective chart review was performed for patients who underwent two-stage exchange arthroplasty with a temporary long or short IM nail between November 2010 and June 2018 at our institution ( n  = 67). Continuous and categorical variables were assessed using t -test/Mann-Whitney U test and chi-squared test, respectively. Logistic regression analyses were conducted to assess the effect of IM nail length on success rate while adjusting for age, sex, body mass index, and race. A total of 36 patients underwent temporary treatment with a long IM nail, while 31 patients received a short IM nail. There were no differences in success rate for reimplanted patients treated with long and short IM nails (odds ratio 0.992; p  = 0.847). Fewer patients with a long IM nail went on to reimplantation (52.8 vs. 83.9%; p  = 0.007). There was no difference in satisfaction (7.86 vs. 7.68; p  = 0.515), pain scores (3.39 vs. 4.45 points; p  = 0.126), or Knee Society score outcome scores (150.61 vs. 166.26 points; p  = 0.117) between long or short IM nail patients. Following reimplantation, there was no difference in the number of patients who became reinfected (15.8 vs. 11.5%; p  = 0.679) or went on to amputation (0 vs. 7.7%; p  = 0.210). Periprosthetic joint infection (PJI) is a rare but serious postoperative complication following TKA. Our findings suggest that the use of long and short IM nails during two-stage exchange can have equal utility in PJI patients with severe bone defects., Competing Interests: J.D.C. reports personal fees from Biocomposities, personal fees from Bonesupport, personal fees from DePuy Synthes, personal fees from MHE Coalition, personal fees from Orthofix, Inc, personal fees from OrthoPediatrics, personal fees from Pega Medical, personal fees from Smith and Nephew, personal fees from Stryker, personal fees from University of Florida, personal fees from Zimmer, personal fees from Zimmer Biomet, outside the submitted work. R.E.D. reports other from Flexion Therapeutics, other from Orthofix Inc, other from Stryker Corp, other from United Orthopedics Corp, other from Tissue Gene, outside the submitted work. R.E.D. reports other from Flexion Therapeutics, other from Orthofix Inc, other from Stryker Corp, other from United Orthopedics Corp, other from Tissue Gene, outside the submitted work. F.J.P. reports other from Biocomposites Inc., personal fees from Total Joint Orthopedics, personal fees and other from VisualDx, outside the submitted work., (Thieme. All rights reserved.)

Background: Few studies investigate the influence of inflammatory bowel disease (IBD) on complications following total knee arthroplasty (TKA). Therefore, we compared complications and readmissions frequencies after TKA in patients with Crohn's disease (CD) and ulcerative colitis (UC) to patients without IBD., Methods: A large administrative claims database was used to identify patients who underwent primary TKAs from 2010 to 2019 and had a diagnosis of IBD before TKA. Patients were stratified into two groups: those with CD (n = 8,369) and those with UC (n = 11,347). These patients were compared a control of 1.3 million patients without an IBD diagnosis. Chi-square and unadjusted odds ratios (OR) with 95% confidence intervals (CI) were used to compare complication frequencies. Multivariable logistic regression was used to evaluate independent risk factors for 90-day complications., Results: Compared to patients without IBD, patients with IBD were associated with higher unadjusted 90-day odds for Clostridium difficile infection (CDI) (CD: OR 2.81 [95% CI 2.17 to 3.63]; p < 0.001; UC: OR 3.01 [95% CI 2.43 to 3.72]; p < 0.001) and two-year periprosthetic joint infection (CD: OR 1.34 [95% CI 1.18 to 1.52]; p < 0.001; UC: OR 1.26 [95% CI 1.13 to 1.41]; p < 0.001). After controlling for risk factors like obesity, tobacco use, and diabetes, both types of IBD were associated with higher 90-day odds for CDI and PJI (p < 0.001 for all)., Conclusion: IBD is associated with higher 90-day postoperative CDI and PJI compared with patients without IBD. Providers should consider discussing these risks with patients who have a diagnosis of IBD., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: RED receives research support from member; Biocomposites, Inc.; CyMedica Orthopedics; DePuy Synthes Product, Inc.; Flexion Therapeutics; Microport Orthopedics, Inc.; Orthofix, Inc.;Patient-Centered Outcomes Research Institute (PCORI); Smith & Nephew; Stryker; Tissue Gene; and United Orthopedic Corporation; and is a board member of the Baltimore City Medical Society All other authors have nothing to disclose., (Copyright © 2022 Elsevier B.V. All rights reserved.)

As the number of total knee arthroplasties (TKAs) increases, it is reasonable to expect the number of revision TKAs (rTKAs) to rise in parallel. The patient-related and societal burdens of rTKA are poorly understood. Therefore, the purpose of this study was to determine temporal changes in: (1) the incidence of rTKA; (2) patient and hospital characteristics; (3) complications, hospital lengths of stay (LOSs), and discharge dispositions; and (4) costs, charges, and payer types. All patients who underwent rTKA between 2009 and 2016 were identified from the National Inpatient Sample database using International Classification of Diseases, Ninth Revision and Tenth Revision codes and were studied. Univariate analyses were performed to compare the incidence of rTKA, patient and hospital characteristics, LOS and discharge dispositions, as well as costs, charges, and payer types. A multivariate logistic regression model was built to compare the odds of complications in 2009 and 2016. Over our study period, there was a 4.3% decrease in the incidence of rTKA. The mean age of patients who underwent rTKA was 65 years and a majority were female (58%). Mean hospital LOS decreased from 4.1 days in 2009 to 3.3 days in 2016 ( p  < 0.001). The rate of several complications decreased significantly over our study period including myocardial infarction, cardiac arrest, transfusion, pneumonia, urinary tract infection, and mortality. A significantly lower percentage of rTKA patients were discharged to a skilled nursing facility in 2016 (26.5%) compared with 2009 (31.6%; p  < 0.001). There was an 18.7% increase in the mean costs, and a 43.3% increase in the mean charges ( p  < 0.001). Over the study period, there was a decrease in the incidence of rTKAs. Despite potential improvements in primary TKA, the burden associated with rTKA remains large. This report can be used to help educate medical providers about outcomes that may result from a primary and/or revised TKA., Competing Interests: G.R.S. reports personal fees from Acelity, personal fees from Biomet, personal fees from Convatec, other from Force Therapeutics, personal fees from Medtronic, other from Operation Walk USA, grants and personal fees from Pacira, personal fees from Zimmer, outside the submitted work. R.E.D. reports grants from Flexion Therapeutics, grants from Orthofix, grants from Stryker, grants from TissueGene, grants from United Orthopedics, outside the submitted work. M.A.M. reports personal fees from Cymedica, personal fees from Flexion Therapeutics, grants and personal fees from Johnson & Johnson, other from Peerwell, personal fees from Pfizer, grants, personal fees, and other from Stryker, grants and personal fees from TissueGene, other from USMI, outside the submitted work. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

Hyaluronic acid (HA) and corticosteroid (CS) injections are utilized in symptom management for patients with osteoarthritis. However, contamination of the joint may increase the risk of infection following total knee arthroplasty (TKA). Therefore, the purpose of this study was to examine 90-day surgical site infection (SSI) and manipulation under anesthesia (MUA) as well as up to 2-year prosthetic joint infection (PJI) in intra-articular knee injection recipients prior to TKA compared with patients who did not have knee injections. We specifically assessed (1) timing of HA and CS prior to TKA; (2) type of intra-articular knee injection; as well as (3) associated risk factors. We queried a national database to identify patients who underwent primary TKA from September 2015 to October 2020 ( n  = 1.5 million). Patients with prior knee injections were stratified to five cohorts: HA within 4 weeks ( n  = 140), HA 4 to 6 weeks prior ( n  = 337), CS within 4 weeks ( n  = 2,344), CS 4 to 6 weeks ( n  = 2,422), and a no injection, control, cohort prior to TKA ( n  = 5,000). Bivariate chi-square analyses of outcomes were conducted, and multivariate regressions were used to adjust for comorbidities and assess associated risk factors. The adjusted analysis showed a significant risk in infection for patients receiving an injection within 4 weeks of TKA ( p  < 0.023) and showed no difference in type of injection ( p  > 0.050). Additionally, SSIs were increased 1.58 times in the CS within 4 weeks of TKA cohort ( p  = 0.023). However, no difference in MUA risk was shown at 90-day postoperative ( p  > 0.212). Furthermore, tobacco use was identified as a risk factor that further increased likelihood of PJI. Intra-articular knee injection less than 4 weeks before TKA increased the risk for PJI; however, past 4 weeks did not confer infection risk. Tobacco use was identified as an associated risk factor that further increased likelihood for PJI. These results highlight the need for surgeons to wait 4 weeks between knee injection and TKA to decrease risk of septic revision., Competing Interests: None declared., (Thieme. All rights reserved.)

Poor metaphyseal fixation secondary to bone loss in revision total knee arthroplasty (TKA) continues to be challenging. One technique to increase implant stability is the use of novel three-dimensional (3D) printed titanium metaphyseal cones with adjunctive stems for added fixation. However, the survival of these novel constructs is poorly understood. Therefore, we sought to examine 3D-printed titanium metaphyseal cone components in revision TKA for aseptic as well as septic reasons and aimed to evaluate: (1) revision-free survivorships; (2) patient-reported outcomes measures (PROMs); (3) postoperative medical complications; and (4) radiographic outcomes. A consecutive series of 62 patients who underwent revision TKA with use of a titanium metaphyseal cone at a single institution between September 1, 2015 and May 31, 2021 were examined. The patients had a minimum follow-up period of 2 years (mean, 40 months, range, 24-72 months). PROMS included Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR) scores at baseline and last clinical follow-up. Overall, when excluding infections, the combined implant survivorship was 96% (52 out of 54), while it was 95% (35 out of 57) for aseptic revisions and 100% (17 out of 17) for septic revisions. Reasons for revisions within the aseptic revision cohort included loosening (5%) as well as periprosthetic joint infections (PJIs) (7.5%). All failures following an index septic revision were due to PJI. Mean KOOS scores at baseline as well as at final follow-up was 43 points (range, 16-80) and 70 points (range, 34-100), respectively. None of the patients had medical complications. Other than the loosening reported (only femoral component), of the surviving patients no patients had evidence of progressive radiolucencies. The use of titanium cones in revision TKA provides good revision-free survivorship at 2 years. Further research is warranted on the longer-term survivorship of 3D-printed titanium cones. The current study has found that 3D-printed titanium cones can be incorporated as part of the revision knee surgeon's armamentarium., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction:  Isolated medial knee osteoarthritis can be surgically treated with either unicompartmental knee arthroplasty (UKA) or high tibial osteotomy (HTO). Proponents of UKA suggest superior survivorship, while HTO offers theoretically improved alignment and joint preservation delaying total knee arthroplasty (TKA). Therefore, we compared complications in a large population of patients undergoing UKAs or HTOs. We specifically assessed 90 days, 1 year, and 2 years: (1) periprosthetic joint infection (PJI) rates, (2) conversion to TKA rates, as well as (3) complication rates., Methods:  A review of an administrative claims database was used to identify patients undergoing primary UKA ( n  = 13,674) or HTO ( n  = 1,096) from January 1, 2010 to December 31, 2019. Complication rates at 90 days, 1 year, and 2 years were compared between groups using unadjusted odds ratios (ORs) with 95% confidence intervals. Subsequently, multivariate logistic regressions were performed for PJI and conversion to TKA rates., Results:  At all time points, patients who underwent UKA were associated with lower rates of infection compared with those who underwent HTOs (all OR ≤ 0.51, all p ≤ 0.010). After 1 year, patients who received UKAs were found to have lower risk of requiring a conversion to a TKA versus those who received HTOs (all OR ≤ 0.55, all p  < 0.001). Complications such as dislocations, periprosthetic fractures, and surgical site infections were found at lower odds in UKA compared with HTO patients., Conclusion:  This study provides large-scale analyses demonstrating that UKA is associated with lower infection rates and fewer conversions to TKA compared with patients who have undergone HTO. Dislocations, periprosthetic fractures, and surgical site infections were also found to be lower among UKA patients. However, with careful patient selection, good results and preservation of the native knee are achieved with HTOs. Therefore, UKA versus HTO may be an important discussion to have with patients in an effort to lower the incidence of postoperative infections and complications., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: None declared.

Mechanical knee symptoms secondary to knee osteoarthritis (OA) may warrant knee arthroscopy (KA). Degenerative changes may progress and require a subsequent total knee arthroplasty (TKA). Recent studies have evaluated the timing of KA prior to TKA, associated a narrow interval with increased post-TKA complications. However, an updated analysis is required. We compared surgical outcomes in recipients of KA prior to TKA as stratified by four, time-dependent cohorts (< 12, 12 to 16, 16 to 20, and 20 to 24 weeks prior to TKA). We specifically compared: 90-day (1) manipulations under anesthesia (MUAs); (2) septic revisions at 90 days, 1 year, and 2 years; as well as (3) how various independent risk factors influenced the manipulations or revisions. We queried a national database for patients undergoing TKA. Patients who underwent KA with the following intervals: < 12 ( n  = 1,023), 12 to 16 ( n  = 816), 16 to 20 ( n  = 1,957), and 20 to 24 weeks (1,727) prior to TKA were compared with those patients who did not have a history of KA ( n  = 5,000). Bivariate analyses were utilized to assess 90 days through 2 years surgical outcomes. Afterwards, multivariate regression models were utilized to assess for independent risk factors. The unadjusted analyses showed an increase in MUA through 2 years among all the KA recipients ( p  < 0.001). Septic revisions and surgical site infections at all time points were not associated with any of the four arthroscopy time intervals ( p  > 0.476). The adjusted analyses showed an increased risk for 90-day MUA among all TKA cohorts ( p  < 0.001). Risk for septic revisions did not reach significance. Delaying TKA by 24 weeks in KA recipients was not associated with a decreased risk in septic revisions. However, there was an apparent risk of MUA at 90 days for all KA cohorts suggesting that waiting after KA before TKA makes no difference in MUA rates. These results update existing literature, may serve as an adjunct to current practice guidelines, and can contribute to shared decision making in the preoperative setting., Competing Interests: None declared., (Thieme. All rights reserved.)

Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32-3.70]), postoperative delirium (6.40 [1.78-23.03]), and length of stay greater than 2 days (3.90 [1.00-15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66-4.72]) or discharge to a specialized facility (1.48 [0.80-2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [ Orthopedics . 2022;45(6):e315-e320.].

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

Background: Anti-retroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in human immunodeficiency virus (HIV) patients. However, a large study comparing HIV patients taking ART prior to total knee arthroplasty (TKA) is lacking. We sought to examine: (1) readmissions; (2) post-operative complications; and (3) revisions in ART-treated or untreated HIV patients compared with a non-HIV population., Methods: We queried a national, all-payer database to identify TKA patients from 2010-2020 (n = 1,393,357). The presence or absence of ART was identified and matched with non-HIV patients based on age, sex, diabetes, obesity, and tobacco status resulting in 889 patients in each cohort. Readmissions, post-operative complications, and revisions were assessed., Results: Readmissions were higher among all HIV patients and even higher in those not taking ART, as compared to the matching cohort (4.8 versus 1.6%, p < 0.01). Prosthetic joint infections (PJIs) at 1-year were higher among HIV patients who were either taking ART (4.0%; OR, 1.41 [0.82-2.45]) or not taking ART (5.1%; OR, 2.44 [1.42-4.21]) as compared to non-HIV patients (2.1%, all p < 0.03). Revision rates at 1-year trended higher in HIV patients who were taking ART (2.6%; Odds Ratio (OR), 1.94 [0.96-3.93]) and who did not take ART (3.1%; OR, 2.38 [1.20-4.70]), compared to non-HIV patients (1.3%, all p < 0.09)., Conclusions: ART-treated HIV patients are associated with lower readmissions, post-operative complications, and revisions when compared to HIV patients not taking ART. The findings of this study underscore the utility of ART and patient optimization to reduce risk in HIV patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

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

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t -tests assessed categorical and continuous variables, respectively. A p -value of <0.05 was set as the threshold for statistical significance. The analysis demonstrated that less same-day patients were readmitted, with statistical but not clinical difference in revisions, and mortality (all p  < 0.050). Higher 30-day cost ($33,522 vs. $29,053, p  < 0.001), decreased total LOS (4.52 vs. 4.94 days, p  < 0.001), and lower rates of PEs (0.3 vs. 1.1%, p  < 0.001) and transfusions (2.1 vs. 8.5%, p  < 0.001) but similar total complications ( p >0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements., Competing Interests: J. N. reports personal fees from Microport, outside the submitted work and Research Support from Stryker Corp. Publication/Editorial board for Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic Knowledge Online, Journal of Knee Surgery, and Board or Committee Member of Arthritis foundation. R.E.D. reports other from Baltimore City Medical Society, other from Orthofix, Inc, other from Stryker, other from United Orthopedics, other from Flexion Therapeutics, other from TissueGene, outside the submitted work. Rest authors declare no conflict of interest., (Thieme. All rights reserved.)

In the United States, one-third of adults are considered obese, and demand for total knee arthroplasty (TKA) is expected to rise in these patients. Surgeons are reluctant to operate on obese patients, but it is important to understand how obesity has affected TKA utilization. This study utilizes a national database to evaluate incidence, demographics, outcomes, charges, and cost in nonobese, overweight, nonmorbidly obese, and morbidly obese TKA patients. We queried the National Inpatient Sample from 2009 to 2016 for primary TKA patients identifying 4,053,037 nonobese patients, 40,077 overweight patients, 809,649 nonmorbidly obese patients, and 428,647 morbidly obese patients. Chi-square was used to analyze categorical variables, and one-way analysis of variance was used to analyze continuous variables. Nonmorbidly obese and morbidly obese patients represented 23.2% of all TKAs. TKA utilization increased 4.1% for nonobese patients, 121.6% for overweight patients, 73.6% for nonmorbidly obese patients, and 83.9% for morbidly obese patients. Morbidly obese patients were younger ( p  < 0.001), female ( p  < 0.001), Black ( p  < 0.001), poor ( p  < 0.001), and utilized private insurance ( p  < 0.001). They also had the longest length of stay ( p  < 0.001) and the highest mortality rate ( p  < 0.001). More morbidly obese patients were discharged to other facilities ( p  < 0.001), and they had the highest rate of complications ( p  < 0.001). Patients with morbid obesity had the highest charges ( p  < 0.001), but overweight patients had the highest costs ( p  < 0.001). The results of this study demonstrate the rise in obese and morbidly obese patients seeking TKAs, which may be reflection of the obesity epidemic in America. Although TKA utilization has increased for morbidly obese patients, this body mass index (BMI) category also has the highest rates of charges and complications, suggesting morbid obesity to be a modifiable risk factor leading to worse surgical and economic outcomes. Obese patients undergoing TKA may benefit from preoperative optimization of their weight, in an effort to reduce the risk of adverse outcomes., Competing Interests: None declared., (Thieme. All rights reserved.)

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained ( P <.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained ( P <.001). Mean cost decreased for both cohorts of patients (both P <.001). Discharges to home increased for both cohorts ( P <.001), while length of stay decreased (both P <.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [ Orthopedics . 2022;45(1):e11-e16.].

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database ( n  = 71,022) and the National Inpatient Sample ( n  = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p  < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p  < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p  < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges ( p  < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets., Competing Interests: None declared., (Thieme. All rights reserved.)

Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis ( n  = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t -test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p  < 0.001), while Knee Society Scores (function) significantly increased (55.6 vs. 77.7, p  < 0.001). A majority of patients were full weight-bearing immediately following surgery (38.7%). Treating poor health status patients with PJI of the knee can be difficult after multiple revisions. With a success rate similar to conventional methods, our results demonstrate that two-stage exchange with a temporary short intramedullary nail may be a desirable treatment option for patients with bony defects wishing to avoid amputation or permanent arthrodesis. However, this method does not outperform other treatment modalities, and may not be suitable for all patients. Patient expectations and health status should be carefully assessed to determine if this procedure is appropriate in this complex patient population., Competing Interests: R.E.D. reports other from Baltimore City Medical Society, other from Orthofix, Inc, other from Stryker, other from United Orthopedics, other from Flexion Therapeutics, other from TissueGene, outside the submitted work. M.A.M. reports personal fees and other from Peerwell, other from USMI, personal fees from Cymedica, personal fees and other from DJ Orthopaedics, personal fees from Flexion Therapeutics, personal fees and other from Johnson & Johnson, personal fees and other from Ongoing Care Solutions, personal fees and other from Orthosensor, personal fees from Pacira, personal fees from Performance Dynamics Inc, personal fees from Pfizer, personal fees from Skye Biologics, personal fees and other from Stryker, personal fees and other from TissueGene, other from National Institute of Health (NIAMS & NICHD), outside the submitted work; In addition, M.A.M. has a patent Microport with royalties paid, a patent Stryker with royalties paid, a patent Medicus Works LLC with royalties paid, a patent Up-To-Date with royalties paid, and a patent Wolters-Kluwer Health - Lippincott Williams & Wilkins with royalties paid and Editorial or Governing Board: Journal of Arthroplasty; Journal of Knee Society; Orthopedics; Surgical Techniques International; Board/Committee Member: American Academy of Orthopaedic Surgery; American Association of Hip and Knee Surgeons; Knee Society. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

As obesity in the United States increases, the proportion of obese and morbidly obese patients undergoing same-day bilateral total knee arthroplasty (sd-BTKA) remains unknown. Therefore, this study analyzed: (1) incidence, (2) patient demographics, (3) patient course, and (4) patient outcomes in obese and morbidly obese patients undergoing sd-BTKA in the United States from 2009 to 2016. The National Inpatient Sample was queried for all sd-BTKA patients from 2009 to 2016, yielding 39,901 obese and 20,394 morbidly obese patients. Analyzed variables included overall incidence, age, length of stay (LOS), sex, race, payer, Charlson comorbidity index (CCI) status, disposition, complications, location/teaching status, region of hospital, costs, and charges. Categorical variables were evaluated with chi-square analysis, while continuous variables were analyzed by Student's t -tests. Overall, the number of sd-BTKAs decreased over the study period, although the proportion of both obese and morbidly obese patients increased ( p  < 0.001 for all). The most common CCI status, 3 + , decreased in proportion for both groups ( p  < 0.001 for all). Hospital costs decreased and charges increased for both groups ( p  < 0.001 for all). Mean LOS decreased and patients were most commonly discharged to skilled nursing facilities, although these proportions decreased ( p  < 0.001 for all). Respiratory failures ( p  < 0.001 for all) increased for both groups, while proportion of deep vein thromboses and hematomas/seromas ( p  < 0.001 for all) increased for obese patients and proportion of pulmonary emboli ( p  < 0.001) increased for morbidly obese patients. The results of this study appear to portray improving optimization and patient selection of higher body mass index (BMI) individuals undergoing this procedure. More information is needed comparing the safety of the sd-BTKA across patients of all BMI groups., Competing Interests: None declared., (Thieme. All rights reserved.)

Aims: Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure., Methods: Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters., Results: Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023)., Conclusion: Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J  2021;103-B(6 Supple A):113-118.

Same-day bilateral total knee arthroplasties (SBTKAs) are associated with shorter rehabilitation and lower cost. However, controversy surrounding the safety of SBTKAs exists. Recent studies are lacking to determine whether patient selection has brought SBTKA in line with unilateral total knee arthroplasty (UTKA). Therefore, the authors evaluated and compared patient characteristics, hospital characteristics, and inpatient course between UTKA and SBTKA from 2009 to 2016. The National Inpatient Sample was queried from 2009 to 2016 for UTKA and SBTKA patients. Of the 5,329,466 patients identified, 5,084,328 (95.4%) patients received UTKAs and 245,138 (4.6%) patients underwent SBTKAs. Incidence, rate, patient and hospital characteristics, health status, length of stay (LOS), discharge disposition, hospital charges, hospital costs, and complications were analyzed and statistically compared. The incidence (-1.4%) and rate (15.8%) of SBTKAs decreased (both P <.001). The SBTKA cohort had more patients who were younger, male, White, obese, healthier, and using private insurance ( P <.001 for all). The SBTKA cohort had longer LOS, a higher proportion of discharges to skilled nursing facilities, higher cost and charges, and more complications, including deep venous thromboses/pulmonary emboli (DVT/PE) and transfusions ( P <.001 for all). Conversely, SBTKA was associated with fewer myocardial infarctions ( P <.001). Although improved from previous literature, SBTKA is still associated with longer LOS, higher cost and charges, and more complications, including DVT/PE and transfusions, although with a lower rate of myocardial infarction. However, studies are needed to determine whether the risk of 1 SBTKA outweighs the cumulative risk of staged UTKAs. [ Orthopedics . 2021;44(3):e407-e413.].

Recently, 3-dimensional (3D) printing technology has been used in the development of titanium metaphyseal cones to manage severe bone loss in revision total knee arthroplasty (rTKA). This study assessed (1) radiographs; (2) functional outcomes; (3) complications; and (4) 2-year implant survivorship in patients receiving 3D-printed titanium metaphyseal cones for moderate-to-severe tibial and femoral bone loss in rTKA. A single institution, retrospective chart review was performed for patients with large bone defects treated with a 3D-printed femoral or tibial titanium metaphyseal cone between 2015 and 2017 during rTKA (N=54). Paired sample t tests analyzed Knee Society Scores (KSS). Kaplan-Meier analyses determined implant survivorship when the endpoint was cone revision for aseptic loosening, cone revision for any reason, and reoperation for any reason. The authors found that 51 (98.1%) of 52 available radiographs demonstrated well-fixed components without any evidence of loosening or migration. Mean postoperative KSS scores were significantly higher when compared with preoperative scores (80.4 vs 52.0; P>.001). One patient experienced aseptic loosening of their cone. Seven additional cones were explanted as a consequence of reinfection, 1 of which was removed prior to arthrodesis. Cone survivorship was 98.5% when the endpoint was cone revision due to aseptic loosening, 88.2% when cone revision was due to any reason, and 77.9% for any reoperation. Metaphyseal cones appear to be well-suited for large bone defects during rTKA and the authors' findings suggest that cones may be a viable option for metaphyseal fixation during rTKA. Future studies should focus on their durability during a longer time period. [Orthopedics. 2021;44(1):43-47.]., (Copyright 2020, SLACK Incorporated.)

Background: Same-day bilateral total knee arthroplasty (BiTKA) is a controversial topic in orthopedics, prompting a consensus statement to be released by national experts. To date, no studies have evaluated the trends of this method since these recommendations. This study utilized a national database to evaluate: 1) incidence; 2) patient characteristics; 3) hospital characteristics; and 4) inpatient course for same-day BiTKAs in the United States from 2009 to 2016., Method: The National Inpatient Sample database was queried for individuals undergoing same-day BiTKAs, yielding 245,138 patients. Patient demographics included age, sex, race, obesity status and Charlson Comorbidity Index (CCI) score. Hospital characteristics consisted of location/teaching status, geographic region, charges, and costs. Inpatient course included length of stay, discharge disposition, and complications., Results: Same-day BiTKA incidence decreased from 5.6% to 4.0% over the study (p < 0.001). Decreases in patient age and female proportion (p < 0.001 for both) were seen, while African American and Hispanic patients increased (p < 0.001), as did obese patient proportions (p < 0.001). Patients with CCI scores of 2 increased, while those with ≥3 decreased (p < 0.001). Hospital charges increased, while costs decreased (p < 0.001 for both). Length of stay following same-day BiTKA decreased (p < 0.001) and routine home discharges increased (p < 0.001). Most inpatient complications decreased, although the percentage of mechanical complications and respiratory failures increased (p < 0.01 for all)., Conclusions: During the study period, younger patients with fewer comorbidities underwent BiTKAs, which likely resulted from improved patient assessment and management. Future investigations should include an evaluation of long-term complications and outcomes in certain patient populations for this procedure., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Increasing demand for total knee arthroplasties (TKA) has been targeted by legislation to minimize costs and maximize outcomes. Home discharges reduce costs, and it is important to determine patient variables associated with this discharge disposition. We explored non-modifiable and modifiable factors associated with non-home discharges to determine what patient specific factors require attention., Methods: This retrospective study included 171,903 National Surgical Quality Improvement Program (NSQIP) patients between 2011 and 2016. Patient specific variables and discharge destinations included home, short-term nursing facilities (SNF), not home, and rehabilitation. Chi-squared analyses and analyses of variance (ANOVA) were conducted for categorical and continuous data, respectively. Multinomial regression model was utilized to assess associations between discharge destination and patient specific variables., Results: Every year increase above the mean age (66 years) was associated with a nine percent (p < .001) and six percent (p < .001) increased odds for discharge to SNF or rehabilitation, respectively, compared to home discharges. Every 10% increase in BMI from the mean was associated with a 10% increase in discharge to both SNF and rehabilitation (p < .001 for both)., Conclusion: With increasing demands for TKAs and expenditures to Medicare, evaluating factors that impact patient discharge can help optimize costs and outcomes of TKA procedures. Arthroplasty surgeons can benefit by recognizing these correlations and exploring reductions to non-home discharges through pre-operative patient optimization. Future studies should evaluate the economic cost potential associated with optimizing routine home discharge in TKA patients., Level of Evidence: IV., Competing Interests: Declaration of competing interest RED receives research support from Orthofix, Inc., Stryker, United Orthopedics, Flexion Therapeutics, and TissueGene outside the submitted work. All other authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)