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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.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/mThe timing of BS (6 months and 1 year) had similar incidences of medical/surgical complications and revisions, with both lower than the BMI40 cohort (P.001). Differences between types of BS were also lower than the BMI40 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.Timing (6 months or 1 year prior to TKA) and type of BS shared similar complication profiles, lower than BMI40 and higher than BMI 20-35. These findings support a surgeon's decision to proceed with TKA at six months post-BS if indicated.

Poor restoration of cruciate-driven kinematics after total knee arthroplasty may result from technical difficulties, but the ligament may also be functionally compromised by the presence of arthritis. We asked whether the function of the posterior cruciate ligament (PCL) could be assessed intraoperatively to predict the quality of the resulting posterior cruciate kinematics.PCL integrity was assessed using intraoperative infrared trackers to monitor knee kinematics in 73 patients. Three-dimensional images of the femur and tibia were projected onto a screen, allowing the surgeon to visualize kinematic relationships in real time. We measured femoral rollback (distance of femoral contact as a percentage of antero-posterior tray width) from images captured by the robotic system during initial kinematic assessment, gap balancing, and assessment of the final construct and from lateral flexion radiographs obtained 2 years after surgery. Associations were characterized using Pearson's correlation and graphical methods.Thirty-six knees (49%) showed rollback60% during gap balancing, indicative of PCL insufficiency. The rollback during gap balancing was positively correlated with that seen in the final cruciate retaining constructs (r = 0.60, P.001), which in turn predicted rollback 2 years after surgery on lateral flexion X-rays (r = 0.50, P = .006).Intraoperative functional evaluations can allow the surgeon to identify cases where rollback is not consistent with desirable knee kinematics, and posterior stabilization may lead to a better outcome for those patients.

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.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.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).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.

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.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.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.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.

The purpose of this study was to determine if elevated pre-operative D-dimer levels in patients undergoing revision total knee arthroplasty (rTKA) pose an increased risk of: (1) post-operative venous thromboemboli (VTE); (2) intra-operative blood loss; and (3) need for transfusion of blood products. Eighty-nine patients who underwent rTKA by a single surgeon between January 1, 2017, and December 31, 2019, met the inclusion criteria. Elevated pre-operative D-dimer levels did not pose an increased risk of VTE, blood loss, or transfusion of blood products, demonstrating that elevated pre-operative D-dimer is not a contraindication to the use of tranexamic acid for rTKA.

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

In recent time, there has been an increased push toward transparency in industry funding toward physicians. The Physician Payments Sunshine Act called for the creation of the Open Payments Database managed by the Centers for MedicareMedicaid Services. To our knowledge, there have been no studies evaluating the trends in payments among adult reconstruction fellowship-trained orthopedic surgeons. The purpose of this study is to investigate trends in all payments to adult reconstruction-trained orthopedic surgeons from 2014 to 2019. Secondary outcomes included evaluating trends in yearly subpayment categories, regional variations, as well as characterizing the top 5 industry companies.A review of the Centers for MedicareMedicaid Services Open Payments Database was performed to identify all payments to adult reconstruction-trained orthopedic surgeons. A total of 94,265 payments were made to 4911 surgeons accounting for a total of $258,865,231.20 during the study period. Our primary outcome was to assess the trend in median payment per year to individual surgeons. Secondary outcomes included evaluating payment trends with respect to subtype, location as defined by United States Census regions, as well as specifics concerning the top 5 companies.Over the study period, there was a nonsignificant increasing trend in median payment per surgeon (r = 0.49, P = .096). However, there was also a significantly increasing trend in the number of payments per year (r = 0.83, P = .014), as well as the number of surgeons receiving payments (r = 0.88, P = .019). With respect to subcategory payments, there were significantly increasing trends in the median payment per surgeon for education (1054%, r = 0.942, P.001) and entertainment/food and beverage expenses (20.2%, r = 0.49, P = .020), as well as a significantly decreasing trend for median honoraria payments per surgeon (20.2%, r = -0.04, P = .005). No significant regional trends were identified. Of the top 5 companies, one demonstrated a significantly decreasing trend in median payment per surgeon (21.6%, r = -0.109, P.001), whereas the others remained unchanged.In this study, we found a nonsignificant increasing trend in payments to adult reconstruction-trained surgeons as well as an increasing number of surgeons receiving payments. There were increasing trends in median payment per surgeon for education and entertainment expenses, but a decreasing trend for honoraria payments. No significant regional trends were identified. The majority of the top 5 companies had nonsignificant trends in their payments. Further studies are needed to characterize the disclosure of payments and the impact of industry payments on clinical outcomes.IV.

Dressings for total knee arthroplasty (TKA) typically focus on promoting optimal healing, while preventing infection, allowing for functionality and immediate ambulation, while providing for excellent cosmesis. We have previously described four aspects of closure after TKA involving the: (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) a specific aseptic dressing. In this meta-analysis and systematic review of the literature, we will focus on the dressing. Specifically, we assessed: (1) infection risk of different techniques; (2) re-operation or readmission risk; and (3) length of time until dressing change needed. There were 16 reports on infection risk, re-operation risk, and length of time until change needed. A meta-analysis focused on the qualifying wound complication risk reports was also performed. The meta-analysis including four studies (732 patients) demonstrated overall lower wound complication risk with the use of adhesives and mesh dressings (odds ratio 0.67) versus traditional closures. Additionally, studies demonstrated fewer re-operations and readmissions with the use of adhesives and mesh dressings. Furthermore, one report demonstrated mesh dressings persist longer than silver dressings. Therefore, multiple recent reports suggest superior outcomes when using adhesive and mesh dressings for TKAs.

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.

Introduction Randomized controlled trials (RCTs)are regarded as highest level of scientific evidence. There is belief that while prospective randomized control trials (PRCTs) are the gold standard for evaluating efficacy of interventions, there are very few conducted on lower extremity joint arthroplasty. However, there was a more than adequate amount (n=197) of published RCTs in knee arthroplasty during the 2021 calendar year. Therefore, we studied RCTs on knee arthroplasties for 2021 and assessed them for overall study topic reasons (i.e., devices as well as prostheses, rehabilitation, pain control, blood loss [tranexamic acid], and other), which were then subcategorized by: (1) country of origin; (2) sample size; and (3)whether or not they were follow-up studies. After this, we specifically focused on the studies (n=26) concerning devices or prostheses. Methods A search of PubMed on “knee arthroplasty” specifying “RCT” using their search function and dates between January 1, 2021 to December 24, 2021 resulted in the analyzed reports. A total of 17.3% reports analyzed rehabilitation methods while 28.4% studied pain control. A total of 20.3% examined blood loss topics and 20.8% investigated other topics. Results We found that 26 studies (13.2%) involved prosthetic design and implantation. Overall, only 15% knee arthroplasty RCTs were conducted in the United States, the mean total final sample size was 133±146 patients, and 7% were follow-up studies. None of the prostheses studies were performed in the United States, and the mean total final sample size of all of these studies was 86±54 patients, and 23% were follow-up studies. Total knee arthroplasty prospective RCTs were not performed in the United States. Conclusion The authors believe that other study designs, such as database or registry analyses, are also appropriate in this rapidly advancing field of joint arthroplasty for the continuing evaluation and approval of new prostheses and techniques, while we await more PRCTs in our field.

Skin antisepsis, such as ready-to-use, no-rinse, 2% chlorhexidine-impregnated cloths, is one of the fundamental cornerstones for reducing periprosthetic infections after primary lower extremity total joint arthroplasties. This systematic review presents background material concerning the problem and methods to deal with and then describes the use of chlorhexidine cloth prophylaxis related to various surgical applications. The authors found an almost universal benefit of the cloths. In the meta-analysis, the total pooled effect showed a reduction in infection rates. The use of chlorhexidine cloths is appropriate for prophylaxis for knee arthroplasty, hip arthroplasty, and a variety of other surgeries.

With an expected increase in total knee arthroplasty (TKA) procedures, revision TKA (rTKA) procedures continue to be a burden on the United States health care system. The evolution of surgical techniques and prosthetic designs has, however, provided a paradigm shift in the etiology of failure mechanisms of TKA. This review can shed light on the current reasons for revision, which may lead to insights on how to improve outcomes and lower future revision risks. We will primarily focus on the epidemiology of rTKA in the present time, but we will also review this in the context of various time periods to see how the field has evolved. We will review rTKAs: 1) prior to 1997; 2) between 1997 and 2000; 3) between 2000 and 2012; and 3) in the modern era since 2012. We will further subdivide each of the sections into reasons for early (first 2 years after index procedure) versus late revisions (greater than 2 years after index procedure). In doing so, it was determined that prior to 1997, the most prevalent causes of failure were infection, patella failure, polyethylene wear, and aseptic loosening. After a major shift of failure mechanisms was described by Sharkey et al, polyethylene wear and aseptic loosening became the leading causes for revision. However, with the improved manufacturing technology and implant design, polyethylene wear was replaced with aseptic loosening and infection as the leading causes of failure between 2000 and 2012. Since that time, in the modern era of TKA, mechanical loosening and infection have taken over the most prevalent causes for failure. Hopefully, with continued developments in component design and surgical techniques, as well as increased focus on infection reduction methods, the amount of rTKA procedures will decline.

This study compared differences in (1) task duration; (2) biometric parameters (ie, caloric energy expenditure, heart rate); and (3) subjective measures of mental as well as physical demand of robotic-assisted total hip arthroplasty (THA) and manual THA. A total of 12 THAs were performed on 6 cadaveric specimens by two surgeons using a wearable technology to track biometric parameters and taking a questionnaire to compare the physical and mental demands. The results of our study suggest that as compared with manual techniques, robotic assistance for THA may reduce mental and physical fatigue.

Knee pain is among the most common complaints that an orthopedic surgeon may see in practice. It is often worked up with X-rays and MRI, leading to a myriad of potential diagnoses ranging from minimal edema patterns to various types of osteonecrosis. Similarities in certain causes can pose diagnostic challenges. The purpose of this review was to present the 3 types of osteonecrosis observed in the knee as well as additional causes to consider to help aid in the diagnosis and treatment..

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

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.

AimsAlternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment.MethodsA total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019.ResultsMean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group.ConclusionWith the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59–66.

The impact of gender on total knee arthroplasty (TKA) postoperative complications, readmission rates, and costs of care has not been often evaluated. Therefore, the purpose of this study was to investigate which sex had higher rates of: (1) medical complications; (2) implant complications; (3) lengths of stay (LOSs); (4) readmission rates; and (5) costs after TKA. A query was performed using an administrative claims database from January 1, 2005, to March 31, 2015. Patients who had TKAs were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Males and females were filtered separately and matched according to age and various medical comorbidities leading to 1,590,626 patients equally distributed. Primary outcomes analyzed included 90-day medical complications, LOSs, 90-day readmission rates, in addition to day of surgery and total global 90-day episode of care costs. Pearson's chi-square analyses were used to compare medical complications and readmission rates. Welch's t-tests were used to test for significance in matching outcomes and costs. A p-value of less than 0.01 was considered statistically significant. Males had a smaller risk of complications than women (1.35 vs. 1.40%, p

This study compared surgeon cervical (C) spine postures and repetitive motions when performing traditional manual total knee arthroplasty (MTKA) versus robotic-assisted TKA (RATKA). Surgeons wore motion trackers on T3 vertebra and the occiput anatomical landmarks to obtain postural and repetitive motion data during MTKA and RATKA performed on cadavers. We assessed (1) flexion–extension at T3 and the occiput anatomical landmarks, (2) range of motion (ROM) as the percentage of time in the flexion–extension angle, (3) repetition rate, defined as the number of the times T3 and the occiput flexion-extension angle exceeded ±10°; and (4) static posture, where T3 or occiput postures exceed 10° for more than 30 seconds. The average T3 flexion–extension angle for MTKA cases was 5-degree larger than for RATKA cases (19 ± 8 vs. 14 ± 8 degrees). The surgeons who performed MTKA cases spent 15% more time in nonneutral C-spine ROM than those who performed RATKA cases (78 ± 25 vs. 63 ± 36%, p

Haptic robotic-arm-assisted total knee arthroplasty (RATKA) seeks to leverage three-dimensional planning, intraoperative assessment of ligament laxity, and guided bone preparation to establish and achieve patient-specific targets for implant position. We sought to compare (1) operative details, (2) knee alignment, (3) recovery of knee function, and (4) complications during adoption of this technique to our experience with manual TKA. We compared 120 RATKAs performed between December 2016 and July 2018 to 120 consecutive manual TKAs performed between May 2015 and January 2017. Operative details, lengths of stay (LOS), and discharge dispositions were collected. Tibiofemoral angles, Knee Society Scores (KSS), and ranges of motion were assessed until 3 months postoperatively. Manipulations under anesthesia, complications, and reoperations were tabulated. Mean operative times were 22 minutes longer in RATKA (p

Implant malalignment during total knee arthroplasty (TKA) may lead to suboptimal postoperative outcomes. Accuracy studies are typically performed with experienced surgeons; however, it is important to study less experienced surgeons when considering teaching hospitals where younger surgeons operate. Therefore, this study assessed whether robotic-arm assisted TKA (RATKA) allowed for more accurate and precise implant position to plan when compared with manual techniques when the surgery is performed by in-training orthopaedic surgical fellows. Two surgeons, currently in their fellowship training and having minimal RATKA experience, performed a total of six manual TKA (MTKA) and six RATKAs on paired cadaver knees. Computed tomography scans were obtained for each knee pre- and postoperatively. These scans were analyzed using a custom autosegmentation and autoregistration process to compare postoperative implant position with the preoperative planned position. Mean system errors and standard deviations were compared between RATKA and MTKA for the femoral component for sagittal, coronal, and axial planes and for the tibial component in the sagittal and coronal planes. A 2-Variance testing was performed using an α = 0.05. Although not statistically significant, RATKA was found to have greater accuracy and precision to plan than MTKA for: femoral axial plane (1.1° ± 1.1° vs. 1.6° ± 1.3°), coronal plane (0.9° ± 0.7° vs. 2.2° ± 1.0°), femoral sagittal plane (1.5° ± 1.3° vs. 3.1° ± 2.1°), tibial coronal plane (0.9° ± 0.5° vs. 1.9° ± 1.3°), and tibial sagittal plane (1.7° ± 2.6° vs. 4.7° ± 4.1°). There were no statistical differences between surgical groups or between the two surgeons performing the cases. With limited RATKA experience, fellows showed increased accuracy and precision to plan for femoral and tibial implant positions. Furthermore, these results were comparable to what has been reported for an experienced surgeon performing RATKA.

Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [ Orthopedics . 2020;43(5):295–302.]

The learning curve has been established for robotic-assisted total knee arthroplasty (RATKA) during the first month of use; however, there have been no studies evaluating this on a longer term. Therefore, the purpose of this study was to compare operative times for three cohorts during the first year following adoption of RATKA (initial, 6 months, and 1 year) and a prior cohort of manual TKA. We investigated both mean operative times and the variability of operative time in each cohort. This is a learning curve study comparing a single surgeon's experience using RAKTA. The study groups were made up of two cohorts of 60 cementless RATKAs performed at ∼6 months and 1 year of use. A learning curve was created based on the mean operative times and individual operative times were stratified into different cohorts for comparison. Study groups were compared with the surgeon's initial group of 20 cemented RATKAs and 60 cementless manual cases. Descriptive numbers were compiled and mean operative times were compared using Student's t-tests for significant differences with a p-value of

Thirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors.Using the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson's chi-square and Student t-tests.The proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P.001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors.This is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.

Background Limiting treatment to those recommended by the American Academy of Orthopaedic Surgeon Clinical Practice Guidelines has been suggested to decrease costs by 45% in the year prior to total knee arthroplasty, but this only focuses on expenditures leading up to, but not including, the surgery and not the entire episode of care. We evaluated the treatment costs following knee osteoarthritis (OA) diagnosis and determined whether these are different for patients who use intra-articular hyaluronic acid (HA) and/or knee arthroplasty. Methods Claims data from a large commercial database containing de-identified data of more than 100 million patients with continuous coverage from 2012 to 2016 was used to evaluate the cumulative cost of care for over 2 million de-identified members with knee OA over a 4.5-year period between 2011 and 2015. Median cumulative costs were then stratified for patients with or without HA and/or knee arthroplasty. Results Knee OA treatment costs for 1,567,024 patients over the 4.5-year period was $6.60 billion (mean $4210/patient) as calculated by the authors. HA and knee arthroplasty accounted for 3.0 and 61.5% of the overall costs, respectively. For patients who underwent knee arthroplasty, a spike in median costs occurred sooner for patients without HA use (around the 5- to 6-month time point) compared to patients treated with HA (around the 16- to 17-month time point). Conclusions Non-arthroplasty therapies, as calculated by the authors, accounted for about one third of the costs in treating knee OA in our cohort. Although some have theorized that limiting the use of HA may reduce the costs of OA treatment, HA only comprised a small fraction (3%) of the overall costs. Among patients who underwent knee arthroplasty, those treated with HA experienced elevated costs from the surgery later than those without HA, which reflects their longer time to undergoing knee arthroplasty. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on the cost to the healthcare system.

Background Newer generation cementless total knee arthroplasty (TKA) designs have provided stronger osteointegration between the implant and bone. Despite excellent survivorship and outcomes with cemented TKAs, areas of concern within the bone–cement interface remain a concern and necessitate studies on alternative constructs. This study assesses: (1) implant survivorship; (2) clinical outcomes; and (3) complications with radiographic outcomes at a 5-year minimum follow-up of cementless highly porous titanium-coated baseplates in TKAs. Methods Part of this study has been reported. We retrospectively reviewed a prospectively collected database at a single high-volume institution between July 1, 2013 and June 30, 2014 for patients who underwent a primary TKA using cementless highly porous titanium-coated baseplate implants. Patients were evaluated clinically at postoperative follow-up visits at a minimum of 5 years. To calculate the survivorship, Kaplan–Meier analysis was performed to determine all-cause, aseptic, and septic implant survivorship at each final follow-up for all patients. Results A total of 228 TKAs were performed and followed for a minimum of 5 years (range, 5–6 years). As of the latest follow-up, one case of septic loosening of the patellar button and one case of patellar dislodgment secondary to physical manipulation were recorded and revised. Overall, the cohort displayed implant survivorship of 99.5% at 5-year minimum follow-up. Improvements were seen in both Knee Society pain and function scores and were 37 points (range, 17–60 points) and 28 points (range, 15–47 points), respectively. The mean improvement in flexion was 17.8 (range, –20 to 40 degrees) and mean improvement in extension was –5.5 (range, –30 to 5 degrees). Discussion Cementless TKAs serve as strong alternative choice to cemented TKAs. Although cemented fixation is commonly known as the gold standard, results of this study confirm the findings of previous investigations on the survivorship of cementless TKA implants. Therefore, patients who undergo primary TKA with a cementless tritanium baseplate can expect excellent clinical outcomes at a 5-year minimum follow-up.

The purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non-opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care.All patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs.Patients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P.0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P.001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P.0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P.0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients.These findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.

Aims Thresholds for operative eligibility based on body mass index (BMI) alone may restrict patient access to the benefits of arthroplasty. The purpose of this study was to evaluate the relationship between BMI and improvements in patient-reported outcome measures (PROMs), and to determine how many patients would have been denied improvements in PROMs if BMI cut-offs were to be implemented. Methods A prospective cohort of 3,449 primary total hip arthroplasties (THAs) performed between 2015 and 2018 were analyzed. The following one-year PROMs were evaluated: hip injury and osteoarthritis outcome score (HOOS) pain, HOOS Physical Function Shortform (PS), University of California, Los Angeles (UCLA) activity, Veterans Rand-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (VR-12 MCS). Positive predictive values for failure to improve and the number of patients denied surgery in order to avoid a failed improvement were calculated for each PROM at different BMI cut-offs. Results There was a trend to improved outcomes in terms of pain and function improvements with higher BMI. Patients with BMI ≥ 40 kg/m2 had median (Q1, Q3) HOOS pain improvements of 58 points (interquartile range (IQR) 41 to 70) and those with BMI 35 to 40 kg/m2 had median improvements of 55 (IQR 40 to 68). With a BMI cut-off of 30 kg/m2, 21 patients would have been denied a meaningful improvement in HOOS pain score in order to avoid one failed improvement. At a 35 kg/m2 cut-off, 18 patients would be denied improvement, at a 40 kg/m2 cut-off 21 patients would be denied improvement, and at a 45 kg/m2 cut-off 21 patients would be denied improvement. Similar findings were observed for HOOS-PS, UCLA, and VR-12 scores. Conclusion Patients with higher BMIs show greater improvements in PROMs. Using BMI alone to determine eligibility criteria did not improve the rate of clinically meaningful improvements. BMI thresholds prevent patients who may benefit the most from surgery from undergoing THA. Surgeons should consider PROMs improvements in determining eligibility for THA while balancing traditional metrics of preoperative risk stratification. Cite this article: Bone Joint J 2020;102-B(6):683–692.

Early findings of superior total knee arthroplasty (TKA) outcomes at high volume centers have been thought to have led to distinct referral patterns. However, the effect of these selective referral processes has not been well assessed. Therefore, this study compared the characteristics of primary TKA patients at high, intermediate, and low volume hospitals.A total of 12,541 primary TKA patients were stratified into risk groups based on age (65 years), body mass index (40), and Charlson Comorbidity Index (≥4). Hospitals were classified as low, intermediate, or high volume based on mean annual TKA volumes (250, 250-499, and500). Multivariate logistic regression models evaluated the relationship between baseline patient characteristics and hospital volume.There was a greater percentage of high risk patients at high volume (19%, n = 853) compared to those at intermediate (16%, n = 899) or low volume (17%, n = 444) hospitals (P.001). Patients with a body mass index40 were more likely to be treated at high compared to intermediate (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6, P.001) and low volume centers (OR 1.4, 95% CI 1.2-1.7, P.001). Patients with Charlson Comorbidity Index scores ≥4 were also more likely be treated at high compared to intermediate (OR 1.5, 95% CI 1.3-1.6, P.001) or low (OR 1.2, 95% CI 1.0-1.4, P = .002) volume centers.This study found that TKA patients at high volume centers have significantly different baseline characteristics compared to those at lower volume centers. This study highlights the importance of considering hospital volume status and the associated disparity in the preoperative risk of patients when comparing primary TKA outcomes between centers.

Catheterization for the prophylaxis against or treatment for urinary retention commonly occurs after total knee arthroplasty (TKA). Recent studies have questioned the use of the indwelling catheterization, especially in its potential role as a nidus for infection. We are still unsure of its downstream effects on periprosthetic joint infections (PJIs). Therefore, this study aimed to compare the risks of postoperative PJI following intermittent vs indwelling catheterization after TKA.Between 2017 and 2019, 15 hospitals in a large health system collected data on patients undergoing TKA. Patient treatments with indwelling catheter only, intermittent straight catheter only, and both indwelling and intermittent straight catheterizations were recorded. Patient demographics, comorbidities, body mass indices, and PJIs were collected from time of surgery to time of data collection at mean 14 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models to compare catheterization treatment types.A total of 9123 TKAs were performed, with patients receiving indwelling catheter only (62%, n = 734), intermittent straight catheter only (25%, n = 299), or both indwelling and intermittent catheterizations (13%, n = 160). Univariate analyses showed that PJIs occurred in 1.1% of no-catheter patients and 2.3% of patients treated with bladder catheterization (P = .002). Using multivariate analyses, indwelling catheter use (odds ratio [OR] 2.647, P.001), diabetes (OR 1.837, P = .005), and peripheral vascular disease (OR 2.372, P = .046) were found to have a statistically significant increased risk for PJIs. The use of intermittent straight catheterization (OR 1.249, P = .668) or both indwelling and intermittent (OR 1.171, P = .828) did not increase the risk for PJIs.Urinary bladder catheterization is commonly required for prophylaxis against or treatment for urinary retention following TKA. The use of a urinary catheter can provide a potential nidus for infection in these patients. This study found that indwelling catheterization, but not intermittent catheterization, was associated with an increased risk for PJI. Surgeons should therefore limit the duration of catheterization in an effort to decrease the risk for PJI.

Large-scale studies evaluating the effects of Parkinson's disease (PD) on primary total knee arthroplasty (TKA) are limited. The purpose of this study was to determine if PD patients undergoing primary TKA have increased: (1) medical complications; (2) implant-related complications; (3) readmission rates; and (4) costs. A query was performed using an administrative claims database. The study group consisted of all patients undergoing primary TKA who had a history of PD. Matched non-PD patients undergoing primary TKA served as a control group. The query yielded 72,326 patients (PD = 18,082; matching cohort = 54,244). Pearson's chi-square tests, logistic regression analyses, and Welch's t-tests were used to test for significance between the cohorts. Primary TKA patients who had PD were found to have greater incidences and odds of medical complications (4.21 vs. 1.24%; odds ratio [OR]: 3.50, 95% confidence interval [CI]: 3.15–3.89, p

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

Studies evaluating the effects of depressive disorders in patients undergoing primary total knee arthroplasty (TKA) are sparse. Therefore, the purpose of this study is to investigate whether patients who have depressive disorders undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS), (2) readmission rates, (3) medical complications, (4) implant-related complications, and (5) costs of care.Patients with depressive disorders undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. The query yielded 138,076 patients who had (n = 23,061) or did not have (n = 115,015) depressive disorders. Primary outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, and costs of care. A P value less than .003 was considered statistically significant.Patients who have depressive disorders had significantly longer in-hospital LOS (6.2 days vs 3.1 days; P.0001). Additionally, study group patients had a higher incidence and odds of readmissions (15.5% vs 12.1%; odds ratio [OR], 1.33; P001), medical complications (5.0% vs 1.6%; OR, 3.34; P.0001), and implant-related complications (3.3% vs 1.7%; OR; 1.97; P.0001) Study group patients also incurred significantly higher day of surgery ($12,356.59 vs $10,487.71; P.0001) and 90-day costs ($23,386.17 vs $22,201.43; P.0001).After adjusting for age, sex, and comorbidities, this study demonstrated that patients who have depressive disorders have increased rates of in-hospital LOS, readmissions, complications, and cost. The study is useful in allowing orthopedists to adequately educate patients of potential complications which may occur.

➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.

A greater number of medically complex patients with multiple comorbidities are now more readily considered for total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine whether comorbidity burden, measured with the Elixhauser Comorbidity Index (ECI), correlated with 90-day medical complications and longer in-hospital lengths-of-stay (LOS) in TKA patients. The PearlDiver supercomputer was queried for all primary TKA patients in the Medicare Standard Analytic Files from 2005 to 2014 using International Classification of Disease, 9th edition codes. Patients were included based on ECI scores, ranging from 1 to 5. ECI 1 patients served as the control cohort, while ECI 2, 3, 4, and 5 patients were considered study cohorts. Each study cohort was matched based on age and gender to the control cohort, resulting in a total of 715,398 patients included for analysis (ECI 1, n = 144,072; ECI 2, n = 144,072; ECI 3, n = 144,072; ECI 4, n = 144,072; ECI 5, n = 139,110). Logistic regression analyses were performed to compare 90-day medical complications and Welch's t-tests were performed to compare LOS between the cohorts. Patients with higher ECI scores were more likely to develop medical complications and have longer LOS compared with matched patients in the control cohort. Compared with matched ECI 1 patients, patients with ECI scores of 2 (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.14–1.24), 3 (OR: 1.27, 95% CI: 1.21–1.32), 4 (OR: 1.32, 95% CI: 1.27–1.38), and 5 (OR: 1.33, 95% CI: 1.27–1.39) were significantly more likely to develop 90-day medical complications. Additionally, the mean LOS of patients in the ECI 2 (2.59 ± 1.49 vs. 2.73 ± 1.52 days), ECI 3 (2.59 ± 1.49 vs. 2.88 ± 1.51 days; p

The number of total knee arthroplasties (TKAs) performed in the United States has increased considerably in recent years, with a major contribution from younger patients. Maximizing survivorship of these implants has always been a point of emphasis. Early TKA designs with cementless fixation were associated with high rates of complications and implant failures. However, recent advances in cementless designs have shown excellent results. The decision to use cemented or cementless fixation for patients undergoing TKA is typically based on the surgeon's experience and preference. However, several patient characteristics must also be taken into account. The purpose of this review was to describe the clinical outcomes of studies in which a cementless TKA system was utilized for patients who (1) were less than 60 years of age, (2) were greater than 75 years of age, (3) were obese, (4) had rheumatoid arthritis, and (5) had osteonecrosis of the knee. Based on the studies included in this review, it appears that cementless fixation is a viable option for patients who have all of the above demographics.

Recent studies have demonstrated patients with rheumatoid arthritis (RA) have deranged coagulation parameters predisposing them to venous thromboembolisms (VTEs). Therefore, the purpose of this study was to investigate whether patients who have RA undergoing primary TKA have higher rates of (1) VTEs; (2) readmission rates; and (3) costs of care.Patients who have RA undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. Exclusions included patients with a history of VTEs and hypercoagulable states. Primary outcomes analyzed included rates of 90-day VTEs, along with lower extremity deep vein thromboses and pulmonary embolisms, 90-day readmission rates, in addition to day of surgery, and 90-day costs of care. A P-value less than .05 was considered statistically significant.Patients who have RA were found to have significantly higher incidence and odds (OR) of VTEs (1.9 vs 1.3%; OR: 1.51, P.0001), deep vein thromboses (1.6 vs 1.1%; OR: 1.55, P.0001), and pulmonary embolisms (0.4 vs 0.3%; OR: 1.26, P= .0001). Study group patients also had significantly higher incidence and odds of readmissions (21.6 vs 14.1%; OR: 1.67, P.0001) compared to controls. In addition, RA patients incurred significantly higher day of surgery ($12,475.17 vs $11,428.96; P.0001) and 90-day costs of care ($15,937.34 vs $13,678.85; P.0001).After adjusting for age, sex, and comorbidities, the study found patients who have RA undergoing primary TKA had significantly higher rates of VTEs, readmissions, and costs.

Background The purpose of this study was to evaluate the associations of hospital volume with revision surgery for infection and superficial incisional infections. Methods A review of 12,541 primary total knee arthroplasties (TKAs) at a large integrated health system from 2014 to 2017 was conducted. Sixteen hospitals were classified as low-volume, medium-volume, or high-volume hospitals according to the mean number of TKAs/year ( 500, respectively). Thresholds were guided by percentiles and the literature on volume-outcome relationships. Medical records were reviewed for revision surgery for infection and superficial incisional infections during a mean 2-year review period. Multivariate analyses, adjusted for clinical and patient characteristics, were performed to evaluate the association between hospital volume and infection. Results The overall rate of revision surgery for infection was 0.7% (n = 82), and the overall rate of superficial incisional infection was 2.6% (n = 324). After accounting for potential confounders, hospital volume was not found to have a significant association with revision surgery for infection when comparing high-volume and low-volume hospitals (odds ratio, 1.615; 95% confidence interval, 0.761-3.427; P = .212) as well as when comparing high-volume and medium-volume hospitals (odds ratio, 1.464; 95% confidence interval, 0.853-2.512; P = .166). Moreover, the risk of superficial incisional infection at high-volume hospitals was similar to that at low-volume (P = .107) and medium-volume (P = .491) hospitals. Conclusion Infection outcomes are quality metrics that are frequently used to compare hospitals including those of varying volumes. Using contemporary thresholds, this study found that infection rates after TKA at high-volume hospitals are comparable to low-volume and medium-volume hospitals.

Background The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. Methods In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. Results Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. Conclusion A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

Introduction: The broad aim of this study was to compare the safety and efficacy of using barbed sutures and running closure versus interrupted placement of standard of care sutures for closure of the arthrotomy during total hip arthroplasty (THA). Specifically, we compared duration of arthrotomy closure, the number of sutures utilised for arthrotomy closure, and 90-day outcomes including wound-related readmission, reoperation, and complications. Methods: A total of 60 patients undergoing 60 THAs were enrolled in a prospective, single-blinded trial and randomised to receive either running closure of the arthrotomy with barbed sutures ( n = 30) or interrupted closure with standard of care sutures ( n = 30). Patients were eligible if they were undergoing primary THA for osteoarthritis and excluded if they had a BMI > 45 kg/m2 or age > 80 years or Results: Arthrotomy closure duration was significantly shorter in the barbed suture group (3 minutes ± 9 seconds) versus the standard of care group (8 minutes ± 26 seconds, p < 0.001). The suture utilisation for arthrotomy closure was 1 suture in the barbed sutured group 28/30 (93%) patients versus 2–4 sutures in 27/30 (90%) in the standard of care group ( p < 0.001). The overall number of wound-related complications in the barbed suture group was 1/30 (3%) versus 1/30 (3%) in the standard of care group ( p = 1.00). The rate of suture abscesses was 1/30 (3%) in barbed suture group versus the standard of care ( p = 1.00). There was trochanter bursitis 1/30 (3%) in the standard of care group versus zero in the barbed suture group ( p = 1.00). Conclusions: These results suggest that barbed suture utilisation may be faster and more resource efficient than use of standard of care sutures for arthrotomy closure in THA. ClinicalTrials.gov Identifier: NCT03285555

BACKGROUND We compared the following 30-day outcomes for total knee arthroplasty (TKA) and total hip arthroplasty in spinal anesthesia (SA) versus general anesthesia (GA) (1) mortality, (2) major and minor complication rates, and (3) discharge disposition. METHODS From 2011 to 2016, the American College of Surgeons National Surgical Quality Improvement Program database contained 45,871 SA total hip arthroplasties and 65,092 receiving GA. There were 80,077 SA TKAs and 103,003 GA TKAs. Adjusted multivariate logistic regression evaluated associations between anesthesia type and 30-day outcomes. RESULTS Anesthesia modality was not associated with 30-day mortality (P > 0.05). The GA cohorts were at a greater risk for any complication, major complications, and minor complications (P < 0.05). Patients who received GA were at an increased risk for nonhome discharge. CONCLUSION Patients who undergo total joint arthroplasty with SA experience fewer 30-day complications and are less likely to have a nonhome discharge than those with GA.

Introduction: Computed tomography scan (CT)-based three-dimensional (3D) modeling operative technologies have been shown to improve upon many perioperative results of manual total knee arthroplasties (TKAs). Although patient satisfaction has been reported for CT-based TKAs, studies evaluating large cohorts are limited. The purpose of this study was to compare the clinical outcomes of a surgeon’s first 1,000 CT-based TKAs with manual TKAs during a minimum follow-up time of approximately six months. Specifically, we analyzed: (1) survivorship; (2) functional outcomes; (3) radiographic outcomes (i.e., alignment, progressive radiolucencies); and (4) complications. Materials and Methods: A total of 1,000 consecutive primary CT-based total knee arthroplasty cases (988 patients) performed by a single surgeon at a single center between July 1, 2016 and July 1, 2021 were compared to a total of 1,000 consecutive manual TKAs (996 patients) completed by the same surgeon between May 18, 2013 and July 1, 2016. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) surveys were collected at approximately six months postoperatively. Subgroup analyses were performed on the physical function and pain scores. Follow-up radiographs were also examined for alignment, progressive radiolucencies, and/or loosenings. Results: There was 100% survivorship at approximately six months follow up. The mean physical function score for the manual cohort and CT-based cohort were 10 ± 4 (range, 0 to 32) and 5 ± 4 (range, 0 to 22), respectively (p

Periprosthetic joint infections (PJIs) are one of the most feared complications in the realm of adult reconstruction due to the substantial morbidity and mortality associated with these cases. Advancements in arthroplasty have been made across a variety of areas of interest including implant surfaces, implant design, material science, etc., but a focus on infection prevention and treatment is of utmost importance. A new technology has been created that targets biofilm and aims to prevent infection in total joint arthroplasty. In this manuscript we aim to describe the benefits of this technology and describe the ideal use in a case scenario format. We believe that with this technology that we can approach the goal of a zero periprosthetic infection rate.

Heterotopic ossification (HO) is a well-recognized complication following operative fixation of acetabular fractures with a range of severity and clinical consequences. The purpose of this review was to: (1) report the incidence of heterotopic ossification (HO) formation following operative fixation of acetabular fractures; (2) determine the effectiveness of prophylactic treatments for HO; and (3) assess the radiographic severity of HO with and without prophylactic treatment.A literature search for peer-reviewed articles was conducted utilizing a variety of research databases. PRISMA guidelines were followed and included in this review were full-length, English language manuscripts published before September 2019, using the following search criteria: "heterotopic ossification AND acetabulum OR acetabular." Studies that reported HO as one of the reported outcomes were included. Articles were excluded if radiographic HO was not reported and if it was evaluated in surgeries other than those involved in acetabular fractures. Extracted data included, but was not limited to: type of prophylaxis; incidence of HO; severity of HO based on the Brooker classification; and statistical significance. A methodologic quality appraisal of the included studies was also conducted. A total of 54 full-text studies with 5,890 patients with operatively fixed acetabular fractures met inclusion criteria. There were four level I studies, four level II study, 26 level III studies, and 20 level IV studies.The overall incidence of HO after acetabular fracture surgery was 28.4%. The rate of HO formation was: 34.9% without prophylaxis, 28.3% with non-steroidal anti-inflammatory drugs (NSAID) prophylaxis, and 21.2% with radiation therapy (RT). Patients receiving a combination of both RT and NSAIDs developed HO 21.8% of the time. The rate of radiographic severe HO was 13.9% (range, 0-75%) in patients without prophylaxis, 9.4% (range, 0-50%) with NSAID prophylaxis, 5.7% (range, 0-12.8%) with RT prophylaxis, and 11.7% (range, 0-18.5%) with the combination of RT and NSAIDs.With the current literature collected in this systematic review, there was a lower incidence and severity of heterotopic bone formation following acetabular fracture fixation using radiation prophylaxis compared to NSAIDs or no treatment. The available literature is heterogeneous in fracture characteristics, surgical approaches, and prophylactic regimens with a general lack of randomized control trials. Further prospective studies are required to make definitive claims on the optimal prophylactic strategy to prevent heterotopic ossification.

Introduction: Opioid use disorder (OUD) patients have an increased risk of venous thromboembolism (VTE), readmissions, and higher costs following primary elective primary total joint arthroplasty, but these risks have not yet been clarified for other arthroplasty surgeries. Thus, the purpose of this study was to investigate whether OUD patients undergoing revision total knee arthroplasty (RTKA) have higher rates of: VTEs, readmissions, and costs of care. Materials and Methods: Patients who had a 90-day history of OUD prior to undergoing RTKA were identified and randomly matched to a comparison cohort in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, obesity, and tobacco use with a total of 16,851 patients collectively in both groups. The 90-day frequency and odds (OR) of developing VTE, deep vein thrombosis (DVTs), and PEs along with 90-day readmission rates and 90-day costs of care were analyzed. A p-value less than 0.01 was considered statistically significant. Results: OUD patients undergoing RTKA were found to have a higher incidence and odds of VTE (2.91 vs. 1.88; OR: 1.58, p

Recent studies have shown the prevalence of depressive disorders has increased within the United States. Studies investigating the impact of depressive disorders following primary THA are limited. Therefore, the purpose of this study was to determine whether patients with depressive disorders have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmission rates; 3) medical complications; and 4) implant-related complications.A retrospective query of the Humana claims database was performed. Patients undergoing primary THA with a history of depressive disorders were identified by International Classification of Disease, Ninth Revision (ICD-9), and Current Procedural Terminology (CPT) codes. Study group patients were matched to controls in a 1:5 ratio by age, sex, and comorbidities. The query yielded 67,245 patients with (n=11,255) and without (n=55,990) depressive disorders. Welch's t-tests were used to test for significance in LOS between the cohorts; whereas, logistics regression analyses were used for complications and readmissions. A p-value less than 0.003 was statistically significant.Patients with depressive disorders undergoing primary THA had significantly longer in-hospital LOS (6.59 days vs. 2.96 days, p0.0001). Additionally, patients with depressive disorders had higher incidence and odds of readmission rates (46.02 vs. 35.43%; OR: 1.55, p0.0001), medical complications (7.05 vs. 1.84%; OR: 4.04, p0.0001), and implant-related complications (5.76 vs. 2.75%; OR: 2.16, p0.0001) compared to patients without depressive disorders.After matching age, sex, and medical comorbidities, the results of the study demonstrate patients with depressive disorders have longer in-hospital LOS and increased rates of complications and readmission rates. The study is useful as it can allow orthopedic surgeons to properly counsel these patients of the potential complications which may arise following their procedure.