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Background: There is increasing debate among orthopaedic surgeons over the temporal relationship between lumbar spinal fusion (LSF) and total hip arthroplasty (THA) for patients with hip-spine syndrome. Few large studies have directly compared the results of patients who undergo LSF prior to THA (LSF-THA) to those who undergo LSF after THA (THA-LSF). The current study matched THA patients with a prior LSF to patients who underwent LSF after THA to assess: 90-day and 1-year (1) medical/surgical complications; and (2) revisions., Methods: We queried a national, all-payer database to identify all patients undergoing THA between 2010 and 2018 ( n  = 716,084). The LSF-THA patients and THA-LSF patients were then matched 1:1 on age, sex, Charleson Comorbidity Index, and obesity. Medical/surgical complications and revisions at 90 days and 1 year were recorded. Categorical and continuous variables were analysed utilising t -tests and chi-square, respectively., Results: LSF-THA patients experienced significantly more postoperative dislocations at 90 days and 1 year compared to THA-LSF patients ( p  = 0.048 and p  < 0.001). There were a similar number of revisions performed for LSF-THA and THA-LSF patients at both 90 days and 1 year ( p  = 0.183 and p  = 0.426). Furthermore, at 1 year, LSF-THA patients experienced more pneumonia ( p  = 0.005) and joint infection ( p  = 0.020)., Conclusions: Prior LSF has been demonstrated to increase the risk of postoperative dislocation in patients undergoing THA. The results of the present study demonstrate increased dislocations with LSF-THA compared to THA-LSF. For "hip spine syndrome" patients requiring both LSF and THA, it may be more beneficial to undergo THA prior to LSF. Arthroplasty surgeons may wish to collaborate with spinal surgeons to ensure optimal outcomes for this group of patients., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RED: 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, United Orthopedic Corporation.All other authors declare that there is no conflict of interest.

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.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H803).

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: Obstructive sleep apnea (OSA) impacts approximately 936 million individuals globally and is known to complicate post-surgical recovery, particularly after total hip arthroplasty (THA). While continuous positive airway pressure (CPAP) is commonly recommended for managing OSA, its effect on THA recovery remains uncertain. The study aimed to assess the impact of CPAP use on post-THA outcomes in patients with OSA, focusing on medical complications and periprosthetic joint infection (PJI) at 90 days and 1 year., Methods: A national, all-payer database was utilized to identify patients undergoing primary THA between 2010 and 2021. Patients with OSA were stratified based on CPAP use through propensity score matching. Three matched groups were formed: OSA without CPAP, OSA with CPAP, and no OSA. Medical and surgical complications were assessed at 90 days and 1 year post-THA., Results: Patients with OSA using CPAP exhibited more baseline comorbidities than those without CPAP. CPAP use was associated with inferior outcomes, including higher odds of PJI, wound complications, and venous thromboembolism at 90 days and 1 year post-THA. These trends were consistent even after adjusting for confounders., Conclusion: CPAP use, indicative of severe OSA, was linked to worse post-THA outcomes, emphasizing the importance of recognizing OSA severity preoperatively. The study does not advocate for or against CPAP use but underscores the heightened risk in this patient population, guiding clinicians in tailoring perioperative strategies and counseling patients about potential risks., Competing Interests: None., (© 2023 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Introduction: Complex proximal humerus fractures pose challenges in elderly patients, as this common scenario can lead to unpredictable outcomes, regardless of treatment method. Given the evolving nature of the treatment for 3-and-4-part proximal humerus fractures, an epidemiological analysis offers a way to minimize the gap between appropriate understanding and effective intervention. As such, we aimed to i) evaluate the trends of nonoperative and operative management; and ii) compare the complication rates of ORIF to conversion ORIF (to RTSA)., Methods: We utilized a national, all-payer database to include patients who underwent open reduction and internal fixation for 2-part (n = 2783), 3-part (n = 2170), 4-part (n = 1087) proximal humerus fractures between April 2016 to December 2022. Patients who failed ORIF to RTSA included n = 108 for 2-part fractures, n = 123 for 3-part fractures, and n = 128 for 4-part fractures. We collected demographic and postoperative medical and surgical complications at 90-days, in addition to time-interval between ORIF and RTSA., Results: The malunion and nonunion rates for ORIF between different types of proximal humerus fractures were similar (2-part fractures: 1.8 %, 4.7 %; 3-part fractures: 1.8 %, 3.5 %; 4-part fractures: 2.4 %, 3.7 %). The conversion rates of failed ORIF to RTSA were 1.9 %, 2.8 %, and 5.9 % for 2-part, 3-part, and 4-part fractures, respectively. The time interval from failed ORIF to RTSA was 190 days for 2-part fractures, 169 days for 3-part fractures, and 129 for 4-part fractures., Conclusion: An epidemiological analysis of proximal humerus fractures by fracture type demonstrated an increase in RTSA for 2-part, 3-part, and 4-part fractures while nonoperative treatment showed no change from 2016 to 2020. Additional research is needed to determine which fractures are best treated operatively while maximizing outcomes. In the setting of complex proximal humerus fractures, several options seem feasible depending on patient demographic characteristics., Competing Interests: SSB- None. JAD- None. EAR-None. RG- None. DH-None. RM- None. JVI- None., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. 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: Traditional total knee arthroplasty (TKA) designs fail to reproduce physiologic knee kinematics, which can contribute to patient dissatisfaction. In an attempt to restore more normal knee kinematics, the medial pivot (MP) design may improve knee function and stability as well as patient satisfaction. A limited number of studies have compared postoperative outcomes of exclusively cementless Cruciate-Retaining (CR) TKAs to cementless MP TKAs. We aimed to compare: (1) 90-day, 1-year, and 2-year complications and revisions, (2) preoperative and postoperative range of motion (ROM), (3) Knee Injury and Osteoarthritis Outcome (KOOS-JR), and (4) visual analog scale (VAS) pain scores at 3-month, 6-month, 1-year, and 2-years., Methods: A retrospective analysis was performed to identify all patients who had previously undergone a TKA at our institution and compare a cementless CR system to a cementless MP design. Categorical variables, including demographics, comorbidities, and complications utilized Chi -square tests in bivariable analysis. Continuous variables, such as age, were compared using Student's t -tests. Significance was defined as p  < 0.05., Results: Cementless CR and cementless MP cohorts showed low profiles of postoperative complications and favorable patient-reported outcome measures (PROMs). The MP cohort had lower VAS pain at 1-year (1.70 vs. 3.76, p < 0.001) and 2-years (1.43 vs. 2.60, p < 0.001) and higher ROM at 3-months (118 vs. 100, p < 0.001), 6-months (113 vs. 103, p < 0.0001), and 1-year (117 vs. 110, p = 0.02), respectively., Conclusion: This study is the first comparison of postoperative outcomes between a cementless CR TKA and cementless MP TKA designs. Implant design and fixation type are vital components influencing patient satisfaction after TKA. Pain scores and range of motion favored the cementless MP cohort in comparison to the cementless CR cohort., (© 2023 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Background: Dual mobility liners for primary and revision total hip arthroplasties can lead to decreased dislocation and revision rates. However, there are a lack of data analyzing their utilization when cementing into well-fixed acetabular components in a variety of scenarios. Therefore, the purpose of this study was to examine cementation of dual mobility liners into well-fixed existing acetabular components from previous hip procedures, into new acetabular components, or directly into the acetabulum without prior implants. We specifically aimed to assess the following: (1) aseptic revision-free implant survivorship, (2) patient-reported outcomes, (3) prosthetic joint infections, dislocations, and osteolysis, (4) medical complications and readmissions, and (5) radiographic outcomes., Methods: A total of 35 patients who underwent treatment with a cemented dual mobility liner from October 1, 2014, to July 1, 2018, were identified and followed up for a mean of 4 years (range, 4-8). The primary outcome of interest was revision-free survival. The secondary outcomes included patient-reported outcome measurements, dislocations, periprosthetic infections, periprosthetic fractures, pulmonary emboli, deep vein thromboses, radiographic osteolysis, and emergency visits as well as inpatient admissions. The patient-reported outcome measurements used were the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, Short-Form 12 Health Survey Mental Component, and Short-Form 12 Health Survey Physical Component., Results: Aseptic revision-free survivorship was 93.3%, 92.3%, and 100% for previous acetabular cup, new cup, and native acetabulum, respectively. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement improved and the Short-Form 12 Physical Component improved postoperatively for all groups. Surgical complications included 3 prosthetic joint infections (1 in a new cup and 2 in native acetabula). A total of 1 patient (previous cup) had an emergency visit and inpatient readmission. Only 1 cemented dual mobility recipient (new cup) demonstrated progressive acetabular radiolucencies and all cemented dual mobility patients had no evidence of acetabular subsidence., Conclusions: Cemented dual mobility bearing liners demonstrated exceptional survivorship, low complication rates, adequate radiographic results, and improved functional outcomes when cemented into previously inserted well-fixed acetabular components, new components, or native acetabula. To the best of the authors' knowledge, this is the first study to demonstrate success at a minimum of 4-year follow-up. These data are important to surgeons deciding on the appropriate implantation methods to use for their high-risk patients., (© 2023 The Authors.)

The promise of controlling spending and improving the quality of care incentivizes health care providers to prioritize value through alternative payment models. Findings regarding improved value and cost savings of the Comprehensive Care for Joint Replacement (CJR) redesign are consistent throughout selected metropolitan hospitals. Before refinement can take place, reporting on baseline financial status is a necessity to ensure the starting point of hospitals before CJR takes effect. Evidence-based protocols, outcomes-based measures to evaluate results, and cooperation across specialties to deliver high quality care will be necessary to insure improved care throughout the episode. This commentary reviews the CJR program and provides recommendations for the near future in order to best serve the needs of patients as we move forward in the bundled payments direction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin., Methods: A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion., Results: From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p  < 0.05)., Conclusion: Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients., Competing Interests: JD- None. DH-None. JN- Arthritis Foundation: Board or committee member, Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic, Knowledge Online: Editorial or governing board, Journal of Knee Surgery: Editorial or governing board, Knee: Editorial or governing board, Microport: Paid consultant; Paid presenter or speaker; Research support, Stryker: Research support United: Research support RD- Baltimore City Medical Society.: Board or committee member, Biocomposites, Inc.: Research support, CyMedica Orthopedics: Research support, DePuy Synthes, Product, Inc.: Research support, Flexion Therapeutics: Research support, Microport Orthopedics, Inc.: Research support, Orthofix, Inc.: Research support, Patient-Centered Outcomes Research Institute (PCORI): Research support, Smith & Nephew: Research support, Stryker: Research support, Tissue Gene: Research support, United Orthopedic Corporation: Research support MM - None. SB - None., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

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.)

Introduction: Morbid obesity is a known risk-factor for increased complications following total hip arthroplasty (THA). Thus, many orthopaedic surgeons recommend bariatric surgery (BS). However, there is no consensus on the type (commonly either a Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and timing of BS prior to THA. Therefore, the purpose of this study is to compare BS recipients prior to THA to assess differences in 90-day to 2-year medical/surgical complications as well as revisions for: (1) type of BS (RYGB and SG); and (2) timing of BS. Additionally, we aim to assess risk factors for postoperative prosthetic joint infections (PJIs), dislocations, and revisions., Methods: We queried a national, all-payer database to identify patients undergoing primary THA from January 2010 to October 2020 ( n  = 715,100). Patients were then divided into 6 cohorts: 2 cohorts without history of BS (body mass index [BMI] kg/m 2 20-35 [ n  = 59,995]) and BMI > 40 [ n  = 36,799]); 2 cohorts with previous RYGB ( n  = 1278) or SG ( n  = 1051); and 2 cohorts that underwent BS either 6-12 months ( n  = 412) and >12 months ( n  = 1655) prior to the THA. Bivariate chi-square analyses of medical and surgical outcomes at 90 days-2 years were conducted. Multivariate logistic regressions identified independent risk factors for PJIs, dislocations, and revisions., Results: At 90 days-2 years, no differences in postoperative medical/surgical complications or revisions were seen among timing or type of BS. The BMI > 40 kg/m 2 cohort had the highest complication profile among all other cohorts. Timing and type of BS has similar odds of PJIs, dislocations, and revisions., Conclusions: Patients undergoing RYGB or SG 6-12 months and >1 year prior to THA showed similar complications profiles. These results suggest, bariatric patients do not need to wait 1 year before undergoing a THA., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JN: is a paid consultant for: Microport; receives research support from: Microport, Stryker, United Orthopedic Corporation.RED: 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, United Orthopedic Corporation.All other authors declare that there is no conflict of interest.

Background: The American Academy of Orthopaedic Surgeons (AAOS) provides clinical guidelines and frequently updates and expands on the recommendations. High quality, up-to-date, and applicable clinical guidelines are increasingly important tools for physicians to have. Assessing these continuously updating guidelines' overall quality has most recently been done in 2013 when there were 14 guidelines. Since then, nearly all guidelines have been updated and now 28 guidelines are provided. Our goal was to evaluate the updated 2023 AAOS guidelines using the well-established Advancing Guideline Development, Reporting and Evaluation in Health Care (AGREE II) tool., Methods: On April 23, 2023, all 28 guidelines set forth by AAOS were compiled. Using the AGREE II tool, a well-recognized and established tool for evaluation of guideline quality used across all disciplines, three independent reviewers appraised the current guidelines. These data were used to run descriptive statistics and assessed accordingly., Results: Across the 28 guidelines, the average AGREE II domain scores were as follows: Scope and Purpose (median score, 85%), Stakeholder Involvement (median score, 87%), Rigor of Development (median score, 87%), Clarity of Presentation (median score, 87%), Applicability (median score, 48%), Editorial Independence (median score, 87%), and Overall Assessment (median score, 80s%)., Conclusions: Five of the six AGREE II domains, including the overall assessment, tested achieved a median score above the 50% mark. These results indicate that the AAOS guidelines met many criteria for high quality based on a critical appraisal., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Introduction: Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA., Methods: A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA., Results: The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64-1.06], p  = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07-2.17], p = 0.022 and OR 1.44 CI [1.06-1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety., Conclusions: Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia., Competing Interests: ZC- None. SB- None. JD- None. DH- None. OS- None. MM- None. SP- None. RD-is a paid consultant for Microport Orthopedics, receives Research support from a company or supplier as a Principal Investigator from Microport Orthopedics, Stryker, United Orthopedic Corporation, on the Medical/Orthopaedic publications editorial/governing board of Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic Knowledge, Journal of Knee Surgery, Knee and Board member/committee appointments for a society Of the arthritis foundation. JN- receives research support from Johnson & Johnson, Biocomposites, CyMedica Orthopedics, Depuy Synthes Product, Flexion Therapeutics, Microport, Orthopedics, Orthofix, Patient-Centered Outcomes Research Institute (PCORI), Smith & Nephew, Stryker, Tissue Gene, United Orthopedic Corporation, is a Medical/Orthopaedic publications editorial/governing board for Journal of Knee Surgery and Board member/committee appointments for a society for Baltimore City Medical Society., (© 2023 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

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.)

Introduction: Over ⅓ of the population in the United State is obese (body mass index [BMI] >30 kg/m 2 ), with an increasing proportion being morbidly obese (BMI >40 kg/m 2 ). As the obesity rate climbs, an increasing number have entered the super-obese category (BMI >50 kg/m 2 ), theoretically increasing risk for complications after total hip arthroplasty (THA). This study compared complications in non-obese, obese, morbidly obese, and super-obese patients undergoing THA. We specifically assessed: (1) 1- and 2-year peri-prosthetic joint infection (PJI) rates; (2) complication rates; as well as (3) 1- and 2-year revision rates., Methods: A database review identified patients undergoing primary THA from 01 January 2010 to 31 December 2019. Patients were stratified based on the presence of International Classification of Diseases, 9th and 10th revision diagnosis codes of non-obese (BMI <30 kg/m 2 ) ( n   =  8680), obese (BMI <40 kg/m 2 ) ( n   =  12,443), morbidly obese (BMI <50 kg/m 2 ) ( n   =  5250), and super-obese (BMI >50 kg/m 2 ) ( n   =  814) prior to THA. Complication rates at 90 days, 1 year, and 2 years were compared across groups., Results: At all time points, super-obese patients were associated with higher rates of PJI, even when compared to morbidly obese patients. Complications such as sepsis, venous thrombo-embolism, and revision surgeries were found in higher numbers in super-obese as well as morbidly obese patients, compared to obese and non-obese patients., Conclusions: This study provides large-scale analyses demonstrating the association between super-obese and morbidly obese patients and higher infection rates, as well as complications, following THA. Importantly, the association of PJI is highest among super-obese patients, even when compared to morbidly obese patients. Attaining a BMI <40 kg/m 2 prior to surgery may be an important goal discussed with patients to lower the chance of postoperative infections.

Introduction: An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database., Methods: Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities., Results: Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA., Conclusion: Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Introduction: Revision total hip arthroplasty (rTHA) is at increased risk for postoperative instability when compared to primary cases, which has been mitigated to some extent with the introduction of dual mobility (DM) reconstructions. These constructs were designed to lower dislocation rates and to improve impingement-free range of motion. As a follow-up to our prior institutional study, we expanded on a cohort of DM reconstructions compared to non-DM constructs. We examined a modular dual mobility system in rTHA to measure loosening of the acetabular component, as well as revision and dislocation rates in comparison to an historical cohort of single articulation prostheses.Materials/Methods: This retrospective cohort study from a single center included 254 patients who underwent rTHA with a dual mobility liner by three fellowship-trained surgeons between January 1, 2014 and December 1, 2019. This was a follow-up to an historical cohort of revisions performed with a single articulation prosthesis (n = 120) from the same surgeons performed between January 1, 2011 and December 23, 2013. The inclusion criteria included consecutively performed rTHAs that had a minimum follow-up of 2 years. We excluded patients who had femoral revisions and head/liner revisions only. The average follow-up in the dual mobility cohort and the single articulation cohort was 5 years (range, 2-10 years) and 2.5 years (range, 1.5-4.3 years), respectively. The primary outcomes were dislocation, aseptic loosening, and re-revision rates. Secondary outcomes were radiographic analyses of cup migration and osteolysis., Results: There were 4 out of 256 (1.6%) dislocations from the dual mobility cohort compared to 7 out of 120 (5.8%), P  < 0.001 from the single articulation cohort. The rates of aseptic loosening were 3.2% (8 out of 254) and 4.2% (5 out of 120), P  = 0.124, respectively, between the cohorts. The re-revision rate was 5.9% for the DM liners and 8.3% in the control cohort, P  = 0.38. Radiographic analyses revealed no cup migration and osteolysis in any of the patients that had no dislocations., Conclusion: The dual mobility articulations in rTHA demonstrated improved results in terms of lower dislocations rates when compared to a single articulation prostheses. Our center uses these articulations for revisions and surgeons should consider the use of these bearings when performing rTHA., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. 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: Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures)., Methods: We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated., Results: The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies., Conclusion: The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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: Approximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years., Methods: A national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models., Results: The septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history., Conclusion: Less than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis., (Copyright © 2022 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.)

In recent years, the use of national databases in orthopaedic surgery research has grown substantially with database studies comprising an estimated ∼10% of all published lower extremity arthroplasty research. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic database arthroplasty project. In part II, we discuss how to collect data, propose a novel checklist/standards for presenting orthopaedic database information (SOPOD), discuss methods for appropriate data interpretation/analysis, and summarize how to convert findings to a manuscript (providing a previously published example study). Data collection can be divided into two stages: baseline patient demographics and primary/secondary outcomes of interest. Our proposed SOPOD is more orthopaedic-centered and builds upon previous standards for observational studies from the EQUATOR network. There are a host of statistical methods available to analyze data to compare baseline demographics, primary/secondary outcomes, and reduce type 1 errors seen in large datasets. When drafting a manuscript, it is important to consider and discuss the limitations of database studies, including their retrospective nature, issues with coding/billing, differences in statistical versus clinical significance (or relevance), lack of surgery details (approach, laterality, and implants), and limited sampling or follow-up. We hope this paper will serve as a starting point for those interested in conducting lower extremity arthroplasty database studies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The number of liver transplant recipients (LTR) is worldwide increasing and, as the survival is improving as well, there is an increasing number of patients needing total hip arthroplasty (THA). There might be increased risks for this specific group of patients and due to their comorbidities costs might be higher too. Using a big national database outcome and cost of THA should be compared between liver transplant recipients and the general population., Methods: The study was performed using a collection of Medicare, Medicaid, and private insurance claims. Length of stay (LOS), 30-day readmissions, complications rates up to 5 years, and 90-day total cost of care between liver transplant recipients and matched non-transplant patients should be compared. All primary THAs from 2010 to 2019 were identified. 513 patients with a liver transplant before their THA were matched to 10,759 patients without a history of solid organ transplant at a 1:20 ratio based on age, sex, Charlson Comorbidity Index, obesity, and diabetes status., Results: LTR had a longer average LOS (4.2 vs. 3.4 days, p  < 0.001). There was no difference in the thirty-day readmissions (5.7% vs. 4.1%, p   =  0.117) and 90-day dislocation rates (2.9% vs. 2.4%, p   =  0.600). Total costs in the first ninety days after THA were not different between the LTR and controls ( p   =  0.756)., Conclusions: These findings suggest that complications and costs are no major point of concern in patients with liver transplant that are operated with THA.

Background: Use of clinical and administrative databases in orthopaedic surgery research has grown substantially in recent years. It is estimated that approximately 10% of all published lower extremity arthroplasty research have been database studies. The aim of this review is to serve as a guide on how to (1) design, (2) execute, and (3) publish an orthopaedic administrative database arthroplasty project., Methods: In part I, we discuss how to develop a research question and choose a database (when databases should/should not be used), detailing advantages/disadvantages of those most commonly used. To date, the most commonly published databases in orthopaedic research have been the National Inpatient Sample, Medicare, National Surgical Quality Improvement Program, and those provided by PearlDiver. General advantages of most database studies include accessibility, affordability compared to prospective research studies, ease of use, large sample sizes, and the ability to identify trends and aggregate outcomes of multiple health care systems/providers., Results: Disadvantages of most databases include their retrospective observational nature, limitations of procedural/billing coding, relatively short follow-up, limited ability to control for confounding variables, and lack of functional/patient-reported outcomes., Conclusion: Although this study is not all-encompassing, we hope it will serve as a starting point for those interested in conducting and critically reviewing lower extremity arthroplasty database studies., (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.].

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H191 ).

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.)

Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P <.01) and 1 year (6.8% vs 2.1%, P <.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P <.01) and 1 year (3.7% vs 1.7%, P <.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P <.04), whereas those with injections beyond 6 months had no differences in PJIs ( P ≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [ Orthopedics . 2023;46(1):19-26.].

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.)

Background: Use of "orthobiologics" continues to expand for patients who have knee osteoarthritis (OA). We sought to perform a systemic review of biologic therapies relative to comparative groups, including the following: (1) platelet-rich plasma (PRP); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amniotic-derived mesenchymal stem cells (AMSCs). We assessed the following: (1) study methodologies; (2) cell preparations and formulations; (3) patient-reported outcome scores (PROMs); and (4) structural changes., Methods: PubMed, Cochrane Library, and Embase databases were queried (2013-2021) to conduct a systematic review of biologic therapies for knee OA, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighty-two studies were included: PRP (51); BMSC (15); ADSC (11); and AMSC (5). Study evaluations were made using the Modified Coleman Methodology Score. PROMs included the Western Ontario and McMaster Universities Arthritis Index and the Visual Analog Scale. Structural change evaluations included ultrasounds, radiographs, or magnetic resonance imaging., Results: PRP comprised a majority of the studies (n = 51), most with "fair" to "good" Modified Coleman Methodology Score. Studies had variable cell preparations and formulations, with comparison study results leading to inconsistent PROMs, and structural changes. A limited number of studies were included for BMSC, ADSC, and AMSC, all with similar findings to PRP., Conclusion: Available literature evaluating "orthobiologics" for knee OA remain nonsuperior to comparison cohorts. Higher level studies with larger sample sizes and improved methodologies are warranted to suggest differences. Despite a growth of "orthobiologics" in clinics, this updated systematic review highlights the uncertain efficacy for use in knee OA., (Copyright © 2022 Elsevier Inc. 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.