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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 <18 years. Results: Arthrotomy closure duration was significantly shorter in the barbed suture group (3 minutes ± 9 seconds) versus the standard of care group (8 minutes ± 26 seconds, p < 0.001). The suture utilisation for arthrotomy closure was 1 suture in the barbed sutured group 28/30 (93%) patients versus 2–4 sutures in 27/30 (90%) in the standard of care group (p < 0.001). The overall number of wound-related complications in the barbed suture group was 1/30 (3%) versus 1/30 (3%) in the standard of care group (p = 1.00). The rate of suture abscesses was 1/30 (3%) in barbed suture group versus the standard of care (p = 1.00). There was trochanter bursitis 1/30 (3%) in the standard of care group versus zero in the barbed suture group (p = 1.00). Conclusions: These results suggest that barbed suture utilisation may be faster and more resource efficient than use of standard of care sutures for arthrotomy closure in THA. ClinicalTrials.gov Identifier: NCT03285555 [ABSTRACT FROM AUTHOR]

Introduction: This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates. Methods: The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates. Results: Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43–2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31–3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42–2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20–3.23). Conclusions: The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk. [ABSTRACT FROM AUTHOR]

Reducing airborne bioburden in total joint arthroplasty (TJA) is of critical importance. The efficacy of crystalline ultraviolet‐C (C‐UVC) filtration in reducing bioburden in a dynamic operating room (OR) environment has not been evaluated. We assessed whether C‐UVC filtration reduced (i) total particle counts (TPC); (ii) viable particle counts (VPC); and (iii) colony‐forming units (CFUs). Fifty primary TJA cases were performed in a positive‐pressure OR; 25 cases with the C‐UVC unit and 25 cases without. The air was sampled by a particle counter and an impact air sampler to measure particle counts and CFUs, respectively. To compare TPC, VPC, and CFU/m3 between groups, independent t tests and multivariate regression, adjusted for number of OR staff and door openings, were performed. The C‐UVC group had significantly lower TPC (2.6 × 106 vs. 4.7 × 106 particles, p = 0.001) and VPC (18,605 vs. 27,516 particles, p = 0.001). There were fewer CFUs in the C‐UVC group (10.9 CFU/m3 vs. 13.7 CFU/m3, p = 0.163). Multivariate analysis identified C‐UVC filtration as a significant predictor of decreased TPC (β = −0.44, p = 0.002) and VPC (β = −0.47, p = 0.001) after accounting for door openings and number of OR staff. The reduction in CFUs was not significant on multivariate analysis. In this prospective pilot study, a C‐UVC air disinfection and recirculation unit led to a significant reduction in both TPC and VPC and a non‐significant reduction in CFU. Statement of clinical significance: Further studies are needed to investigate the effects of C‐UVC filtration units on surgical‐site infection rates. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:431‐437, 2020 [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge.Methods: A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls.Results: The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004).Conclusion: These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Background: The alpha-defensin test has been reported to have high accuracy to diagnose periprosthetic joint infection (PJI). There are remaining concerns about the utility of the test in patients with inflammatory diseases. The purpose of this study is to determine sensitivity and specificity of laboratory-based alpha-defensin in diagnosing PJI in patients with systemic inflammatory disease in revision total hip/knee arthroplasty.Methods: A retrospective review was conducted of 1374 cases who underwent revision total hip/knee arthroplasty at a single healthcare system from 2014 to 2017. Cases with inflammatory diseases who received a 1-stage revision arthroplasty, the first stage of 2-stage revision arthroplasty, or irrigation and debridement with available preoperative alpha-defensin results were included. Patients who received a second-stage procedure, spacer exchange, who had insufficient Musculoskeletal Infection Society criteria, or with early postoperative PJI were excluded from this study. Cases were classified as infected or not according to Musculoskeletal Infection Society criteria. A total of 41 cases met the inclusion criteria. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of alpha-defensin to diagnose PJI were calculated.Results: The alpha-defensin test demonstrated a sensitivity of 93%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 96%, and an accuracy of 97% for diagnosing PJI. There was 1 patient with polymyositis who had a false-negative result.Conclusion: Alpha-defensin had high accuracy for diagnosing PJI even in inflammatory diseases. The alpha-defensin test provides useful information with high accuracy in diagnosing PJI in patients with inflammatory diseases. [ABSTRACT FROM AUTHOR]

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

Purpose: Therefore, the purpose of this study was to evaluate the short-term perioperative outcomes of PD patients who underwent total knee arthroplasty (TKA). We specifically evaluated: (1) perioperative surgical and medical complications; (2) lengths of stay (LOS); and (3) total hospital charges.Methods: The Nationwide Inpatient Sample was used to identify PD patients who underwent TKA between 2002 and 2013. To control for potential confounders, PD TKA and non-PD TKA patients were propensity score matched (1:3) based on age, sex, ethnicity, Charlson Comorbidity Index, and insurance type. A total of 31,979 PD and 95,596 non-PD TKA patients were included.Results: PD patients had a 44% higher risk of suffering from any complication (OR 1.44; 95% CI 1.35-1.54), a 45% increased risk for any medical complication (OR 1.45; 95% CI 1.36-1.55), and a 9% higher risk for any surgical complication (OR 1.09; 95% CI 0.84-1.41). Compared to the matched cohort, PD patients had a mean LOS that was 6.5% longer (95% CI 5.46-7.54) and mean total hospital charges that were 3.05% higher (95% CI 1.99-4.11).Conclusions: PD patients are more likely to have postoperative complications, longer LOS, and higher costs after TKA than non-PD TKA patients. Since many of these complications can be prevented, a team-based multi-specialty patient optimization is needed.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Dislocation is a major complication following total hip arthroplasty, with risk factors such as surgical technique, implant positioning, and implant design. Literature has suggested the distance the femoral head must travel before dislocation to be a predictive factor of dislocation where smaller travel distance has increased dislocation risk. The purpose of this study was to compare 3 designs (hemispherical, metal-on-metal, and dual mobility [DM]) in terms of the dynamic dislocation distance and force required to dislocate.Methods: This dynamic dislocation distance model used a material testing system that defined acetabular component inclination (30°, 45°, and 60°), anteversion angles (0°, 15°, and 30°), and pelvic tilt (5° [standing] and 26° [chair rise]). Testing groups included a hemispherical shell with a modular polyethylene liner and 32-mm head, a metal-on-metal hip resurfacing cup design with a 40-mm CoCr head, and a DM design with a 42-mm outside diameter articulating liner and an inner 28-mm articulating head.Results: The dynamic dislocation distance of the DM hip was greater than that of the other designs for all inclination, anteversion, and pelvic tilt angles tested with the exception of 60° inclination/0° anteversion. At 26° pelvic tilt, it was observed that dislocation distance increased with greater anteversion and decreased with larger inclination.Conclusion: Clinical results have shown the DM design may reduce dislocation. These data support those findings and suggest that if instability is a concern preoperatively or intraoperatively, using a DM implant increases the dynamic dislocation distance. [ABSTRACT FROM AUTHOR]

Background: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it. Questions/purposes: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms?. Methods: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baselinePROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distributionbased method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs. Results: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]). Conclusion: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA. [ABSTRACT FROM AUTHOR]

Background The postoperative period and subsequent discharge planning are critical in our continued efforts to decrease the risk of complications after THA. Patients discharged to skilled nursing facilities (SNFs) have consistently exhibited higher readmission rates compared with those discharged to home healthcare. This elevated risk has been attributed to several factors but whether readmission is associated with patient functional status is not known. Questions/purposes After controlling for relevant confounding variables (functional status, age, gender, caregiver support available at home, diagnosis [osteoarthritis (OA) versus non-OA], Charlson comorbidity index [CCI], the Area Deprivation Index [ADI], and insurance), are the odds of 30- and 90-day hospital readmission greater among patients initially discharged to SNFs than among those treated with home healthcare after THA? Methods This was a retrospective, comparative study of patients undergoing THA at any of 11 hospitals in a single, large, academic healthcare system between 2017 and 2022 who were discharged to an SNF or home healthcare. During this period, 13,262 patients were included. Patients discharged to SNFs were older (73 611 years versus 656 11 years; p < 0.001), less independent at hospital discharge (6-click score: 16 6 3.2 versus 22 6 2.3; p < 0.001), more were women (71% [1279 of 1796] versus 56% [6447 of 11,466]; p < 0.001), insured by Medicare (83% [1497 of 1796] versus 52% [5974 of 11,466]; p < 0.001), living in areas with greater deprivation (30% [533 of 1796] versus 19% [2229 of 11,466]; p < 0.001), and had less assistance available from at-home caregivers (29% [527 of 1796] versus 57% [6484 of 11,466]; p < 0.001). The primary outcomes assessed in this study were 30- and 90-day hospital readmissions. Although the system automatically flags readmissions occurring within 90 days at the various facilities in the overall healthcare system, readmissions occurring outside the system would not be captured. Therefore, we were not able to account for potential differential rates of readmission to external healthcare systems between the groups. However, given the large size and broad geographic coverage of the healthcare system analyzed, we expect the readmissions data captured to be representative of the study population. The focus on a single healthcare system also ensures consistency in readmission identification and reporting across subjects. We evaluated the association between discharge disposition (home healthcare versus SNF) and readmission. Covariates evaluated included age, gender, primary payer, primary diagnosis, CCI, ADI, the availability of at-home caregivers for the patient, and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks basic mobility score in the hospital. The adjusted relative risk (ARR) of readmission within 30 and 90 days of discharge to SNF (versus home healthcare) was estimated using modified Poisson regression models. Results After adjusting for the 6-clicks mobility score, age, gender, ADI, OA versus non-OA, living environment, CCI, and insurance, patients discharged to an SNF were more likely to be readmitted within 30 and 90 days compared with home healthcare after THA (ARR 1.46 [95% CI 1.01 to 2.13]; p= 0.046 and ARR 1.57 [95% CI 1.23 to 2.01]; p < 0.001, respectively). Conclusion Patients discharged to SNFs after THA had a slightly higher likelihood of hospital readmission within 30 and 90 days compared with those discharged with home healthcare. This difference persisted even after adjusting for relevant factors like functional status, home support, and social determinants of health. These results indicate that for suitable patients, direct home discharge may be a safer and more cost-effective option than SNFs. Clinicians should carefully consider these risks and benefits when making postoperative discharge plans. Policymakers could consider incentives and reforms to improve care transitions and coordination across settings. Further research using robust methods is needed to clarify the reasons for higher SNF readmission rates. Detailed analysis of patient complexity, care processes, and causes of readmission in SNFs versus home health could identify areas for quality improvement. Prospective cohorts or randomized trials would allow stronger conclusions about cause-and-effect. Importantly, no patients should be unfairly "cherry-picked" or "lemon-dropped" based only on readmission risk scores. With proper support and care coordination, even complex patients can have good outcomes. The goal should be providing excellent rehabilitation for all, while continuously improving quality, safety, and value across settings. Level of Evidence Level III, therapeutic study. [ABSTRACT FROM AUTHOR]