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Adverse outcomes after total knee arthroplasty (TKA) have been associated with preoperative psychological disorders and poor mental health. We aimed to investigate and quantify the association between preoperative mental health and 1) postoperative 90-day health care utilization; and 2) 1-year patient-reported outcomes after primary TKA.Retrospective review of prospectively collected data of patients who underwent primary elective TKA (n = 7,476) was performed. Preoperative mental health was evaluated using Veterans Rand-12 Mental Composite Scores (VR-12 MCS). Outcomes included prolonged length of stay (2-days), nonhome discharge, 90-day readmissions, emergency department visits, and reoperation. Improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) and Patient Acceptable Symptom State (PASS) achievement were evaluated at 1-year. Multivariable regression was implemented to explore associations between preoperative VR-12 MCS and outcomes of interest.A total of 5,402 (72.3%) completed 1-year follow-up. Lower preoperative VR-12 MCS was associated with higher odds of prolonged length of stay (MCS 20-39: odds ratio (OR): 1.46;P.001), and nonhome discharge disposition (MCS 20-39: OR: 1.92;P.001), but not 90-day readmission or reoperation (MCS20-39; P = .12 and P = .64). At 1-year, patients with a lower MCS were less likely to attain a substantial clinical benefit in KOOS-pain (MCS 0-19; OR: 0.25; P.001) and less likely to achieve PASS (MCS20-39; OR: 0.74; P = .002). Patients with an MCS60 were more likely to be discharged home (OR: 1.42; P = .008), achieve substantial clinical benefit in their KOOS-JR (OR: 1.16; P = .027),-Pain (OR: 1.220; P = .007) and PASS at 1-year (OR: 1.28; P = .008).Lower VR-12 MCS is associated with increased postoperative health care utilization and worse patient-reported outcome measures at 1-year post-TKA. These findings suggest that a VR-12 MCS ≤40 could be used to designate increased risk, guide the preoperative discussion and potential interventions.

Prospectively Captured Cohort.To explore associations between the preoperative opioid-specific NarxCare Scores NCS(NCS-opioids) as well as sedative-specific NCS(NCS-sedatives) as measures of patients' prescription drug use and (1)90-day postoperative readmission; (2)E.D. visits; (3)reoperation; (4)prolonged (2 d) hospital length of stay(LOS); and (5)non-home discharge. In addition, we sought to evaluate the previously suggested 300+ threshold as a cutoff for moderate/high-risk designation.The association between preoperative opioids and sedative use and healthcare utilization after non-emergent spine surgery is not well quantified. The NarxCare score (NCS) is a weighted scalar measure of opioids and sedatives that accounts for the number of prescribing providers, dispensing pharmacies, milligram equivalence doses, and overlapping prescription days.A total of 4,680 non-emergent spine surgery cases were included. Preoperative NCS-Opioids/Sedatives were captured. Bivariate and multivariable regression models were constructed to analyze associations between NCS-opioids/sedatives ranges and outcomes while accounting for baseline differences. Spline regression and propensity score matching (PSM) analyses were also implemented.For NCS-opioid, multivariable regression demonstrated higher odds of prolonged LOS starting in the 400-499 NCS-opioids category (odds ratio(OR)1.44; 95% confidence interval(CI)[1.05-1.97];P=0.026) going into the 500+ category(OR:1.94; 95%CI[1.29-2.93];P=0.002). The 500+ categories exhibited higher odds of 90-day readmission (OR:1.77; 95%CI[1.01-3.09];P=0.045). PSM comparison demonstrated that patients within the 300+ category had higher incidence of prolonged LOS[n=455(44%) vs. n=537(52%); P0.001], 90-day readmission [n=118(11%) vs. n=155(15%);P=0.019] and 90-day reoperation[n=51(4.9%) vs. n=74(7.2%); P=0.042]. For NCS-sedative; there was higher odds of prolonged LOS(OR:1.73; 95%CI[1.14- 2.63];P=0.010) and non-home discharge(OR:2.09; 95%CI:[1.22-3.63];P=0.008) within the 400-499 NCS-sedatives category. PSM comparison demonstrated significantly higher rates of prolonged LOS within the 300+ NCS-sedative cohort (vs. scores300), [n=277(44%) vs. 319(50%);P=0.021].Spine surgery continues to advance towards patient-specific care. Higher NCS-Opioids/Sedatives values may predict up to a two-fold increase in postoperative healthcare utilization. High values should prompt an interdisciplinary approach to mitigate deleterious prescription drug use.

PURPOSE OF REVIEW: 8.5 to 50% of total joint arthroplasty (TJA) patients are reported to have preoperative malnutrition. The narrative review identifies the relationship between preoperative malnutrition for TJA patients and postoperative outcomes as well as the use of perioperative nutritional intervention to improve postoperative complications. RECENT FINDINGS: Biochemical/laboratory, anthropometric, and clinical measures have been widely used to identify preoperative nutritional deficiency. Specifically, serum albumin is the most prevalent used marker in TJA because it has been proven to be correlated with protein-energy malnutrition due to the surgical stress response. However, there remains a sustained incidence of preoperative malnutrition in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients due to a lack of agreement among the available nutritional screening tools and utilization of isolated laboratory, anthropometric, and clinical variables. Previous investigations have also suggested preoperative malnutrition to be a prognostic indicator of complications in general, cardiac, vascular, and orthopaedic surgery specialties. SUMMARY: Serum albumin, prealbumin, transferrin, and total lymphocyte count (TLC) can be used to identify at-risk patients. It is important to employ these markers in the preoperative setting because malnourished TKA and THA patients have shown to have worse postoperative outcomes including prolonged length, increased reoperation rates, increased infection rates, and increased mortality rates. Although benefits from high-protein and high-anti-inflammatory diets have been exhibited, additional research is needed to confirm the use of perioperative nutritional intervention as an appropriate treatment for preoperative TJA patients.

Cucurbitacins are a class of highly oxidized tetracyclic triterpenoids. It’s hydrophobic properties and poor solubility in water, polymeric micellar systems exhibited improved antitumor efficacy because of a better solubilization and targeting after local and/or systemic administration. The aim of the present work was to evaluate the anticancer activity of CEG-AgNPs against benzo[a]pyren (BaP)-induced lung carcinoma. CEG-AgNPs was prepared, characterized and evaluated for its cytotoxic activity against A549 lung carcinoma cell line. Also, the anticancer activity of CEG-AgNPs (70.25 mg/kg) against BaP-induced lung carcinoma was evaluated in vivo, using 30 adult mice for 43 days. IC50 of CEG-AgNPs against A549 lung carcinoma cell line were approximately 94.47 μg/mL. Administration of BaP (50 mg/kg b.w.) to mice induced lung carcinoma with a significant increase in lung MMP-2, MMP-9, MMP-12, MDA, IL-6 and NF-κB as well as significant decreased in lung CAT, GPx and GSH level. Also, treatment with BaP produced significant increase in lung VEGF-C, COX-2 and Bcl-2 gene expression as compared to control group. Daily oral administration of CEG-AgNPs to mice treated with BaP showed a significant protection against-induced increase in lung MMP-2, MMP-9, MMP-12, MDA, IL-6 and NF-κB levels. The treatment also resulted in a significant increase in lung CAT, GPx and GSH level. In addition, the CEG-AgNPs could inhibit lung VEGF-C, COX-2 and Bcl-2 gene expression as compared to BaP treated mice. The histological and MRI examination showed that a significant normalization has been observed through in CEG-AgNPs treated mice. The biochemical, histological and MRI results showed that CEG-AgNPs have potent anticancer activity against BaP-induced lung carcinoma through modulating multiple cellular behaviours and signaling pathways leading to the suppression of adaptive immune responses.

It is unknown if the National Inpatient Sample (NIS) remains suitable to conduct projections for total knee arthroplasty (TKA) and total hip arthroplasty (THA), after their removal from “inpatient-only lists” in 2018 and 2020, respectively. We aimed to: (1) quantify primary THA and TKA volume from 2008 to 2018; (2) project estimates of future volume of THA and TKA until 2050; and (3) compare projections based on NIS data from 2008 to 2018 and 2008 to 2017, respectively. We identified all primary THA and TKA performed from 2008 to 2018 from the NIS. The projected volumes of THA and TKA were modeled using negative binomial regression models while incorporating log-transformed population data from the Centers for Disease Control and Prevention. Annual volume increased by 26% for THA and 11% for TKA (2008/2018: THA: 360,891/465,559; TKA:592,352/657,294). Based on 2008 to 2018 data, THA volume is projected to grow 120%, to 1,119,942 THAs by 2050. While, based on 2008 to 2017 data, THA volume is projected to grow 136%, to 1,219,852 THAs by 2050. Based on 2008 to 2018 data, TKA volume is projected to grow 4%, to 794,852 TKAs by 2050. While, based on 2008 to 2017 data, TKA volume is projected to grow 28%, to 1,037,474 TKAs by 2050. Projections based on 2008 to 2017 data estimated up to 240,000 (23%) more annual TKAs by 2050, compared with projections based on 2008 to 2018 data. The largest discrepancy among THA projections was an 8.2% difference (99,000 THAs) for 2050. After 2018 for TKA, and potentially 2020 for THA, projections based on the NIS will have to be interpreted with caution and may only be appropriate to estimate future inpatient volume. Level of evidence is prognostic level II.

Background The International Classification of Diseases-10 (ICD-10) came into effect in October 2015. The new procedural codes (ICD-10-PCS) were designed to specify granular aspects of the procedure, including laterality and revised components. This specificity could improve data collection in institutional databases, large registries, and administrative claims data. Given these possible applications, this study’s purpose was to assess the accuracy of ICD-10-PCS coding for revision total knee arthroplasty (rTKA). Methods This multicenter retrospective analysis utilized the rTKA databases at four academic medical centers for all aseptic rTKAs between October 1, 2015 and July 3, 2019. Operative reports were reviewed to determine laterality and revised components (tibial, femoral, liner, and patellar component), which were then compared with the ICD-10-PCS codes associated with the billing records. Proper coding required both component removal and replacement codes. The correct series of removal and replacement codes was determined using the American Joint Replacement Registry’s guidelines. Results In total, 1906 rTKAs were examined, and 98.0% had at least one proper ICD-10-PCS code, indicating an rTKA had occurred. Coding for components replaced was correct in 76.3% of cases. When examining both removal and replacement codes, accuracy dropped to 57.0%. Conclusion Nearly 25% of rTKA procedures were incorrectly coded for replaced components, and over 40% were incorrectly coded for removed and replaced components. ICD-10-PCS codes can accurately identify that an rTKA has occurred; however, the inaccuracy in identifying which specific components were revised should prompt further evaluation of the coding process before utilizing ICD-10-PCS codes to report granular rTKA data. Level of Evidence III, retrospective observational analysis.

INTRODUCTION It is uncertain if generic comorbidity indices commonly used in orthopedics accurately predict outcomes after total hip (THA) or knee arthroplasty (TKA). The purpose of this study was to determine the predictive ability of such comorbidity indices for: (1) 30-day mortality; (2) 30-day rate of major and minor complications; (3) discharge disposition; and (4) extended length of stay (LOS). METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent elective THA (n = 202,488) or TKA (n = 230,823) from 2011 to 2019. The American Society of Anesthesiologists (ASA) physical status classification system score, modified Charlson Comorbidity Index (mCCI), Elixhauser Comorbidity Measure (ECM), and 5-Factor Modified Frailty Index (mFI-5) were calculated for each patient. Logistic regression models predicting 30-day mortality, discharge disposition, LOS greater than 1 day, and 30-day major and minor complications were fit for each index. RESULTS The ASA classification (C-statistic = 0.773 for THA and TKA) and mCCI (THA: c-statistic = 0.781; TKA: C-statistic = 0.771) were good models for predicting 30-day mortality. However, ASA and mCCI were not predictive of major and minor complications, discharge disposition, or LOS. The ECM and mFI-5 did not reliably predict any outcomes of interest. CONCLUSION ASA and mCCI are good models for predicting 30-day mortality after THA and TKA. However, similar to ECM and mFI-5, these generic comorbidity risk-assessment tools do not adequately predict 30-day postoperative outcomes or in-hospital metrics. This highlights the need for an updated, data-driven approach for standardized comorbidity reporting and risk assessment in arthroplasty.

Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training. A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985–May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle–Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI). There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25–4.23). Pooled data analysis revealed TAD > 25 mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD 25 mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out. Level III.

Background: Minimal invasive mitral valve surgery gained wide acceptance. However, criticism continuous about its ability to replace the conventional full sternotomy technique.Aim of the work: The study aimed to compare between the full sternotomy and less invasive approaches for mitral valve surgery.Patients and Methods: The study recruited 100 patients. They were allocated to one of two equal groups [the traditional and minimal invasive approach]. All patients were thoroughly evaluated by history taking, physical examination, laboratory and ancillary radiological investigations. Assessment included incision length, weaning events, aortic cross clamp time, total bypass and operative times, rate of conversion from minimally invasive technique to full sternotomy. In surgical intensive care unit, ventilation hours, post-operative pain and need for analgesia, re-exploration for bleeding, blood loss and blood transfusion, and any complications were documented.Results: Preoperative New York Heart Association [NYHA] class was significantly different between groups A and B. But, no significant difference was reported for patient demographic or preoperative data. The incision length and cross clamp time was shorter in A than B group [6.56±1.88 cm, 61.78±35.91 minutes’ vs 12.54±1.78 cm, and 78.08±36.24 minutes, respectively]. Otherwise, the cannulation, bypass, operative times were significantly longer among group A. The ventilation, ICU stay, hospital stay, bleeding, serum creatinine and pain scores were significantly lower among group A. the postoperative events were comparable between both groups with slight increase of neurological events in A group [3 cases] than B group [2 cases]. At 6 months, both groups yielded non-significant difference, regardless of better outcome at direct postoperative time.Conclusion: Minimal invasive mitral valve surgery had a good short and mid-term outcome as the conventional sternotomy approach. It could replace the conventional approach as a gold-standard for mitral valve surgery.

In staged bilateral total knee arthroplasty (BTKA), the intersurgical time is yet to be determined. This study aimed to (1) test for differences in in-hospital metrics between the index and contralateral TKA and (2) determine the safest intersurgical time interval to minimize adverse outcomes after the contralateral surgery. The National Readmissions Database was queried for patients who received staged BTKA (2016–2017). A total of 20,279 patients were included. Demographics, comorbidities, baseline determinants, and intersurgical time between index and contralateral TKAs (≤ 3 month, 4–6 months, 7–9 months, and 10–12 months intervals) were captured. Outcomes included healthcare utilization (length of stay [LOS] and nonhome discharge), in-hospital costs, and in-hospital complications. Outcomes were compared between index versus contralateral surgeries and among contralateral surgeries of various intersurgical intervals. Contralateral surgeries had shorter LOS (2.2 ± 1.9 vs. 2.4 ± 2.0 days; p 0.05, each). Compared with the less than or equal to 3-month interval, the 4 to 6-month interval exhibited highest odds ratio (OR) of any infection (OR: 1.81; 95% confidence interval [CI]: [1.13–2.88]; p = 0.013), urinary tract infection (OR:1.81, 95%CI: [1.13–2.90]; p = 0.014), and any-cardiac complications (OR:1.17; 95%CI: [1.01–1.35]; p = 0.037). Patients in the 10–12-month cohort had lowest odds of posthemorrhagic anemia (OR: 0.84; 95% CI: [0.72–0.98]; p = 0.03). Overall, the second surgery of a staged BTKA has lower healthcare utilization despite similar complication rates. While patients in the 10 to 12-month intersurgical interval had the most favorable overall safety profile, no single interval exhibited consistently lower complications for all measured outcomes. Special care pathways should be optimized to care for patients undergoing staged BTKA.

Total knee arthroplasty (TKA) is the sole disease-modifying intervention for end-stage osteoarthritis. However, the temporal trends and stratification of age and patient demographics of pain and function levels at which surgeons perform TKA have not been characterized. The present investigation aimed to analyze the temporal trends of preoperative pain and functional patient-reported outcomes measures (PROMs) over the past 5 years when stratifying patient demographics. A prospective cohort of all patients who underwent primary elective TKA between January 2016 and December 2020 at a North American integrated tertiary health care system was retrospectively reviewed. The primary outcome was quarterly baseline (preoperative) pain and function PROM values before primary elective TKA. Evaluated PROMs included Knee Osteoarthritis Outcome Score (KOOS)-pain and KOOS-physical function shortform (PS) for the 5-year study period and were stratified by patient demographics (age, sex, race, and body mass index [BMI]). A total of 10,327 patients were analyzed. Preoperative pain levels remained unchanged over the study period for patients in the 45- to 64-year category (P-trend = 0.922). Conversely, there was a significant improvement in preoperative pain levels in the 65+ years group. Sex-stratified trends between males and females did not demonstrate a significant change in pre-TKA baseline pain over the study period (P-trend = 0.347 and P-trend = 0.0744). Both white and black patients demonstrated consistent KOOS-pain levels throughout the study period (P-trend = 0.0855 and P-trend = 0.626). Only white patients demonstrated improving preoperative KOOS-PS (P-trend = 0.0001), while black and “other” patients demonstrated consistent lower preoperative functional levels throughout the study period (P-trend = 0.456 and P-trend = 0.871). All BMI categories demonstrated relatively consistent preoperative KOOS-pain and KOOS-PS except for overweight and obese patients who demonstrated progressive improvement in preoperative KOOS-PS over the study period. Patients and surgeons are electing to perform primary TKA at higher levels of preoperative function. Stratification by race showed black patients did not experience a similar trend of improving function and exhibited a consistently lower functional level versus white patients. This disparity is likely to be multifactorial but may indicate underlying barriers to TKA access.

The recent Coronavirus Disease 2019 (COVID-19) pandemic made social distancing vital to limiting the spread of infection. As a result many patients postponed their hospital and orthopaedic clinic visits for the fear of contracting the virus, which in turn led to serious complications caused by negligence and lack of follow-up in elbow patients. The pandemic has been an ongoing threat;therefore, establishing an effective virtual assessment technique for patient follow-up has become a valuable option. The authors conducted a systematic approach for proper virtual assessment of patients with elbow disorders using telemedicine.

Background Total hip arthroplasty (THA) is a reliable operation, but it is critical that orthopaedic surgeons characterize which surgical factors influence patient-reported outcomes. The purpose of this study was to determine whether implant selection at the time of THA affects the odds of having (1) inadequate improvement according to patient-reported pain, function, and activity; (2) failure to achieve a substantial clinical benefit (SCB) with respect to pain; or (3) failure to achieve a patient-acceptable symptomatic state (PASS) according to pain and function. Methods Prospective data were collected from 4,716 patients who underwent primary THA (from July 2015 to August 2018) in a single health-care system with standardized care pathways. Patients were categorized according to the type of femoral and acetabular components and bearing surface used. Outcomes included 1-year postoperative patient-reported outcome measures (PROMs) and improvement in the Hip disability and Osteoarthritis Outcome Score (HOOS) and the University of California at Los Angeles (UCLA) activity score. Inadequate improvement was defined as PROMs that changed by less than the minimal clinically important difference (MCID) for the HOOS pain and physical function short form (PS) and as failure to improve beyond a mostly homebound activity status for the UCLA activity score (a score of ≤3). The MCID and SCB thresholds were set at values reported in the literature. Results One-year PROM data were available for 3,519 patients (74.6%). There were no differences in the proportion of patients who attained the MCID in terms of HOOS pain, HOOS PS, or UCLA activity scores at 1 year for all analyzed implant parameters. Multivariate regression demonstrated that implant selection was not a significant driver of inadequate improvement, according to HOOS pain and HOOS PS (p > 0.05). Larger (36-mm) femoral heads demonstrated lower odds of inadequate improvement versus 28-mm femoral heads according to UCLA activity scores (odds ratio [OR]: 0.64; 95% confidence interval, 0.47 to 0.86; p = 0.003). Implant-related criteria were not significant drivers of attaining a PASS or achieving an SCB with respect to HOOS pain. Conclusions For the most part, THA implant characteristics are not drivers of inadequate improvement with respect to pain and function. Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Telemedicine was originally created as a way to treat patients who were located in remote places far away from local health facilities or in areas with shortages of medical professionals. Telemedicine is still used today to address those problems, and is increasingly becoming a tool for convenient medical care. With the emergence of pandemics, telemedicine became almost a mandatory and valuable option for continuing to provide medical care in various specialties. As the threat of pandemic progress has continued for months and may continue for years, it is essential to validate existing tools to maintain clinical assessment and patient treatment to avoid negative consequences of the lack of medical follow-up. Therefore, the establishment of a virtual assessment technique that can be conducted effectively is of outmost importance as a way of adapting to the current situation. This study evaluated the role of telemedicine in the assessment of various orthopedic pathologies by means of a systematic virtual evaluation.

BACKGROUND Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint. AIM To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED METHODS Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05. RESULTS Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast. CONCLUSION From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.

The projected increase in utilization rates of total hip arthroplasty (THA) has created an emphasis on novel technologies that can aid providers in maintaining historically positive outcomes. Widespread utilization of robotic assisted THA (RA-THA) is contingent upon achieving favorable outcomes compared to its traditional manual counterpart (mTHA). Therefore, the purpose of our systematic review was to compare RA-THA and mTHA in terms of the following: (1) functional outcomes and (2) complication rates. The PubMed, Embase, and Cochrane library databases were searched for articles published October 1994 and May 2021 comparing functional outcomes and complication rates between RA-THA and mTHA cohorts. When three or more studies evaluated certain PROMs and complications, a pooled analysis utilizing Mantel–Haenszel (M–H) models was conducted utilizing data from final follow-up. Our final analysis included 18 studies which reported on a total of 2811 patients [RA-THA: n = 1194 (42.48%); mTHA: n = 1617 (57.52%)]. No significant differences were demonstrated for a majority of pooled analyses and when segregating by robotic system. Only WOMAC scores were significantly lower among RA-THA patients (p = 0.0006). For outcomes without sufficient data for a pooled analysis, there were no significant differences reported among included studies. The growing utilization of RA-THA motivates comparisons to its manual counterpart. Collectively, we found comparable functional outcomes and complication profiles between RA-THA and mTHA cohorts. More randomized controlled trials of higher quality and larger sample sizes are necessary to further strengthen these findings.

Comorbidity indices currently used to estimate negative postoperative outcomes in orthopaedic surgery were originally developed among non-orthopaedic patient populations. While current indices were initially intended to predict short-term mortality, they have since been used for other purposes as well. As the rate of hip and knee arthroplasty steadily rises, understanding the magnitude of the effect of comorbid disease on postoperative outcomes has become increasingly more important. Currently, the ASA classification is the most commonly used comorbidity measure and is systematically recorded by the majority of national arthroplasty registries. Consideration should be given to developing an updated, standardized approach for comorbidity assessment and reporting in orthopaedic surgery, especially within the setting of elective hip and knee arthroplasty. Cite this article: EFORT Open Rev 2021;6:629-640. DOI: 10.1302/2058-5241.6.200124

Preoperative risk stratification remains important for both patient safety and cost-effective allocation of resources in total joint arthroplasty. Limited literature exists investigating risk factors for unplanned intensive care unit (ICU) admission following arthroplasty. Therefore, the purpose of this study was to assess a broader spectrum of factors that may increase the risk of ICU admission across multiple surgical settings. We retrospectively reviewed 18,169 patients who underwent a hip (40.7%) or knee (59.3%) arthroplasty procedure (primary: n = 13,384, 90%; revision: n = 1,485, 10%) between August 1, 2015, and January 31, 2019, across nine sites at a single institution. Patient demographics, laboratory data, surgical parameters, and preoperative scores on the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) were recorded. A univariate analysis was conducted to identify differences between patients who required an ICU admission and those with no ICU involvement. Logistic regression was then used to generate predicted risk of ICU Involvement. A total of 147 patients (0.99%) required an ICU admission. Increasing age, higher Charlson's comorbidity index, American Society of Anesthesiologists (ASA) class 3 or greater, elevated blood urea nitrogen (BUN), elevated creatinine, decreased preoperative hemoglobin level, general anesthesia, surgical setting, revision procedure, and lower baseline scores on the KOOS Quality of Life (QOL) subscale (17 vs. 22.5, p = 0.032), VR-12 physical component score (PCS; 24.4 vs 27.1, p = 0.001), and VR-12 mental component score (MCS; 45.9 vs. 49.6, p = 0.003) were associated with a statistically significant increase in the risk of ICU admission. As performance of arthroplasty shifts in both the setting of care and the complexity of patients, identifying patients most at risk of requiring higher acuity of care is important. Preoperative assessment of comorbidities, kidney function, surgical setting, KOOS QOL subscale score, and VR-12 scores may provide guidance for the improvement of value-based care pathways.

Background: Vitamin D deficiency has been postulated as a cause for impaired bone healing and remodeling. The purpose of this study was to assess the potential association between low vitamin D levels and reoperation for nonunion following ankle fusion surgery. Methods: All adult patients (aged ≥18 years) who underwent ankle fusion procedures at a tertiary referral center from January 2010 to January 2019 with available vitamin D levels within 12 months preoperatively were retrospectively reviewed (n = 47). Patients were categorized as vitamin D deficient (Results: The average level in the vitamin D–deficient group (n = 17; 36.2%) was 16.9 vs 46.4 ng/mL in the normal group (n = 30; 63.8%). All recorded reoperations for nonunion occurred exclusively in the vitamin D–deficient cohort (4/17 [23.5%]; P = .013). There were similar reoperation rates for causes other than nonunion (2/17 [11.8%] vs 4/30 [13.3%]; P > .99) and repeat reoperation rates (3/17 [17.6%] vs 1/30 [3.3%]; P = .128) among vitamin D–deficient vs normal patients. Conclusion: Vitamin D deficiency may be associated with an increased risk of reoperation for nonunion after ankle fusion.

The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored.(1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes?Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA.After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay2 days (OR 2.2 [95% CI 1.5 to 3.2]; p0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay2 days (OR 1.003 [95% CI 1.002 to 1.005]; p0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02).Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility.Level III, diagnostic study.