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Background: Although there have been several studies describing risk factors for complications after outpatient total hip arthroplasty (THA), data describing the timing of such complications is lacking. Methods: Patients who underwent outpatient or inpatient primary THA were identified in the 2012-2019 National Surgical Quality Improvement Program database. For 9 different 30-day complications, the median postoperative day of diagnosis was determined. Multivariable regressions were used to compare the risk of each complication between outpatient vs inpatient groups. Multivariable Cox proportional hazards modeling was used to evaluate the differences in the timing of each adverse event between the groups. Results: After outpatient THA, the median day of diagnosis for readmission was 12.5 (interquartile range 5-22), surgical site infection 15 (2-21), urinary tract infection 13.5 (6-19.5), deep vein thrombosis 13 (8-21), myocardial infarction 4.5 (1-7), pulmonary embolism 15 (8-25), sepsis 16 (9-26), stroke 2 (0-7), and pneumonia 6.5 (3-10). On multivariable regressions, outpatients had a lower relative risk (RR) of readmission (RR = 0.73), surgical site infection (RR = 0.72), and pneumonia (RR = 0.1), all P < .05. On multivariable cox proportional hazards modeling, there were no statistically significant differences in the timing of each complication between outpatient vs inpatient procedures (P > .05). Conclusions: The timing of complications after outpatient THA was similar to inpatient procedures. Consideration should be given to lowering thresholds for diagnostic testing after outpatient THA for each complication during the at-risk time periods identified here. Although extremely rare, this is especially important for catastrophic adverse events, which tend to occur early after discharge.

Background: During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown. Methods: All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the “Top Box” response to the survey question “Likelihood of your recommending our video visit service to others,” were identified. Results: Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05). Conclusions: Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Background: Studies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA. Methods: Study population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation. Results: Among the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023). Conclusions: Surgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

Abstract Purpose Although most patellar dislocations are associated with medial patellofemoral ligament (MPFL) injury, many patients also sustain concomitant patellar osteochondral fractures following a patellar dislocation. Few prior studies have described or evaluated risk factors for patellar osteochondral fractures in pediatric patients. The purpose of the present study was to describe the incidenceand location of patellar osteochondral fractures following acute patellar dislocation in pediatric patients. In addition, we described risk factors for patellar osteochondral fractures in this population. We hypothesized that most fractures would occur at the inferomedial quadrant of the patella following a traumatic injury mechanism. Methods Following Institutional Review Board approval, the electronic medical record was queried to identify pediatric patients ≤ 18 years old who underwent MPFL reconstruction (MPFLR) or non‐operative treatment for patellar instability between July 2016 and February 2020. Osteochondral fractures were defined as full‐thickness chondral injuries with attached subchondral bone or purely osseous injuries measuring ≥ 3 mm (mm) in at least two magnetic resonance imaging (MRI) planes. Patients were included in the study if they had complete preoperative x‐ray and MRI studies with minimum 6‐month follow‐up. Patients were excluded if they had incomplete imaging, isolated chondral fractures, or less than 6 months follow‐up. Univariate analysis was used to identify patient factors associated with osteochondral fractures. Multivariate regression analysis was used to identify risk factors for osteochondral fractures. Results Sixty patients (63 knees) were included in the study, 15 (23.8%) of whom had a patellar osteochondral fracture. The majority of osteochondral fractures (87%) involved the inferomedial quadrant of the patella. Univariate analysis showed an association between male sex (p = 0.041), skeletal immaturity (p = 0.028), and decreased patellar tilt (p = 0.021) and patellar osteochondral fractures. Multivariate regression analysis identified male sex as an independent risk factor for osteochondral fractures (relative risk: 4.8, 95% confidence interval [CI]: 1.08–20.9, p = 0.039). No patients had recurrent dislocation at minimum 6‐month follow‐up. All patients with osteochondral fractures returned to sports at most recent follow up. Conclusion In this study, 23% of pediatric patients with acute patellar dislocations have a concomitant patellar osteochondral fracture. The majority of patellar osteochondral fractures involve the inferomedial quadrant of the patella. Male sex is an independent risk factor for patellar osteochondral fractures, and skeletal immaturity is associated with patellar osteochondral fractures in this population. Level of evidence Level III.

Background: Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are two treatment options for end-stage degenerative hip conditions. The objective of this single-center retrospective cohort study was to compare implant survival and patient-reported outcomes (PROs) in young patients (≤35 years) who underwent HRA or THA. Methods: All patients aged 35 years or younger who underwent HRA or THA with a single high-volume arthroplasty surgeon between 2004 and 2015 were reviewed. The sample included 33 THAs (26 patients) and 76 HRAs (65 patients). Five-year implant survival and minimum 2-year PROs were compared between patient cohorts. Results: Three patients in the THA group (9%) were revised within 5 years for instability (n = 1), squeaking (n = 1), or squeaking with a ceramic liner fracture (n = 1). No patients who underwent HRA were revised. The University of California, Los Angeles, activity score, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement increased by 74%, 64%, and 49%, respectively, among all patients. Compared to the HRA cohort, patients who underwent THA had lower preoperative and postoperative University of California, Los Angeles, activity, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement scores, yet there were no differences in the absolute improvements in any of the three measures between the two groups. Conclusions: Excellent functional outcomes were seen in young patients undergoing either HRA or THA. Although young patients undergoing THA started at lower preoperative baseline and postoperative PROs than patients undergoing HRA, both groups improved by an equal amount after surgery, suggesting that both HRA and THA afford a similar degree of potential improvement in a young population.

Background: Recent studies have examined the impact of the COVID-19 pandemic on the practice of total joint arthroplasty. A scoping review of the literature with compiled recommendations is a useful tool for arthroplasty surgeons as they resume their orthopedic practices during the pandemic. Methods: In June 2020, PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, CINAHL, medRxiv, and bioRxiv were queried for articles using controlled vocabulary and keywords pertaining to COVID-19 and total joint arthroplasty. Studies were characterized by their region of origin, design, and Center of Evidence Based Medicine level of evidence. The identified relevant studies were grouped into 6 categories: changes to future clinical workflow, education, impact on patients, impact on surgeons, technology, and surgical volume. Results: The COVID-19 pandemic has had a significant impact on arthroplasty practice, including the disruption of the clinical teaching environment, personal and financial consequences for patients and physicians, and the drastic reduction in surgical volume. New pathways for clinical workflow have emerged, along with novel technologies with applications for both patients and trainees. Conclusions: The COVID-19 pandemic emphasizes the recent trend in arthroplasty toward risk stratification and outpatient surgery, which may result in improved clinical outcomes and significant cost-savings. Furthermore, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.

Background: The incidence of subaxial spinal metastases increases due to longer life expectancy resulting from successful modern cancer treatments. The three most utilized approaches for surgical treatment include the anterior, posterior, and combined approaches. However, despite increasing surgical volume, data on the postoperative complication profiles of different operative approaches for this patient population is scarce. Methods: The institutional databases of two large referral centers in Thailand were retrospectively reviewed. Patients with subaxial cervical spine metastasis who underwent cervical surgery during 2005 to 2015 were identified and enrolled. Clinical presentations, baseline characteristics, operative approach, perioperative complications, and postoperative outcomes, including pain, neurological recovery, and survival, were compared among the three surgical approaches. Results: The 70 patients (44 with anterior approach, 14 with posterior approach, 12 with combined approach) were enrolled. There were no statistically significant differences in preoperative characteristics, including Charlson Comorbidity Index (CCI), Tomita score, and Revised Tokuhashi score, among the three groups. There were no significant differences among groups for medical complications, surgical complications, neurological recovery, verbal pain score improvement, survival time, or ambulatory status improvement. However, the combined approach did show a significantly higher rate of overall perioperative complications (p = 0.01), intraoperative blood loss (p

BackgroundThe internet is a well-known source of information that patients use to better inform their opinions and to guide their conversations with physicians during clinic visits. The novelty of the recent COVID-19 outbreak has led patients to turn more frequently to the internet to gather more information and to alleviate their concerns about the virus. ObjectiveThe aims of the study were to (1) determine the most commonly searched phrases related to COVID-19 in the United States and (2) identify the sources of information for these web searches. MethodsSearch terms related to COVID-19 were entered into Google. Questions and websites from Google web search were extracted to a database using customized software. Each question was categorized into one of 6 topics: clinical signs and symptoms, treatment, transmission, cleaning methods, activity modification, and policy. Additionally, the websites were categorized according to source: World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), non-CDC government, academic, news, and other media. ResultsIn total, 200 questions and websites were extracted. The most common question topic was transmission (n=63, 31.5%), followed by clinical signs and symptoms (n=54, 27.0%) and activity modification (n=31, 15.5%). Notably, the clinical signs and symptoms category captured questions about myths associated with the disease, such as whether consuming alcohol stops the coronavirus. The most common websites provided were maintained by the CDC, the WHO, and academic medical organizations. Collectively, these three sources accounted for 84.0% (n=168) of the websites in our sample. ConclusionsIn the United States, the most commonly searched topics related to COVID-19 were transmission, clinical signs and symptoms, and activity modification. Reassuringly, a sizable majority of internet sources provided were from major health organizations or from academic medical institutions.

One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old. This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥.18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed. Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P =.38), reoperations (1.3% versus 0.8%, P =.44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days. Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA. [ABSTRACT FROM AUTHOR]

Background: Racial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time.Methods: We conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities.Results: During the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, Ptrend < .001). These results held in all adjusted analyses.Conclusion: In this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care. [ABSTRACT FROM AUTHOR]

Purpose: (1) To compare the total number and dollar amount of industry funding and National Institutes of Health (NIH) funding to academic orthopaedic sports medicine surgeons and (2) to examine the impact of academic influence on industry funding and NIH funding to academic orthopaedic sports medicine surgeons.Methods: Academic orthopaedic sports medicine surgeons were identified using faculty web pages. Academic influence was approximated by a physician's Hirsch index (h index) and number of publications and obtained from the Scopus database. Total industry payments were acquired through the Open Payments Database, and NIH funding was determined from the NIH website. Statistical analysis was performed using Mann-Whitney U test and Spearman correlations with significance set at P < .05.Results: Physicians who received industry research payments and NIH funding had a significantly higher mean h index and more mean total publications than physicians who did not receive industry research payments and NIH funding. There were no significant differences in h index (P = .374) or number of publications (P = .126) between surgeons receiving industry nonresearch funding and those who did not. h Index and number of publications were both weakly correlated with the amount of industry research and nonresearch funding.Conclusion: Although academic influence is associated with industry research funding and NIH funding, there is no association between measures of academic influence and total industry and industry nonresearch payments. Combined with the weak associations between academic influence and the amount of industry payments, academic influence does not appear to be a major determinant of industry funding to academic orthopaedic sports medicine surgeons.Clinical Relevance: Surgeons should be cognizant of potential conflicts with industry, but the relationship between academic sports medicine surgeons and industry may be less subject to bias than previously believed. [ABSTRACT FROM AUTHOR]

Background: The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.Methods: Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.Results: Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.Conclusion: h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Multiple stakeholders are interested in improving patient experience after primary total hip arthroplasty due to shifts toward patient-centered care. Patient free-text narratives are a potentially valuable but largely unexplored source of data.Methods: The records of 383 patients who underwent primary total hip arthroplasty between August 2016 and August 2019 were combined with vendor-supplied patient satisfaction data, which included patient free-text comments and the Press Ganey satisfaction survey. A total of 1295 patient comments were analyzed for sentiment, and negative comments were categorized into nine themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not. Multivariable regression was used to determine perioperative variables associated with providing a negative comment.Results: Of the 1295 patient comments: 54% were positive, 24% were negative, 10% were mixed, and 12% were neutral. Top two themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in studied outcomes (eg. peak pain intensity, length of stay, or improvements in hip injury and osteoarthritis outcome scores Jr. and pain visual analog scale scores at 6-week follow-up) between those who provided negative comments vs those who did not (P > .05). However, patients who made negative comments were less likely to recommend their hospital care to peers (P < .001). Finally, patients who had >2 allergies (P = .024) were more likely to provide negative comments.Conclusion: The present study demonstrates that patient satisfaction appears not to be a reliable sole proxy for traditional objective outcome measures of pain relief and functional improvement. [ABSTRACT FROM AUTHOR]

Background: The etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.Methods: A national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.Results: Four hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).Conclusion: Early aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.Level Of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: Patients considering total joint arthroplasty often search for information online regarding surgery; however, little is known about the specific topics that patients search for and the nature of the information provided. Google compiles frequently asked questions associated with a search term using machine learning and natural language processing. Links to individual websites are provided to answer each question. Analysis of this data may help improve understanding of patient concerns and inform more effective counseling.Methods: Search terms were entered into Google for total hip and total knee arthroplasty. Frequently asked questions and associated websites were extracted to a database using customized software. Questions were categorized by topic; websites were categorized by type. JAMA Benchmark Criteria were used to assess website quality. Pearson's chi-squared and Student's t-tests were performed as appropriate.Results: A total of 620 questions (305 total knee arthroplasties, 315 total hip arthroplasties) were extracted with 602 associated websites. The most popular question topics were Specific Activities (23.5%), Indications/Management (15.6%), and Restrictions (13.4%). Questions related to Pain were more common in the TKA group (23.0% vs 2.5%, P < .001) compared to THA. The most common website types were Academic (31.1%), Commercial (29.2%), and Social Media (17.1%). JAMA scores (0-4) were highest for Government websites (mean 3.92, P = .005).Conclusion: The most frequently asked questions on Google related to total joint arthroplasty are related to arthritis management, rehabilitation, and ability to perform specific tasks. A sizable proportion of health information provided originate from non-academic, non-government sources (64.4%), with 17.1% from social media websites. [ABSTRACT FROM AUTHOR]

Background: There is interest in improving patient experience after total knee arthroplasty (TKA) due to recent shifts toward value-based medicine. Patient narratives are a valuable but unexplored source of information.Methods: Records of 319 patients who had undergone primary TKA between August 2016 and August 2019 were linked with vendor-supplied patient satisfaction data, which included patient comments and the Press Ganey satisfaction survey. Using machine-learning-based natural language processing, 1048 patient comments were analyzed for sentiment and classified into themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not (positive, neutral, mixed grouped together). Multivariable regression was used to determine perioperative variables associated with providing a negative comment.Results: Of the 1048 patient comments, 25% were negative, 58% were positive, 8% were mixed, and 9% were neutral. Top 2 themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in most of the studied outcomes (eg, peak pain intensity, length of stay, or Knee Injury and Osteoarthritis Outcome Score Junior and pain scores at 6-week follow-up) between the 2 cohorts (P > .05). However, patients who made negative comments were less likely to highly recommend their hospital care to peers (P < .001). Finally, patients who had higher American Society of Anesthesiologists Score and those who received a scopolamine patch were more likely to provide negative comments (P < .05).Conclusion: Although the current study showed that patient satisfaction might not be a proxy for traditional objective perioperative outcomes, efforts to improve the nontechnical aspects of medicine are still crucial in providing patient-centered care. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).Methods: Using the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.Results: At two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.Conclusion: In primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population. [ABSTRACT FROM AUTHOR]

Background: With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.Methods: Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.Results: This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).Conclusion: Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent. [ABSTRACT FROM AUTHOR]

Background: Spironolactone is used off-label for androgenic alopecia because of its ability to arrest hair loss progression and long-term safety profile. However, little is known about the safety of spironolactone in breast cancer (BC) survivors. Because spironolactone has estrogenic effects, there is a theoretical risk for BC recurrence. Given that spironolactone is an important tool in the treatment of alopecia, we investigated whether spironolactone increased risk for BC recurrence.Objective: To determine whether spironolactone is associated with increased BC recurrence.Methods: A retrospective analysis was conducted using the Humana Insurance database. Patients with a history of BC were identified using International Classification of Diseases codes, stratified by spironolactone prescription, and also matched 1:1 using propensity score analysis. Patient characteristics and cancer recurrence rates between both cohorts were compared and analyzed.Results: BC recurrence developed in 123 patients (16.5%) who were prescribed spironolactone compared with 3649 patients (12.8%) who developed BC recurrence without spironolactone prescribed (P = .004). After propensity matching, adjusted Cox regression analysis showed no association between spironolactone and increased BC recurrence (adjusted hazard ratio, 0.966; 95% confidence interval, 0.807-1.156; P = .953).Limitations: Retrospective study.Conclusion: Spironolactone was not independently associated with increased BC recurrence and may be considered for the treatment of alopecia in BC survivors. [ABSTRACT FROM AUTHOR]

Background: A higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.Methods: Patients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.Results: A total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.Conclusion: Overall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay. [ABSTRACT FROM AUTHOR]

Background: Laboratory studies are routinely performed as a part of the preoperative workup for a total knee arthroplasty (TKA). The ramifications of abnormal preoperative platelet counts remain uncharacterized in large, multicenter patient populations.Methods: Patients who underwent elective primary TKA were identified in the 2011-2015 National Surgical Quality Improvement Program database. Risk of 30-day postoperative complications was calculated as a function of preoperative platelet counts. Patients were characterized as having a normal platelet count, abnormally low platelet count, and abnormally high platelet count based on relative risk calculations. Univariate and multivariate analyses were performed to associate abnormal platelet counts with patient demographics, operative variables, 30-day postoperative complications, and readmissions.Results: In total, 140,073 patients who underwent elective TKA were identified. Using the relative risk threshold of 1.5 for any adverse event, abnormally low and abnormally high platelet count thresholds were set at ≤116,000/mL and ≥492,000/mL, respectively. Multivariate analyses revealed low platelet counts to be associated with higher rates of any, major, and minor adverse events and longer length of stay. Analogously, high platelet counts were associated with higher rates of any and minor adverse events and longer length of stay.Conclusion: The present study employed a large patient sample size and showed that elective TKA patients with abnormally high, as well as low, platelet counts are at increased risk of postoperative adverse outcomes. Focused attention needs to be paid to TKA patients with preoperative abnormal platelet counts for optimization and postoperative care.Level Of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Purpose: To compare the efficacy, as measured through the rate of reoperation, and rates of other 30-day perioperative complications between arthrotomy and arthroscopy for the treatment of septic native shoulders in a national patient population.Methods: Patients who were diagnosed with septic arthritis in a native shoulder and underwent irrigation and debridement through arthrotomy or arthroscopy were identified in the 2005-2016 National Surgical Quality Improvement Program database. Patient preoperative characteristics were characterized. Rate of reoperation, a proxy used to measure treatment efficacy, and other perioperative complications were compared between the 2 procedures.Results: In total, 100 patients undergoing shoulder arthrotomy and 155 patients undergoing shoulder arthroscopy for septic shoulder were identified. On univariate analysis, there were no statistically significant differences in patient preoperative characteristics, operative time (60 vs. 48 minutes, P = .290), length of stay (7.5 vs. 6.6 days, P = .267), or time to reoperation (8.9 vs. 7.2 days, P = .594) between the 2 surgical groups. On multivariate analysis controlling for patient characteristics, there were no statistically significant differences in risk of reoperation (relative risk [RR] = 1.914, 99% confidence interval [CI] = 0.730-5.016, P = .083), any adverse events (RR = 1.254, 99% CI = 0.860-1.831, P = .122), minor adverse events (RR = 1.304, 99% CI = 0.558-3.047, P = .421), serious adverse events (RR = 1.306, 99% CI = 0.842-2.025, P = .118), or readmission (RR = 0.999, 99% CI = 0.441-2.261, P = .998) comparing arthrotomy with arthroscopy.Conclusions: By demonstrating similar rates of reoperation, other postoperative complications, and 30-day readmissions, the current study suggests that arthrotomy and arthroscopic surgery have similar efficacy in treating septic shoulders. However, owing to the small sample size, there is still the possibility of a type II error.Level Of Evidence: Level III, therapeutic retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: The incidence of periprosthetic hip fractures is increasing due to higher numbers of total hip arthroplasties being performed. Unlike native hip fractures, the effect of time to surgery of periprosthetic hip fractures is not well established. This study evaluates the effect of time to surgery on perioperative complications for patients with periprosthetic hip fractures.Methods: Patients who underwent surgery for periprosthetic hip fracture were identified in the 2005-2016 National Surgical Quality Improvement Program database and stratified into 2 groups: <2 and ≥2 days from hospital admission to surgery. Multivariate regressions were used to compare risk for perioperative complications between the 2 groups. Independent risk factors for postoperative serious adverse events were characterized.Results: In total, 409 (<2 days from admission to surgery) and 272 (≥2 days from admission to surgery) patients were identified. Multivariate analysis revealed only higher risk of extended postoperative stay for patients who had delays of ≥2 days to surgery compared to those who had <2 days from admission to surgery. Independent risk factors for serious adverse events included increasing age, dependent preoperative functional status, and preoperative congestive heart failure, but not time to surgery.Conclusion: Unlike for native hip fractures, time to surgery for periprosthetic hip fractures does not appear to affect most 30-day perioperative complications. However, it is worth noting that this study was unable to control for all potential confounders and therefore the results may not be generalizable to all types of periprosthetic hip fractures. [ABSTRACT FROM AUTHOR]

Background: Reduced hospital stay programs for total knee arthroplasty (TKA) are being implemented in order to increase patient satisfaction and reduce healthcare costs. Although elderly patients are often included in these pathways, there have been limited data on whether older patients can safely be discharged within a day after TKA. The purpose of this study is to compare perioperative complications following primary TKA with ≤1 day in the hospital in patients aged ≥80 compared to <80 years old in the National Surgical Quality Improvement Program database.Methods: Patients who underwent primary TKA with hospital length of stay ≤1 day were identified in the 2005-2016 National Surgical Quality Improvement Program database. These patients were separated into 2 age groups: <80 and ≥80 years old. Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for perioperative adverse events and readmission. Independent risk factors for serious adverse events following such TKAs were identified.Results: In total, 17,191 (<80 year olds) and 1005 (≥80 year olds) cases were identified. Of these patients, 1750 cases were discharged the same day. Multivariate analysis revealed only higher risk for 30-day readmission and nonhome discharge in ≥80 compared to <80 year olds. Notably, the octogenarians had a significantly higher rate of nonsurgical site-related readmissions. Independent risk factors for serious adverse events include only American Society of Anesthesiologists score ≥3 and not patient age.Conclusion: These data suggest that, although octogenarians can safely be discharged in ≤1 day, greater postdischarge care may be warranted to reduce the rate of nonsurgical site-related readmissions. [ABSTRACT FROM AUTHOR]

Background: Studies comparing total ankle arthroplasty (TAA) to ankle fusion (AF) for end-stage ankle osteoarthritis have demonstrated conflicting results with respect to long-term outcomes. Literature regarding perioperative outcomes are limited and could complement longer-term outcomes studies. Methods: TAA and AF patients were abstracted from 2005 -- 2015 American College of Surgeons National Surgical Quality Improvement Database (NSQIP). Demographics and comorbidities were determined. Hospital course and 30-day adverse events were compared with multivariate analyses. Results: Of the 740 total cases identified, 587 (79%) underwent TAA and 153 (21%) underwent AF. AF patients were more likely to be younger, male, obese, and have greater medical disease burden (ASA class as well as individual comorbidities). Multivariate analysis revealed that TAA and AF patients had similar odds of having extended operative time, extended hospital length of stay (LOS), adverse events (any, serious, or minor), discharge to higher level of care, and hospital readmission. Conclusion: When controlling for TAA and AF patient characteristics, there were no differences in hospital course or perioperative outcomes identified. Therefore, procedure selection is turned back to questions of longer-term outcomes and individual patient goals. [ABSTRACT FROM AUTHOR]

Background: The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (<70 and 70-79 year olds).Methods: Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups: <70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions.Results: This study included 6523 (<70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to <70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations.Conclusion: These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age. [ABSTRACT FROM AUTHOR]

Background Identifying patients at highest risk for a complex perioperative course following total hip arthroplasty (THA) is more important than ever in order to educate patients, optimize outcomes, and to minimize cost and length of stay. There are no known studies comparing the clinically relevant discriminative ability of 3 commonly used comorbidity indices for adverse outcomes following THA: Elixhauser Comorbidity Measure (ECM), the Charlson Comorbidity Index (CCI), and the modified Frailty Index (mFI). Methods Patients undergoing THA were extracted from the 2013 National Inpatient Sample. The discriminative ability of ECM, CCI, and mFI, as well as the demographic factors age, body mass index, and gender for the occurrence of index admission Centers for Medicare & Medicaid Services procedure-specific complication measures, extended length of hospital stay, and discharge to a facility were assessed using the area under the curve analysis from receiver operating characteristic curves. Results ECM outperformed CCI and mFI for the occurrence of all 5 adverse outcomes. Age outperformed gender and obesity for the occurrence of all 5 adverse outcomes. ECM (the best performing comorbidity index) outperformed age (the best performing demographic factor) in discriminative ability for the occurrence of 3 of 5 adverse outcomes. Conclusion The less commonly used ECM outperformed the more often utilized CCI and newer mFI as well as demographic factors in correctly preoperatively identifying patients' probabilities of experiencing an adverse outcome suggesting that wider adoption of ECM should be considered in both identifying likelihoods of adverse patient outcomes and for research purposes in future studies. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the current study was to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to determine whether there were differences in 30-day perioperative complications between open arthrotomy and arthroscopy for the treatment of septic knees in a large national sample.Methods: Patients who were diagnosed with a septic knee and underwent open arthrotomy or arthroscopy were identified in the 2005-2014 NSQIP data sets. Patient demographics and perioperative complications were characterized and compared between the 2 procedures.Results: In total, 168 patients undergoing knee arthrotomy and 216 patients undergoing knee arthroscopy for septic knee were identified. There were no statistically significant differences in demographic variables between the 2 groups. On univariate analysis, the rate of minor adverse events (MAEs; 15.48% vs 8.80%, P = .043) was higher in the open arthrotomy treatment group, while the rate of serious adverse events (SAEs; 37.50% vs 26.19%, P = .019) was higher in the arthroscopic surgery treatment group. On multivariate analysis, which controlled for patient characteristics/comorbidities and used the Bonferroni correction for multiple comparisons, there were no statistically significant differences in risk of any adverse events (relative risk [RR] = 0.851; 99% confidence interval [CI], 0.598-1.211; P = .240), MAE (RR = 1.653; 99% CI, 0.818-3.341; P = .066), SAE (RR = 0.706; 99% CI, 0.471-1.058; P = .027), return to the operating room (RR = 0.810; 99% CI, 0.433-1.516; P = .387), or readmission (RR = 1.022; 99% CI, 0.456-2.294; P = .944) between open compared with arthroscopic surgery.Conclusions: Univariate analysis revealed a lower rate of MAE but a higher rate of SAE in the arthroscopic surgery treatment group. However, on multivariate analysis, similar perioperative complications, rate of return to the operating room, and rate of readmission were found after open and arthroscopic debridement for septic knees. Based on the lack of demonstrated superiority of either of these 2 treatment modalities for this given diagnosis, and the expectation that most differences in perioperative complications for this diagnosis would have declared themselves within the first 30 days, deciding between the studied treatment modalities may be based more on other factors not included in this study.Level Of Evidence: Retrospective comparative study, Level III. [ABSTRACT FROM AUTHOR]

Background: Advances in surgical techniques and anesthesia have made performing unicompartmental knee arthroplasty (UKA) in the outpatient setting a possibility. The touted benefits of outpatient surgery include higher patient satisfaction and reduced costs. However, detailed information on the perioperative outcomes of outpatient compared with inpatient UKA in a large, national patient population in the United States has never been reported. The present study compares perioperative complications between outpatient and inpatient UKAs in the National Surgical Quality Improvement Program database.Methods: Patients who underwent UKA were identified in the 2005-2015 National Surgical Quality Improvement Program database. Outpatient procedures were defined as those with length of hospital stay = 0 days, whereas inpatient procedures were defined as those with length of hospital stay = 1-4 days. Patients' characteristics and comorbidities were compared between the two groups. Propensity score matched comparisons were performed for 30-day perioperative complications and readmissions between the two cohorts.Results: This study included 568 outpatient and 5312 inpatient UKA cases. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in any perioperative complications or any postdischarge complications between the outpatient and inpatient cohorts. Notably, the rate of 30-day readmissions between the two cohorts was not statistically different.Conclusion: Based on the perioperative outcome measures assessed in this study, outpatient UKA can be appropriately considered in carefully selected patients based on the lack of differences in rates of 30-day perioperative complications and readmissions between the outpatient and matched inpatient groups. [ABSTRACT FROM AUTHOR]

Background: Total knee arthroplasty (TKA) is an effective treatment option for patients with advanced osteoarthritis and has become one of the most frequently performed orthopedic procedures. With the increasing prevalence of diabetes mellitus (DM), the burden of its sequela and associated surgical complications has also increased. For these reasons, it is important to understand the association between DM and the rates of perioperative adverse events after TKA.Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent TKA between 2005 and 2014 were identified and characterized as having insulin-dependent DM (IDDM), non-insulin-dependent DM (NIDDM), or not having DM. Multivariate Poisson regression was used to control for demographic and comorbid factors and to assess the relative risks of multiple adverse events in the initial 30 postoperative days.Results: A total of 114,102 patients who underwent TKA were selected (IDDM = 4881 [4.3%]; NIDDM = 15,367 [13.5%]; and no DM = 93,854 [82.2%]). Patients with NIDDM were found to be at greater risk for 2 of 17 adverse events studied relative to patients without DM. However, patients with IDDM were found to be at greater risk for 12 of 17 adverse events studied relative to patients without DM.Conclusion: In comparison with patients with NIDDM, patients with IDDM are at greater risk for many more perioperative adverse outcomes relative to patients without DM. These findings have important implications for patient selection, preoperative risk stratification, and postoperative expectations. [ABSTRACT FROM AUTHOR]

Background There has been a recent surge of interest in performing primary total knee arthroplasty (TKA) in the outpatient setting to reduce cost and increase patient satisfaction. Detailed information on the safety of outpatient TKA in large sample sizes is scarce. Methods Patients who underwent primary, elective TKA were identified in the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days, whereas inpatient procedure was defined as having a length of stay ≥1 days. To reduce the effect of confounding factors and nonrandom assignment of treatment, propensity score matching was used. Multivariate analyses on the matched samples were used to compare the rates of adverse events that happened any time during the 30-day postoperative period, postdischarge adverse events, and readmissions between the outpatient and inpatient cohorts. Results A total of 112,922 TKA patients met the inclusion criteria. Of these, only 642 (0.57%) were outpatient procedures. Outpatients tended to be men, slightly younger, and have less comorbidity. After propensity matching, multivariate analysis revealed a higher rate of postdischarge blood transfusions ( P < .001) in the outpatient cohort. There were no other significant differences in 30-day postoperative individual adverse events or readmissions. Conclusion Based on the perioperative outcome measures studied here, outpatient TKA can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients postdischarge may be warranted. [ABSTRACT FROM AUTHOR]

• The combined therapy produced better clinical results and a longer survival. • Perioperative complications are significantly higher with combined approach. • Anterior and posterior approach have the same neurological improvement rate. The incidence of subaxial spinal metastases increases due to longer life expectancy resulting from successful modern cancer treatments. The three most utilized approaches for surgical treatment include the anterior, posterior, and combined approaches. However, despite increasing surgical volume, data on the postoperative complication profiles of different operative approaches for this patient population is scarce. The institutional databases of two large referral centers in Thailand were retrospectively reviewed. Patients with subaxial cervical spine metastasis who underwent cervical surgery during 2005 to 2015 were identified and enrolled. Clinical presentations, baseline characteristics, operative approach, perioperative complications, and postoperative outcomes, including pain, neurological recovery, and survival, were compared among the three surgical approaches. The 70 patients (44 with anterior approach, 14 with posterior approach, 12 with combined approach) were enrolled. There were no statistically significant differences in preoperative characteristics, including Charlson Comorbidity Index (CCI), Tomita score, and Revised Tokuhashi score, among the three groups. There were no significant differences among groups for medical complications, surgical complications, neurological recovery, verbal pain score improvement, survival time, or ambulatory status improvement. However, the combined approach did show a significantly higher rate of overall perioperative complications (p = 0.01), intraoperative blood loss (p < 0.001), and operative time (p < 0.001) compared to the other two approaches. Patients in the combined approach group had the highest rates of perioperative complications. However, although the differences were not statistically significant, patients in the combined group tended to have better clinical outcomes after follow-up and the longest survival time. [ABSTRACT FROM AUTHOR]