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Prior literature has associated preoperative corticosteroid shoulder injection (CSI) with infection following shoulder surgery. A recent study found an equally elevated risk of total knee arthroplasty infection with preoperative injection of either CSI or hyaluronic acid. The implication is that violation of a joint prior to surgery, even in the absence of corticosteroid, may pose an elevated risk of infection following orthopedic surgery. The aim of the present study was to determine whether violation of the shoulder joint for Magnetic Resonance Arthrogram (MRA) poses an elevated risk of infection following shoulder arthroscopy and to compare this risk to that introduced by preoperative CSI.A national, all-payer database was queried to identify patients undergoing shoulder arthroscopy between January 2015 and October 2020. Patients were stratified into the following groups: (1) no CSI or MRA within 6 months of surgery (n = 5,000), (2) CSI within 2 weeks of surgery (n = 1,055), (3) CSI between 2 and 4 weeks prior to surgery (n = 2,575), (4) MRA within 2 weeks of surgery (n = 414), (5) MRA between 2 and 4 weeks prior to surgery (n = 1,138). Postoperative infection (septic shoulder or surgical site infection) was analyzed at 90-days, 1-year, and 2-years postoperatively. Multivariable logistic regression analysis controlled for differences among groups.MRA within 2 weeks prior to shoulder surgery was associated with an increased risk of infection at 1 year (OR, 2.17; P = 0.007), while MRA 2-4 weeks preceding surgery was not associated with an increased risk of postoperative infection at any time point. By comparison, CSI within 2 weeks prior to surgery was associated with an increased risk of postoperative infection at 90-days (OR, 1.72; P = 0.022), 1-year (OR, 1.65; P = 0.005) and 2-years (OR, 1.63; P = 0.002) following surgery. Similarly, CSI 2-4 weeks prior to surgery was associated with an increased risk of postoperative infection at 90-days (OR, 1.83; P0.001), 1-year (OR, 1.62; P0.001), and 2-years (OR, 1.79; P0.001).Preoperative CSI within 4 weeks of shoulder arthroscopy elevates the risk of postoperative infection. Needle arthrotomy for shoulder MRA elevates the risk of infection in a more limited fashion. Avoidance of MRA within 2 weeks of shoulder arthroscopy may mitigate postoperative infection risk. Additionally, the association between preoperative CSI and postoperative infection may be more attributed to medication profile than to needle arthrotomy.

Few studies investigate the influence of inflammatory bowel disease (IBD) on complications following total knee arthroplasty (TKA). Therefore, we compared complications and readmissions frequencies after TKA in patients with Crohn's disease (CD) and ulcerative colitis (UC) to patients without IBD.A large administrative claims database was used to identify patients who underwent primary TKAs from 2010 to 2019 and had a diagnosis of IBD before TKA. Patients were stratified into two groups: those with CD (n = 8,369) and those with UC (n = 11,347). These patients were compared a control of 1.3 million patients without an IBD diagnosis. Chi-square and unadjusted odds ratios (OR) with 95% confidence intervals (CI) were used to compare complication frequencies. Multivariable logistic regression was used to evaluate independent risk factors for 90-day complications.Compared to patients without IBD, patients with IBD were associated with higher unadjusted 90-day odds for Clostridium difficile infection (CDI) (CD: OR 2.81 [95% CI 2.17 to 3.63]; p 0.001; UC: OR 3.01 [95% CI 2.43 to 3.72]; p 0.001) and two-year periprosthetic joint infection (CD: OR 1.34 [95% CI 1.18 to 1.52]; p 0.001; UC: OR 1.26 [95% CI 1.13 to 1.41]; p 0.001). After controlling for risk factors like obesity, tobacco use, and diabetes, both types of IBD were associated with higher 90-day odds for CDI and PJI (p 0.001 for all).IBD is associated with higher 90-day postoperative CDI and PJI compared with patients without IBD. Providers should consider discussing these risks with patients who have a diagnosis of IBD.

Background: The number of liver transplant recipients (LTR) is worldwide increasing and, as the survival is improving as well, there is an increasing number of patients needing total hip arthroplasty (THA). There might be increased risks for this specific group of patients and due to their comorbidities costs might be higher too. Using a big national database outcome and cost of THA should be compared between liver transplant recipients and the general population. Methods: The study was performed using a collection of Medicare, Medicaid, and private insurance claims. Length of stay (LOS), 30-day readmissions, complications rates up to 5 years, and 90-day total cost of care between liver transplant recipients and matched non-transplant patients should be compared. All primary THAs from 2010 to 2019 were identified. 513 patients with a liver transplant before their THA were matched to 10,759 patients without a history of solid organ transplant at a 1:20 ratio based on age, sex, Charlson Comorbidity Index, obesity, and diabetes status. Results: LTR had a longer average LOS (4.2 vs. 3.4 days, p Conclusions: These findings suggest that complications and costs are no major point of concern in patients with liver transplant that are operated with THA.

Highly cross-linked polyethylene (HXLPE) has become the preferred bearing surface in total hip arthroplasty. However, its acceptance in total knee arthroplasty (TKA) has not been as robust because of concerns pertaining to wear and its impact on implant failure. Therefore, this multicenter study was purposed to evaluate the 10-year (1) radiographic outcomes; (2) complications; and (3) implant survivorship in patients with TKA receiving a sequentially irradiated and annealed HXLPE. A retrospective, multi-center study was performed on 139 patients (171 TKAs) who underwent primary TKA with HXLPE and possessed a minimum of 10-year follow-up. Radiographs were analyzed for radiolucencies along the implant-fixation interface using the Modern Knee Society Radiographic Evaluation System. Kaplan-Meier analysis determined implant survivorship when the end points were revision for polyethylene wear and polyethylene revision for any reason. Sixteen TKAs (9.9%) demonstrated periprosthetic linear radio-lucencies. Seventeen TKAs (9.9%) required additional surgeries, 9 (5.3%) of which were revisions, with 1 (0.6%) TKA requiring revision because of polyethylene wear. Other causes of revision included instability (1.8%), infection (1.6%), and arthrofibrosis (1.6%). The mean time to revision was 5.9 years (range, 0.1–11.1 years). Survivorship pertaining to polyethylene revision for wear was 99.4%, whereas all-cause polyethylene revision was 94.7%. This study in patients undergoing primary TKA using a second-generation HXLPE demonstrated excellent results with respect to polyethylene wear characteristics and strength with a 99.4% survivorship at 10 years. [ Orthopedics . 2023;46(2):e111–e117.]

Background There is a paucity of data on the long-term performance of highly cross-linked polyethylene (HXLPE). Therefore, this study evaluated 10-year 1) functional, 2) radiographic, and 3) surgical outcomes in patients who underwent total hip arthroplasty with sequentially irradiated and annealed HXLPE. Methods A retrospective, multicenter study was conducted on patients who underwent primary total hip arthroplasty and received HXLPE polymer (n = 151). Two-dimensional radiographic linear and volumetric wear analyses were quantified using the Martell Hip Analysis software, while functional outcomes were assessed by analyzing postoperative Short-Form-12 (SF-12) Physical and Mental Health Surveys and Harris Hip Scores. Radiographic outcomes included yearly linear (mm/y) and volumetric (mm3/y) wear rates. Surgical outcomes included additional operations and survivorship. Results SF-12 scores were within 1 standard deviation (SD) of the normal population (SF-12 Physical: 47.0; SF-12 Mental: 52.0), while the Harris Hip Scores of 89.5 was borderline between “good” and “excellent.” Total and annual linear wear rates were 0.164 mm (SD: 0.199 mm) and 0.015 mm/y (SD: 0.018 mm/y), respectively. The mean total volumetric wear rate was 141.4 mm3 (SD: 165.0) and 12.6 mm3/y (SD: 14.9 mm3/y) when broken down into a yearly rate. Eleven patients required revisions, resulting in an all-cause polyethylene survivorship of 92.7%, with a polyethylene wear survivorship of 100.0%. Conclusions Our results demonstrate clinically undetectable linear and volumetric wear rates after 10 years in those who received the unique sequentially irradiated and annealed HXLPE. Furthermore, high rates of survivorship coupled with low all-cause revision rates illustrate the polymers' capability to potentially increase implant longevity.

Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32–3.70]), postoperative delirium (6.40 [1.78–23.03]), and length of stay greater than 2 days (3.90 [1.00–15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66–4.72]) or discharge to a specialized facility (1.48 [0.80–2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [ Orthopedics . 2022;45(6):e315–e320.]

Recent institutional evidence suggests that conversion total hip arthroplasty (THA) incurs higher complication rates and costs when compared to primary THA. These findings contrast with the current reimbursement system as conversion and primary THAs are classified under the same diagnosis-related group. Thus, a national all-payer database was utilized to compare complication rates up to 2 years, 30-day readmission rates, and 90-day costs between conversion THA and matched primary THA patients.A retrospective review of the PearlDiver database between 2010 and second quarter of 2018 was performed using Current Procedural Terminology (CPT) codes to compare conversion THA (CPT 27132) to primary THA (CPT 27130). Patients were matched at a 1:3 ratio based on age, gender, Charlson Comorbidity Index, body mass index, tobacco use, and diabetes (conversion = 8369; primary = 25,081 patients).Conversion THA had higher rates of periprosthetic joint infections (conversion: 7.7% vs primary: 1.4%), hip dislocations (4.5% vs 2.0%), blood transfusions (2.0% vs 1.0%), mechanical complications (5.5% vs 1.0%), and revision surgeries (4.0% vs 1.5%) (P.001 for all) by 90 days. The 30-day readmission rate for conversion THA was significantly higher compared to the primary group (7.3% vs 3.3%) (P.001). Median cost at 90 days for conversion THA was significantly higher compared to primary THA ($18,800 vs $13,611, P.001).This study revealed increased complication rates, revisions, readmissions, and costs among conversion THA patients compared to matched primary THA patients. These results support the reclassification of conversion into a diagnosis-related group separate from primary THA.

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

Aims Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. Methods Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. Results Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). Conclusion Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113–118.

Background The introduction of robotic technologies into the field of arthroplasty ushered in promises of increased precision and superior outcomes over conventional methods. However, the effect on outcomes in total hip arthroplasty (THA) remains debatable, particularly when considering the additional financial burden created by the addition of robotics. The purpose of this study is to examine total cost of care, length of stay (LOS), and postoperative complications in robotic-assisted vs conventional THA recipients. Materials and methods A retrospective review of the Mariner database was performed within PearlDiver Technologies for patients undergoing THA from 2010 to 2018 (n = 714,859). Patients with robotic-assisted procedures were matched with patients undergoing conventional THA at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, smoking, and obesity status (n = 4630). LOS, total cost of care, readmission rates, and medical and surgical outcomes were examined. Results Robotic-assisted patients had shorter average LOS (3.4 vs 3.7 days, P = .001). The mean cost for robotic-assisted patients was $1684 and $1759 less at 90 days and 1 year, respectively (both P = .001). Readmission rates were higher for robotic-assisted patients at 1 year (7.8 vs 6.6%; P = .001), while surgical outcomes were not significantly different at all timepoints (all P > .498). Robotic-assisted patients demonstrated significantly higher blood transfusion rates (4.4 vs 3.2%; P = .001). Conclusions Robotic-assisted THA was associated with minimal decreases in LOS and costs as compared to conventional methods. However, robotics was associated with slightly higher readmissions and blood transfusions.

Recently, 3-dimensional (3D) printing technology has been used in the development of titanium metaphyseal cones to manage severe bone loss in revision total knee arthroplasty (rTKA). This study assessed (1) radiographs; (2) functional outcomes; (3) complications; and (4) 2-year implant survivorship in patients receiving 3D-printed titanium metaphyseal cones for moderate-to-severe tibial and femoral bone loss in rTKA. A single institution, retrospective chart review was performed for patients with large bone defects treated with a 3D-printed femoral or tibial titanium metaphyseal cone between 2015 and 2017 during rTKA (N=54). Paired sample t tests analyzed Knee Society Scores (KSS). Kaplan–Meier analyses determined implant survivorship when the endpoint was cone revision for aseptic loosening, cone revision for any reason, and reoperation for any reason. The authors found that 51 (98.1%) of 52 available radiographs demonstrated well-fixed components without any evidence of loosening or migration. Mean postoperative KSS scores were significantly higher when compared with preoperative scores (80.4 vs 52.0; P >.001). One patient experienced aseptic loosening of their cone. Seven additional cones were explanted as a consequence of reinfection, 1 of which was removed prior to arthrodesis. Cone survivorship was 98.5% when the endpoint was cone revision due to aseptic loosening, 88.2% when cone revision was due to any reason, and 77.9% for any reoperation. Metaphyseal cones appear to be well-suited for large bone defects during rTKA and the authors' findings suggest that cones may be a viable option for metaphyseal fixation during rTKA. Future studies should focus on their durability during a longer time period. [ Orthopedics . 2021;44(1):43–47.]

BACKGROUND Same-day bilateral total knee arthroplasty (BiTKA) is a controversial topic in orthopedics, prompting a consensus statement to be released by national experts. To date, no studies have evaluated the trends of this method since these recommendations. This study utilized a national database to evaluate: 1) incidence; 2) patient characteristics; 3) hospital characteristics; and 4) inpatient course for same-day BiTKAs in the United States from 2009 to 2016. METHOD The National Inpatient Sample database was queried for individuals undergoing same-day BiTKAs, yielding 245,138 patients. Patient demographics included age, sex, race, obesity status and Charlson Comorbidity Index (CCI) score. Hospital characteristics consisted of location/teaching status, geographic region, charges, and costs. Inpatient course included length of stay, discharge disposition, and complications. RESULTS Same-day BiTKA incidence decreased from 5.6% to 4.0% over the study (p

In the United States, one-third of adults are considered obese, and demand for total knee arthroplasty (TKA) is expected to rise in these patients. Surgeons are reluctant to operate on obese patients, but it is important to understand how obesity has affected TKA utilization. This study utilizes a national database to evaluate incidence, demographics, outcomes, charges, and cost in nonobese, overweight, nonmorbidly obese, and morbidly obese TKA patients. We queried the National Inpatient Sample from 2009 to 2016 for primary TKA patients identifying 4,053,037 nonobese patients, 40,077 overweight patients, 809,649 nonmorbidly obese patients, and 428,647 morbidly obese patients. Chi-square was used to analyze categorical variables, and one-way analysis of variance was used to analyze continuous variables. Nonmorbidly obese and morbidly obese patients represented 23.2% of all TKAs. TKA utilization increased 4.1% for nonobese patients, 121.6% for overweight patients, 73.6% for nonmorbidly obese patients, and 83.9% for morbidly obese patients. Morbidly obese patients were younger (p

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011–2013) and post-GBR (2014–2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p

Background: Maryland implemented the Global Budget Revenue (GBR) to reduce hospital costs, improve quality, and decrease readmissions. Studies assessing its impact on inpatient total hip arthroplasty (THA) procedures are lacking. This study compared before and after GBR changes in 1) patient characteristics; 2) discharge dispositions and lengths of stay (LOS); 3) costs and charges of inpatient stays; and 4) 30-day readmission rates (RR) for THA recipients. Methods: The Maryland State Inpatient Database was queried for patients who underwent THA between 2010 and 2016 utilizing the ICD-9 and ICD-10 procedure codes (n = 43,251). Pre- and post-GBR periods were grouped as 2010 to 2013 and 2014 to 2016, respectively. Chi-square analyses were used to analyze patient characteristics. Student’s t-tests were utilized to compare ages, LOS, costs, charges, and RR. Results: There were no differences in the proportion of minorities undergoing THA between the pre- and post-GBR periods (18.3% vs 19.4% African American, 1.2% vs 1.3% Hispanic; P = .056). The number of THA patients with Medicaid insurances increased during post-GBR (4.0% vs 6.7%; P < .001). There was an increased rate of home discharges during post-GBR (33.1% vs 40.9%; P < .001). We found lower LOS (−0.50 days; 95% CI: −0.458 to −0.533; P < .001), mean inpatient costs (−$1417.44; 95% CI −$1143.76 to −$1150.32; P < .001), and mean inpatient charges (−$2196.50; 95% CI: −$1980.10 to −$2412.90; P

Few studies have investigated nationwide patient trends and health care costs for reverse shoulder arthroplasty (RSA) after 2014. This study uses a large validated nationwide database to retrospectively assess changes in patient and hospital demographic features, hospital costs, and hospital charges for inpatient RSA procedures before and after implementation of the Affordable Care Act. The National Inpatient Sample database was used to identify all patients who underwent RSA between January 2011 and December 2015, yielding 163,171 patients (63.4% female; mean age, 72 years). Categorical data were assessed with chi-square/Fisher's exact test, and continuous data were assessed with analysis of variance. There was an increased proportion of RSA recipients identifying as Hispanic (4.1% to 4.8%) and Native American (0.1% to 0.4%; P P P =.002), whereas an increase occurred in hospital charges (+$6,314; P Orthopedics . 2022;45(2):97–102.]

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained ( P P P P P Orthopedics . 2022;45(1):e11–e16.]

Background: The risk of periprosthetic joint infection following revision total knee arthroplasty is high, as is the cost of care. Decreasing periprosthetic joint infection risk may include utilization of calcium sulfate beads. Calcium sulfate beads have been gaining momentum in treating infected joints because of their potential advantages, including antibiotic elution and dissolvability. However, literature documenting their utilization in aseptic revision is sparse. This study compares: 1) infection rates; 2) length of stay; 3) subsequent infection procedures; and 4) final surgical outcome between one-stage aseptic revision total knee arthroplasty patients who received calcium sulfate beads and those who did not. Methods: We performed a retrospective chart review to identify patients who underwent aseptic one-stage revision total knee arthroplasty between January 2013 and December 2017. Outcomes collected included postoperative infection rate, length of stay, subsequent irrigation and debridement, and final surgical outcome, classified as a successful total knee arthroplasty reimplantation, a retained antibiotic spacer, or an above knee amputation. Chi-square analysis was used to analyze all categorical variables, while Student’s t-testing was used for continuous variables. A p-value of 0.5 was set as the threshold for statistical significance. Results: Calcium sulfate bead patients did not differ from non-calcium sulfate bead patients with regard to the number of postoperative infections (p=0.103), lengths of stay (p=0.210), irrigation and debridement procedures (p=0.063) and surgical outcome (p=0.085). Conclusion: Patients who received calcium sulfate beads had analogous surgical outcomes and infection rates to non-calcium sulfate bead patients. The use of calcium sulfate beads in aseptic one-stage revision total knee arthroplasty may not be beneficial in preventing infection and reducing costs.

Same-day bilateral total knee arthroplasties (SBTKAs) are associated with shorter rehabilitation and lower cost. However, controversy surrounding the safety of SBTKAs exists. Recent studies are lacking to determine whether patient selection has brought SBTKA in line with unilateral total knee arthroplasty (UTKA). Therefore, the authors evaluated and compared patient characteristics, hospital characteristics, and inpatient course between UTKA and SBTKA from 2009 to 2016. The National Inpatient Sample was queried from 2009 to 2016 for UTKA and SBTKA patients. Of the 5,329,466 patients identified, 5,084,328 (95.4%) patients received UTKAs and 245,138 (4.6%) patients underwent SBTKAs. Incidence, rate, patient and hospital characteristics, health status, length of stay (LOS), discharge disposition, hospital charges, hospital costs, and complications were analyzed and statistically compared. The incidence (−1.4%) and rate (15.8%) of SBTKAs decreased (both P P P P Orthopedics . 2021;44(3):e407–e413.]

Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014–2016). The female proportion decreased (−1.9%; P =.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P P P P P Orthopedics . 2021;44(2):e266–e273.]

BACKGROUND: Clostridioides difficile infection (CDI) may be a surrogate for poor patient health. As such, a history of CDI before THA may be used to identify patients at higher risk for postoperative CDI and complications after THA. Investigations into the associations between CDI before THA and postoperative CDI and complications are lacking. QUESTIONS/PURPOSES: We compared the (1) frequency and potential risk factors for CDI after THA, (2) the frequency of 90-day complications after THA in patients with and without a history of CDI, and (3) the length of stay and frequency of readmissions in patients experiencing CDIs more than 6 months before THA, patients experiencing CDIs in the 6 months before THA, and patients without a history of CDI. METHODS: Patients undergoing primary THA from 2010 to 2019 were identified in the PearlDiver database using ICD and Current Procedural Terminology codes (n = 714,185). This analysis included Medicare, Medicaid, and private insurance claims across the United States with the ability to perform longitudinal and costs analysis using large patient samples to improve generalizability and reduce error rates. Patients with a history of CDI before THA (n = 5196) were stratified into two groups: those with CDIs that occurred more than 6 months before THA (n = 4003, median 2.2 years [interquartile range 1.2 to 3.6]) and those experiencing CDIs within the 6 months before THA (n = 1193). These patients were compared with the remaining 708,989 patients without a history of CDI before THA. Multivariable logistic regression was used to evaluate the association of risk factors and incidence of 90-day postoperative CDI in patients with a history of CDI. Variables such as antibiotic use, proton pump inhibitor use, chemotherapy, and inflammatory bowel disease were included in the models. Chi-square and unadjusted odds ratios with 95% confidence intervals were used to compare complication frequencies. A Bonferroni correction adjusted the p value significance threshold to < 0.003. RESULTS: Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before THA: OR 8.44 [95% CI 6.95 to 10.14]; p < 0.001; CDI ≤ 6 months before THA: OR 49.92 [95% CI 42.26 to 58.54]; p < 0.001). None of the risk factors included in the regression were associated with increased odds for postoperative CDI in patients with preoperative history of CDI. Patients with a history of CDI before THA were associated with higher unadjusted odds for every 90-day complication compared with patients without a history of CDI before THA. CDI during either timespan was associated with longer lengths of stay (no CDI before THA: 3.8 days; CDI > 6 months before THA: 4.5 days; CDI ≤ 6 months before THA: 5.3 days; p < 0.001) and 90-day readmissions (CDI > 6 months before THA: OR 2.21 [95% CI 1.98 to 2.47]; p < 0.001; CDI ≤ 6 months before THA: OR 3.39 [95% CI 2.85 to 4.02]; p < 0.001). CONCLUSION: Having CDI before THA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. A history of CDI within the 6 months before THA was associated with the greatest odds for postoperative complications and readmissions. Providers should strongly consider delaying THA until 6 months after CDI, if possible, to provide adequate time for patient recovery and eradication of infection. LEVEL OF EVIDENCE: Level III, therapeutic study.

CASE A 19-year-old woman with a history of Hoffa fat pad syndrome underwent infrapatellar fat pad synovectomy and subsequently developed extensor mechanism disruption secondary to iatrogenic patellar tendon injury. She received a modified extensor mechanism patella-patellar tendon-tibial tubercle allograft to restore extensor function with satisfactory results at 2-year follow-up. We also review alternative techniques that were considered for her extensor mechanism repair. CONCLUSION The patient demonstrated satisfactory outcomes, similar to other established techniques. This modified extensor mechanism allograft reconstruction may be an effective alternative for patients experiencing acute extensor mechanism disruptions.

Background The niche surgery of same-day bilateral total knee arthroplasty (sd-BTKA) continues to create debate amongst specialists in arthroplasty. To date, there is a significant lack of literature on obese patients undergoing sd-BTKA, and no study has evaluated outcomes of this procedure when compared to non-obese patients. Therefore, this study will perform a retrospective analysis to compare (I) incidence, (II) demographics, and (III) complications of sd-BTKA in non-obese, obese, and morbidly obese patients in the United States from 2009 to 2016. Methods The National Inpatient Sample (NIS) database was queried for all individuals that underwent sd-BTKA from 2009 to 2016. This returned 184,844 non-obese patients, 39,901 obese patients, and 20,394 morbidly obese patients. Analyzed variables included mean age, mean length of stay (LOS), race, payer, age-adjusted Charlson Comorbidity Index score, discharge disposition, hospital charges, hospital costs, and complications. Chi-square analyses and analyses of variance were utilized to assess categorical and continuous variables, respectively. Results Non-obese patients most commonly underwent sd-BTKA over the course of the study. As weight status increased, mean age decreased and the proportion of females, LOS, hospital charges and costs, and proportion of discharges to skilled nursing facilities increased. Regression analysis demonstrated obese and morbidly obese cohorts were at an overall increased odds for experiencing complications. Specifically, obese patients were at increased risk for pulmonary emboli, periprosthetic joint infections, and respiratory failures, while morbidly obese patients are at increased risk for pulmonary emboli, respiratory failures, and urinary tract infections. Conclusions Surgeons should thoroughly evaluate the risks and benefits of performing sd-BTKA on obese and morbidly obese patients, as both confer higher overall complication rates and increased length of stay. More research is necessary to characterize the cost analysis of this procedure, as health care models continue to transition to more cost-effective procedures.

Introduction: Inpatient dislocation following total hip arthroplasty (THA) may incur substantial financial penalties for hospitals in the United States. However, limited studies report on current incidence and variability of dislocations. We utilised a large national database to evaluate inpatient hip dislocation trends regarding: (1) yearly incidences; (2) lengths of stay (LOS); (3) demographic factors; and (4) hospital metrics. Methods: The National Inpatient Sample was queried from 2012 to2016 for primary THA patients ( n = 1,610,155), identifying 2490 inpatient dislocations. Various patient demographics and hospital characteristics were assessed. Multivariate regression analyses were conducted to identify dislocation risk factors. Results: Dislocation rates increased from 0.11% in 2012 to 0.18% in 2016 ( p Conclusion: Inpatient dislocation has increased in recent years. Optimised management and recognition of the patient and hospital factors outlined in this study may help decrease inpatient dislocation risks following THA, thus avoiding hospital reimbursement penalties for this preventable complication.

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t-tests assessed categorical and continuous variables, respectively. A p-value of 0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements.

Total hip arthroplasty (THA) is reaching a broader spectrum of younger patients who struggle with incapacitating hip disease. This study aimed to explore national bearing surface trends for young THA recipients. Specifically, we evaluated bearing surface utilization, patient demographics, and hospital demographics in 20- to 50-year-old THA recipients in the United States from 2009 to 2016.The National Inpatient Sample database was queried for patients aged 20 to 50 who underwent primary THA from 2009-2016 (n=279,190). Patients were grouped according to bearing surface type (metal-on-polyethylene [MOP], metal-on-metal [MOM], ceramic-on-ceramic [COC], and ceramic-on-polyethylene [COP]). Demographics included sex, age, race, obesity status, age-adjusted Charlson Comorbidity Index (CCI), primary payer, median household income, region, and teaching status. Chi-square analyses were employed for categorical variables, while independent t-tests were utilized for continuous variables.The incidence of THA for patients aged 20 to 50 increased slightly from 33,003 in 2009 to 33,545 in 2016 (p0.001). Overall, bearing surface type was reported in 46.8% (n=127,876) of THAs. Of the THAs with bearing surface codes, the use of MOP (29.6 to 18.7%) and MOM (39.6 to 4.4%) decreased, while COC (9.0 to 14.3%) and COP (21.8 to 62.6%) utilization increased (p0.001 for all). Those receiving COC implants had the youngest average age (42 years) (p0.001). Females were more likely to receive COC (44.2%) or COP (43.6%) implants (p0.001). Obese individuals were more likely to receive MOP (21.3%) or COP (21.2%) (p0.001).Over an 8-year period, considerable shifts in bearing surface trends have occurred across the United States among 20 to 50-year-old patients. Advantages of ceramic femoral heads, along with increased acceptance of highly cross-linked polyethylene, appear to be reasons for the selection of COP over other bearing surfaces.

Introduction As morbid obesity disproportionately affects minorities and those of lower socioeconomic status, body mass index (BMI) restrictions on total hip arthroplasty (THA) may harm populations already facing disparities in care. Therefore, this study analyzed demographics and outcomes in morbidly obese primary THA patients. Methods The National Inpatient Sample was queried for THAs performed between 2009 and 2016. Of 2,676,086 patients identified, 453,250 had a BMI over 25 kg/m2. Patients were stratified by BMI into overweight (BMI=25.0-29.9 kg/m2), non-morbidly obese (BMI=30.0-40.0 kg/m2), and morbidly obese (BMI>40.1 kg/m2). Patient demographics (age, sex, race, insurance, income, and Charlson Comorbidity Index) and outcomes (length of stay [LOS], mortality, disposition, complications, charges, and costs) were assessed. Categorical and continuous data were analyzed with chi-square analyses and one-way analyses of variance, respectively. Results The number of overweight, non-morbidly obese, and morbidly obese patients increased by 299.0%, 109.3%, and 90.9%, respectively, between 2009 and 2016 (p

Background: Hip fractures are a common condition associated with high morbidity and mortality. In this study, we assess (1) yearly incidences, (2) demographic factors, (3) postoperative outcomes, (4) primary diagnoses, and (5) primary procedures. Materials and Methods: The National Inpatient Sample was queried for patients admitted with hip fractures from 2009 to 2016 (n = 2 761 850). Variables analyzed were age, sex, race, obesity status, Charlson Comorbidity Index, smoking status, osteoporosis status, lengths of stay (LOS), discharge dispositions, charges, costs, mortalities, inpatient complications, primary and secondary diagnoses, and primary procedures. Results: From 2009 to 2016, the overall gross number of hip fractures decreased ( P < .001). At the conclusion of the study, more patients were male, obese, and smokers, while fewer had a diagnosis of osteoporosis ( P < .001 for all). Mean LOS significantly decreased ( P < .001), while charges and costs increased ( P < .001 for both). Both mortality and the overall complication rate decreased ( P < .001 for both). Specifically, complications that decreased included myocardial infarctions, deep vein thromboses, pulmonary emboli, pneumoniae, hematomas/seromas, urinary tract infections, and transfusions ( P < .001 for all). Complications that increased included cardiac arrests, respiratory failures, mechanical complications, and sepsis ( P < .001 for all). The most common diagnosis was “closed fracture of intertrochanteric section of neck of femur.” The procedure performed most often was “open reduction of fracture with internal fixation, femur.” Conclusion: An increasing number of males and smokers have sustained hip fractures, although fewer patients with osteoporosis experienced these injuries. A decreasing overall complication rate may indicate improving perioperative courses for hip fracture patients. However, several shortcomings still exist and can be improved to further decrease negative outcomes.

Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis (n = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t-test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p

Proximally coated, morphometric wedge femoral stems illustrated excellent survivorship and clinical outcomes at a minimum five-year postoperative follow up.We completed a retrospective review of 186 THA patients from three high-volume surgeons to assess clinical- and patient-reported outcomes five years after implantation with a cementless, proximally coated morphometric wedge femoral stem. We reviewed Gruen zones on early postoperative and mid-term radiographs for signs of osteolysis, loosening, and wear. Clinical- and patient-reported outcomes were compared with previously published two-year outcomes for these femoral stems.No progression of radiolucencies or loosening was observed radiographically when comparing minimum one-year and five-year follow up. Reactive radiodense lines were observed in 23 cases (12.64%), and 13 cases (7.14%) exhibited true radiolucencies of 1-3mm, and all remained unchanged between follow ups or were no longer present on the five-year film. Cortical hypertrophy was noted in Gruen zones 3 and/or 5 in 11 cases (6.04%). No stems were revised for mechanical loosening or for periprosthetic fracture. Nine (9) patients (4.87%) underwent revisions during the follow-up period for periprosthetic infection, femoral head and/or acetabular component revisions, and impingement requiring release and femoral head change. Average Harris Hip Scores were excellent at five years and improved slightly when compared to a two-year follow up; however, this change was not statistically significant. Health-related quality of life mental component and physical component scores were a mean of 48.45 and 43.10 at 5 years, respectively. All cause Kaplan-Meier survivorship of the femoral stem was calculated at 98.4% at an average 65.7 months post implantation. Additionally, this cohort exhibited 100% aseptic survivorship during the follow-up period.Newer-generation morphometric wedge femoral stems for THA exhibit excellent radiographic stability, patient satisfaction, and clinical outcomes five years post implantation.

Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients’ satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student’s t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: 0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

Osteoarthritis (OA) continues to be a leading cause of disability and healthcare expenditure in the United States (US). This is only expected to rise as the population continues to age (1).

The exercise pressor reflex (EPR) is activated by muscle contractions to increase heart rate and blood pressure during exercise. While this reflex is beneficial in healthy individuals, the reflex activity is exaggerated in patients with cardiovascular disease, which is associated with increased mortality. Group III and IV afferents mediate the EPR and have been shown to express both tetrodotoxin-sensitive (TTX-S, NaV1.6, and NaV1.7) and -resistant (TTX-R, NaV1.8, and NaV1.9) voltage-gated sodium (NaV) channels, but NaV1.9 current has not yet been demonstrated. Using a F−-containing internal solution, we found a NaVcurrent in muscle afferent neurons that activates at around −70 mV with slow activation and inactivation kinetics, as expected from NaV1.9 current. However, this current ran down with time, which resulted, at least in part, from increased steady-state inactivation since it was slowed by both holding potential hyperpolarization and a depolarized shift of the gating properties. We further show that, following NaV1.9 current rundown (internal F−), application of the NaV1.8 channel blocker A803467 inhibited significantly more TTX-R current than we had previously observed (internal Cl−), which suggests that NaV1.9 current did not rundown with that internal solution. Using immunohistochemistry, we found that the majority of group IV somata and axons were NaV1.9 positive. The majority of small diameter myelinated afferent somata (putative group III) were also NaV1.9 positive, but myelinated muscle afferent axons were rarely labeled. The presence of NaV1.9 channels in muscle afferents supports a role for these channels in activation and maintenance of the EPR.NEW & NOTEWORTHY Small diameter muscle afferents signal pain and muscle activity levels. The muscle activity signals drive the cardiovascular system to increase muscle blood flow, but these signals can become exaggerated in cardiovascular disease to exacerbate cardiac damage. The voltage-dependent sodium channel NaV1.9 plays a unique role in controlling afferent excitability. We show that NaV1.9 channels are expressed in muscle afferents, which supports these channels as a target for drug development to control hyperactivity of these neurons.

Maryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.).We identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods.After GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (-4.2% vs -1.8%) (all P.001). There were proportionally less home health care patients in Maryland, but more in the U.S. (-3.5% vs +1.6%; both P.001). The mean costs decreased for both cohorts (-$1780.80 vs -$209.40; both P.001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P.001 for both).Maryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.

Introduction This review summarizes single vs dual antibiotic cement literature, evaluating for synergistic activity with dual antibiotics. Methods A systematic review was performed for literature regarding dual antibiotics in cement, identifying 13 studies to include for review. Results Many in vitro studies reported higher elution from cement and/or improved bacteria inhibition with dual antibiotics, typically at higher dosages with a manual mixing technique. Limited clinical data from hip hemiarthroplasties and spacers demonstrated that dual antibiotics were associated with improved infection prevention and higher intra-articular antibiotic concentrations. Conclusion In addition to broader pathogen coverage, several studies document synergy of elution and increased antibacterial activity when dual antibiotics are added to cement. Limited clinical evidence suggests that dual antibiotic cement may be associated with reduced infection rates.

Glucocorticoids (GCs) strongly regulate myostatin transcript levels in mammals via glucocorticoid response elements (GREs) in the myostatin promoter, and bioinformatics methods suggest that this regulatory mechanism is conserved among many vertebrates. However, the multiple myostatin genes found in some fishes may be an exception. In rainbow trout (Oncorhynchus mykiss), two genome duplication events have produced three putatively functional myostatin genes, myostatin-1a, -1b and -2a, which are ubiquitously and differentially expressed. In addition, in silico promoter analyses of the rainbow trout myostatin promoters have failed to identify putative GREs, suggesting a divergence in myostatin function. Therefore, we hypothesized that myostatin mRNA expression is not regulated by glucocorticoids in rainbow trout. In this study, both juvenile rainbow trout and primary trout myoblasts were treated with cortisol to examine the relationship between this glucocorticoid and myostatin mRNA expression. Results suggest that exogenous cortisol does not regulate myostatin-1a and -1b expression in vivo, as myostatin mRNA levels were not significantly affected by cortisol treatment in either red or white muscle tissue. In red muscle, myostatin-2a levels were significantly elevated in the cortisol treatment group relative to the control, but not the vehicle control, at both 12 h and 24 h post-injection. As such, it is unclear if cortisol was acting alone or in combination with the vehicle. Cortisol increased myostatin-1b expression in a dose-dependent manner in vitro. Further work is needed to determine if this response is the direct result of cortisol acting on the myostatin-1b promoter or through an alternative mechanism. These results suggest that regulation of myostatin by cortisol may not be as highly conserved as previously thought and support previous work that describes potential functional divergence of the multiple myostatin genes in fishes.