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Introduction: As ne arly half of all total joint arthroplasty (TJA) procedures are projected to be performed in the outpatient setting by 2026, the impact of this trend on health disparities remains to be explored. This study investigated the racial/ethnic differences in the proportion of TJA performed as outpatient as well as the impact of outpatient surgery on 30-day complication and readmission rates., Methods: The ACS National Surgical Quality Improvement Program was retrospectively reviewed for all patients who underwent primary, elective total hip and knee arthroplasty (THA, TKA) between 2011 and 2018. The proportion of TJA performed as an outpatient, 30-day complications, and 30-day readmission among African American, Hispanic, Asian, Native American/Alaskan, and Hawaiian/Pacific Islander patients were each compared to White patients (control group). Analyses were performed for each racial/ethnic group separately. A general linear model (GLM) was used to calculate the odds ratios for receiving TJA in an outpatient vs. inpatient setting while adjusting for age, gender, body mass index (BMI), functional status, and comorbidities., Results: In total, 170,722 THAs and 285,920 TKAs were analyzed. Compared to White patients, non-White patients had higher likelihood of THA or TKA performed as an outpatient (OR 1.31 and 1.24 respectively for African American patients, OR 1.65 and 1.76 respectively for Hispanic patients, and OR 1.66 and 1.59 respectively for Asian patients, p < 0.001). Outpatient surgery did not lead to increased complications in any of the study groups compared to inpatient surgery (p > 0.05). However, readmission rates were significantly higher for outpatient TKA in all the study groups compared to inpatient TKA (OR range 2.47-10.15, p < 0.001). Complication and readmission rates were similar between inpatient and outpatient THA for all the study groups., Conclusion: While this study demonstrated higher proportion of TJA performed as an outpatient among most non-White racial/ethnic groups, this observation should be tempered with the increased readmission rates observed in outpatient TKA, which could further the disparities gap in health outcomes., (© 2022. W. Montague Cobb-NMA Health Institute.)

Background: Patient reviews provide an important referral source for physicians and an opportunity to improve practice performance. This study's objective was to characterize the online reviews of hip and knee arthroplasty surgeons published by three of the industry's leading platforms., Methods: A random sample of 1000 hip and knee arthroplasty surgeons across all 50 US states (10 hip and 10 knee surgeons per state) was generated using Google Search. A total of 7842 online reviews posted for those surgeons on Healthgrades, Vitals, and Google were analyzed. A range of surgeons, affiliated hospitals, and reviewer attributes was compared to identify significant predictors of patient satisfaction., Results: The study cohort had 98.1% male surgeons with a mean age of 53.55 ± 8.94 years and mean experience of 26.43 ± 9.21 years. Younger age (p < 0.001), shorter years of experience (p < 0.001), and arthroplasty fellowship training (p < 0.001) were associated with more positive ratings. Reviewer anonymity, observed in 30.93% of all reviews, tended to correlate with more negative ratings (p < 0.001). Overall, 86.93% of patient remarks were positive, and only 74.81% of remarks centered on physician attributes. The five leading components of patient satisfaction were perceptions of physician competence (34.81%, p < 0.001), bedside manner (23.83%, p = 0.002), and communication (16.17%, p = 0.94); interactions with physician extenders (14.75%, p < 0.001); and wait time (2.73%, p < 0.001)., Conclusion: While most ratings of hip and knee arthroplasty surgeons were positive, more than a quarter of reviews were either not directly related to the individual surgeons or were submitted anonymously. Caution is advised regarding overreliance on patient experience surveys as predictors of physician performance., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mohamad J. Halawi reports editorial/governing body memberships with The Journal of Bone and Joint Surgery, The Journal of Arthroplasty, and Arthroplasty Today. He also reports board membership/committee appointments with American Academy of Orthopaedic Surgeons and American Orthopaedic Association.

Background: While risk factors have been published for readmissions following primary total joint arthroplasty, little is known about the etiology of those costly adverse events. In this study, we sought to identify the reasons for 30-day readmission following primary total joint arthroplasty in a contemporary national patient sample., Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify 367,199 patients who underwent primary total knee (TKA) or hip arthroplasty (THA) between 2011 and 2018. The primary outcomes were the annual rates of 30-day readmissions and the causes of those readmissions., Results: The 30-day readmission rate trended downward from 4.5% in 2011 to 3.3% in 2018. Medical complications accounted for 52.6% and 38.5% of readmissions following TKA and THA, respectively. Diseases of the circulatory system, abnormal laboratory values, and diseases of the digestive system were the leading causes of medical readmissions. Surgical complications accounted for 37.7% and 50.7% of readmissions following TKA and THA, respectively. Surgical site infections/wound disruption and venous thromboembolism were the leading two causes of surgical readmissions for THA and TKA. Prosthetic complications-namely dislocations and periprosthetic fractures-were the third leading cause of surgical readmissions for THA. For TKA, musculoskeletal conditions-namely pain and hematoma-were the third leading cause of surgical readmissions., Conclusion: Medical complications accounted for half of all TKA readmissions and more than a third of THA readmissions. This could penalize institutions participating in value-based payment programs or dissuade others who are considering participation in such programs., (Published by Elsevier Inc.)

Background: There is currently no consensus regarding the optimal anesthetic technique for total hip and knee arthroplasty (THA, TKA). This study aimed to compare the utilization rates and safety of spinal vs. general anesthesia in contemporary THA/TKA practice., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a retrospective review of 307,076 patients undergoing total hip or knee arthroplasty under either spinal or general anesthesia between January 2015 and December 2018 was performed. Propensity matching was used to compare differences in operative times, hospital length of stay, discharge destination, and 30-day adverse events. The annual utilization rates for both techniques between 2011 and 2018 were also assessed., Results: Patients receiving spinal anesthesia had a shorter length of stay (P < 0.001) for TKA while no statistical differences in length of stay were observed for THA. Patients were also less likely to experience any 30-day complication (OR = 0.82, P <0.001 and OR = 0.92, P < 0.001 for THA and TKA, respectively) while being more likely to be discharged to home (OR = 1.46, P < 0.001 and OR = 1.44, P < 0.001 for THA and TKA, respectively). Between 2011 and 2018, spinal anesthesia utilization only increased by 1.4% for THA (P < 0.001) and decreased by 0.2% for TKA (P < 0.001), reaching 38.1% and 40.3%, respectively., Conclusion: Spinal anesthesia remains a grossly underutilized tool despite providing better perioperative outcomes compared to general anesthesia. As orthopedic surgeons navigate the challenges of value-based care, spinal anesthesia represents an invaluable tool that should be considered the gold standard in elective, primary total hip and knee arthroplasty., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: For hospitals participating in bundled payment programs, unplanned readmissions after surgery are often termed "bundle busters." The aim of this study was to develop the framework for a prospective model to predict 90-day unplanned readmissions after elective primary total hip arthroplasty (THA) at a macroscopic hospital-based level., Methods: A national, all-payer, inpatient claims and cost accounting database was used. A mixed-effect logistic regression model measuring the association of unplanned 90-day readmissions with a number of patient-level and hospital-level characteristics was constructed., Results: Using 427,809 unique inpatient THA encounters, 77 significant risk factors across 5 domains (ie, comorbidities, demographics, surgical history, active medications, and intraoperative factors) were identified. The highest frequency domain was comorbidities (64/100) with malignancies (odds ratio [OR] 2.26), disorders of the respiratory system (OR 1.75), epilepsy (OR 1.5), and psychotic disorders (OR 1.5), being the most predictive. Other notable risk factors identified by the model were the use of opioid analgesics (OR 7.3), Medicaid coverage (OR 1.8), antidepressants (OR 1.6), and blood-related medications (OR 1.6). The model produced an area under the curve of 0.715., Conclusion: We developed a novel model to predict unplanned 90-day readmissions after elective primary THA. Fifteen percent of the risk factors are potentially modifiable such as use of tranexamic acid, spinal anesthesia, and opioid medications. Given the complexity of the factors involved, hospital systems with vested interest should consider incorporating some of the findings from this study in the form of electronic medical records predictive analytics tools to offer clinicians with real-time actionable data., (Published by Elsevier Inc.)

Background: The obese population is more likely to develop degenerative joint disease requiring total joint arthroplasty (TJA) and also experience increased rates of adverse post-surgical outcomes. This study assessed whether a quantifiable weight loss prior to TJA had any impact on perioperative and 30-day outcomes in obese patients., Method: Using the American College of Surgeons-National Surgical Quality Improvement Program database, obese patients who underwent total hip or total knee arthroplasty and lost at least 10% of their total body weight prior to surgery were identified and matched to other obese individuals undergoing the same procedures without weight loss. Perioperative outcomes, including operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality, were then compared using conditional Logistic regression analysis., Results: Analysis showed no difference between the two groups in terms of operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality., Conclusion: The results of this study suggest that weight loss alone in the preoperative period may not be sufficient to mitigate the effects of obesity on immediate post-TJA outcomes., (© 2022. The Author(s).)

Introduction: Racial disparities have been well reported in the utilization and outcomes of knee arthroplasty, but it is unclear whether disparities also extend to the choice of surgical treatment. The primary objective of this study is to identify if race plays a role in the selection of unicondylar versus total knee arthroplasty (UKA, TKA) for isolated tibiofemoral osteoarthritis (OA). A secondary objective is to identify the differences in the complication rates for each procedure by racial identity., Methods: A retrospective review of the 2006-2018 American College of Surgeons National Surgical Quality Improvement Program was performed. Asian, Black, Hawaiian/Pacific Islander, Hispanic, Native American/Alaskan, and White individuals who underwent primary elective UKA or TKA were compared in terms of UKA vs. TKA utilization rates and outcomes., Results: A total of 308,715 patients were analyzed. After controlling for all baseline differences, Whites (3.5%), Asians (3.7%), and Hawaiian/Pacific Islanders (3.1%) had around twice the rate of UKA compared to Blacks (1.6%), while Hispanics (2.1%) and Native American/Alaskans (1.7%) were in between (p &lt;0.001). TKA was associated with higher complications compared to UKA in all racial groups (p &lt; 0.001)., Conclusion: Minority patients, especially Blacks, were less likely to receive UKA for treatment of isolated knee OA. This is significant because treatment selection in patients who are eligible for UKA can have a significant impact on postoperative recovery and complications rates., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Acute kidney injury (AKI) is one of the most common medical causes for readmission following total joint arthroplasty (TJA). This study aimed to (1) examine whether the incidence of AKI has changed over the past decade with the adoption of modern perioperative care pathways and (2) identify the risk factors and concomitant adverse events (AEs) associated with AKI., Methods: 535,291 primary TJA procedures from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2018 were retrospectively reviewed. The annual incidence of AKI was analyzed for significant changes over time. Matched cohort analyses were performed to identify the risk factors and AEs associated with AKI using multivariate logistic regression., Results: The mean incidence of AKI was 0.051%, which remained unchanged during the study period (P = 0.121). Factors associated with AKI were diabetes (OR 1.96, P = 0.009), bilateral procedure (OR 6.93, P = 0.030), lower preoperative hematocrit level (OR 1.09, P = 0.015), body mass index (OR 1.04, P = 0.025), and higher preoperative BUN (OR 1.03, P = 0.043). AKI was associated with length of stay (LOS) > 2 days (OR 4.73, P <  0.001), non-home discharge (OR 0.25, P <  0.001), 30-day readmission (OR 12.29, P <  0.001), and mortality (OR 130.7, P <  0.001)., Conclusions: The incidence of AKI has not changed over the past decade, and it remains a major bundle buster resulting in greater LOS, non-home discharge, readmissions, and mortality. Avoidance of bilateral TJA in patients with DM and high BMI as well as preoperative optimization of anemia and BUN levels are advised., (© 2022. The Author(s).)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/G689 ).

Background: Electrolyte levels are commonly obtained as part of the preoperative workup for total joint arthroplasty, but limited information exists on the interplay between electrolyte abnormalities and outcomes., Methods: The National Surgical Quality Improvement Program was queried for primary, elective total hip arthroplasty and total knee arthroplasty (THA, TKA) performed between 2011 and 2017. Three patient groups were compared: normal (control), hypernatremia, and hyponatremia. The primary outcomes were length of stay (LOS) and 30-day adverse events: complications, readmissions, reoperations, and mortality., Results: A total of 244,538 TKAs and 145,134 THAs were analyzed. The prevalence of hyponatremia and hypernatremia was 6.9% and 1.0%, respectively. After controlling for any baseline differences, hypernatremia was an independent predictor of ventilation >48 hours (THA, odds ratio [OR] 3.53), unplanned intubation (THA, OR 3.14), cardiac arrest (THA, OR 2.42), pneumonia (THA, OR 2.16), Clostridium difficile infection (OR 4.66 and 3.25 for THA and TKA, respectively), LOS >2 days (THA, OR 1.16), and mortality (THA, OR 4.69). Similarly, hyponatremia was an independent predictor of LOS >2 days (TKA, OR 1.21), readmission (TKA, OR 1.40), reoperation (OR 1.32 and 1.47 for THA and TKA, respectively), surgical site infections (OR 1.39 and 1.54 for THA and TKA, respectively), and transfusion (OR 1.13 and 1.20 for THA and TKA, respectively)., Conclusion: As the focus of total joint arthroplasty continues to shift toward value-based payment models and outpatient surgery, caution should be exercised in patients with abnormal preoperative sodium levels, particularly hypernatremia, because of significantly increased risk of prolonged LOS and 30-day adverse events., (Published by Elsevier Inc.)

Objective: This study analyzed the yearly trends in procedure utilization, comorbidity profiles, hospital length of stay (LOS), and 30-day outcomes in Hispanic/Latino patients undergoing primary total knee arthroplasty (TKA). Risk stratification for the development of postsurgical adverse events (AEs) was also investigated., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for all Hispanic/Latino patients who underwent primary, elective TKA between 2011 and 2017. Thirty-day outcomes and risk factors were determined using multivariate models that controlled for baseline and perioperative differences., Results: A total of 12,767 Hispanic/Latino patients were identified. Over the study period, the rate of TKA utilization increased by 108%. During the same time, there were significant reductions in the rates of COPD (1.9% vs. 2.9%, p = 0.015), anemia (18.0% vs. 23.5%, p < 0.001), dyspnea (2.9% vs. 4.0%, p = 0.006), and procedure length > 100 min (35.2% vs. 39.4%, p < 0.001). Postoperatively, there was a significant decrease in LOS > 2 days (41.3% vs. 75.6%, p < 0.001), but there was an increase in the rate of developing 30-day AEs (5.8% vs. 4.7%, p = 0.046). Independent risk factors for 30-day AEs included age > 65 years, male sex, chronic steroid use, ASA > 2, diabetes, bleeding disorder, chronic kidney disease, and procedure length > 100 min., Conclusion: While the recent trends in procedure utilization, comorbidity profiles, and LOS in Hispanic/Latino patients undergoing primary TKA are reassuring, these have not been accompanied with improved postoperative safety. Patients with bleeding disorders, chronic steroid use, and those admitted from facilities other than home appear to be at highest risk for developing 30-day AEs., (© 2020. W. Montague Cobb-NMA Health Institute.)

Background: The objective of this study was to present contemporary national data on the state of racial and ethnic disparities pertaining to primary total knee arthroplasty (TKA) in the USA., Methods: The 2011-2017 National Surgical Quality Improvement Program was used to capture all patients who underwent primary TKA. The study outcomes were differences in demographic, comorbidity burden, perioperative factors, procedure utilization, hospital length of stay (LOS), and 30-day outcomes. The five major minority groups as defined by the National Institutes of Health were compared to non-Hispanic Whites., Results: In total, 262,954 patient records were analyzed, with racial identification available on 230,712 patients (87.7%). White patients accounted for 72.5% of all TKA procedures. There were higher rates of diabetes, hypertension, anemia, and prolonged surgery times among racial and ethnic minorities (p < 0.001). Baseline disparities were especially pronounced among non-Hispanic Blacks/African Americans who were also like to have higher rates of tobacco smoking and CHF (p < 0.001). After controlling for baseline differences, significant disparities in outcomes persisted, especially among Blacks/African Americans and Hispanics/Latinos who had higher odds for experiencing complications and readmissions (p < 0.001). All racial and ethnic groups, except Asians, had longer LOS (p < 0.001). Asian patients had significantly lower rates of readmissions, reoperations, and overall complications (p < 0.001)., Conclusion: Racial and ethnic disparities remain a public health challenge for patients undergoing TKA. While initiatives aimed at improving preoperative disease-burden and comorbidity profiles represent an important step, they alone are insufficient to fully account for or eliminate the disparities in TKA outcomes., (© 2020. W. Montague Cobb-NMA Health Institute.)

Background: Perioperative care for total knee arthroplasty (TKA) has improved over time. We present an analysis of inpatient safety after TKA., Methods: 14,057 primary TKAs captured by the Medicare Patient Safety Monitoring System between 2010 and 2017 were retrospectively reviewed. We calculated changes in demographics, comorbidities, and adverse events (AEs) over time. Risk factors for AEs were also assessed., Results: Between 2010 and 2017, there was an increased prevalence of obesity (35.1% to 57.6%), tobacco smoking (12.5% to 17.8%), and renal disease (5.2% to 8.9%). There were reductions in coronary artery disease (17.3% to 13.4%) and chronic warfarin use (6.7% to 3.1%). Inpatient AEs decreased from 4.9% to 2.5%, ( P < .01), primarily driven by reductions in anticoagulant-associated AEs, including major bleeding and hematomas (from 2.8% to 1.0%, P < .001), catheter-associated urinary tract infections (1.1% to 0.2%, P  < .001), pressure ulcers (0.8% to 0.2%, P < .001), and venous thromboembolism (0.3% to 0.1%, P  = .04). The adjusted annual decline in the risk of developing any in-hospital AE was 14% (95% confidence interval [CI] 10%-17%). Factors associated with developing an AE were advanced age (odds ratio [OR] = 1.01, 95% CI 1.00-1.01), male sex (OR = 1.21, 95% CI 1.02-1.44), coronary artery disease (OR = 1.35, 95% CI 1.07-1.70), heart failure (OR = 1.70, 95% CI 1.20-2.41), and renal disease (OR = 1.71, 95% CI 1.23-2.37)., Conclusions: Despite increasing prevalence of obesity, tobacco smoking, and renal disease, inpatient AEs after primary TKA have decreased over the past several years. This improvement is despite the increasing complexity of the inpatient TKA population over time., (© 2021 The Authors.)

Background: The purpose of this was to investigate recent trends in procedure utilization, comorbidity profiles, hospital length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) among Black patients undergoing total hip arthroplasty (THA)., Methods: Using the American College of Surgeons National Surgery Quality Improvement Program, we retrospectively reviewed all Black patients who underwent elective, primary THA between 2011 and 2017. Mixed effects logistic regression analyses were performed to determine the trends in the study outcomes across each individual year. Multivariate logistic regression analyses were performed to identify independent risk factors for AEs., Results: A total of 11,574 Black patients were analyzed. Over the study period, there was an increase by 109% in THA procedures performed in this racial group. During the same time, there were reductions in the prevalence of anemia, dyspnea, tobacco smoking, and osteonecrosis (p < 0.001). The rates of 30-day surgical complications, readmissions, reoperations, and mortality remained unchanged. Only the rate of medical complications demonstrated improvement, driven by a decrease in the incidence of postoperative myocardial infarction (p < 0.001). There was also a significant reduction in LOS > 2 days (68 to 37%, p < 0.001). Independent risk factors for AEs were body mass index > 35, American Society of Anesthesiologists score > 2, dependent functional status, diabetes, bleeding disorders, chronic kidney disease, and osteonecrosis as the surgical indication., Conclusion: Between 2011 and 2017, there were improving trends in procedure utilization, comorbidity profiles, and LOS among Black patients undergoing primary THA, but the overall rates of 30-day outcomes remained unchanged. We identified a number of risk factors that may help guide preoperative optimization and patient counseling to mitigate postoperative AEs.

Background: This study aimed to define the three-dimensional functional alignment of the pelvis, proximal femur, and acetabulum during postural and physical activities., Methods: Thirty volunteers aged 40 years or greater were recruited. Reflective markers placed on bony prominences on the pelvis and lower extremities were tracked using a 12-camera motion analysis system. Measurements were obtained for various postures (ie, supine, standing, and sitting) and activities (ie, walking and ascending/descending stairs)., Results: Significant pelvic motion occurred only in the sagittal plane. The mean posterior inclinations of the pelvis were 15°, 18°, and 51° in the supine, standing, and sitting positions, respectively. These corresponded to acetabular anteversion/inclination angles of 26°/44°, 28°/45°, and 55°/55°, respectively. For activities, the mean posterior inclinations of the pelvis were 19°, 19°, and 20° during walking and ascending and descending stairs, respectively. These corresponded to acetabular anteversion/inclination angles of 29°/45°, 29°/45°, and 30°/46°, respectively., Discussion: The functional parameters for pelvic and acetabular alignment were defined. Further research is needed to understand the extent to which these normal parameters are altered in the setting of hip and/or spinal degenerative disease to guide acetabular implant placement., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

Background: Little is known about the persistence of health disparities in joint arthroplasty. The objective of this study was to update our knowledge on the state of racial and ethnic disparities in total hip arthroplasty (THA)., Methods: Patients undergoing primary, elective THA using the 2011-2017 American College of Surgeons National Surgical Quality Improvement Program were retrospectively reviewed. Five minority groups (non-Hispanic black or African American, Hispanic or Latino, Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander) were compared with non-Hispanic whites. The primary outcomes were in the differences in demographic characteristics, comorbidities, perioperative characteristics, THA utilization, length of stay (LOS), and 30-day adverse events (mortality, readmission, reoperation, and complications)., Results: A total of 155,870 patients were identified with racial and ethnic data available on 134,961 (86.6%) of them. Non-Hispanic white patients comprised 74.5% of all THA procedures. Except for Asians, all minority groups were more likely to be younger, have a higher body mass index, and smoke tobacco ( P < .001). There were higher rates of nonprimary osteoarthritis, procedure length exceeding 100 minutes, and comorbidities among all minority groups. All minority groups, except Asian and Hawaiians or Pacific Islanders, were more likely to require an LOS >2 days. Blacks were more likely to develop surgical or medical complications (odds ratio [OR]: 1.21 and 1.2, respectively), whereas Hispanics or Latinos were more likely to develop surgical complications (OR: 1.28). American Indians or Alaska Natives were more likely to undergo reoperations (OR: 1.91)., Conclusions: Health disparities persist among minority groups with respect to comorbidities, THA utilization, LOS, and complications. Blacks and Hispanics or Latinos appear to be the most impacted by these disparities., (© 2020 The Authors.)

Background: Increased adverse events (AEs) have been reported among black patients undergoing joint arthroplasty, but little is known about their persistence and risk factors. The purpose of this study is (1) to examine recent annual trends in 30-day outcomes after total knee arthroplasty (TKA) and (2) to develop a preoperative risk stratification model in this racial minority., Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for all black/African American patients who underwent primary TKA between 2011 and 2017. Time trends in demographic variables, comorbid conditions, perioperative characteristics, length of stay (LOS), and 30-day readmissions, reoperations, medical complications, surgical complications, and mortality were assessed. Multivariate logistic regression analyses were performed to identify independent risk factors for development of 30-day AEs., Results: In total, 19,496 black patients were analyzed. Between 2011 and 2017, there have been improved comorbidity profiles (P < .02), decreased LOS (P < .001), and lower rates of AEs (P < .001). Significant risk factors for developing AEs were male gender, tobacco smoking, American Society of Anesthesiologists score >2, dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, metastatic cancer, dyspnea, chronic kidney disease, bilateral TKA, and operative time >100 minutes., Conclusion: There have been significant improvements in the annual trends of LOS and 30-day outcomes among black patients undergoing primary TKA in recent years. A predictive model for 30-day AEs was developed to help guide risk stratification and optimization of modifiable factors, namely anemia, tobacco smoking, bilateral surgery, and operative time., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study explored recent time trends in length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) pertaining to total hip arthroplasty in the Hispanic and Latino population., Methods: A total of 4107 Hispanic and Latino patients who underwent primary total hip arthroplasty between 2011 and 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Annual trends in LOS and 30-day outcomes (readmission, reoperation, complications, and mortality) were calculated using univariate mixed-effect regression analyses. Risk factors for AEs were determined using multivariate analyses., Results: Between 2011 and 2017, there was a significant reduction in LOS >2 midnights (67.6% to 29.5%, P < .001) among Hispanic patients, which was similar to that among non-Hispanic white patients and was also accompanied with improvements in comorbidity profiles and shorter operative times. Postoperatively, the annual rates of 30-day outcomes were comparable with those of white patients ( P > .05). Chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use were the strongest independent predictors for AEs., Conclusions: In the context of historically lower arthroplasty outcomes among the Hispanic and Latino population, current evidence suggests a receding tide, with annual trends showing significantly shorter LOS and comparable overall 30-day outcomes with whites. Patients with chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use are at the highest risk for developing 30-day AEs., (© 2020 The Authors.)

Background: Despite advances in perioperative total joint arthroplasty (TJA) pain protocols, opiates continue to play a major role in postoperative pain control. This brief communication reports our experience with a restrictive opioid protocol allowing patients only a single prescription of low-dose opioids., Methods: One hundred consecutive elective, primary, and revision TJAs were analyzed. All patients received preoperative counseling and multimodal analgesia. Counseling involved discussion of patient expectations on postoperative pain management, weaning off opioids before surgery, and emphasis that opioid refills were not permitted. Ninety-day outcomes including pain-related phone calls, opioid refill requests, emergency room visits, complications, and readmissions were assessed. Opioid dispensing was tracked using our state prescription monitoring program., Results: There was a high prevalence of preoperative opioid use, depression, and anxiety (25%, 34%, and 39%, respectively). Sixty-eight percent of chronic opioid users were able to wean off opioids before surgery. The average initial prescription of opioids was equivalent to 48 pills of 5 mg oxycodone. There were only 10 pain-related phone calls from 9 patients; all were using opioids preoperatively, with only one patient requesting a refill. All pain-related phone calls occurred in the first week after surgery. There were no emergency room visits, complications, or readmissions related to pain., Conclusions: A single prescription of low-dose opioids was sufficient for patients undergoing TJA when using preoperative patient preparation and multimodal analgesia. Standardized guidelines are needed to guide best practices for patient education and pain management, especially in patients on chronic opioid therapy. This information will help implement evidence-based strategies to accelerate the decline of opioid use and hopefully pave the way for opioid-free TJA., (© 2020 The Authors.)

Background: Recent reports on the influence of gender on the outcomes of total joint arthroplasty were limited by either lack of longitudinal data or absent stratification by total hip arthroplasty (THA) or total knee arthroplasty (TKA). As a result, there remains a lack of clarity on this topic., Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for all primary, elective THAs and TKAs performed between 2011 and 2017. Differences in demographics, comorbidity profiles, operative time, hospital length of stay (LOS), and 30-day outcomes were compared between male and female patients. Multivariate analyses were performed separately for THA and TKA., Results: A total of 418,885 patients were analyzed; 59.1% were females. Compared with males, females were likely to be older, have a higher body mass index, identify as nonwhite, and require preoperative functional assistance ( P < .001). Females had lower rates of diabetes, hypertension, anemia, and kidney disease but a higher rate of chronic steroid use ( P < .001). They were also likely to have shorter operative times for both THA and TKA ( P < .001). After controlling for the aforementioned differences, female gender was an independent risk factor for readmission, reoperation, and wound infection after THA ( P < .001). In contrast, male sex was an independent risk factor for readmission, reoperation, and overall complications after TKA ( P < .001). Regardless of the procedure, females were 64%-82% more likely to require an LOS >2 days than males., Discussion: A variable effect of gender was observed on the post-total joint arthroplasty LOS and outcomes depending on the procedure type (THA or TKA). Differences attributed to gender should be accounted for in risk-stratification models. Future studies are also needed to elucidate the underlying causes of gender differences in joint arthroplasty., (© 2020 The Authors.)

Background: Physician work is a critical component in determining reimbursement for total joint arthroplasty (TJA). The purpose of this study is to quantify the time spent during the different phases of TJA care relative to the benchmarks used by the Centers for Medicare and Medicaid Services., Methods: We retrospectively reviewed all patients captured in our institutional joint database between January 1, 2014, and December 31, 2018. Four phases of care were assessed: (1) preoperative period following the decision to proceed with TJA and leading to the day before surgery, (2) immediate 24 hours preceding surgery (preservice time), (3) operative time from skin incision to dressing application (intraservice time), and (4) postoperative work including day of surgery and the following 90 days., Results: A total of 666 procedures were analyzed (379 total hip arthroplasties and 287 total knee arthroplasties). The mean preoperative care coordination, preservice, intraservice, immediate postservice, and 91-day global period times were 21.9 ± 10, 84.1, 114 ± 24, 35, and 150 ± 37 minutes, respectively. Except for a slightly higher preoperative time associated with Medicare coverage (P = .031), there were no differences in the other phases of care by payer type. There were no temporal differences between 2014 and 2017. However, in 2018, there were significant increases in preoperative and intraservice times (6 and 20 minutes, respectively, P < .001) which were accompanied with a significant decrease in postoperative service time (34 minutes, P < .001)., Conclusion: Even when performing TJA under the most optimal conditions, the overall time has remained stable over the past 5 years and consistent with current benchmarks., (Copyright © 2019 Elsevier Inc. All rights reserved.)

By streamlining surgical care and eliminating postoperative hospitalization, the transition to ambulatory total knee arthroplasty (TKA) has the potential to improve efficiency and minimize the costs of care. However, practical, legal, and financial implications remain to be addressed. The Centers for Medicare and Medicaid Services has also yet to address concerns generated by the removal of TKA from the Inpatient-Only List and provide guidance on patient selection. Rolling out regulatory changes that impact high-volume procedures, such as TKA, in a short period of time and without appropriate feedback can only lead to further confusion. As surgeons, we are in a unique business model that requires us to constantly innovate to deliver high quality care, while also taking financial cuts as a result of our innovations., (© 2020 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Background: While advancements in surgery and reduced complication rates have made total knee arthroplasty (TKA) one of the most successful and cost-effective procedures in orthopaedic surgery, routine postoperative laboratory tests are still being ordered without evidence as to their necessity. With expansion of the bundled payment models, there may exist an opportunity to cut overall costs while maintaining quality of care by eliminating unnecessary interventions. The objective of this study was to examine the utility of routine postoperative laboratory tests in TKA., Methods: A retrospective review of 319 TKAs performed at a single institution over a 2-year period was performed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits and readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values., Results: 89 patients (27.9%) had abnormal postoperative laboratory results, of which 78% were exclusively due to electrolyte (sodium or potassium) abnormalities. The rates of AKI and blood transfusion were 3.8% and 1% respectively. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (p = 0.002 and = 0.006 for sodium and potassium respectively) and anemia (p = 0.049). Factors associated with blood transfusion were ASA score ≥3, preoperative anemia, and no tranexamic acid use. Factors associated with AKI were chronic kidney disease or having at least two of the following: age >65 years, BMI> 35, ASA score ≥3, diabetes, heart disease, and/or anemia. Laboratory results did not change the course of care in 305 of 319 patients (95.6%). There was no increased risk for 90-days ED visits or readmissions with abnormal laboratory values (p = 0.356)., Conclusion: With increasing pressure for cost containment in an era of bundled payment models, the very low rate of laboratory associated interventions suggest that routine postoperative laboratory tests is not justified. Obtaining laboratory after primary, unilateral TKA should be driven by patients' risk factors., (© 2019 Delhi Orthopedic Association. All rights reserved.)

Background: Patient-reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty. The objective of this study is to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome., Methods: Our institutional joint database was queried for patients who underwent primary, elective, unilateral total joint arthroplasty. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Oxford Hip Score, Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation, and University of California Los Angeles activity level rating., Results: In general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, Oxford Hip Score, KSCRS) compared to general health (Short Form-12), activity level (University of California Los Angeles activity level rating), or perception of normalcy (Single Assessment Numerical Evaluation). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, P < .001; KSCRS pain subscale, R = 0.49, P < .001)., Conclusion: There is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The American Academy of Orthopaedic Surgeons (AAOS) has published evidence-based Clinical Practice Guidelines (CPGs) for the nonarthroplasty management of knee osteoarthritis (OA). The purpose of this study is to determine how closely our orthopedic providers adhered to the recommendations included in those CPGs., Methods: We retrospectively reviewed 1096 consecutive ambulatory visits with primary diagnosis of knee OA at a single center. Demographic, radiographic, and treatment information was collected. The primary outcome was the frequency of agreement between our treatment recommendations and the AAOS CPGs. A secondary outcome was the associated costs of care., Results: The total number of interventions generated during the visits was 1955. Adherence to the AAOS guidelines was 65% (362/557), 60% (226/377), and 40% (413/1021) in new/never treated, new/previously treated, and return patients, respectively. Intra-articular injection with either corticosteroids or hyaluronic acid was the most common intervention (32%) followed by physical therapy (29%). As the severity of OA increased, adherence to the AAOS guidelines decreased (61%, 60%, 54%, and 49% for Kellgren-Lawrence grades I through IV, respectively). The estimated annual costs associated with our treatment recommendations were $2,403,543.18, of which $1,206,757.8 (50.2%) was supported by evidence. The most expensive treatment intervention was intra-articular hyaluronic acid injection, which carried a strong evidence against its use., Conclusion: Adherence to the recommendations contained within the AAOS CPGs was modest regardless of the Kellgren-Lawrence grade or history of treatment. Given the size of the affected patient population, there is a need for uniformly accepted guidelines to clarify the role and timing of the different treatment interventions. CPGs should be combined with education, patient engagement, and shared decision-making to minimize variation in treatment patterns, improve patient outcomes, and lower overall costs of care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to investigate if there were differences in disease-specific, overall health, and activity outcomes after total joint arthroplasty (TJA) between treated and untreated depressed patients., Methods: Patients who underwent primary, elective, unilateral TJA were divided into 3 groups based on self-reported history of depression and treatment at the time of surgery: 1) patients without depression, 2) patients with treated depression, and 3) patients with untreated depression. The primary outcomes were the differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA activity rating scale up to 12 months postoperatively. A secondary outcome was the effect of depression treatment on patients' perception of experiencing limitation in their activities due to depression. Univariate and mixed-effects model analyses were performed to control for potential confounding factors., Results: The prevalence of depression was 189/749 (25%). Compared to patients with treated depression, untreated patients had lower baseline SF-12 MCS (P < .001) and were more likely to have Medicaid insurance (P < .001). After controlling for potential confounding factors, there were no differences in either the absolute scores or net changes in any of the assessed outcomes at 12 months postoperatively among depressed patients regardless of treatment (P > .05). In addition, depression treatment did not affect patients' perception of activity limitation (P = .412)., Conclusion: Although it is clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment does not necessarily imply resolution of depressive symptoms. Future studies should explore alternative interventions to reduce the health-related consequences of depression to optimize the outcomes of TJA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine the optimal window for collection of patient-reported outcome measures (PROMs) after total joint arthroplasty (TJA)., Methods: Our prospectively collected institutional joint registry was queried for patients who underwent primary, unilateral TJAs. The primary outcomes were the net changes in WOMAC, SF-12 MCS, SF-12 PCS, OHS, KSCRS, and UCLA activity rating system at 6, 12, and 24 months postoperatively. Secondary outcomes were data acquisition costs and follow-up attrition rates., Results: Eight hundred sixty-six procedures (450 total hip arthroplasties, 416 TKAs) were analyzed. A consistent plateau in all PROMs was noted by 6 months postoperatively-except for SF-12 MCS which showed no significant changes at any time interval. For TKA, the percentage of overall improvement achieved by 6 months was 88.7%, 84.5%, 100%, and 90.5% for the WOMAC, SF-12 PCS, UCLA, and KSCRS, respectively. For total hip arthroplasty, these values were 92.7%, 83.5%, 88.0%, and 89.8% for WOMAC, SF-12 PCS, UCLA, and OHS, respectively. There were marginal improvements from 6 to 12 months and no improvement from 12 to 24 months. Follow-up rates at 6, 12, and 24 months were 85%, 69%, and 40%, respectively. Our institutional costs for collecting a complete data set per patient were $128, $158, and $272 for 6, 12, and 24 months, respectively., Conclusions: Most of the improvement in PROMs after primary TJA occurs within the first 6 months. In addition, limiting PROMs collection to 6 months appears to be cost-efficient owing to increased attrition rates beyond this time interval., (© 2019 The Authors.)

The purpose of this study was to investigate the association between insurance type and length of stay (LOS) in primary total joint arthroplasty. A retrospective review of 848 patients was performed. Patients were divided into 3 groups based on their insurance type: Medicare, Medicaid, or commercial coverage. Medicare patients had a significantly higher rate of LOS > 2 days than the Medicaid and commercial groups ( P < .0001). The effect of Medicare coverage on LOS remained significant even after controlling for baseline differences among the study groups. There were no differences in the rates of 90-day emergency room visits and readmissions between the 3 groups ( P > .05). Arthroplasty surgeons not experienced with outpatient surgery should not be pressured to default to outpatient admission in Medicare patients., (© 2019 The Authors.)

The objective of this study is to explore the effect of morbid obesity on patient-reported outcomes in primary total joint arthroplasty. We retrospectively reviewed 755 primary total joint arthroplasty cases with a minimum of 1-year follow-up. Two groups were compared: (1) patients with BMI < 40 and (2) those with BMI ≥ 40. The primary outcome was the difference in Short Form-12 physical component summary, Short Form-12 mental component summary, Western Ontario and McMaster Universities Osteoarthritis Index, and patient satisfaction. Multivariate analyses were performed to control for potential confounding factors. 37 patients (5%) were morbidly obese. Morbidly obese patients undergoing total knee arthroplasty had significantly lower net gains in their Short Form-12 physical component summary ( P = .008), Short Form-12 mental component summary ( P = .049), and Western Ontario and McMaster Universities Osteoarthritis Index ( P = .009) in the first 6 months only. For total hip arthroplasty, morbid obesity did not affect any of the outcomes measured ( P > .05). There was also no difference in patient satisfaction rates between the two groups ( P = .401 and .143 for total hip arthroplasty and total knee arthroplasty, respectively). The impact of morbid obesity on patient-reported outcomes appears to be limited to total knee arthroplasty only in the initial 6 months after surgery., (© 2019 The Authors.)

Background: The purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA)., Methods: A retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed., Results: The prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P < .0001) and more likely to have depression (P < .0001), lower educational attainment (P < .0001), smoke tobacco (P = .003), be Hispanic/Latino (P = .001), live alone (P = .001), and have higher rates of nonprimary osteoarthritis (P < .0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P = .049 and .006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P = .913 and .782 for THA and TKA, respectively), emergency room visits (P = .467 and .355 for THA and TKA respectively), or readmissions (P = .118 and .334 for THA and TKA, respectively)., Conclusion: Psychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from its inpatient only (IPO) list as of January 1, 2018. The purpose of this study was to establish a risk-stratifying nomogram to aid in determining the need for inpatient admission among Medicare-aged patients undergoing primary TKA., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients aged ≥65 years who underwent primary TKA between 2006 and 2015. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and perioperative variables were incorporated in a multivariate logistic regression model to yield a risk stratification nomogram., Results: Sixty-one thousand two hundred eighty-four inpatient and 26,066 outpatient admissions were analyzed. Age >80 years (odds ratio [OR] = 2.27, P < .0001, 95% confidence interval [CI] = 2.13-2.42), simultaneous bilateral TKA (OR = 2.02, P < .0001, 95% CI = 1.77-2.30), dependent functional status (OR = 1.95, P < .0001, 95% CI = 1.62-2.35), metastatic cancer (OR = 1.91, P = .055, 95% CI = 0.99-3.73), and female gender (OR = 1.76, P < .0001, 95% CI = 1.70-1.82) were the greatest determinants of inpatient stay. The resulting predictive model demonstrated acceptable discrimination and excellent calibration., Conclusion: Our model enabled a reliable and straightforward identification of the most suitable candidates for inpatient admission in Medicare aged-patients undergoing primary TKA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA)., Methods: A retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed., Results: There were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052)., Conclusion: Tobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Despite improvements in surgical technique and implant longevity, some patients continue to report dissatisfaction after total joint arthroplasty (TJA). As patient satisfaction is increasingly used as a quality metric, the objective of this study was to gain better understanding of satisfaction with total joint arthroplasty from the patient perspective., Methods: Five hundred fifty-one primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a minimum of 1-year follow-up and were responsive to a satisfaction survey were analyzed. The incidence, predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate and multivariate logistic regression analyses were performed., Results: Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most significant predictor of dissatisfaction (P = .037). The most common reasons for dissatisfaction after THA were persistent pain (N = 14/34, 41%), functional limitation (N = 12/34, 35%), surgical complication and reoperation (N = 4/34, 12%), staff or quality of care issues (N = 2/34, 6%), and slow recovery (N = 2/34, 6%). The most common reasons for dissatisfaction after TKA were persistent pain (N = 19/46, 41%), functional limitation (N = 12/46, 26%), surgical complication and reoperation (N = 8/46, 17%), staff or quality of care issues (N = 5/46, 11%), and unmet expectations (N = 2/46, 4%)., Conclusion: While persistent pain and functional limitation are the 2 leading reasons for dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical outcome and should be interpreted with caution. Potential for incomplete pain relief or full functional recovery should be discussed during preoperative counseling. Empathic care is also important and should be encouraged to enhance the overall patient experience., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Patient-reported outcomes (PROs) are gaining an important role in the assessment of quality of care. There are currently limited data on the effect of payer type on PROs in total joint arthroplasty (TJA). This study compared both disease-specific and general health PROs among patients stratified according to their payer type., Methods: Our institutional joint registry was queried for patients who underwent primary, elective, and unilateral hip and knee arthroplasty. Patients were divided according to their insurance type at the time of surgery into 3 groups: Medicaid, Medicare, or commercial. The outcomes assessed were the net changes in PROs as well as absolute scores at 6 months and 1 year. Six of the most commonly used PROs were assessed: Short Form-12 physical and mental components, Western Ontario and McMaster Universities Osteoarthritis Index, Single Assessment Numerical Evaluation, University of Californian Los Angeles activity level rating, and Oxford Hip Score. Analysis of variance and covariance were used., Results: We evaluated 756 procedures (273 Medicaid, 270 Medicare, and 213 commercial insurance). Medicaid patients had significantly lower mean baseline scores across all PROs compared to either Medicare or commercial insurance patients. Medicaid patients were also more likely to be smokers, live alone, have lower educational level, African-American, and have nonprimary osteoarthritis as the indication for TJA. At 1-year follow-up, the net mean outcome gains were comparable among the 3 payer types (P > .05), but Medicaid patients continued to score lower while Medicare and commercial insurance patients continued to score higher (P < .01). When adjusting for all baseline differences among Medicaid patients, the negative effects of payer type resolved except for Oxford Hip Score which remained lower in the Medicaid group (P = .006)., Conclusion: When using PROs to assess the value of care, the preoperative to postoperative changes are a better indicator of surgical success than comparing absolute values, especially in Medicaid patients. While TJA imparts similar net improvements to patients of all payer types, Medicaid coverage is a predictor of lower absolute outcome scores at any given time as result of increased baseline health burden (eg, depression, tobacco smoking, and poor overall well-being). Arthroplasty surgeons should be aware of these factors when counseling patients and seek optimization when necessary. The findings should be taken into account by stakeholders when constructing value-based payment models. Further research is needed to better understand the barriers leading to higher prevalence of increased health disparities among Medicaid beneficiaries and how to effectively address them., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This study aimed to measure femoral head perfusion during hip resurfacing arthroplasty through a trochanter-sparing modified direct lateral approach. High-power laser Doppler probes were inserted into the femoral heads of 26 patients (26 hips, age range 35-70 years). Changes in blood flow were recorded (1) pre-capsulectomy (reference), (2) post-capsulectomy, and (3) following femoral head dislocation and reduction. There were no statistically significant changes in perfusion amplitudes post-capsulectomy and following femoral head dislocation and reduction (mean -10%, P  = .134 and +27%, P  = .166, respectively). Prolonged dislocation with the hip maximally flexed and externally rotated resulted in significantly decreased perfusion (mean -28%, P  = .002). This study provides in vivo evidence that surgical hip dislocation is feasible using a modified direct lateral approach.

Background: Postoperative laboratory testing has been used routinely for patients undergoing total hip arthroplasty (THA). However, with modern-day improvements in perioperative care pathways, it is unclear whether this practice remains justified. The purpose of this study was to assess the utility of routine postoperative laboratory tests in primary THA., Methods: The electronic medical records of 351 patients who underwent primary, unilateral THA between 2015 and 2017 were retrospectively reviewed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits or readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values., Results: Seventy-four patients (21%) had abnormal postoperative laboratory results, of which 82.4% were exclusively due to electrolyte (sodium or potassium) abnormalities. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (P < .001 and P = .013 for sodium and potassium, respectively), diabetes (P = .007), and lack of tranexamic acid use (P < .01). The rates of AKI and blood transfusion were 2.0% and 2.3%, respectively. Factors associated with blood transfusion were higher American Society of Anesthesiologists class and intraoperative blood loss ≥250 mL combined with either preoperative anemia or lack of tranexamic acid use. Factors associated with AKI were higher American Society of Anesthesiologists class and diabetes. Laboratory results did not change the standard course of care in 338 of 351 patients (96%). Abnormal laboratory values were not associated with increased length of stay (P = .228) or emergency department visits/readmissions (P = .21)., Conclusion: This study provides evidence that routine postoperative laboratory testing is not necessary in modern-day primary, unilateral THA. Instead, the decision to obtain laboratory tests after surgery should be driven by patients' risk factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: As we transition to value-based care delivery models, risk stratification in total joint arthroplasty is more important than ever. The purpose of this study was to identify patients who would likely require higher level of care and may not be suitable for inclusion in bundled payment models., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent primary total joint arthroplasty between 2011 and 2012. Five types of adverse events were assessed: medical complications, surgical complications, readmission, reoperation, and mortality. Univariate and multivariate logistic regression analyses were performed using a large number of demographic and morbidity variables., Results: A total of 14,185 patients were identified. The 30-day medical complication, surgical complication, readmission, reoperation, and mortality rates were 2.0%, 3.2%, 4.0%, 1.5%, and 0.2%, respectively. Among the different variables assessed, only the American Society of Anesthesiologists (ASA) physical classification system was a significant risk factor for most outcomes assessed. Peripheral vascular disease was the most significant risk factor for medical complications and reoperation (odds ratio, 2.73 and 3.23, respectively). Bleeding disorders were the most significant risk factor for readmission and mortality (odds ratio, 2.03 and 5.86, respectively)., Conclusions: ASA score is a more reliable risk stratification tool than Charlson Comorbidity Index, but it is not sufficient by itself. Patients with higher ASA scores combined with peripheral vascular disease and/or bleeding disorders are at especially high risk of developing postsurgical adverse events and may not be suitable for inclusion in bundled payment models. These data can be used to develop better risk stratification models that are critically needed.

Background: The Centers for Medicare and Medicaid Services has solicited comments regarding the removal of total hip arthroplasty (THA) from its inpatient-only list. The goal of this study is to develop and internally validate a risk stratification nomogram to aid in the identification of optimal inpatient candidates in this patient population., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all patients >65 years of age who underwent primary THA between 2006 and 2015. Inpatient stay was the primary outcome measure, as defined by stay >2 days in length. The impact of numerous demographic, comorbid, and perioperative variables was assessed through a multivariable logistic regression analysis to construct a predictive nomogram., Results: In total, 30,587 inpatient THAs and 17,024 outpatient THAs were analyzed. Heart failure (odds ratio [OR] 2.11, P = .001), simultaneous bilateral THA (OR 2.47, P < .0001), age >80 years (OR 2.91, P < .0001), female gender (OR 1.90, P < .0001), and dependent functional status (OR 1.89, P < .0001) were the most influential determinants of inpatient status. The final prediction algorithm showed good accuracy, excellent calibration, and internal validation (bias-corrected concordance index of 0.69)., Conclusion: Our model enabled accurate and simple identification of the best candidates for inpatient admission after THA in Medicare-aged patients. Given the increasing feasibility of outpatient THA coupled with the likelihood of THA being removed from the Centers for Medicare and Medicaid Services inpatient-only list, this model provides a framework to guide discussion and decision-making for stakeholders., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay., Methods: Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors., Results: One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001)., Conclusion: The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Depression and poor mental health are known to be negative predictors of patient-reported outcomes after total joint arthroplasty. Although previous studies have examined these risk factors in isolation to each other, they are, in reality, closely related, and yet each represents a different aspect of one's psychological well-being. The objective of this study was to investigate the association between depression and patient-reported outcomes, taking into account patients' baseline mental health., Methods: Our prospective, institutional joint registry was queried for patients who had undergone primary elective total joint arthroplasty and had a minimum follow-up of 1 year. Baseline mental health was measured by the Short Form-12 Mental Component Summary (SF-12 MCS). Four cohorts were analyzed on the basis of the presence or absence of depression and patients' SF-12 MCS scores at the time of the surgical procedure, which were categorized as either poor or good on the basis of previously defined cutoffs. The primary outcomes were the net changes in SF-12 MCS, SF-12 Physical Component Summary (PCS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at 4 and 12 months postoperatively. Univariate and mixed-effects model analyses were performed to control for potential confounding factors., Results: Patients with depression but good baseline mental health achieved gains in patient-reported outcomes that were comparable with those of normal controls (p > 0.05). Patients with poor baseline mental health achieved significant gains in all patient-reported outcomes, but the changes were largest for those without depression (p < 0.05). Only patients with depression and poor baseline mental health did not cross the threshold for good mental health at the time of the latest follow-up despite achieving similar gains in physical function compared with their counterparts who did not have depression., Conclusions: The effect of depression on patient-reported outcomes is more complex but less pessimistic than previously thought. Patients with depression undergoing total joint arthroplasty may have significant improvements in their patient-reported outcomes, but the net gains are modulated by their mental health at the time of the surgical procedure. Preoperative screening of patients with depression using the SF-12 MCS may help to identify those who are at risk for attaining suboptimal patient-reported outcomes and may benefit from counseling or psychiatric referral for optimization before undergoing a surgical procedure., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: The optimal reconstructive method for advanced degenerative hip disease in young adults is a topic of ongoing discussion. The purpose of this study is to report the largest single institution experience from the United States on the outcomes of Birmingham hip resurfacing (BHR) vs. cementless total hip arthroplasty (THA) in patients 55 years or younger at a minimum follow-up of five years. Currently, BHR is the only FDA-approved hip resurfacing implant available in the US., Methods: A cohort of 505 patients representing all BHR cases performed at our institution between 2006 and 2010 was compared with an identical size cohort of consecutive patients who underwent primary cementless THA. Exclusion criteria were age greater than 55 years, non-elective cases, revision procedures, and those performed for fractures, tumors, or by low-volume arthroplasty surgeons. THAs with metal on metal articulation were also excluded., Outcomes: assessed were all-cause reoperations, complications, patient satisfaction, and mortality. After exclusions, 442 patients with BHR and 327 with THA were included., Results: Mean follow-up was 73.2 months. After controlling for potential confounding factors, multivariate analyses showed significant increase in the rates of revision surgery (p < 0.001), overall complications (p < 0.001), all-cause reoperations (p = 0.014), and mortality (p < 0.001) in the THA cohort. Component loosening was the most common cause for revision in the THA group. Patients with THA were also less likely to be satisfied (p = 0.046)., Conclusions: This is largest US study to report on the midterm outcomes of BHR vs. THA. The results demonstrate favorable results for BHR in patients 55 years or younger. Long-term multicenter studies are needed to better understand the optimal patient characteristics when deciding between THA versus BHR.

Femoroacetabular impingement (FAI) is an abnormality of the hip joint that is increasingly being recognized as a cause of athletic disability and early degenerative hip disease. Despite significant advances in the knowledge of FAI, it remains a frequently unrecognized cause of hip pain in adolescents and young adults among orthopedic providers. The purpose of this article is to present a simple 3-view radiographic approach to young adults with hip pain. The radiographs include a standing anteroposterior view of the pelvis, a cross-table lateral view, and a false profile view. Good quality radiographs showing the common sites of potential impingement combined with a basic understanding of certain radiographic parameters may allow faster diagnosis, eliminate unnecessary studies, and allow earlier referral and management., Competing Interests: Author's Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.