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Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients.A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients.A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P0.001, P0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P0.001). Surgical time (113 versus 96 versus 98 mins; P0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P0.001 and 73.8 versus 28.4 versus 29.8; P0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P0.001).Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.

Spinal anesthesia (SA) is the preferred method of anesthesia at many centers for total joint arthro- plasty (TJA). However, a small subset of patients fails SA, necessitating a conversion to general anesthesia (GA). This report assesses the patient characteristics associated with failed SA.A retrospective study was conducted on patients who underwent SA during their primary TJA between Janu- ary 2015 and December 2016 at our institution. A subset of this group required a conversion from SA to GA. Anesthesia reports were reviewed for the number of attempts at SA and the documented reason for failure. The SA failure cohort was then subdivided into failure categories based on the reasons that had been provided.A total of 5,706 patients were included in this study, 78 of which experienced SA failure. The number of attempts was most strongly associated with SA failure, with three attempts resulting in a five times increased failure rate (OR = 4.73, p = 0.010) and four attempts resulting in 12 times increased failure rate compared to the no failure cohort (OR = 12.3, p0.001). Greater than two attempts occurred in 87.5% of the "technical failure" sub-group of the SA failure cohort (p0.001). No difference was demon- strated among the other patient characteristics, such as age, sex, body mass index, race, American Society of Anesthesia (ASA) score, and surgical time.The results suggest that the major predic- tor influencing spinal to general anesthesia conversion was the number of attempts at SA, especially among technical failure cases. Based on the results, it may be appropriate for anesthesiologists to convert to GA after two failed spi- nal attempts. Further studies are warranted to assess this relationship for firm clinical recommendations.

Aims Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). Conclusion The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102–107.

As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA. A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution’s standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress. A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p

Fluid and food restrictions prior to surgery are thought to reduce the risk for perioperative aspiration pneumonia. However, the recent anesthesia literature suggests that clear fluids up to 2 hours before surgery may be tolerated. Here we investigate the safety and efficacy of a standardized hydration protocol among same-day discharge total hip arthroplasty (SDD-THA) candidates. All patients scheduled to undergo primary SDD THA between January 2017 and October 2018 were included. Surgical recipients between January 2017 and August 2017 were used as historical controls. Surgical recipients between September 2017 and October 2018 participated in the hydration initiative which allowed for the consumption of 32 oz of clear fluid 2 hours prior to surgery. Baseline demographics and quality metrics were prospectively collected and analyzed to define the impact of a hydration protocol in SDD THA. In total, 585 consecutive SDD-THA candidates were included in this study, of which 309 and 276 patients were in the control and hydration cohorts, respectively. Univariable analysis of postoperative outcomes demonstrated that a similar number of THA recipients failed SDD (7.44 vs. 7.97%; p = 0.88); however, a clinically meaningful reduction in hypotensive episodes was observed among the hydration cohort (0.4 vs. 1.9%; p = 0.08). Multivariable regression demonstrated similar outcomes after controlling for all collected patient risk factors (odds ratio 0.95; 95% confidence interval 0.48–1.88; p = 0.89). Our study suggests hydration protocols are safe and may reduce the clinical incidence of postoperative hypotension when compared with standard nil per os restrictions. Future studies are needed to better elucidate the role of perioperative hydration before THA. The level of evidence of the study is level II, prospective observational cohort.

The Risk Assessment Prediction Tool (RAPT) predicts discharge disposition after total joint arthroplasty with only 75% accuracy. The goal of this study was to evaluate whether higher accuracy can be achieved with basic electronic health record (EHR) data combined with machine learning (ML) algorithms. Three ML analysis models were developed: model 1 (M1) evaluated the accuracy of predicted discharge disposition in concordance with the RAPT; model 2 (M2) used the RAPT questionnaire to develop an ML algorithm to predict the likelihood of discharge to home vs facility; and model 3 (M3) was developed with non-RAPT data (age, surgeon, and discharge preference) with the same ML training process as M2. Evaluation metrics included accuracy for home discharge (HD), positive predictive value for HD (PPV-HD), negative predictive value for HD (NPV-HD), sensitivity, specificity, and area under the receiver operating curve (AUROC). A total of 1405 patients were included. With M1, the overall accuracy for HD was 83.5%, PPVHD was 92.1%, NPV-HD was 45%, sensitivity was 0.88, and specificity was 0.56. With M2, the overall accuracy for HD decreased to 82.8%, PPV-HD was 91.7%, NPV-HD was 43.1%, sensitivity was 0.87, specificity was 0.53, and mean AUROC was 0.87±0.03. With M3, overall accuracy for HD increased to 90.3%, PPV-HD was 95.2%, NPV-HD was 68.6%, sensitivity was 0.93, specificity was 0.76, and AUROC was 0.91±0.02. The use of basic EHR data combined with ML can exceed the accuracy of the RAPT. Applying big data on an individual level for this purpose may allow for safer and more appropriate discharge planning. [ Orthopedics . 2022;45(4):e211–e215.]

Oxidized zirconium (OxZr) femoral heads were developed to emulate the superior wear and scratch properties of ceramics while eliminating their unwanted tendency for brittle fracturing. Studies using OxZr have demonstrated reduced linear and volumetric wear of polyethylene (PE) liners when compared with cobalt chrome, ceramic, and steel femoral heads. The purpose of this systematic review was to determine the difference in revision rates, radiologically determined linear wear rates, and patient-reported outcomes among OxZr and alternative bearing materials. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols, a systematic review of published literature through April 24, 2018 was conducted. Among the 862 cases included at a mean weighted follow-up of 4.78 years, the revision THA rate and patient-reported outcomes were similar among OxZr and alternative bearing materials. One of the five studies demonstrated significantly lower linear wear rates in the OxZr group when paired with ultrahigh molecular-weight PE (OxZr 0.03 mm/y vs. stainless-steel 0.11 mm/y; p

The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA.The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers.There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P.01), of "other' ethnicity (43.1% vs 25.6%, P.01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026).Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS.III, retrospective observational analysis.

Osteogenesis imperfecta (OI) is a rare group of connective tissue disorders commonly associated with bone fragility, deformity, and fractures, leading to instability and early osteoarthritis. Current advancements in the medical and surgical management of OI have extended the life span of these patients, resulting in an increased need for joint arthroplasty to help maintain quality of life. However, surgery among this patient population is technically challenging and comes with a high burden of revision. In this report, we present a case of revision total hip arthroplasty in a patient with OI and review important considerations to help ensure proper preoperative planning and correct precautions to minimize complications and decrease implant failure.

Background: There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA. Methods: A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used. Results: A total of 7342 cases were identified: 88.65% primary TKA and 11.35% revision TKA. Opioid consumption for the first 24 hours postoperatively was significantly higher for the revision TKA group (133.1 MMEs vs 56.14 MMEs, P < .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group. Conclusion: The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.

Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function.All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively.One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P.001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P.001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18).Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Background The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient’s hospital experience. This study aims to assess whether HCAHPS scores vary by demographic or surgical factors in patients undergoing primary total hip arthroplasty. Methods Patients who completed an HCAHPS survey after a primary total hip arthroplasty between October 2011 and November 2016 were included in this study. Patient demographics and surgical factors were evaluated for correlations with individual HCAHPS questions. Results One thousand three hundred eighty-three HCAHPS questionnaires were reviewed for this study. Patients with a submitted HCAHPS response had an average age of 63.83 ± 10.17 years. Gender distribution was biased toward females at 57.27% (792 females) versus 42.73% (591 males). The average body mass index (BMI) was 28.68 ± 5.86 kg/m2. Race distribution was predominantly Caucasian at 81.49% (1127 patients), followed by “unknown” at 8.60% (119 patients) and African-American at 8.46% (117 patients). Home discharge occurred for 93.06% (1287 patients) versus 6.94% for facility discharge (96 patients). Mean length of stay was 2.41 ± 1.17 days. Each 1-year increase in age was positively correlated with a 0.16% increase in top-box response rate (β = 0.0016 ± 0.0008; P .05). Conclusion The HCAHPS quality measurement metric affects physician reimbursement and may be biased by a number of variables including sex, length of stay, and BMI, rather than a true reflection of the quality of their hospital experience. Further research is warranted to determine whether HCAHPS scores are an appropriate measure of the quality of care received.

Background Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. Methods All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. Results Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. Conclusion GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

Purpose A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS). Material and methods This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated. Results In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge. Conclusion Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.

CASE REPORT A 67-year-old man presented with signs of acute periprosthetic infection after total hip arthroplasty (THA). Surgical debridement, antibiotics, and a head and liner exchange were performed. After showing no improvement, a single-stage revision was conducted. Postoperatively, he developed back pain and lower extremity weakness. Electrodiagnostic studies showed a Guillain-Barre syndrome (GBS) variant. Intravenous immunoglobulin was administered to halt disease progression. After 1 year, he still demonstrated neuromuscular deficits and required a cane for ambulation. CONCLUSION This case highlights GBS after THA. A high degree of clinical suspicion is essential to prevent misinterpretation as a postsurgical complication. LEVEL OF EVIDENCE V, case report.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA).Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed.In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/mHCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Patient-reported outcome (PRO) instruments are measures that allow for a standardized assessment of a patient's functional status, symptoms, and quality of life (QoL) through self-reported questionnaires. The purpose of this study was to assess the relationship between PRO scores, which measure patients' preoperative pain and functional status, and discharge disposition in the total hip arthroplasty (THA) population. The authors conducted a retrospective review of patients with a primary diagnosis of osteoarthritis who underwent THA at a single, urban, tertiary care center between September 2013 and August 2016. Patient demographics and preoperative PRO scores (Hip Disability and Osteoarthritis Outcome Score [HOOS] and EuroQol 5-Dimension [EQ-5D] questionnaire) were collected, and discharge disposition was categorized into the following two cohorts: THA recipients discharged to home and those discharged to a postacute care facility. When comparing PRO scores between the two groups, patients discharged home were found to have significantly higher average preoperative global EQ-5D, EQ-5D-QoL, HOOS activities of daily living (ADL), HOOS pain, HOOS sports, and HOOS symptoms scores. Patients discharged home trended toward higher HOOS QoL scores (28.1 vs. 22.6%), but this did not achieve significance (p

Background The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient’s inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA. Methods Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution’s Center for Quality and Patient Safety department, which was cross-referenced with our hospital’s electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant. Results In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of “top box” choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses. Conclusion Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient’s health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Oxinium is an alternative bearing surface designed to emulate the superior wear and scratch properties of ceramic femoral heads in total hip arthroplasty while minimizing the risk for brittle fracturing. However, recent studies have indicated that hip dislocation following total hip arthroplasty may be a risk factor for catastrophic failure of the femoral head. Here, we report on a novel case of a catastrophic Oxinium head and polyethylene liner failure in the absence of previous hip dislocation or trauma and review the probable failure mechanism. This report underscores the need to be vigilant about proper acetabular cup and liner seating, particularly in the setting of Oxinium femoral head use. In the event of Oxinium head failure, metallosis may compromise stabilizing soft tissues including the abductors. Dual-mobility articulation, which was successful in this case, is one option to consider when the risk for chronic redislocation is elevated. Keywords: Liner dissociation, Dual-mobility system, Oxinium, Oxidized zirconium, Total hip arthroplasty, Total hip replacement

Total knee arthroplasty (TKA) has been established as the most effective treatment for end-stage, symptomatic osteoarthritis of the knee. However, improper polyethylene size selection has been proposed to predispose patients to postoperative stiffness following TKA. The aim of this study is to evaluate if there is a correlation between the use of the thinnest tibial implant thickness and implant manufacturer with the likelihood of undergoing manipulation under anesthesia (MUA). A retrospective review of unilateral TKAs performed between January 2012 and November 2015 was performed. Each knee implant system was normalized by total tibial component thickness for each individual implant system (metal back plus polyethylene) and reaggregated to assess the difference in MUA rates when comparing the thinnest tibial component thickness against the next two sizes. Subset analysis was performed comparing the thinnest tibial component thickness for each individual implant system versus (1) all other tibial component sizes and (2) tibial components one and two sizes larger. A total of 2,728 patients were retrospectively evaluated, of which 71 (2.60%) underwent MUA. Combined tibial component thickness ranged from 8 to 21 mm. When aggregated together to compare the MUA rate between the thinnest liner and the next two sizes, no statistically significant difference was observed (p = 1). Subset analysis demonstrated inconsistent significant differences in MUA rates. Our results suggest that the polyethylene liner thickness alone is not a predictor of postoperative knee stiffness necessitating MUA. When selecting a polyethylene liner, a proper fit maximizing flexion/extension stability is the most crucial factor.

Same-day discharge (SDD) surgery in total hip arthroplasty (THA) has been shown to have similar outcomes to non-SDD THA in select patient populations. Hip resurfacing arthroplasty (HRA) is an alternative to THA for young, active patients, making them ideal candidates for SDD. This study compared the safety and efficacy of non-SDD HRA and SDD HRA for specific postoperative outcomes. An electronic data warehouse query was performed for procedures labeled “hip resurfacing.” Data collected included demographics, surgical factors, and quality metrics. Statistical analyses were evaluated using a graphing and statistics software program. Categorical variables were analyzed with chi-square tests and continuous variables with Student's t tests, with P P P =.01). Rates of infection, periprosthetic fractures, emergency department visits, and hospital readmissions were equivalent ( P =.99). Same-day discharge HRA is a safe and effective procedure with similar outcomes to non-SDD HRA regarding infections, fractures, emergency department visits, and readmissions. The major benefit of SDD is a shorter hospital stay that may lead to decreased cost while preserving and enhancing quality of care and patient satisfaction. [ Orthopedics . 2020;43(6):e595–e600.]

There is debate regarding the benefit of liposomal bupivacaine (LB) as part of a periarticular injection (PAI) in total hip arthroplasty (THA). Here, we evaluate the effect of discontinuing intraoperative LB PAI on immediate postoperative subjective pain, opioid consumption, and objective functional outcomes.On July 1, 2019, an institutional policy discontinued the use of intraoperative LB PAI. A consecutive cohort that received LB PAI and a subsequent cohort that did not were compared. All patients received the same opioid-sparing protocol. Nursing documented verbal rating scale pain scores were averaged per patient per 12-hour interval. Opiate administration events were converted into morphine milligram equivalences per patient per 24-hour interval. The validated Activity Measure for Postacute Care (AM-PAC) tool was used to evaluate functional outcomes.Six hundred thirty eight primary THAs received LB followed by 939 that did not. In the non-LB THAs, BMI was higher (30.06 vs 29.43; P.05). Besides marital status, the remaining baseline demographics were similar between the two cohorts (P.05). The non-LB THA cohort demonstrated a marginal increase in verbal rating scale pain scores between 12 to 24 hours (4.42 ± 1.70 vs 4.20 ± 1.87; P.05) and 36 to 48 hours (4.49 ± 1.72 vs 4.21 ± 1.83; P.05). There was no difference in inpatient opioid administration up to 96 hours postoperatively (P.05) or AM-PAC functional scores within the first 24 hours (P.05).A small statistical, but not clinically meaningful, difference was observed in subjective pain scores with LB PAI discontinuation. Opioid consumption and postoperative AM-PAC functional scores were unchanged after LB PAI discontinuation.

Background:There are currently a lack of investigations that characterised narcotic utilisation following revision total hip arthroplasty (THA). We sought to determine if immediate post-surgical opioid use was different between revision THA and primary THA.Methods:A single institution total joint arthroplasty database was used to identify adult patients who underwent revision THA or primary THA from 2016 to 2019. Morphine milligram equivalents (MME) were calculated for different time periods.Results:6977 patients were identified, 89.72% primary THA and 10.28% revision THA. Aggregate opioid consumption was higher for revision THA patients (317.40 MME vs. 93.01 MME), as was opioid consumption in the first 24 hour and second 24-hour periods. Visual analogue pain (VAS) scores were significantly higher in the 0–12 hour postoperative and the 12–24 hours postoperative periods in the revision THA group.Conclusions:Patients undergoing revision THA had significantly higher narcotic utilisation than those undergoing primary THA, particularly in the first 24 hours postoperatively.

Electronic health record (EHR) technologies have improved the ease of access to structured clinical data. The standard means by which data are collected continues to be manual chart review. The authors compared the accuracy of manual chart review against modern electronic data warehouse queries. A manual chart review of the EHR was performed with medical record numbers and surgical admission dates for the 100 most recent inpatient venous thromboembolic events after total joint arthroplasty. A separate data query was performed with the authors' electronic data warehouse. Data sets were then algorithmically compared to check for matches. Discrepancies between data sets were evaluated to categorize errors as random vs systematic. From 100 unique patient encounters, 27 variables were retrieved. The average transcription error rate was 9.19% (SD, ±5.74%) per patient encounter and 11.04% (SD, ±21.40%) per data variable. The systematic error rate was 7.41% (2 of 27). When systematic errors were excluded, the random error rate was 5.79% (SD, ±7.04%) per patient encounter and 5.44% (SD, ±5.63%) per data variable. Total time and average time for manual data collection per patient were 915 minutes and 10.3±3.89 minutes, respectively. Data collection time for the entire electronic query was 58 seconds. With an error rate of 10%, manual chart review studies may be more prone to type I and II errors. Computer-based data queries can improve the speed, reliability, reproducibility, and scalability of data retrieval and allow hospitals to make more data-driven decisions. [ Orthopedics . 2020;43(5):e404–e408.]

Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails.This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups.Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs.Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.

Aims Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84.

Background Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs. Questions/purposes Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA? Methods Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts. Results Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day. Conclusions In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists. Level of evidence Level III, economic and decision analysis.

Unicondylar knee arthroplasty (UKA), as an alternative to total knee arthroplasty (TKA), has been shown to be an effective option for patients with single-compartment end-stage knee osteoarthritis. Implant survival is contingent upon proper alignment, which has been improved with the advent of robotic-assisted surgery (r-UKA), but whether this outweighs the increased cost of the robotic-assist device has not been analyzed in the literature. The purpose of this study was to investigate the mid-term cost-effectiveness of r-UKA compared with UKA with traditional instrumentation (t-UKA) in the United States. A cost-effectiveness analysis using a four-state Markov model was performed using data from the 2018 National Joint Registry of England and Wales and a retrospective multicenter, cohort study on a cohort of 65-year-old patients having undergone r-UKA. The main outcome was cost per revision avoided and sensitivity analyses were conducted to evaluate the impact of using different model assumptions on the results. The Markov model illustrated that the benefit derived from r-UKA versus t-UKA was beneficial from a payer's perspective. The estimated incremental cost-effectiveness ratio (ICER) was $14,737 per revision avoided in a facility seeing 100 patients a year. Case volume was shown to be the primary variable affecting cost-effectiveness, with the value of r-UKA directly increasing with higher case volumes. Cost-effectiveness analyses demonstrated that the use of r-UKA is an effective alternative to t-UKA in patients with single-compartment knee osteoarthritis. While this study could benefit from longer follow-up clinical studies to illustrate the benefits of r-UKAs beyond the current 2 years time horizon, r-UKAs remained cost-effective, even after investigating several different assumptions.

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

We sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA).A single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019.In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P.001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P.001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P.001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P.0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed.UKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes.Retrospective Cohort Study.

We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT).A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019.In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P.001), more likely to be white, insured by Medicare, and less likely to be active smokers (P.0001). Both surgical time (90.03 vs 113.1 minutes, P.0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P.0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P.0001), LOS (2.62 vs 2.84 days, P.0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P.001).For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training.Retrospective Cohort Study.

Background Hospital length of stay is a major driver of cost in the total hip arthroplasty (THA) episode of care, and as a result, significant efforts are being made to minimize it. This study aims to assess the utility of the Outpatient Arthroplasty Risk Assessment (OARA) screening tool in accurately identifying patients for safe and early discharge after THA. Methods A retrospective review was conducted on 332 consecutive patients who underwent primary THA at a single tertiary academic center. Patients were evaluated using the OARA score, a tool that has been proposed to identify patients who can safely undergo early discharge after THA. The validity of these claims was assessed by analyzing the OARA score’s positive and negative predictive values for high vs low OARA scores between patients enrolled in our (1) same-day discharge (SDD) and 2) next-day discharge (NDD) pathways. Results When comparing the utility of the OARA score in accurately predicting length of stay, the OARA score demonstrated a (1) higher, but constant, positive predictive value for discharge on postoperative day (POD) 0 for SDD (86.1%) than POD1 for NDD (35.5%) and (2) lower negative predictive value for discharge on POD0 (23.1%) for SDD than POD1 for NDD (86.1%). Conclusion The OARA score was developed to risk-stratify patients who can safely undergo SDD or NDD after THA. In this study, the OARA score was a highly predictive tool in identifying NDD patients at risk for failure of discharge by POD1.

Vascular complications in revision total hip arthroplasty may occur in cases where the components of the hip implant migrate through the acetabular wall, through the iliopectineal line of the pelvis, and into the pelvic cavity. This migration may lead to substantial intrapelvic vascular compromise, drastically increasing the surgical complexity and potential risk for morbidity and mortality in these surgical cases. Here, we present a case of a 78-year-old woman with significant acetabular protrusio, which resulted in intraoperative compromise of the external iliac artery with rapid extravasation. As a result of prudent preoperative planning, interdisciplinary collaboration, and precautionary measures, significant patient morbidity and mortality was averted. Level of Evidence: Level V, Case Report. Keywords: Vascular surgery, Revision total hip arthroplasty

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

Summary As an essential means to resolve conflicts, aggression is expressed by both sexes but often at a higher level in males than in females. Recent studies suggest that cells in the ventrolateral part of the ventromedial hypothalamus (VMHvl) that express estrogen receptor alpha and progesterone receptor (Esr1/PR) are essential for male but not female mouse aggression. In contrast, here we show an indispensable role of VMHvlEsr1+ cells in female aggression. This population is active when females attack naturally. Inactivation of these cells reduces female aggression whereas their activation elicits attack. Additionally, we found that female VMHvl contains two anatomically distinguishable subdivisions that show differential gene expression, projection and activation patterns after mating and fighting. These results support an essential role of the VMHvl in both male and female aggression and reveal the existence of two previously unappreciated subdivisions in the female VMHvl that are involved in distinct social behaviors.

SummaryWhile the ventromedial hypothalamus, ventrolateral area (VMHvl) is now well established as a critical locus for the generation of conspecific aggression, its role is complex, with populations of neurons responding during the motivational, sensory, and action phases of aggression, and also during social interactions with the opposite sex. It has been previously unclear how the brain uses this complex multidimensional signal and generates a discrete action: the attack. Here we find that the largest posterior target of the VMHvl, the lateral periaqueductal gray (lPAG) encodes a simplified attack-selective signal during aggression. Single units in the lPAG exhibit greater selectivity for the attack action during aggression than VMHvl neurons and a subpopulation of neurons in the PAG exhibit short-latency, time-locked spiking relative to the activity of jaw muscles for biting during attack. In addition, channelrhodopsin assisted circuit mapping reveals a preferential projection from VMHvl glutamatergic cells to lPAG glutamatergic cells. Using projection-specific fiber photometry, we find that this excitatory projection conveys male-biased signals from the VMHvl to downstream glutamatergic PAG neurons that integrate ongoing male-related activity over several seconds, which suggests that action-selectivity is generated by a combination of both pre and postsynaptic filtering mechanisms.

Background Dilute betadine wash has been used for the prevention of prosthetic joint infection (PJI). Appropriateness for this purpose has recently come into question as the Food and Drug Administration determined that several commercial products did not pass the standards of proper sterility. The goal of this study is to determine if change in our institution’s perioperative infection protocol to sterile chlorhexidine gluconate wash affected rates of PJI. Methods This is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty and total hip arthroplasty. Chart review was performed to determine 90-day and 1-year readmissions and the development of PJI as per the diagnostic criteria of the Musculoskeletal Infection Society. Results A total of 2386 consecutive patients were included in this study. There were no significant demographic differences between the 2 groups. There was no statistically significant difference in the rate of PJI requiring a return trip to the operating room between the 2 cohorts: 4 in chlorhexidine vs 7 in betadine at 3 months (P = .61); and 9 in chlorhexidine and 14 in betadine at 1 year (P = .48, respectively). There was also no difference in the rate of wound complications between the betadine and chlorhexidine use (P = .93). Conclusion When comparing patients who received a betadine wash intraoperatively to those who received a chlorhexidine gluconate wash, there were no statistically significant differences in the rate of postoperative PJIs or return trips to the operating room. Although chlorhexidine gluconate and betadine have equal efficacy in the prevention of PJI, betadine is a far less expensive alternative if their sterility concerns are unwarranted Level of Evidence Therapeutic Level III.

Background No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents’ performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge. Methods Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores. Results There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009). Conclusions VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum. Level of Evidence Level 1.

Background Previous reports establish that infection with hepatitis C virus (HCV) predisposes total joint arthroplasty (TJA) recipients to poor postoperative outcomes. However, there is a paucity of literature evaluating the role of measurable HCV viral load (VL) on outcomes in TJA recipients. The purpose of the current study is to assess whether variation in HCV viral load influences perioperative outcomes following TJA. Methods A multicenter retrospective review of all patients diagnosed with HCV that underwent primary TJA between January 2005 and April 2018 was conducted. Patients were stratified into two cohorts: (1) patients with an undetectable VL (U-VL) (2) patients with a detectable VL (D-VL). Kaplan-Meier survivorship analysis was calculated with revision TJA as the end-point. Sub-analysis on the VL profile (low: 800,000 IU) was done. Results A total of 233 patients that underwent 289 TJAs were included. There were 98 patients that underwent 118 TJAs in the U-VL cohort, and 135 patients that underwent 171 TJAs in the D-VL cohort. Patients in the D-VL cohort had longer operative times (133.9 vs 109.2 minutes; p p p p p p =0.10). Kaplan-Meier survivorship analysis demonstrated that patients in the U-VL cohort trended towards better survivorship, however this failed to reach statistical significance ( p =0.17). On sub-analysis of low and high VL, no difference in outcomes was appreciated. Conclusion TJA recipients with a detectable HCV VL have longer operative times, experience more intraoperative blood loss, have longer hospital length of stays (LOSs), and are more likely to experience infection and require revision TJA. The blood loss, hospital LOS, and revision rate findings should be interpreted with caution, however, as there are confounding factors affecting these results. Our findings suggest that HCV VL is a modifiable risk factor that, if managed prior to TJA, can reduce the risk for periprosthetic infection and revision surgery. Additionally, serum HCV VL was not correlated with patient outcomes. Level of Evidence Level III, Retrospective Observational Study