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Many previous studies of total hip arthroplasty (THA) have focused on adverse events occurring within 30 days of surgery. Studies examining 90-day postoperative adverse events have typically not focused on the timing of adverse events within that period. The current study evaluated the rate and timing of adverse events within 90 days of THA.Adult THA patients between 2010 and 2020 Q3 were identified from a large administrative dataset. Rates and timing of 90-day adverse events were determined. The median, interquartile range, and middle 80% were calculated based on the time of diagnosis for each adverse event. These were also dichotomized as occurring before or after 30 days and predictive factors for later adverse events were determined.Overall, 81,158 adverse events were noted, of which 56,500 (69.0%) were diagnosed within 30 days of surgery and 25,355 (31.0%) were diagnosed 31-90 days after surgery. The proportion of adverse events occurring 31-90 days after surgery ranged from 6% (transfusion) to 45% (wound dehiscence). Patients experiencing a later adverse event were more likely to be women and to have higher Elixhauser Comorbidity Index (ECI) scores.Almost one-third of adverse events following THA were diagnosed between postoperative days 31 and 90, highlighting the importance of looking beyond 30 days when estimating patients' risk of postoperative adverse events. These data may inform future research, patient counseling, and prevention strategies.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76–0.92; P P =.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [ Orthopedics . 202x;4x(x):xx–xx.]

Background People with cerebral palsy (CP) may be considered for total hip arthroplasty (THA). However, short- and long-term outcomes after THA in this population remain poorly characterized. Methods Data from patients undergoing THA were abstracted from the 2010-2018 PearlDiver Mariner administrative database. Those with CP were matched to those without CP based on demographic and comorbid factors (1:4 matching). Ninety-day incidence of postoperative complications and hospital readmission was identified and compared. Five-year implant survival (based on need for revision) was also assessed and compared. Perioperative adverse events were then compared using multivariate logistic regression to adjust for any potential residual differences in demographic and comorbid factors after matching. Implant survival over time was compared with Kaplan-Meier plots with a log-rank test. Significance was set at P Results In total, 864 patients with CP were matched to 3448 patients without CP. After adjusting for differences in demographics and comorbidities, multivariate analyses demonstrated patients with CP had higher odds of urinary tract infection (odds ratio [OR] = 2.42, P = .007), pneumonia (OR = 3.77, P = .001), and periprosthetic fracture (OR = 2.55, P = .001). Rates of the other studied adverse events, including readmissions, were not significantly different between groups. At five years, 94.2% of the CP cohort and 95.2% of the non-CP cohort THAs remained unrevised (no difference by log rank, P = .195). Conclusion Compared with patients without CP, patients with CP undergoing THA were found to have higher odds of perioperative urinary tract infection, pneumonia, and periprosthetic fracture but not other perioperative complications or difference in five-year implant survival.

Background: Achondroplasia is the most common skeletal dysplasia, and total joint arthroplasty of the hip and/or knee in this patient population may present unique challenges. Methods: All patients undergoing primary total hip or total knee arthroplasty (THA or TKA) for osteoarthritis in the 2010-2019 PearlDiver Mariner administrative database with least 90 days of postoperative follow-up were identified. Those with achondroplasia were matched 1:10 to patients without achondroplasia based on age, sex, and medical comorbidities. Ninety-day adverse events were assessed and compared using multivariate logistic regression. Five-year implant survival was determined and compared with Kaplan-Meier implant survival curves. Significance was set at P < .05. Results: For THA, 150 patients with achondroplasia were matched to 1484 patients without and had significantly higher 90 days odds of surgical site infection (odds ratio [OR] = 3.49, P = .005) and readmission (OR = 2.35, P = .016). For TKA, 285 patients with achondroplasia were matched to 2828 without and had higher odds of aggregated any adverse event (OR = 1.52, P = .006) and transfusion (OR = 2.31, P < .001). Rates of the other studied adverse events were not significant for either set of the analyses. At 5 years, implant survival for those with and without achondroplasia was not different for those undergoing THA (P = .321) or TKA (P = .910). Conclusions: The present study represents the largest cohort of patients with achondroplasia undergoing total joint arthroplasty to date. Although several short-term adverse events had greater odds for those with achondroplasia, 5-year survival was not different for those with or without achondroplasia after THA or TKA, supporting confidence in longer term implant success.

Background Owing to COVID-19, arthroplasty fellowship programs will be required to interview virtually for the current application cycle. Unrelated to COVID-19, our arthroplasty fellowship offered the 2019-2020 interviewees the option of an in-person or virtual interview. The purpose of the present study is to compare interviewee perceptions regarding in-person vs virtual interview formats from that application cycle at a single institution. Methods A 17-question survey was sent to all 26 interviewees (13 in-person and 13 virtual) shortly after the rank-list submission deadline. Interviewees were asked to what extent they agreed or disagreed with several statements, ranging from whether the interview was enjoyable to whether interviewees felt they were being adequately evaluated. In this Likert scale rating system, “strongly agree” was given 5 points (more positive outlook), and “strongly disagree” was given 1 point (more negative outlook). Chi-square analyses were performed. Results Seventeen interviewees (8 in-person and 9 virtual) returned questionnaires (response rate: 65%). Both in-person and virtual interview ratings were similar when averaged across all statements (4.5 vs 4.4, P = .67). In-person and virtual ratings were also similar for each individual statement (all P > .05). On average, interviewees spent $557/in-person interview. Fifteen (88%) said virtual interviews were more convenient, and 14 (94%) said they were more cost-effective. Conclusion At a single institution, perceptions on interview format, as quantified through Likert scale ratings, were similar between in-person and virtual groups. The vast majority also viewed virtual interviews as more convenient and cost-efficient. These findings have immediate implications for future fellowship application cycles.

The patient found it hard to climb stairs-and to complete a particular task when getting dressed. Difficulty with that task provided a useful diagnostic clue.

Nicole M Del Toro-Pagán,1,2 Feng Dai,3 Trevor Banack,4 Jill Berlin,4 Satya A Makadia,4 Lee E Rubin,5 Bin Zhou,3 Phu Huynh,6 Jinlei Li4 1Department of Pharmacy, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, USA; 2Applied Precision Pharmacotherapy Institute, Tabula Rasa HealthCare, Moorestown, NJ, USA; 3Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA; 4Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA; 5Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA; 6Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USACorrespondence: Jinlei Li, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT, 06520-8051, USA, Tel + 1 475 434 4038, Email jinlei.li@yale.eduPurpose: Opioid consumption after total knee arthroplasty (TKA) remains a challenge with single injection nerve blocks even with common local anesthetic adjuvants dexamethasone (DEX). This study aimed to investigate the effects of adding methylprednisolone acetate (MPA) to adductor canal blocks (ACB) and interspace between the popliteal artery and capsule of the posterior knee (iPACK) blocks on postoperative opioid consumption.Methods: A retrospective analysis was conducted on 100 consecutive TKA patients equally assigned into two groups, with one group receiving DEX through ACB and iPACK block and the other group receiving DEX and methylprednisolone acetate (DEX/MPA) through the same nerve blocks. The primary outcome was cumulative opioid consumption (oral milligram morphine equivalent, OME) during hospitalization for up to three days. Secondary outcomes included daily opioid consumption, highest rest and active pain scores, prosthetic knee joint active range of motion (AROM), laboratory studies including fasting serum glucose (FSG) and white blood cell count (WBC) on each postoperative day (POD), and length of hospital stay.Results: Cumulative opioid consumption was significantly lower in the DEX/MPA group vs DEX group (median difference (95% CI) = − 45.3 (− 80.5 to − 10), P = 0.011). The highest rest and active pain scores were both significantly lower in the DEX/MPA group than in DEX group on POD 2 (least square mean difference (95% CI) = − 1.3 (− 2.3 to − 0.4), P = 0.005 and − 0.9 (− 1.8 to − 0.1), P = 0.031, respectively). Except on POD 1, FSG values were significantly lower in the DEX/MPA group (median difference (95% CI) = − 22.5 (− 36 to − 8.9), P = 0.001). AROM, WBC, and length of stay were comparable between both groups.Conclusion: Compared to perineural DEX alone, the addition of MPA further decreases postoperative opioid consumption without clinically significant changes on FSG and WBC.Level of Evidence: III.Keywords: perineural, arthroplasty, glucocorticoids, total knee arthroplasty, TKA, peripheral nerve block, PNB, methylprednisolone acetate

INTRODUCTION Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the "inpatient-only" list from January 1, 2018. The impact of this change on actual hospital length of stay (LOS) and patient coding is of interest. METHODS Patients undergoing TKA were abstracted from the 2015 to 2018 National Surgical Quality Improvement Program database. Patient characterization as "inpatient" or "outpatient" and actual LOS were assessed. Ordinal and categorical data comparisons were done with Pearson chi-squared tests. Continuous variables were tested for normality, and nonparametric analyses were conducted using the Mann-Whitney test. Significance was set at P < 0.05. RESULTS In total, 125,613 TKA patients from 2017 to 2018 were identified (232,269 TKA patients from 2015 to 2018). Most patients undergoing TKA were of Medicare eligibility (≥65 years old; 60.78% in 2017 and 62.42% in 2018). Overall, LOS decreased significantly from 2017 to 2018 (2.31 ± 1.56 days versus 2.05 ± 1.57 days; P < 0.001), and more patients were discharged the same day (5.09% versus 2.28%; P < 0.001). In 2017, patients were coded as "outpatient" 1.66% of the time (those with LOS = 0 days were 22.85%, LOS = 1 day were 1.80%, LOS = 2 days were 0.79%, and LOS ≥3 days were 0.85%). In 2018, patients were coded as "outpatient" 17.14% of the time (those with LOS = 0 days were 78.2%, LOS = 1 day were 29.75%, LOS = 2 days were 6.96%, and LOS ≥3 days were 3.05%). This represented a significant change for each LOS day (P < 0.001). These results remained true when stratifying by Medicare eligibility (P < 0.001 for those

Elder abuse is a public health issue requiring attention. Unlike abuse in the pediatric population, predictors of elder abuse in patients with fracture have not been well defined.Elderly patients with physical abuse and fracture were abstracted using the 2007 to 2017 National Emergency Department Sample database. Univariate comparisons, multivariate regression, and adjusted odds ratios were used to determine independent predictors of elder abuse compared with nonabuse fracture controls.Thirteen percent of elder physical abuse patients presenting to the emergency department had fracture. Of all patients with fracture, elder abuse patients tended to be younger; be female; belong to lower income quartiles; and have codiagnoses of volume depletion, mental disorders, dementia, and intellectual disability. Presentation with other forms of elder abuse, such as psychological abuse, neglect, and sexual abuse, and multiple fractures were also associated with elder physical abuse. Multivariate regression found elder abuse to be more likely in the setting of skull and rib fractures and less likely in the setting of femur and foot and ankle fractures.This study identified predictors of elder physical abuse in fracture patients older than 60 years. As with pediatric abuse, heightened awareness of potential physical abuse should be considered, especially in higher risk patients.

Patients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized.The PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts.In total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P.001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001).Compared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA.Level III.

STUDY DESIGN Cross-sectional survey. OBJECTIVE Examine patients' and physicians' estimates of radiation exposure related to spine surgery. SUMMARY OF BACKGROUND DATA Patients are commonly exposed to radiation when undergoing spine surgery. Previous studies suggest that patients and physicians have limited knowledge about radiation exposure in the outpatient setting. This has not been assessed for intraoperative imaging. METHODS A questionnaire was developed to assess awareness/knowledge of radiation exposure in outpatient and intraoperative spine care settings. Patients and surgeons estimated chest radiograph (CXR) equivalent radiation from: cervical and lumbar radiographs (anterior-posterior [AP] and lateral), computed tomography (CT), magnetic resonance imaging (MRI), intraoperative fluoroscopy, and intraoperative CT (O-arm). Results were compared to literature-reported radiation doses. RESULTS Overall, 100 patients and 26 providers completed the survey. Only 31% of patients were informed about outpatient radiation exposure, and only 23% of those who had undergone spine surgery had been informed about intraoperative radiation exposure. For lumbar radiographs, patients and surgeons underestimated CXR-equivalent radiation exposures: AP by five-fold (P

Articular cartilage injury, as a hallmark of arthritic diseases, is difficult to repair and causes joint pain, stiffness, and loss of mobility. Over the years, the most significant problems for the drug-based treatment of arthritis have been related to drug administration and delivery. In recent years, much research has been devoted to developing new strategies for repairing or regenerating the damaged osteoarticular tissue. The RNA interference (RNAi) has been suggested to have the potential for implementation in targeted therapy in which the faulty gene can be edited by delivering its complementary Short Interfering RNA (siRNA) at the post-transcriptional stage. The successful editing of a specific gene by the delivered siRNA might slow or halt osteoarthritic diseases without side effects caused by chemical inhibitors. However, cartilage siRNA delivery remains a challenging objective because cartilage is an avascular and very dense tissue with very low permeability. Furthermore, RNA is prone to degradation by serum nucleases (such as RNase H and RNase A) due to an extra hydroxyl group in its phosphodiester backbone. Therefore, successful delivery is the first and most crucial requirement for efficient RNAi therapy. Nanomaterials have emerged as highly advantage tools for these studies, as they can be engineered to protect siRNA from degrading, address barriers in siRNA delivery to joints, and target specific cells. This review will discuss recent breakthroughs of different siRNA delivery technologies for cartilage diseases.

Total hip arthroplasty (THA) may be complicated by dislocation. The incidence of and risk factors for dislocation are incompletely understood. This study aimed to determine the incidence and predictors of hip dislocation within 2 years of primary THA.The 2010 to 2020 PearlDiver MHip database was used to identify patients undergoing primary THA for osteoarthritis with a minimum of 2 years of postoperative data. Dislocation was identified by associated codes. Age, sex, body mass index, Elixhauser Comorbidity Index, fixation method, and bearing surface were compared for patients with dislocation versus control subjects by multivariate regression. Timing and cumulative incidence of dislocation were assessed.Among 155,185 primary THAs, dislocation occurred within 2 years in 3,630 (2.3%). By multivariate analysis, dislocation was associated with younger age (65 years), female sex, body mass index20, higher Elixhauser Comorbidity Index, cemented prosthesis, and use of metal-on-poly or metal-on-metal implants ( P0.05 for each). Among patients who experienced at least one dislocation, 52% of first-time dislocations occurred in the first 3 months; 57% had more than one and 11% experienced5 postoperative dislocation events. Revision surgery was done within 2 years of index THA for 45.6% of those experiencing dislocation versus 1.8% of those who did not ( P0.001).This study found that 2.3% of a large cohort of primary THA patients experienced dislocation within 2 years, identified risk factors for dislocation, and demonstrated that most patients experiencing dislocation had recurrent episodes of instability and were more likely to require revision surgery.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are outstanding options for many older patients at the discretion of the patient and the surgeon. As patients turn 65 years, greater than 98% of the US population becomes eligible for Medicare, and this represents a time of changing healthcare coverage for many.Patients undergoing elective TKA and THA were abstracted from the 2012 to 2018 National Surgical Quality Improvement Program database. Incidences of TKA and THA (combined and separate) were plotted and assessed by age. To assess factors associated with who "delayed" surgery until 65 years, demographic and preoperative characteristics, and postoperative adverse events were compared for the 2 years above and the 2 years below the 65-year-old mark with multivariate analysis. Significance was set at P0.05.In total, 515,139 TKA and THA patients were identified (62.04% TKA and 37.95% THA). When the number of procedures was plotted by age, a discontinuity in the bell-shaped curve was noted at age 65 years. Highlighting this finding, the changes in percent population between 63 and 64 years was -1.52%, between 64 and 65 years was +15.36%, and between 65 and 66 years was -2.32%. Relative to those who were 63 and 64 years (n = 36,511), those who were 65 and 66 years (n = 41,671) were more likely to be female, be non-Hispanic White, have a lower body mass index, and have a lower functional status but were not different in the preoperative American Society of Anesthesiologists class.In this large national sample, there was a clear step increase in undergoing TKA or THA once patients reached the age of 65 years (Medicare eligibility). This discontinuity in the bell-shaped curve may be evidence for a moral hazard in healthcare markets. Although factors in decision-making were not assessed, there were demographic factors associated with this step finding.

Patients with classic hemophilia can develop joint hemarthroses, degenerative changes, and eventually require total hip arthroplasty (THA). Little data exist concerning THA outcomes in this population, and evidence-based guidelines specifically addressing venous thromboembolism (VTE) prophylaxis in this population are lacking.A retrospective study was conducted using the 2010-2020 PearlDiver MHip database. Patients undergoing primary THA were identified, and those with classic hemophilia were matched 1:10 with non-hemophilia patients based on age, gender, and Elixhauser Comorbidity Index. Ninety-day serious adverse events, minor adverse events, and any adverse events were compared with multivariate analysis. Reoperation at 5 years was assessed using Kaplan-Meier analysis.Five hundred eighteen classic hemophilia THA patients were matched 1:10 with 5,193 non-hemophilia patients. On multivariate analysis, those with classic hemophilia had greater odds of aggregated any adverse events (odds ratio [OR] 1.76), serious adverse events (OR 2.30), and minor adverse events (OR 1.52) (P.001 for each). Patients with classic hemophilia had greater odds of bleeding issues (transfusion, OR 1.98; hematoma, OR 4.23; P.001 for both), VTE (deep vein thrombosis, OR 2.67; pulmonary embolism, OR 4.01; P.001 for both), and acute kidney injury (OR 1.63; P = .03). Five-year implant survival was lower in hemophilia patients (91.9%) relative to matched controls (95.3%; P = .009).Hemophilia patients undergoing THA had elevated risks of both 90-day bleeding complications (transfusion and hematoma) and VTE (deep vein thrombosis and pulmonary embolism) relative to matched controls. These findings emphasize the need to balance factor replacement and VTE prophylaxis. Although the 5-year implant survival was lower in hemophilia patients, this represented a difference of 3.4% at 5 years, suggesting that THA remains effective in this cohort.

Unicompartmental knee arthroplasty (UKA) may be considered for select patients to relieve pain and restore function of the knee joint. Little research to date has explored the complication profile of UKA in an older population. The current study uses a large national surgical database to examine the 30-day postoperative adverse events in octogenarians compared with those in nonoctogenarians.The 2012-2018 National Surgical Quality Improvement Program database was queried for all patients undergoing UKA for osteoarthritis. Those patients aged 80 years or older composed the octogenarian age group. Demographics and medical comorbidities were cataloged, in addition to 30-day adverse events. Multivariate regression analysis controlled for differences in demographics and comorbidities. Significance was set atA total of 10,103 patients undergoing UKA were identified, of which 728 (7.2%) were octogenarians. The octogenarian cohort had significantly higher comorbidity burden than nonoctogenarians. After controlling for demographics other than age, American Society of Anesthesiologists score, and medical comorbidities, octogenarians had higher 30-day odds of death (odds ratio [OR] = 6.12,The present study found a statistically significant increase in several adverse events within 30 days of surgery for patients aged ≥80 years when compared with patients younger than 80 years. Namely, UKA in octogenarians was associated with significantly increased odds of short-term mortality, urinary tract infection, transfusion, prolonged hospital stay, and readmission.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic disease has imposed an unprecedented degree of stress on healthcare systems. This study aimed to understand whether COVID-19 positivity is associated with an increased risk of adverse outcomes after geriatric hip fracture surgery. METHODS: From a national administrative claims data set, patients who underwent hip fracture surgery from April 1, 2020, to December 1, 2020 were selected for analysis. COVID-19-positive status was assessed by the emergency International Classification of Diagnoses, 10th Revision, COVID-19 code within 2 weeks before the surgery. Demographic, comorbidity, and 30-day postoperative adverse event information were extracted. Logistic regression before and after 10:1 propensity matching was performed to identify patient risk factors associated with the occurrence of postoperative adverse events. RESULTS: Of 42,002 patients who underwent hip fracture surgery, 678 (1.61%) were identified to be positive for COVID-19 infection. No significant differences in age, sex, and procedure type were found between COVID-19-positive and COVID-19-negative groups, but the COVID-19-positive patients demonstrated a higher incidence of several comorbidities. These differences were no longer significant after matching. After matching, the COVID-19-positive group had a higher incidence of any, serious, and minor adverse events (P < 0.001 for all). Controlling for preoperative variables, COVID-19 positivity was associated with an increased risk of experiencing any adverse events (odds ratio [OR] = 1.62, 95% confidence interval [95% CI] = [1.37 to 1.92], P < 0.001), serious adverse events (OR = 1.66, 95% CI = [1.31 to 2.07], P < 0.001), and minor adverse events (OR = 1.59, 95% CI = [1.34 to 1.89], P < 0.001). DISCUSSION: After matching and controlling for confounding variables, COVID-19-positive hip fracture patients had increased odds of multiple postoperative events. Clinicians caring for this vulnerable geriatric population should be mindful of this risk to improve the care for these patients during the ongoing global pandemic.

Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

INTRODUCTION As rates of primary total joint arthroplasty continue to rise, so do rates of revision. Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) are more frequently done at larger centers, are associated with higher morbidity, and may have different patient satisfaction outcomes. This study compares the survey results of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) between patients who underwent primary versus revision THA or TKA. METHODS All adult patients who underwent inpatient, elective, primary, and revision THA or TKA at a single institution were selected for retrospective analysis. Patient demographics, comorbidities, functional status, surgical variables, 30-day outcomes, and HCAHPS scores were assessed. Univariate and multivariate analyses were done to determine correlations between the aforementioned variables and top-box HCAHPS survey scores for primary versus revision THA and TKA. RESULTS Of 2,707 patients who met the inclusion criteria and had returned the HCAHPS survey, primary THA was documented in 1,075 patients (39.71%), revision THA in 75 (2.77%), primary TKA in 1,497 (55.30%), and revision TKA in 60 (2.22%). Revision THA patients were more functionally dependent, and TKA patients had higher American Society of Anesthesiologists score than their primary comparators. Revisions had longer hospital length of stay for both procedures. For THA, revision THA patients demonstrated lower total top-box rates compared withprimary THA patients (71.64% versus 75.67% top-box, P < 0.001) and lower scores on the care from doctors subsection (76.26% versus 85.34%, P < 0.001) of the HCAHPS survey. Similarly, for TKA, revision TKA patients demonstrated lower total top-box rates (76.13% versus 79.22%, P < 0.013) and lower scores on the care from doctors subsection (66.28% versus 83.65%, P < 0.001) of the HCAHPS survey. DISCUSSION For both THA and TKA, revision procedures were associated with lower total HCAHPS scores and rated care from doctors. This suggests that HCAHPS scores may be biased by factors outside the surgeon's control, such as the complexity associated with revision procedures. LEVEL OF EVIDENCE Level III.

STUDY DESIGN Retrospective cohort study OBJECTIVE.: The aim of this study was to investigate how elective spine surgery patient preoperative opioid use (as determined by admission NarxCare narcotics use scores) correlated with 30-day perioperative outcomes and postoperative patient satisfaction. SUMMARY OF BACKGROUND DATA The effect of preoperative narcotics usage on postoperative outcomes and patient satisfaction following spine surgery has been of question. The NarxCare platform analyzes the patients' state Physician Drug Monitoring Program (PDMP) records to assign numerical scores that approximate a patient's overall opioid drug usage. METHODS Elective spine surgery cases performed at a single institution between October 2017 and March 2018 were evaluated. NarxCare narcotics use scores at the time of admission were assessed. Patient characteristics, as well as 30-day adverse events, readmissions, reoperations, and mortality, were abstracted from the medical record. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data were also abstracted when available.Cases were binned based on the following ranges of admission NarxCare scores: 0, 1 to 99, 100 to 299, 300 to 499, and 500+. Multivariate logistic regressions were performed to compare the odds of having an adverse events, readmission, reoperation, and mortality between the different narcotics groups. One-way analysis of variance analyses were performed to compare HCAHPS survey response rates and HCAHPS survey results between the different narcotics score groups. RESULTS In total, 346 patients met criteria for inclusion in the study (NarxScore 0: n = 74, 1-99: n = 58, 300-499: n = 117, and 500+: n = 21). Multivariate logistic regressions did not detect statistically significant differential odds of experiencing adverse events, readmission, reoperation, or mortality between the different groups of admissions narcotics scores. Analyses of variance did not detect statistically significant differences in HCAHPS survey response rates, total HCAHPS scores, or HCAHP subgroup scores between the different narcotics score groups. CONCLUSION Although there are many reasons to address preoperative patient narcotic utilization, the present study did not detect perioperative outcome differences or patient satisfaction based on the narcotic use scores as stratified here. LEVEL OF EVIDENCE 3.

Previous studies have demonstrated varying rates of heterotopic ossification (HO) after total hip arthroplasty (THA) depending on which anatomical approach is utilized. The direct anterior approach (DAA) is considered to be a muscle-sparing approach to the hip, which may lead to decreased rates of HO formation. This study evaluated the incidence of HO formation after DAA THA. The current work is a retrospective review of patients who underwent DAA THA. Six-month postoperative radiographs were evaluated and HO grade was classified using the Brooker classification system. Baseline characteristic differences between the Brooker classification groups were analyzed, specifically looking at: age, sex, type of deep venous thrombosis prophylaxis utilized, and preoperative Bombelli arthritis type. The overall incidence of HO in this DAA group was 179/485 patients (36.9%). There were 14 patients (2.9%) with Brooker Type 3 HO and 1 patient (0.21%) with Brooker Type 4 HO. No surgical excision of HO was performed. Patients were significantly more likely to develop HO if they had Bombelli hypertrophic arthritis (p

To summarize the safety and feasibility of outpatient total joint arthroplasty (TJA) from the perspectives of short-term complications, long-term functional outcomes, patient satisfaction and financial impact, and to provide evidence-based guidance on how to establish an outpatient TJA programme.TJA has been recently transitioned from an exclusively inpatient procedure for all Medicare and Medicaid patients to an outpatient surgery in properly selected total knee arthroplasty patients. This change may decrease costs while maintaining comparable rates of readmission, adverse events, positive surgical outcomes and patient satisfaction.With a standardized clinical pathway, outpatient TJA can be safe and effective in a subset of patients. Essential components of a successful outpatient TJA programme include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid-sparing analgesia, and early and effective postdischarge planning. More studies are needed to further assess and optimize this new care paradigm.

Increased complication rate has been reported in Parkinson's disease (PD) patients following total knee arthroplasty (TKA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following TKA using a national database.The HCUP Nationwide Inpatient Sample was evaluated for the years 2000 to 2012. PD patients were matched 1:10 with non-PD control patients for age, sex, Charlson Comorbidity Index (CCI), and year of admission utilizing a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.Before matching, TKA patients with PD were significantly older (p 0.0001), more frequently male (p 0.0001), and had a greater CCI (p = 0.3058). In the matched cohort, PD was associated with significantly increased length of stay (3.92 vs 3.71 days, p 0.0001) and total hospital charges ($41,523.52 vs $40,657.00, p = 0.0037). There was no significant difference in in-hospital complication rate (8.28% vs 8.04%, p = 0.4297) or in-hospital mortality (0.164% vs 0.150%, p = 0.8465) between PD patients and matched non-PD patients.Matched cohort analysis demonstrated statistically significant but clinically minor increases in length and cost of hospitalization for TKA in PD patients. Complication rate and in-hospital mortality rate was not higher in PD patients, suggesting that this group may be safely considered for TKA.Prognostic - Level III.

Background The demand for total hip and total knee arthroplasty in the USA is projected to increase significantly. Traditionally, face-to-face physical therapy has been an essential component of recovery in patients after total joint arthroplasty. Emerging technology allows telerehabilitation, or virtual physical therapy, which may reduce costs and increase standardization, but its effects on outcomes are not known. Questions/Purpose We sought to review our initial experience using a telerehabilitation protocol for patients after primary total hip or total knee arthroplasty. Methods In this pilot study, we retrospectively compared our first 40 telerehabilitation patients after a primary total hip or knee arthroplasty with a historical cohort or literature referenced values and evaluated (1) readmission rates at 90 days, (2) emergency department visits, (3) patient-reported outcome scores, (4) incidence of closed knee manipulation within 90 days of primary total knee arthroplasty, and (5) patient satisfaction surveys. Results We observed no increase in the telerehabilitation group at 90 days in readmissions, emergency department visits, or closed knee manipulations. Accuracy of telerehabilitation exercises performed was 92%. Patient-reported outcome scores showed improvements comparable with traditional therapy. Extremely high patient satisfaction scores were reported with the telerehabilitation protocol. Conclusion Our early experience demonstrates the feasibility of implementing a telerehabilitation program following primary total hip or knee arthroplasty without compromising clinical quality and with high patient satisfaction. Electronic supplementary material The online version of this article (10.1007/s11420-019-09715-w) contains supplementary material, which is available to authorized users.

BACKGROUND Increased complication rate has been reported in Parkinson's disease (PD) patients following total hip arthroplasty (THA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following THA using a national database. METHODS The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was evaluated for the years 2000-2014. PD patients were matched 1:3 with non-PD control patients for age, gender, Charlson Comorbidity Index, and year of admission using a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. RESULTS 794,689 THAs were performed from 2000-2014. 4003 patients (0.50%) had comorbid Parkinson's disease. Before matching, arthroplasty patients with PD were significantly older (P < .001), more frequently male (P < .001), and had greater Charlson Comorbidity Index (P < .001). In the matched cohort, PD was associated with increased length of stay (3.1 vs 2.7 days, P < .001), total hospital charges ($49,061 vs $45,571, P < .001), and in-hospital complication rate (14.6% vs 11.7%, P < .001). There was no difference in-hospital mortality (0.50% vs 0.47%, P = .781). CONCLUSIONS Matched cohort analysis demonstrated increases in complication rate, length, and cost of hospitalization for THA in patients with PD. However, in-hospital mortality rate in PD patients was not increased. Of note, the elevation in per-episode cost ($3490) may be of concern when considering PD patients for surgery within the evolving "bundled payment" model of care. LEVEL OF EVIDENCE Prognostic- Level III.

Pain control after total hip arthroplasty in sickle cell patients is challenging yet essential to prevent sickle cell crises or protracted hospital stays. We present a case of effective analgesia that lasted for weeks in a young opioid-tolerant female. This was achieved by the administration of glucocorticoids with different durations of action, dexamethasone sodium phosphate/methylprednisolone acetate, via a femoral/lateral femoral cutaneous nerve block placed preoperatively. Postoperatively, the patient's opioid demand was unchanged from her preoperative baseline. She met all the discharge requirements, including physical therapy targets, on postoperative day 2 and did not have any complications during the hospitalization.

With the increasing medical complexity of patients undergoing posterior lumbar surgery, more patients are pharmacologically immunosuppressed to manage chronic conditions. The effects of immunosuppression have become of greater interest across multiple surgical specialties. The goal of the current study was to investigate whether long-term corticosteroid use is independently associated with perioperative adverse outcomes among patients undergoing posterior lumbar surgery. Patients who underwent elective posterior lumbar spine surgery (decompression and/or fusion) were identified in the 2005–2016 National Surgical Quality Improvement Program (NSQIP) database. Patient factors, surgical factors, and 30-day perioperative outcomes for patients taking long-term corticosteroids were compared with those for patients who were not taking these drugs. Propensity matching and multivariate analysis were used to evaluate comparable patients while controlling for potentially confounding variables. In total, 140,519 patients undergoing posterior lumbar spine surgery were identified. Of these, 5243 (3.73%) were taking corticosteroids. After propensity matching and controlling for age, sex, body mass index, functional status, American Society of Anesthesiologists class, and surgical procedure, those taking corticosteroids were at greater risk for any adverse event (odds ratio, 1.45), a serious adverse event (odds ratio, 1.57), a minor adverse event (odds ratio, 1.47), infection (odds ratio, 1.48), reoperation (odds ratio, 1.48), and readmission (odds ratio, 1.47) ( P ≤.001 for each). The findings confirmed that long-term corticosteroid use is associated with significant increases in perioperative adverse outcomes for patients undergoing elective posterior lumbar surgery, even with matching and controlling for potentially confounding variables. These findings can guide patient counseling and preemptive interventions before surgery for this patient population. [ Orthopedics . 2021;44(3):172–179.]