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Background: There remains uncertainty regarding the relative importance of patient factors such as comorbidity and provider factors such as hospital volume in predicting complication rates after total hip arthroplasty (THA). Purpose: We therefore identified patient and provider factors predicting complications after THA. Methods: We reviewed discharge data from 138,399 patients undergoing primary THA in California from 1995 to 2005. The rate of complications during the first 90 days postoperatively (mortality, infection, dislocation, revision, perioperative fracture, neurologic injury, and thromboembolic disease) was regressed against a variety of independent variables, including patient factors (age, gender, race/ethnicity, income, Charlson comorbidity score) and provider variables (hospital volume, teaching status, rural location). Results: Compared with patients treated at high-volume hospitals (above the 20th percentile), patients treated at low-volume hospitals (below the 60th percentile) had a higher aggregate risk of having short-term complications (odds ratio, 2.00). A variety of patient factors also had associations with an increased risk of complications: increased Charlson comorbidity score, diabetes, rheumatoid arthritis, advanced age, male gender, and black race. Hispanic and Asian patients had lower risks of complications. Conclusions: Patient and provider characteristics affected the risk of a short-term complication after THA. These results may be useful for educating patients and anticipating perioperative risks of THA in different patient populations. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. © 2010 The Author(s).

Diagnosis and treatment of avascular necrosis of the hip has long been predicated on the evaluation of plain radiographs, though other modalities (such as magnetic resonance imaging) are being increasingly used to aid in this evaluation. The Ficat classification is commonly used to assess plain radiographs and to help determine what treatment is appropriate for a given patient. It also is used to help evaluate patient outcome after surgical or nonsurgical treatment. This study was designed to evaluate the adequacy of plain radiographs in the evaluation of avascular necrosis of the hip. The plain radiographs of 25 hips with avascular necrosis were analyzed on 3 occasions by 6 readers (450 total readings). A clinically significant difference in radiographic staging was defined as a Stage I or II reading of the radiographs of a given hip on 1 reading and a separate reading of the same radiographs as Stage III or IV. By this definition, interobserver variability for the first reading resulted in clinically significant differences in 10 (40%) of the 25 hips. Intraobserver variability resulted in clinically significant differences for 10 (40%) of the 25 hips as well. The most experienced readers in the study (a total joint specialist and a musculoskeletal radiologist) were consistent internally in their readings in 90% of cases, and had a clinically significant difference in only 1 case (1%); however, these same 2 readers disagreed with one another on the staging of 9 (36%) of 25 hips, with 4 (16%) of 25 hips having a clinically significant difference in readings.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: The purpose of this study was to compare the cost-effectiveness of unicompartmental knee arthroplasty as an alternative to total knee arthroplasty in patients with degenerative arthritis limited to either the medial or lateral compartment.Methods: A decision model was created for the treatment of end-stage unicompartmental knee arthritis. A literature review was used to identify possible outcomes and their probabilities following treatment with either unicompartmental or total knee arthroplasty. Each outcome was weighted for quality of life with use of a utility factor, and effectiveness was expressed in units of quality-adjusted life years. Gross costs were estimated from Medicare reimbursement data for the relevant Current Procedural Terminology and Diagnosis-Related Group codes.Results: Sensitivity analysis demonstrated that the cost-effectiveness of unicompartmental knee arthroplasty is dependent on the assumption that its durability and functional outcomes approach those of total knee arthroplasty. Specifically, it is necessary for the survival of unicompartmental implants to be within three to four years of the assumed survival of total knee implants for unicompartmental arthroplasty to remain a cost-effective alternative. Under these assumptions, the use of unicompartmental arthroplasty is a cost-effective choice as it results in incremental gains in effectiveness at a cost of less than US dollars 50,000 (in 1998 United States dollars) per quality-adjusted life year gained.Conclusions: This study supports unicompartmental knee arthroplasty as a cost-effective alternative for the treatment of unicompartmental arthritis when the durability and function of a unicompartmental replacement are assumed to be similar to those of a primary total knee replacement. This suggests that, with appropriate patient selection, the currently available literature supports unicompartmental arthroplasty as a cost-effective alternative to total knee arthroplasty.Level Of Evidence: Economic and decision analysis, Level II. [ABSTRACT FROM AUTHOR]

Background: The purpose of this investigation was to expand on previous studies by more fully examining the role of a variety of patient and hospital characteristics in determining adverse outcomes following total knee replacement.Methods: With use of data from all hospital admissions in California from 1991 through 2001, multiple logistic regression was performed on the information regarding patients treated with total knee replacement. Rates of mortality and readmission due to infection and pulmonary embolism during the first ninety days after discharge were regressed against a variety of independent variables, including demographic factors (age, gender, race, ethnicity, and insurance type), burden of comorbid disease (Charlson comorbidity index), and provider variables (hospital size, teaching status, and surgical volume). A separate baseline probability analysis was then performed to compare the relative importance of all predictor variables.Results: The sample size for this analysis was 222,684. A total of 1176 deaths (rate, 0.53%), 1586 infections (0.71%), and 914 pulmonary emboli (0.41%) occurred within the first ninety days after discharge. The average age of the patients at the time of surgery was sixty-nine years. Sixty-two percent of the patients were women, and 32% had a Charlson comorbidity index of >0. The significant predictors for complications (p < 0.05) included age, gender, race/ethnicity, Charlson comorbidity index, insurance type, and hospital volume. A baseline probability analysis was performed with the base case considered to be a white woman who was over the age of sixty-five years, had a Charlson comorbidity index of 0, had Medicare insurance, and was treated at a high-volume, non-teaching hospital. For a patient with the baseline case characteristics, the probability of death was 31/10,000, the probability of infection was 59/10,000, and the probability of pulmonary embolism was 41/10,000 in the first ninety days after discharge. Altering the base case by assuming that care was received at a low-volume hospital increased the expected mortality rate by a factor of 26%. Increasing the Charlson comorbidity index to 1 increased the mortality rate by 170%, whereas decreasing the age to younger than sixty-five years lowered the mortality rate by 73%. Hospital volume, comorbidity, and age had similar effects on the expected rates of readmission due to infection and pulmonary embolism.Conclusions: The effects of age and the Charlson comorbidity index on the baseline probability of adverse outcomes following total knee replacement were shown to be similar to or greater than the effect of hospital volume. This study elucidates and compares the relative importance of the effects of several different factors on outcome. This information is important when considering the conclusions and implications of this type of policy-relevant outcomes research. [ABSTRACT FROM AUTHOR]

Background: Warfarin, which requires coagulation monitoring, is associated with relatively high rates of thromboembolism despite providing adequate prophylaxis. This study compared an oral direct thrombin inhibitor, ximelagatran, with warfarin in order to evaluate the safety and efficacy of the medication for the prevention of venous thromboembolism in patients undergoing total knee arthroplasty.Methods: Following surgery, patients were randomly assigned to fixed-dose oral ximelagatran (36 mg twice daily) or warfarin (target international normalized ratio, 2.5), both administered for seven to twelve days in a double-blind, double-dummy design. Warfarin was initiated on the evening of the day of surgery, and ximelagatran, on the morning after surgery. The primary efficacy end point was the incidence of asymptomatic deep-vein thrombosis determined by bilateral venography, objectively confirmed symptomatic deep-vein thrombosis or pulmonary embolism, and death from all causes during treatment.Results: Adequate venograms or confirmed symptomatic events (efficacy population) were obtained for 1949 patients. Venous thromboembolism and death from all causes occurred in 22.5% (221) of 982 ximelagatran-treated patients and in 31.9% (308) of 967 warfarin-treated patients (p < 0.001). Proximal deep-vein thrombosis and pulmonary embolism were observed in 3.1% (thirty) and 0.2%, respectively, of the patients in the ximelagatran group and in 3.4% (thirty-three) and 0.4%, respectively, of the patients in the warfarin group. The six deaths from all causes included 0.3% (four) of the ximelagatran-treated patients and 0.2% (two) of the warfarin-treated patients. Major bleeding was noted in 1% (twelve) of the ximelagatran-treated patients and in 0.4% (five) of the warfarin-treated patients (p = 0.09).Conclusions: Oral ximelagatran (36 mg twice daily), administered without coagulation monitoring or dose adjustment and started the day after total knee arthroplasty, demonstrates superior efficacy compared with warfarin prophylaxis, with no wound complications and no significant difference with respect to bleeding events, although the rate of major bleeding events was greater with ximelagatran than with warfarin.Level Of Evidence: Therapeutic Level I. [ABSTRACT FROM AUTHOR]

Patients undergoing total hip and knee arthroplasty are at increased risk for the development of venous thromboembolic disease, and there is general agreement that these patients require prophylaxis. The selection of a prophylactic agent involves a balance between efficacy and safety and often needs to be individualized for specific patients and institutions. Despite extensive research, the ideal agent for prophylaxis against deep venous thrombosis has not been identified. The results of randomized trials indicate that low-molecular-weight heparin, warfarin, and fondaparinux are the most effective prophylactic agents after total hip arthroplasty and that low-molecular-weight heparin, warfarin, fondaparinux, and pneumatic compression boots are the most effective agents after total knee arthroplasty. The duration of prophylaxis against deep venous thrombosis after total hip and knee arthroplasty remains controversial. Prophylaxis should be continued beyond hospital discharge. In the future, the determination of the duration of prophylaxis will be based on the risk stratification of individual patients. The practice of discharging patients from the hospital without prophylaxis, even when the decision is based on negative results of procedures that screen for the presence of deep venous thrombosis, is not cost-effective. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate the osseous healing of a critical-sized femoral defect in a rat model with use of recombinant human bone morphogenetic protein-2 (rhBMP-2), a matrix fabricated of D,D-L,L-polylactic and hyaluronan acid (OPLA-HY), and a vascularized periosteal flap.Methods: The carrier matrix OPLA-HY with or without rhBMP-2 was implanted in a 1-cm-long femoral defect and secured with a plate and screws. In some groups, a vascularized periosteal flap was harvested from the medial surface of the tibia. In group 1, the femoral defects in the animals were filled with the OPLA-HY matrix alone; in group 2, the OPLA-HY matrix was covered by the vascularized periosteal flap; in group 3, 20 mug of rhBMP-2 was added to the OPLA-HY matrix; and in group 4, the femoral defect containing the OPLA-HY matrix and 20 mug of rhBMP-2 was wrapped circumferentially by the vascularized periosteal flap. The presence and density of new bone formation in the femoral defect were evaluated radiographically, histologically, and with histomorphometry at four and eight weeks postoperatively.Results: Groups 1 and 2, which were not treated with rhBMP-2, showed no radiographic or histologic evidence of mature bone formation at four or eight weeks. Both groups 3 and 4, which were treated with rhBMP-2, demonstrated excellent bone formation. However, with the periosteal flap, group 4 demonstrated more bone formation on histomorphometric analysis at eight weeks (43.1%) than did group 3 (28.3%) (p < 0.01). Additionally, heterotopic bone formed outside the boundaries of the defect in eight of the fifteen animals in group 3, which had no periosteal flap.Conclusions: Bone-tissue engineering with use of the OPLA-HY matrix and rhBMP-2 produced good bone formation in the rat femoral defect model. However, the addition of a vascularized periosteal flap significantly increased bone formation within the boundaries of the defect and prevented heterotopic ossification. [ABSTRACT FROM AUTHOR]

Introduction: Privatized Medicare Advantage (MA) plans are an alternative to traditional Medicare (TM). We sought to identify differences in 90-day postoperative mortality and non-fatal adverse events between TM and MA patients undergoing stage one antibiotic spacer placement for periprosthetic joint infection (PJI) of the hip or knee., Methods: A nationally representative database was queried from 2015 to 2021 for adult patients undergoing stage one antibiotic spacer placement for PJI. Using the International Classification of Disease, Tenth Revision (ICD-10), and Current Procedural Terminology (CPT) codes, as well as hospital charges for antibiotics, patients undergoing stage one exchange arthroplasty for PJI were identified. Patients were then grouped into TM and MA cohorts. The primary outcome was the odds of 90-day mortality. Multivariable logistic regressions were conducted to address possible confounding demographic, comorbidity, and hospital characteristics., Results: Of the 40,346 patients undergoing stage one spacer placement for PJI, 16,637 (41.2%) had TM coverage and 9,218 (22.8%) had MA coverage. Mortality within 90 days of surgery was higher in the MA cohort (1.4% versus 1.0%, P = 0.004). Multivariable logistic regression demonstrated significantly higher adjusted odds of mortality (aOR [adjusted odds ratio] = 1.42, 95% CI [confidence interval] = 1.11 to 1.81, P = 0.005) in MA patients compared to TM., Conclusion: Even after accounting for available confounders with our multivariable analyses, patients enrolled in an MA plan were over 40% more likely to die within 90 days of surgery compared to patients who have TM coverage. Further study is necessary to better understand the underlying cause of this finding., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Given the growing prevalence of obesity, it is crucial to understand the effect of obesity on complications after total knee arthroplasty (TKA). This study aims to assess the relationship between body mass index (BMI) and postoperative periprosthetic joint infection (PJI), medical complications, and surgical complications after TKA., Methods: The Premier Healthcare Database was used to identify all primary elective TKAs between 2016 and 2021. The primary outcome was risk of PJI within 90 days of surgery. Using logistic regression, restricted cubic splines were generated to assess the relationship between BMI as a continuous variable and PJI risk. Bootstrap simulation was then done to identify a BMI inflection point on the final restricted cubic spline model past which the risk of PJI increased. The relationship between BMI and composite 90-day medical and surgical complications was also assessed., Results: A direct relationship was observed between increasing BMI and increasing risk of PJI with a BMI changepoint of 31 kg/m2 identified as being associated with increased risk. Above a BMI of 31 kg/m2, there was an average relative risk increase of PJI of 13.6% for every unit BMI. This relative risk per unit BMI increased from 5.8% for BMI 31 to 39 to 11.5% between BMI 40 and 49 kg/m2, and 21.3% for BMIs ≥50 kg/m2. Similarly, a direct relationship was also found between increasing BMI and both medical and surgical complications with BMI changepoints of 34 and 32 kg/m2 identified, respectively., Discussion: Obese patients with a BMI >31 kg/m2 were at increased risk of PJI. Although the relative risk increase was small per unit BMI above 31 kg/m2, the cumulative increase in risk may be marked for patients with higher BMIs., Conclusion: These data should be used to inform discussions that involve shared decision making between patients and surgeons who weigh the risks and benefits of surgery., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE)., Methods: Patients who have a history of VTE who underwent primary elective TJA from 2015 to 2021 were identified using a commercial health care database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared., Results: Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < .001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < .001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < .001) and DVT (2.37 versus 3.01%, P < .001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio: 0.78, 95% confidence interval: 0.66 to 0.93, P = .006) and DVT (adjusted odds ratio: 0.84, 95% confidence interval: 0.74 to 0.95, P = .006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > .05)., Conclusions: The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA., Level of Evidence: Level III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

When delivering cells on a scaffold to treat a bone defect, the cell seeding technique determines the number and distribution of cells within a scaffold, however the optimal technique has not been established. This study investigated if human adipose-derived stem cells (ASCs) transduced with a lentiviral vector to overexpress bone morphogenetic protein 2 (BMP-2) and loaded on a scaffold using dynamic orbital shaker could reduce the total cell dose required to heal a critical sized bone defect when compared with static seeding. Human ASCs were loaded onto a collagen/biphasic ceramic scaffold using static loading and dynamic orbital shaker techniques, compared with our labs standard loading technique, and implanted into femoral defects of nude rats. Both a low dose and standard dose of transduced cells were evaluated. Outcomes investigated included BMP-2 production, radiographic healing, micro-computerized tomography, histologic assessment, and biomechanical torsional testing. BMP-2 production was higher in the orbital shaker cohort compared with the static seeding cohort. No statistically significant differences were noted in radiographic, histomorphometric, and biomechanical outcomes between the low-dose static and dynamic seeding groups, however the standard-dose static seeding cohort had superior biomechanical properties. The standard-dose 5 million cell dose standard loading cohort had superior maximum torque and torsional stiffness on biomechanical testing. The use of orbital shaker technique was labor intensive and did not provide equivalent biomechanical results with the use of fewer cells., (© 2024 Wiley Periodicals LLC.)

Background: Successfully matching into orthopaedic surgery residency is a challenging endeavor due to the limited number of available positions. Implementation of the Standard Letter of Recommendation (SLOR) in 2017 was intended to allow better comparisons between applicants; however, the form suffered from notable rank inflation ultimately requiring introduction of an updated SLOR for the 2023 to 2024 application cycle. The purpose of this study was to evaluate whether the 2023 SLOR improves on deficiencies of the 2017 SLOR., Methods: Applications submitted to our institution during the 2023 to 2024 orthopaedic surgery residency application cycle were analyzed. Applicant objective metrics were collected, including US Medical Licensing Exam scores, clerkship grades, AΩA status, and research productivity. Scores for each domain of the 2023 SLOR forms were recorded. Mean scores were calculated for each question, and cumulative scores per SLOR were determined. Intraclass correlation coefficients were determined per applicant and evaluator. The Spearman rank correlation coefficient was calculated for comparison of SLOR cumulative scores and objective metrics., Results: Three hundred sixty-eight applications were reviewed, and 743 2023 SLORs were submitted in conjunction with these applications. Most of the 2023 SLORs (n = 399, 53.70%) had cumulative scores placing applicants in at least the 90th percentile. Furthermore, 267 evaluators (72.36%) consistently gave scores of 99s and 10s for each question. Intraclass correlation coefficients were rated as fair to moderate agreement between evaluators for each applicant. Objective applicant metrics did not meaningfully correlate with SLOR cumulative scores., Discussion: The 2023 SLOR demonstrated notable rank inflation with only 22.7% of applicants receiving a score of less than 7 on any domain. By contrast, 69.9% of applicants received a score of "rare, perfect gem" on at least one domain of the form. We encourage the American Orthopaedic Association Council of Orthopaedic Residency Director to continue to improve the form and provide guidance to residency program leadership on proper use of the grading system., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Osteonecrosis of the femoral head (ONFH) affects at least 20,000 patients annually in the United States; however, the pathophysiology of disease progression is poorly understood. The purpose of this study was to determine the relative importance of three distinct elements and their relationship to the collapse of the femoral head as follows: (1) identifiable risk factors, (2) femoral head anatomy, and (3) the extent of the necrotic lesion., Methods: A single-center retrospective cohort study was performed on patients ≥ 18 year old who presented with ONFH. Ficat classification and femoral head anatomic parameters were measured on radiographs. Osteonecrotic lesion size was measured on magnetic resonance imaging using four validated methods. Multivariable regression analyses were performed to identify predictors of femoral head collapse., Results: There were 105 patients and 137 hips included in the final cohort, of which 50 (36.5%) had collapse of the femoral head. Multivariable analyses demonstrated that medical risk factors (adjusted odds ratio (aOR): 1.15), alcohol exposure (aOR: 1.23), and increased alpha angle (aOR: 4.51) were predictive of femoral head collapse. Increased femoral head offset (aOR: 0.54) was protective against collapse. An increased size of the osteonecrotic lesion was significantly predictive of collapse with all four measurement methods evaluated: three-dimensional volumetric (aOR: 3.73), modified Kerboul (aOR: 2.92), index of necrotic extent (aOR: 1.91), and modified index of necrotic extent (aOR: 2.05)., Conclusions: In an analysis of patients who had ONFH, we identified risk factors such as alcohol exposure, high alpha angle, increased lesion size, and decreased femoral offset as increasing the risk of femoral head collapse. Given the challenges of studying this patient population, large prospective studies of patients who have ONFH should seek to identify whether these factors are reliable indicators of femoral head collapse., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: A survey was conducted at the 2023 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to assess practice management strategies among current AAHKS members., Methods: Members of AAHKS used an app to answer both multiple-choice and "yes or no" questions related to a variety of issues related to their practices., Results: The number of AAHKS members in private practice (37%) continues to decline, and 4% are now in private equity-employed practices. Fee for service (30%) and relative value units (30%) are the major forms of compensation. The number of AAHKS members that perform total joint arthroplasties at ambulatory surgery centers continues to increase, and supply chain issues (91%) remain a problem. There has been a decrease in surgeon participation in bundled payment programs and gainsharing arrangements with hospitals., Conclusions: This member's survey provides valuable information regarding practice patterns. The shift to outpatient surgery has continued. Future surveys will be performed to monitor changes in practice patterns over time., (Copyright © 2024. Published by Elsevier Inc.)

Background: The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls., Methods: A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests., Results: Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies., Conclusions: Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Postoperative infection is a devastating complication of total joint arthroplasty (TJA). Perioperative use of dexamethasone in patients who have diabetes mellitus (DM) remains controversial due to concern for increased infection risk. This study aimed to evaluate the association between dexamethasone and infection risk among patients who have DM undergoing TJA., Methods: This was a retrospective cohort study conducted on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2016 and December 2021 using a large national database. We identified 110,568 TJA patients (TKA: 66.6%; THA: 33.4%), 31.0% (34,298) of which had DM. Patients who received perioperative dexamethasone were compared to those who did not. The primary end points were the 90-day risk of postoperative periprosthetic joint infection, surgical site infection (SSI), and other non-SSI (urinary tract infection, pneumonia, sepsis)., Results: When modeling the association between dexamethasone exposure and study outcomes while accounting for the interaction between dexamethasone and morning blood glucose levels, dexamethasone administration conferred no increased odds of postoperative periprosthetic joint infection nor SSI in diabetics. However, dexamethasone significantly lowered the adjusted odds of other postoperative infections in diabetic patients (TKA: adjusted odds ratio = 09, 95% confidence interval = 0.8 to 1.0, P = .030; THA: adjusted odds ratio = 0.7, 95% confidence interval = 0.6 to 0.9, P = .001); specifically in patients with morning blood glucose levels between 110 to 248 mg/dL in TKA and ≤ 172 mg/dL in THA., Conclusions: This study provides strong evidence against withholding dexamethasone in diabetic patients undergoing TJA based on concern for infection. Instead, short-course perioperative dexamethasone reduced infection risk in select patients. The narrative surrounding dexamethasone should shift away from questions about whether dexamethasone is appropriate for diabetic patients, and instead focus on how best to optimize its use., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Morbidly obese patients are an ever-growing high-risk population undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) for end-stage osteoarthritis. This study sought to identify preoperative laboratory values that may serve as predictors of periprosthetic joint infection (PJI) in morbidly obese patients undergoing THA or TKA., Methods: All morbidly obese patients with preoperative laboratory data before undergoing primary elective TKA or THA were identified using the Premier Healthcare Database. Patients who developed PJI within 90 days after surgery were compared with patients without PJI. Laboratory value thresholds were defined by clinical guidelines or primary literature. Univariate and multivariable regression analyses were utilized to assess the association between PJI and preoperative laboratory values, including total lymphocyte count, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), albumin level, platelet count, albumin-globulin ratio, hemoglobin level, and hemoglobin A1c., Results: Of the 6,780 patients identified (TKA: 76.67%; THA: 23.33%), 47 (0.69%) developed PJI within 90 days after surgery. The rate of PJI was 1.69% for patients with a hemoglobin level of <12 g/dL (for females) or <13 g/dL (for males), 2.14% for those with a platelet count of <142,000/µL or >417,000/µL, 1.11% for those with an NLR of >3.31, 1.69% for those with a PLR of >182.3, and 1.05% for those with an SII of >776.2. After accounting for potential confounding factors, we observed an association between PJI and an abnormal preoperative NLR (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.04 to 5.44, p = 0.039), PLR (aOR: 4.86, 95% CI: 2.15 to 10.95, p < 0.001), SII (aOR: 2.44, 95% CI: 1.09 to 5.44, p = 0.029), platelet count (aOR: 3.50, 95% CI: 1.11 to 10.99, p = 0.032), and hemoglobin level (aOR: 2.62, 95% CI: 1.06 to 6.50, p = 0.038)., Conclusions: This study identified preoperative anemia, abnormal platelet count, and elevated NLR, PLR, and SII to be associated with an increased risk of PJI among patients with a body mass index of ≥40 kg/m 2 . These findings may help surgeons risk-stratify this high-risk patient population., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H979 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Venous thromboembolism (VTE) remains a dangerous complication after total hip arthroplasty (THA), despite advances in chemoprophylactic measures. This study aimed to identify risk factors of developing pulmonary embolism (PE) and deep vein thrombosis (DVT) after THA using a modern cohort of patients reflecting contemporary practices., Methods: The Premier Healthcare Database was queried for primary, elective THAs from January 1st, 2015, to December 31st, 2021. Patients who developed PE or DVT within 90 days of THA were compared with patients who did not develop any postoperative VTE. Differences in patient demographics, comorbidities, hospital factors, perioperative medications, chemoprophylactic agents, and allogeneic blood transfusion were compared between cohorts. Multivariable logistic regression models were used to identify independent risk factors of PE and DVT. In total, 544,298 THAs were identified, of which 1,129 (0.21%) developed a PE and 1,799 (0.33%) developed a DVT., Results: Patients diagnosed with a PE had significantly higher rates of in-hospital death (2.6% vs 0.1%, P < 0.001) compared with those without a PE. Age (adjusted odds ratio: 1.02 per year, 95% confidence interval [CI]: 1.01 to 1.03) and Black race (aOR: 1.52, 95% CI: 1.24 to 1.87) were associated with an increased risk of PE. Comorbidities associated with increased risk of PE included chronic pulmonary disease (aOR: 1.58, 95% CI: 1.36 to 1.84), pulmonary hypertension (aOR: 2.06, 95% CI: 1.39 to 3.04), and history of VTE (aOR: 2.38, 95% CI: 1.98 to 2.86). Allogeneic blood transfusion (aOR: 2.40, 95% CI: 1.88 to 3.06) was also associated with an increased risk of PE while dexamethasone utilization was associated with a reduced risk (aOR: 0.83, 95% CI: 0.73 to 0.95)., Discussion: Increasing age; Black race; allogeneic blood transfusion; and comorbidities, including chronic pulmonary disease, pulmonary hypertension, and history of VTE, were independent risk factors of PE after THA. Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons., Methods: This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022)., Results: There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05)., Conclusions: Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Patients with morbid obesity and concomitant hip or knee osteoarthritis represent a challenging patient demographic to treat as these patients often present earlier in life, have more severe symptoms, and have worse surgical outcomes following total hip and total knee arthroplasty. Previously, bariatric and metabolic surgeries represented one of the few weight loss interventions that morbidly obese patients could undergo prior to total joint arthroplasty. However, data regarding the reduction in complications with preoperative bariatric surgery remain mixed. Glucagon-like peptide receptor-1 (GLP-1) agonists have emerged as an effective treatment option for obesity in patients with and without diabetes mellitus. Furthermore, recent data suggest these medications may serve as potential anti-inflammatory and disease-modifying agents for numerous chronic conditions, including osteoarthritis. This review will discuss the GLP-1 agonists and GLP-1/glucose-dependent insulinotropic polypeptide dual agonists currently available, along with GLP-1/glucose-dependent insulinotropic polypeptide/glucagon triple agonists presently being developed to address the obesity epidemic. Furthermore, this review will address the potential problem of GLP-1-related delayed gastric emptying and its impact on the timing of elective total joint arthroplasty. The review aims to provide arthroplasty surgeons with a primer for implementing this class of medication in their current and future practice, including perioperative instructions and perioperative safety considerations when treating patients taking these medications., (© 2024 The Authors.)

Background: Obesity, defined as a body mass index (BMI) ≥ 30, is an ever-growing epidemic, with > 35% of adults in the United States currently classified as obese. Super-obese individuals, defined as those who have a BMI ≥ 50, are the fastest-growing portion of this group. This study sought to quantify the infection risk as well as the incidence of surgical, medical, and thromboembolic complications among super-obese patients undergoing total knee arthroplasty (TKA)., Methods: An all-payer claims database was used to identify patients who underwent elective, primary TKA between 2016 and 2021. Patients who had a BMI ≥ 50 were compared to those who had a normal BMI of 18 to 25. Demographics and the incidence of 90-days postoperative complications were compared between the 2 groups. Univariate analysis and multivariable regression were used to assess differences between groups., Results: In total, 3,376 super-obese TKA patients were identified and compared to 17,659 patients who had a normal BMI. Multivariable analysis indicated that the super-obese cohort was at an increased postoperative risk of periprosthetic joint infection (adjusted odds ratio [aOR] 3.7, 95% confidence interval [CI]: 2.1 to 6.4, P < .001), pulmonary embolism (aOR 2.2, 95%-CI: 1.0 to 5.0, P = .047), acute respiratory failure (aOR 4.1, 95%-CI: 2.7 to 6.1, P < .001), myocardial infarction (aOR 2.5, 95%-CI: 1.1 to 5.8, P = .026), wound dehiscence (aOR 2.3, 95%-CI: 1.4 to 3.8, P = .001), and acute renal failure (aOR 3.2, 95%-CI: 2.4 to 4.2, P < .001) relative to patients who have normal BMI., Conclusions: Super-obese TKA patients are at an elevated risk of postoperative infectious, surgical, medical, and thromboembolic complications. As such, risk stratification, as well as appropriate medical management and optimization, is of utmost importance for this high-risk group., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The relationship between surgeon volume and risk of dislocation after total hip arthroplasty (THA) is debated. This study sought to characterize this association and assess patient outcomes using a nationwide patient and surgeon registry., Methods: The Premier Healthcare Database was queried for adult primary elective THA patients from January 1, 2016, to December 31, 2019. Annual surgeon volume and 90-day risk of dislocation were modeled using multivariable logistic regression with restricted cubic splines. Bootstrap analysis identified a threshold annual case volume, corresponding to the maximum decrease in dislocation risk. Surgeons with an annual volume greater than the threshold were deemed high volume, and those with an annual volume less than the threshold were low volume. Each surgeon within a given year was treated as a unique entity (surgeon-year unit). 90-day complications of patients treated by high-volume and low-volume surgeons were compared., Results: From 2016 to 2019, 352,131 THAs were performed by 5,106 surgeons. The restricted cubic spline model demonstrated an inverse relationship between risk of dislocation and surgeon volume (threshold: 109 cases per year). A total of 9,967 (87.8%) low-volume surgeon-year units had individual dislocation rates lower than the average of the entire surgeon cohort. Patients treated by high-volume surgeons had decreased risk of dislocation (adjusted odds ratio [aOR], 0.60; 95% CI, 0.54 to 0.67), periprosthetic fracture (aOR, 0.87; 95% CI, 0.76 to 0.99), periprosthetic joint infection (aOR, 0.63; 95% CI, 0.56 to 0.69), readmission (aOR, 0.70; 95% CI, 0.67 to 0.73), and in-hospital death (aOR, 0.60; 95% CI, 0.46 to 0.80)., Conclusion: While most of the low-volume surgeons had dislocation rates lower than the cohort average, increasing annual surgeon case volume was associated with a reduction in risk of dislocation after primary elective THA., Therapeutic Level of Evidence: Level IV., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The opinions of the authors expressed in this manuscript are their own and do not reflect official policy of the United States Army or the Department of Defense.

Abstract: Most health systems are vertically integrated, and the leaders of orthopaedic surgery departments or service lines must have a comprehensive understanding of their role in the strategic plan of the health system. Orthopaedic surgery departments must be profitable while supporting the tripartite mission of excellence in clinical care, research, and education. This symposium had 4 specific objectives: to discuss how to (1) create synergy between the department or service line and the health system, (2) develop a strategy to enhance financial stability and revenue growth, (3) develop a comprehensive plan to enhance recruitment and retention of a diverse faculty, and (4) consider alternative strategies to foster education and research, even when the health system may be more focused on revenue generation., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H843 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Same-day total hip arthroplasty (THA) and total knee arthroplasty (TKA) continue to gain popularity in the United States. The present study sought to quantify recent same-day outpatient trends taking into consideration the COVID-19 pandemic as well as the removal of these procedures from the Medicare inpatient only (IPO) list., Methods: Patients undergoing primary elective TKA and THA were identified using the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample from January 1, 2016, to December 31, 2020. The same-day cohort included Nationwide Ambulatory Surgery Sample and National Inpatient Sample patients with a length of stay = 0 days. The inpatient cohort included patients with length of stay ≥1 day. National estimates were extrapolated using weight functions., Results: From January 2016 to December 2020, the proportion of same-day TKA increased from 1.2 (719) to 62.4% (31,293) and the proportion of same-day THA increased from 2.0 (599) to 54.5% (18,252). Following removal from the Medicare IPO list, same-day TKAs increased from 3.2% (1,895) in December 2017 to 13.8% (9,269) in January 2018, and same-day THAs increased from 10.7% (4,295) in December 2019 to 22.5% (8,708) in January 2020. Between February and March 2020, same-day TKAs increased from 42.4 (26,148) to 44.4% (16,972) and same-day THAs increased from 28.5 (10,729) to 30.2% (7,409)., Conclusions: The proportion of same-day TKA and THA dramatically increased following removal from the Medicare IPO list and in response to the COVID-19 pandemic. By December 2020, same-day TKA and THA accounted for >50% of all cases performed in the United States., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: Modular dual-mobility (DM) articulations are increasingly used during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS)-MRI abnormalities with serum metal ion levels in patients with DM articulations., Methods: A total of 45 patients (50 hips) with a modular DM articulation were included with mean follow-up of 3.7 years (SD 1.2). Enrolled patients with an asymptomatic, primary THA and DM articulation with over two years' follow-up underwent MARS-MRI. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels., Results: Overall, two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels > 3.0 μg/l. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/l. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels < 1.0 μg/l, while one (2.6%) had a cobalt level of 1.4 μg/l. One patient (2.2%) had a chromium level > 3.0 μg/l and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels > 5.0 μg/l without associated MARS-MRI abnormalities., Conclusion: Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic DM articulations occur infrequently (4.4%), but further assessment is necessary due to implant heterogeneity., Competing Interests: J. R. Lieberman and N. D. Heckmann received a grant from the American Association of Hip and Knee Surgeons Foundation for Arthroplasty Research and Education (FARE) (GR1052786), related to this study. N. D. Heckmann reports consulting fees from Zimmer, not related to this study. J. R. Lieberman reports royalties and consulting fees from DePuy Synthes, not related to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Background: Inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) practices were dramatically affected in the United States in 2020 as elective surgeries were paused in response to the COVID-19 pandemic. This study sought to provide an updated estimate of inpatient total joint arthroplasty (TJA) case volumes in the United States in 2020., Methods: A retrospective cohort study was performed by identifying all adult patients who underwent primary, elective TJA from January 1st, 2017 to December 31st, 2020, using the National Inpatient Sample. Monthly and annual case volumes were reported with descriptive statistics. Baseline case volumes were established by taking the average number of monthly cases performed in 2017, 2018, and 2019. These monthly averages were compared to 2020 values., Results: From 2017 to 2019, the average case volume was 1,056,669 cases per year (41.0% THA, 59.0% TKA) and 88,055 cases per month. In 2020, 535,441 cases were identified (45.4% THA, 54.6% TKA), corresponding to a 49.3% reduction from the 2017-2019 annual average. Monthly cases decreased to 4515 in April during the "first wave" of COVID-19, corresponding to a 94.8% decrease from prior years. In June, cases rebounded to 55,520 before decreasing again in July to 50,100 during the "second wave" of COVID-19. During the "third wave," COVID-19 cases decreased month-over-month from October through December (56.5% decrease)., Conclusions: This updated estimate identified a 49.3% decrease in inpatient TJA cases in 2020 compared to prior years. This is similar to the 46.5-47.7% decrease in case volume previously reported., (© 2024 The Authors.)

Background: Hyperglycemia has been identified as a risk factor for periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, there is no consensus with regard to the preoperative blood glucose level (BGL) on the day of the surgical procedure associated with increased risk. We sought to identify preoperative BGL thresholds associated with an increased risk of PJI., Methods: The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary, elective THA and had a measurement of the preoperative BGL recorded on the day of the surgical procedure (preoperative BGL) from January 1, 2016, to December 31, 2021. The association between preoperative BGL and 90-day PJI risk was modeled using multivariable logistic regression with restricted cubic splines. Patients with and without diabetes with a preoperative BGL associated with 1.5 times greater odds of PJI (high preoperative BGL) were then compared with patients with a normal preoperative BGL., Results: In this study, 90,830 patients who underwent THA and had a recorded preoperative BGL were identified. The preoperative BGL associated with 1.5 times greater odds of PJI was found to be 277 mg/dL in patients with diabetes and 193 mg/dL in patients without diabetes. Compared with the normal preoperative BGL cohort, those with high preoperative BGL had increased odds of PJI (adjusted odds ratio [OR], 2.60 [95% confidence interval (CI), 1.45 to 4.67] for patients with diabetes and 1.66 [95% CI, 1.10 to 2.51] for patients without diabetes) and 90-day readmissions (adjusted OR, 1.92 [95% CI, 1.45 to 2.53] for patients with diabetes and 1.66 [95% CI, 1.37 to 2.00] for patients without diabetes)., Conclusions: Increased preoperative BGL was found to be associated with an increased risk of PJI following primary THA. Surgeons should be aware of patients with diabetes and a preoperative BGL of >277 mg/dL and patients without diabetes but with a preoperative BGL of >193 mg/dL., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H815 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not., Methods: Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders., Results: The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001)., Conclusions: TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H756 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)