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Background: Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable with little investigation of functional outcomes., Methods: We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed., Results: Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5., Conclusion: Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years., Level of Evidence: Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Recent literature indicates that COVID-19 infection is a negative predictor of good outcomes following elective orthopedic surgery. However, the ideal timing of surgery after infection is unclear. The purpose of this study was to compare the rates of post-operative complications between those who underwent elective orthopedic surgery <50 days and >50 days after COVID-19 infection., Methods: This is a pilot study utilizing retrospective review of 28 adult subjects who underwent orthopedic surgery including 17 total-knee arthroplasties, seven total-hip arthroplasties, three posterior spinal fusions, and one common peroneal decompression. These subjects were indicated for an orthopedic surgery that was canceled due to positive pre-operative COVID-19 testing. The subjects were rescheduled for surgery between March 2020-December 2022.There were two cohorts: those who underwent surgery <50 days after COVID-19 infection (n=14) and subjects who underwent surgery >50 days after COVID-19 infection (n=14). Demographics, preoperative comorbid conditions, and post-operative complications were recorded and compared., Results: There were no significant demographic differences between the two cohorts with respect to age, body mass index, weight, and American Society of Anesthesiologists (ASA) grade. The two cohorts had no significant difference in pre-existing comorbid conditions with hypertension and peripheral vascular disease being the most common comorbidities overall. There were six postoperative complications involving four subjects within 90 days of surgery. One subject developed a postoperative pulmonary embolism (PE), and another subject developed a surgical-site infection, sepsis, and renal failure; both in the >50 days cohort. One patient in each cohort required reoperation. There was no difference in postoperative complications such as deep vein thrombosis (DVT), PE, sepsis, renal failure, and intensive care unit (ICU) admission between the two cohorts., Conclusion: This pilot cohort study demonstrates that COVID-19 infection within 50 days of orthopedic surgery does not significantly increase the risk of postoperative complications such as DVT, PE, surgical site infection, renal failure, ICU admission, reoperation, or death. Further evaluation of the effects of COVID-19 on surgical outcomes in larger cohorts is warranted. Level of Evidence: III ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2024.)

Background: Septic arthritis is an orthopedic emergency. Diagnosis is difficult in patients with concomitant crystalline arthropathy (gout or pseudogout). The symptomatology of crystal arthritis mimics septic arthritis, clouding clinical diagnosis. Arthrocentesis and synovial fluid analysis are the standard diagnostic tests for both pathologies. Crystals on microscopy are diagnostic of crystal arthritis, however their presence does not rule out septic arthritis. Septic arthritis is diagnosed by positive microbiology culture. Though septic arthritis is associated with elevated synovial total nucleated count (TNC), TNC elevations can also occur with gout. The literature suggests that a TNC count of > 50,000 cells in a crystal-positive joint should raise suspicion for concurrent septic arthritis, however data is limited. Further diagnostic indicators are needed to help clinicians promptly identify crystal positive septic arthritis as the treatments and prognoses are different., Methods: Patients were retrospectively identified who had arthrocentesis of a native joint positive for monosodium urate (MSU) and/or (CPPD) crystals. Laboratory data was collected including synovial fluid cultures, total nucleated cell count (TNC), percent polymorphic neutrophils (%PMN), and crystal analysis; and serum CRP, ESR, and white blood cell count (WBC). Statistical analysis performed using Spearman correlation, Univariate-Fischer's exact and Wilcoxon tests, and multivariate analysis., Results: 442 joints identified with positive CPPD and/or MSU crystals, 31% female, 69% male. Of 442 aspirates, 58 had positive cultures. Patients were more likely to have positive cultures if synovial TNC > 50,000 (odds ratio 7.7), CRP > 10 mg/dL (OR 3.2), PMN > 90% (OR 2.17), and if the patient was female (OR 1.9), all were statistically significant with p < 0.05. There were 55 patients who underwent irrigation and debridement based on clinical suspicion or a positive gram stain, 37 of these ultimately had a positive culture (67%), the remaining 18 had negative cultures., Conclusion: Results are consistent with the literature, a TNC > 50,000 warrants a high suspicion for concurrent septic arthritis and should prompt providers to critically evaluate other patient laboratory data. Results further suggests that a patient with positive crystals, synovial TNC > 50,000 cells, PMN > 90%, and serum CRP > 10mg/dL is at high risk for having a concurrent septic arthritis and may warrant urgent irrigation and debridement and antibiotic therapy. This data serves as a supporting to develop an infection risk calculator for crystal positive septic arthritis. Level of Evidence: III ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2024.)

Background and Objective: NSAIDs inhibit cyclooxygenase, but their role in aging and other diseases is not well understood. Our group previously showed the potential benefit of NSAIDs in decreasing the risk of delirium and mortality. Concurrently, epigenetics signals have also been associated with delirium. Therefore, we sought to find differentially methylated genes and biological pathways related to exposure with NSAIDs by comparing the genome-wide DNA methylation profiles of patients with and without a history of NSAIDs use., Methods: Whole blood samples were collected from 171 patients at the University of Iowa Hospital and Clinics from November 2017 to March 2020. History of NSAIDs use was assessed through a word-search function in the subjects' electronic medical records. DNA was extracted from the blood samples, processed with bisulfite conversion, and analyzed using Illumina's EPIC array. The analysis of top differentially methylated CpG sites and subsequent enrichment analysis were conducted using an established pipeline using R statistical software., Results: Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genome (KEGG) showed several biological pathways relevant to NSAIDs' function. The identified GO terms included "arachidonic acid metabolic process," while KEGG results included "linoleic acid metabolism," "cellular senescence," and "circadian rhythm." Nonetheless, none of the top GO and KEGG pathways and the top differentially methylated CpG sites reached statistical significance., Conclusion: Our results suggest a potential role of epigenetics in the mechanisms of the action of NSAIDs. However, the results should be viewed with caution as exploratory and hypothesis-generating given the lack of statistically significant findings., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: To investigate the relationship between history of anti-inflammatory medication use and delirium risk, as well as long-term mortality., Methods: In this retrospective cohort study, subjects recruited between January 2016 and March 2020 were analyzed. Information about anti-inflammatory medication use history including aspirin, NSAIDs, glucosamine, and other anti-inflammatory drugs, was collected. Logistic regression analysis investigated the relationship between anti-inflammatory medications and delirium. Log-rank analysis and cox proportional hazards model investigated the relationship between anti-inflammatory medications and one-year mortality., Results: The data from 1274 subjects were analyzed. The prevalence of delirium was significantly lower in subjects with NSAIDs usage (23.0%) than in those without NSAIDs usage (35.0%) (p < 0.001). Logistic regression analysis controlling for age, sex, dementia status, and hospitalization department showed that the risk of delirium tended to be reduced by a history of NSAIDs use (OR, 0.76 [95% CI, 0.55 to 1.03]). The one-year mortality in the subjects with NSAIDs (survival rate, 0.879 [95% CI, 0.845 to 0.906]) was significantly lower than in the subjects without NSAIDs (survival rate, 0.776 [95% CI, 0.746 to 0.803]) (p < 0.001). A history of NSAIDs use associated with the decreased risk of one-year mortality even after adjustment for age, sex, Charlson Comorbidity Index, delirium status, and hospitalization department (HR, 0.70 [95% CI, 0.51 to 0.96])., Conclusion: This study suggested that NSAIDs usage was associated with decreased delirium prevalence and lower one-year mortality. The potential benefit of NSAIDs on delirium risk and mortality were shown., Competing Interests: Declaration of Competing Interest Gen Shinozaki is co-founder of Predelix Medical LLC and has pending patents as follows: “Non-invasive device for predicting and screening delirium”, PCT application no. PCT/US2016/064937 and US provisional patent no. 62/263,325; “Prediction of patient outcomes with a novel electroencephalography device”, US provisional patent no. 62/829,411; “Epigenetic Biomarker of Delirium Risk” in the PCT Application No. PCT/US19/51276, and in U.S. Provisional Patent No. 62/731,599. All other authors have declared that no conflict of interest exists., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Smoking is a known risk factor for complications following primary total joint arthroplasty (TJA). Little is known regarding the fate of patients who are asked to quit smoking before surgery. The purpose of this study was to evaluate the success of smoking cessation prior to primary TJA and the impact of smoking cessation on perioperative outcomes., Methods: This is a retrospective review of patients who presented between 2008 and 2020 to a single academic medical center with a documented smoking history and were asked to quit smoking prior to receiving a date for primary TJA. The cohort was surveyed about smoking cessation, smoking history, use of quit aids, seeking surgery elsewhere due to the cessation policy, and postoperative complications. Descriptive statistics evaluated the relationship between demographics, smoking cessation, and postoperative complications., Results: A total of 101 patients completed the survey with an overall response rate of 48%. Sixty-two percent of patients quit smoking before surgery, and 51% of these patients reported remaining smoke-free at 6 months postoperatively. The average time to quit before TJA was 45 days (range: 1-365 days), and 62% quit without quit aids. The wound complication/infection rate was significantly higher for patients who did not stop smoking prior to TJA (4 of 16; 27%) than for those who did quit prior to surgery (3 of 63; 5%; P  = .02)., Conclusions: This study demonstrates that most patients (62%) will stop smoking, if required, prior to primary TJA. Furthermore, 51% of patients reported abstinence from smoking at 6 months following TJA. TJA appears to be an effective motivator for smoking cessation., Level of Evidence: III (retrospective cohort study)., (© 2022 The Authors.)

Background: Specific clinical and radiographic risk factors for medial unicompartmental knee arthroplasty (UKA) failure are incompletely understood. The purpose of this study was to perform a midterm survivorship analysis of medial UKA from a single, nondesigner surgeon. Based on observations from clinical practice, we hypothesized that the presence of a lateral trochlear osteophyte on preoperative Merchant radiographs may be predictive of medial UKA failure secondary to progressive osteoarthritis (OA)., Methods: Patients who underwent a mobile-bearing medial UKA by a single surgeon with minimum 24 months of clinical follow-up from 2008 to 2019 were retrospectively identified. Radiographic parameters, including the presence of a lateral trochlear osteophyte, were measured. Kaplan-Meier survivorship analyses were performed. Cox proportional hazards models were used to evaluate variables as risk factors for UKA failure, defined as reoperation or component revision., Results: A total of 233 UKAs were included. The mean age was 60 years, mean BMI 32 kg/m 2 , and 53% of patients were male. The mean follow-up duration was 5.7 years (range, 2.0-13.1 years). Using any reoperation as an endpoint, the 10-year survival was 91%. Using any component revision as an endpoint, the 10-year survival was 93%. Using revision due to progressive OA as an endpoint, the 10-year survival was 95%. The presence of a lateral trochlear osteophyte was associated with an increased risk of any reoperation (hazard ratio 3.6; 95% confidence interval 1.3-9.5) and increased risk of revision due to progressive OA (hazard ratio 9.8; 95% confidence interval 2.9-32.7)., Conclusions: The presence of a lateral trochlear osteophyte on preoperative Merchant view radiographs was associated with an increased risk of medial UKA failure., (© 2022 The Authors.)

Background: Preoperative counseling may reduce postoperative opioid requirements; however, there is a paucity of randomized controlled trials (RCTs) demonstrating efficacy. The purpose of this study was to perform an interventional, telehealth-based RCT evaluating the effect of peri-operative counseling on quantity and duration of opioid consumption following primary total joint arthroplasty (TJA)., Methods: Participants were randomized into three groups: 1. Control group, no perioperative counseling; 2. Intervention group, preoperative educational video; 3. Intervention group, preoperative educational video and postoperative acceptance and commitment therapy (ACT). Opioid consumption was evaluated daily for 14 days and at 6 weeks postoperatively. Best-case and worse-case intention to treat analyses were performed to account for non-responses. Bonferroni corrections were applied., Results: 183 participants were analyzed (63 in Group 1, 55 in Group 2, and 65 in Group 3). At 2 weeks postoperatively, there was no difference in opioid consumption between Groups 1, 2, and 3 (p>0.05 for all). At 6 weeks postoperatively, Groups 2 and 3 had consumed significantly less opioids than Group 1 (p=0.04, p<0.001) (Table 1). Group 3 participants were less likely to obtain an opioid refill relative to Group 1 participants (p=0.04). Participants in groups 2 and 3 ceased opioid consumption a median of 6 days and 2 days sooner than Group 1, respectively (p<0.001, p=0.03) (Table 2)., Conclusion: Perioperative opioid counseling significantly decreases the quantity and duration of opioid consumption at 6 weeks following primary TJA. Level of Evidence: I ., (Copyright © The Iowa Orthopaedic Journal 2022.)

Background: Morbidly obese patients have increased rates of complications following primary total hip arthroplasty (THA) and it is not clear whether improvements in THA care pathways are equally benefitting these patients. The purpose of this study is to assess if reductions in complications have similarly improved for both morbidly obese and non-morbidly obese patients after THA., Methods: Patients undergoing primary THA between 2011 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 and ≥40 kg/m 2 . Thirty-day rates of infectious complications, readmissions, reoperation, and any complication were assessed. Trends in complications were compared utilizing odds ratios and multivariate analyses., Results: In total, 234,334 patients underwent THA and 16,979 (7.8%) had BMI ≥40 kg/m 2 . Patients with BMI ≥40 kg/m 2 were at significantly higher odds for readmission, reoperation, and infectious complications. Odds for any complication were lower for morbidly obese patients in 2011, not different from 2012 to 2014, and higher from 2015 to 2019 compared to lower BMI patients. Odds for any non-transfusion complication were higher for morbidly obese patients and there was no improvement for either group over the study period. There were improvements in rates of readmission and reoperation for patients with BMI <40 kg/m 2 and readmission for BMI >40 kg/m 2 ., Conclusion: Odds for readmission and reoperation for non-morbidly obese patients and readmission for morbidly obese patients improved from 2011 to 2019. Reductions in transfusions are largely responsible for improvements in overall complication rates. Although morbidly obese patients remain at higher risk for complications, there does not appear to be a growing disparity in outcomes between morbidly obese and non-morbidly obese patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Resilience and depression may influence opioid consumption in patients undergoing primary hip and knee arthroplasty (TJA); however, data evaluating these relationships are limited., Methods: We retrospectively identified 119 patients undergoing TJA who completed preoperative questionnaires to measure resilience (Brief Resilience Scale) and depression (PHQ-9) from 2017 to 2018 at a single institution. Patients were stratified into high, normal, and low resilience groups as well as no, mild, and major depression groups. Opioid use was recorded in morphine milligram equivalents (MMEs). Nonparametric statistical testing was performed with significance level at P < 0.05., Results: Higher levels of resilience correlated with less postoperative inpatient opioid use (P = 0.003). Patients with high resilience were less likely to use preoperative opioids compared to those with low resilience (OR = 6.08, 95% CI [1.230.5]). There was no difference in postoperative outpatient opioid prescriptions between resilience groups. Lower levels of depression correlated with less postoperative inpatient opioid use, though this did not reach statistical significance (P = 0.058). Additionally, there was no significant difference in preoperative opioid use or postoperative outpatient opioid prescriptions between depression groups., Conclusion: Patients with higher levels of resilience are less likely to use opioids before TJA and utilize lower amounts of opioids while inpatient following surgery. Depression correlated with higher postoperative inpatient opioid use; however, the present findings regarding this relationship are inconclusive. Resilience is a psychological trait that may impact opioid use in patients undergoing TJA and should be viewed as a modifiable risk factor. Level of Evidence: III ., (Copyright © The Iowa Orthopaedic Journal 2022.)

Background: Obesity poses a challenge to thromboembolic prophylaxis following total joint arthroplasty (TJA). The purpose of this study is to evaluate a weight-based aspirin dosing regimen for prevention of venous thromboembolism (VTE) following TJA., Methods: This is a retrospective observational study of 2403 patients who underwent primary total hip or knee arthroplasty at one institution. A weight-based aspirin dosing regimen for VTE prophylaxis was administered to 1247 patients: patients weighing ≥120 kg received 325 mg aspirin twice daily (BID) and those weighing <120 kg received 81 mg aspirin BID for 4 weeks. In total, 1156 patients in the comparison cohort received 81 mg aspirin BID. VTE and gastrointestinal bleeding events were identified through chart review at 42 days and 6 months postoperatively. A multivariable logistic regression was performed to adjust for covariates., Results: The weight-based aspirin cohort had a significantly lesser incidence of VTE at 42 days (P = .03, relative risk [RR] 0.31, 95% confidence interval 0.12-0.82) and 6 months (P = .03, RR 0.38, 95% confidence interval 0.18-0.80). There was no difference in VTE incidence between total hip arthroplasty and total knee arthroplasty cases (P = .8). There was no difference in gastrointestinal bleeding events between the cohorts at 42 days (P = .69) or 6 months (P = .92). Subanalysis of patients weighing ≥120 kg demonstrated a significant difference between the cohorts with a VTE incidence of 3.48% and 0% in the 81 mg and weight-based cohorts, respectively (P = .02)., Conclusion: Patients prescribed a weight-based aspirin regimen had significantly fewer VTEs after TJA compared to historical controls with an RR reduction of 69% at 6 weeks and 62% at 6 months postoperatively. This suggests the need to factor patient weight when determining postoperative VTE prophylaxis with aspirin., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We have developed the bispectral electroencephalography (BSEEG) method for detection of delirium and prediction of poor outcomes., Aims: To improve the BSEEG method by introducing a new EEG device., Method: In a prospective cohort study, EEG data were obtained and BSEEG scores were calculated. BSEEG scores were filtered on the basis of standard deviation (s.d.) values to exclude signals with high noise. Both non-filtered and s.d.-filtered BSEEG scores were analysed. BSEEG scores were compared with the results of three delirium screening scales: the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Delirium Rating Scale-Revised-98 (DRS) and the Delirium Observation Screening Scale (DOSS). Additionally, the 365-day mortalities and the length of stay (LOS) in the hospital were analysed., Results: We enrolled 279 elderly participants and obtained 620 BSEEG recordings; 142 participants were categorised as BSEEG-positive, reflecting slower EEG activity. BSEEG scores were higher in the CAM-ICU-positive group than in the CAM-ICU-negative group. There were significant correlations between BSEEG scores and scores on the DRS and the DOSS. The mortality rate of the BSEEG-positive group was significantly higher than that of the BSEEG-negative group. The LOS of the BSEEG-positive group was longer compared with that of the BSEEG-negative group. BSEEG scores after s.d. filtering showed stronger correlations with delirium screening scores and more significant prediction of mortality., Conclusions: We confirmed the usefulness of the BSEEG method for detection of delirium and of delirium severity, and prediction of patient outcomes with a new EEG device.

Background: Extended oral antibiotic prophylaxis after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) in patients with body mass index (BMI) ≥40 kg/m 2 may reduce the rate of early periprosthetic joint infection (PJI); however, existing data are limited. The purpose of this study was to examine rates of wound complications and PJI in patients with BMI ≥40 kg/m 2 treated with and without extended oral antibiotic prophylaxis after surgery., Methods: We retrospectively identified all primary THA and TKA performed since 2015 in patients with a BMI ≥40 kg/m 2 at a single institution. Extended oral antibiotic prophylaxis for 7-14 days after surgery was prescribed at the discretion of each surgeon. Wound complications and PJI were examined at 90 days postoperatively., Results: In total, 650 cases (205 THA and 445 TKA) were analyzed. Mean age was 58 years and 62% were women. Mean BMI was 44 kg/m 2 . Extended oral antibiotic prophylaxis was prescribed in 177 cases (27%). At 90 days, there was no difference between prophylaxis and nonprophylaxis groups in rate of wound complications (11% vs 8%; P = .41) or PJI (1.7% vs 0.6%; P = .35). The univariate analysis demonstrated increased operative time (odds ratio (OR) 1.01; 95% confidence interval (95% CI) 1.01-1.02) and diabetes mellitus (OR 1.88; 95% CI 1.03-3.46) to be associated with increased risk of 90-day wound complications. No patient factors were associated with increased risk of PJI at 90 days postoperatively., Conclusion: Extended oral antibiotic prophylaxis after primary THA and TKA did not reduce rates of wound complications or early PJI in a morbidly obese patient population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We have previously developed a bispectral electroencephalography (BSEEG) device, which was shown to be effective in detecting delirium and predicting patient outcomes. In this study we aimed to apply the BSEEG approach for a sepsis. This was a retrospective cohort study conducted at a single center. Sepsis-positive cases were identified based on retrospective chart review. EEG raw data and calculated BSEEG scores were obtained in the previous studies. The relationship between BSEEG scores and sepsis was analyzed, as well as the relationship among sepsis, BSEEG score, and mortality. Data were analyzed from 628 patients. The BSEEG score from the first encounter (1st BSEEG) showed a significant difference between patients with and without sepsis (p = 0.0062), although AUC was very small indicating that it is not suitable for detection purpose. Sepsis patients with high BSEEG scores showed the highest mortality, and non-sepsis patients with low BSEEG scores showed the lowest mortality. Mortality of non-sepsis patients with high BSEEG scores was as bad as that of sepsis patients with low BSEEG scores. Even adjusting for age, gender, comorbidity, and sepsis status, BSEEG remained a significant predictor of mortality (p = 0.008). These data are demonstrating its usefulness as a potential tool for identification of patients at high risk and management of sepsis., (© 2021. The Author(s).)

Background: Routine radiographs have historically been obtained during routine care after total joint arthroplasty (TJA). However, substantial improvements in surgical technique, biomaterials, and changes in payment models placing greater emphasis on value have occurred. Recently, there has been interest in a transition to performing follow-up visits virtually. The purpose of this study was to assess how frequently patients attend postoperative appointments and the clinical utility of routine radiographs after TJA., Methods: Patients undergoing primary total hip arthroplasty and total knee arthroplasty at a single tertiary institution in 2018 were included. Patients attending scheduled follow-up at 6 to 12 weeks and 1 year were assessed. Retrospective chart review was conducted to determine whether abnormalities were noted on routine radiographic surveillance by the orthopedic surgeons or radiologist and if any radiographic findings altered clinical management., Results: A total of 938 TJAs were performed, and 885 met inclusion criteria, with 423 (47.8%) total hip arthroplasties and 462 (52.2%) total knee arthroplasties. Eight hundred sixty-five (97.7%) patients attended a follow-up visit at 6 or 12 weeks and 589 (66.6%) attended at 1 year postoperatively. A single radiographic abnormality was detected, occurring at the 6- to 12-week period by the radiologist and interpreted as being an artifact by the surgeon. No additional radiographic abnormalities were detected at 1 year. Information from radiographs did not change clinical management for any patients., Conclusion: In a large cohort of patients, routine radiographic surveillance did not detect any true abnormalities during the first year after primary TJA. For patients without symptoms attributable to the TJA prosthesis, conducting virtual care visits without routine radiographs may be considered., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the diagnostic performance of standalone alpha defensin (AD) testing of antibiotic spacers during two stage exchange and to determine if the addition of AD testing to other commonly used laboratory tests improves the ability to detect persistent infection in an antibiotic spacer., Methods: Cases of two-stage exchange for periprosthetic joint infection from 2016 to 2019 at a single institution were retrospectively reviewed. Cases were classified as persistently infected or not infected in accordance with 2014 and 2018 Musculoskeletal Infection Society criteria to determine if AD provided any clinical utility beyond the other commonly used tests that make up both criteria. Delphi Consensus criteria at 1 year were used as the gold standard for determining recurrent periprosthetic joint infection., Results: Fifty-two spacers (25 hips and 27 knees) in 51 patients were included for analysis. Five spacers were persistently infected based on Musculoskeletal Infection Society criteria. One spacer underwent reresection and the remaining 4 underwent reimplantation with no subsequent infectious complications. All 48 patients who were categorized as not infected underwent reimplantation; at 1 year postoperatively, 7 (13%) had failed due to infection. Three spacers (6%) had a positive AD test. Two spacers with positive AD tests underwent reimplantation, neither had failed at 1 year postoperatively. Sensitivity of standalone AD testing was 0%, and specificity was 96%., Conclusion: Standalone AD testing for the purpose of predicting repeat infection after two-stage exchange arthroplasty exhibits sensitivity of 0% and low predictive value. Addition of synovial AD testing did not increase the diagnostic performance of commonly used synovial and serologic markers of infection., Level of Evidence: IV-retrospective cohort study., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Resilience and depression may impact clinical outcomes following primary total joint arthroplasty (TJA). This study aimed to quantify baseline resilience and depression prevalence in patients undergoing primary TJA and evaluate their influence on patient-reported clinical outcomes., Methods: We prospectively enrolled 98 patients undergoing primary TJA. Exclusion criteria included patients under 18 years of age, undergoing surgery for fracture, or who underwent additional surgery during the study period. Patients completed the Brief Resilience Scale to measure resilience, Patient Health Questionnaire-9 to measure depression, and Patient-Reported Outcomes Measurement Information System-10 to measure global physical and mental health preoperatively and 1 year postoperatively., Results: Preoperatively, 22% and 15% of patients demonstrated major and mild depression, respectively. High resilience was identified in 34% of patients, normal resilience in 55%, and low resilience in 11%. Preoperative depression correlated with lower resilience, global physical health, and global mental health scores preoperatively as well as at 1 year after surgery (P < .001). Higher levels of preoperative resilience correlated with higher global physical and mental health scores preoperatively and at 1 year postoperatively (P < .001)., Conclusion: Depression symptoms are common among patients undergoing primary TJA and are associated with worse patient-reported outcomes. Patients with higher levels of resilience have higher global physical and mental health scores before and after TJA. Psychological traits and depression impact clinical outcomes following TJA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The patient-reported outcomes measurement information system (PROMIS) offers standardized assessment measures of clinically relevant patient-reported outcomes. This study evaluated the reliability and validity of select PROMIS measures with U.S. military veterans following orthopedic surgery. Data for the current study were collected as part of a pilot randomized control trial assessing the efficacy of a 1-day Acceptance and Commitment Therapy workshop on persistent postsurgical pain in at-risk veterans undergoing orthopedic surgery. Sixty-seven participants completed surveys 3 months after surgery. Participants completed the following PROMIS instruments: PROMIS Anxiety Short Form 8a, PROMIS Depression Short Form 8b, and PROMIS Pain Interference Short Form 8a. PROMIS measures were compared to the Generalized Anxiety Disorder 7-Item Scale, the Patient Health Questionnaire 9-Item Scale, and the Brief Pain Inventory Pain Interference subscale, respectively. All three PROMIS measures demonstrated excellent internal consistency (Cronbach's αs ranged from .93 to .96) and each loaded onto a single factor. The PROMIS measures were moderately correlated with their respective comparison measures ( r = .69 to .76). The PROMIS anxiety and PROMIS depression measures were highly correlated to one another ( r = .91). Findings highlight the potential utility of these PROMIS measures in veterans following orthopedic surgery and the overlap between the PROMIS depression and anxiety measures in this sample.

Background: The COVID-19 pandemic has had far-reaching societal and financial consequences. The purpose of this study was to evaluate how COVID-19 has affected AAHKS industry partners and the surgeon-industry relationship, emphasizing education, resource allocation, and strategic direction for the second half of 2020., Methods: AAHKS industry partners were contacted to participate in a blinded survey and optional interview with the AAHKS Industry Relations Committee. Based on the results, a group of AAHKS member surgeons with disparate practice types were asked to postulate on how the COVID-19 pandemic has and will affect their practice and relationship with Industry., Results: AAHKS industry partner responses indicated decreased resource allocation for regional, "other national," and AAHKS annual meetings (67%, 55%, and 30%, respectively). Web-based educational content was expected to increase in 2020 and will likely remain a point of emphasis in 2021 (100% and 70% of responders). For Q3/Q4 2020, a significant emphasis was placed on site of service/outpatient TJA and COVID-19-related safety measures (70% and 90% of responders), as well as increased availability of instrumentation and implants (40% and 60%, respectively)., Conclusion: The COVID-19 pandemic has altered the orthopedic landscape for the foreseeable future. Survey responses by AAHKS industry partners demonstrate a continued commitment to surgeon education with an increasing shift to a web-based platform. Increased resource allocation for outpatient TJA and COVID-19-related safety measures were significant. Articulating optimal mechanisms to aid industry in supporting surgeons with different practice models to meet demand during the second half of fiscal year 2020 will be critical., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: As the population ages, rate of total knee arthroplasty increases and thus, it is important to maximize efficiency and minimize risk. Identifying patients who are at higher risk for transfusion can help streamline care provided and minimize superfluous, costly hemoglobin monitoring in low risk patients., Methods: Adult patients who underwent total knee arthroplasty (TKA) in 2015 were identified in the National Surgical Quality Improvement Project (NSQIP) database. Patients were divided into two cohorts: those who required transfusion post operatively and those who did not. Patient demographics and comorbidities were compared using univariate analysis; and multivariate analysis was used to determine risk factors for short-term complications., Results: Of 48,055 TKA patients, 3.0% required transfusion. The patients who required transfusion were older, had higher BMI, higher rates of comorbidities and were more frequently ASA class 3-4 (p<0.005). Univariate analysis revealed that patients who required transfusion had higher rates of any complication (9.19% v. 4.23%, p<0.001). Multivariate regression analysis identified the following as risk factors for transfusion requirement: Black race (adjusted odds ratio [OR] 1.2, 95% confidence interval [CI] 1.01-1.4), COPD (OR 1.6, 95% CI 1.3-2.0), corticosteroids (OR 1.4, 95% CI 1.1-1.8), bleeding disorder (OR 1.4, CI 1.1-1.9), ASA class 4 (OR 2.3, CI 1.5-4.8), operative time >2 hours (OR 1.3, 95% CI 1.2-1.5) and lack of functional independence (OR 1.6, 95% CI 1.1-2.3)., Conclusions: In a cohort of patients undergoing primary TKA in 2015, history of COPD, black race, operative time, steroid use, bleeding disorder, lack of functional independence and ASA class 3-4 were independent predictors of need for blood transfusion. Additionally, we found that patients who received transfusion demonstrated a significantly higher rate of the following: any complication, pneumonia, urinary tract infection, septic shock, deep vein thrombosis, renal insufficiency, cardiac arrest, myocardial infarction, unplanned readmission, reoperation and mortality. Presence of these risk factors in TKA patients could represent an indication for hemoglobin monitoring post-operatively. Level of Evidence: IV ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2020.)

Background: Delirium is common and dangerous, yet underdetected and undertreated. Current screening questionnaires are subjective and ineffectively implemented in busy hospital workflows. Electroencephalography (EEG) can objectively detect the diffuse slowing characteristic of delirium, but it is not suitable for high-throughput screening due to size, cost, and the expertise required for lead placement and interpretation. This study hypothesized that an efficient and reliable point-of-care EEG device for high-throughput screening could be developed., Methods: This prospective study, which measured bispectral EEG (BSEEG) from elderly inpatients to assess their outcomes, was conducted at the University of Iowa Hospitals and Clinics from January 2016 to October 2017. A BSEEG score was defined based on the distribution of 2,938 EEG recordings from the 428 subjects who were assessed for delirium; primary outcomes measured were hospital length of stay, discharge disposition, and mortality., Results: A total of 274 patients had BSEEG score data available for analysis. Delirium and BSEEG score had a significant association (P < .001). Higher BSEEG scores were significantly correlated with length of stay (P < .001 unadjusted, P = .001 adjusted for age, sex, and Charlson Comorbidity Index [CCI] score) as well as with discharge not to home (P < .01). Hazard ratio for survival controlling for age, sex, CCI score, and delirium status was 1.35 (95% CI,1.04 to 1.76; P = .025)., Conclusions: In BSEEG, an efficient and reliable device that provides an objective measurement of delirium status was developed. The BSEEG score is significantly associated with pertinent clinical outcomes of mortality, hospital length of stay, and discharge disposition. The BSEEG score better predicts mortality than does clinical delirium status. This study identified a previously unrecognized subpopulation of patients without clinical features of delirium who are at increased mortality risk., (© Copyright 2019 Physicians Postgraduate Press, Inc.)

Background: Orthopedic surgeons may overprescribe opioids postoperatively. Literature examining opioid prescribing guidelines following total joint arthroplasty (TJA) is limited., Methods: Retrospective review was conducted of primary TJAs from June 2017 to February 2018, with 3-month follow-up. Patients were divided into those who underwent surgery before (historical cohort) and after (restrictive cohort) implementation of a strict postoperative opioid prescribing protocol., Results: Three hundred ninety-nine total patients were included (282 in historical cohort, 117 in restrictive cohort). There was no significant difference in preoperative, perioperative, and postoperative inpatient opioid use. Historical cohort was given significantly larger initial prescriptions, received significantly more refills, and received significantly greater total quantity of opioids per patient. There were significantly fewer call-ins in the restrictive cohort. Clinical outcomes were not significantly different., Conclusion: Drastic reductions in opioid prescriptions following TJA are possible without an increase in refills, call-ins, or adverse clinical effects., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Overlapping surgery is common in high-volume total knee arthroplasty (TKA) practices and has come under recent scrutiny in the press. The aim of this study was to evaluate differences in 6-week clinical and radiographic outcomes for primary TKA patients between single and overlapping operating room (OR) days., Methods: We retrospectively reviewed individual patient records of a consecutive series of primary TKAs with complete 6-week follow-up performed by a single academic surgeon between 2008-2016 (N= 452). Patients were stratified by single vs. overlapping OR days. 177 patients (39%) had an overlapping surgery. Age, body mass index (BMI), Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) class were recorded to assess for confounding variables. Outcomes included anesthesia time, 6-week readmission, unplanned return to OR, medical and surgical complication, and 6-week radiographic alignment., Results: There were no significant differences in anesthesiology time (165.5 vs 164.5 min, p=0.85), medical or surgical complication rates (10.5% vs 6.2%, p=0.11), 6-week readmissions (4.4% vs 1.7%, p=0.12), or return to OR (1.8% vs 1.7%, p=1.00) before or after adjusting for age, BMI, gender, ASA and CCI. There was no difference between overlapping and single OR cohorts in rate of neutral coronal alignment (2°-8° valgus) (98.3% vs 98.9%, respectively, p=0.68) or presence of periprosthetic lucency (p=0.43)., Conclusions: This study demonstrates no differences in 6-week clinical or radiographic outcomes between patients undergoing primary TKA on single versus overlapping OR days. These results support the safe practice of overlapping surgical scheduling in high-volume primary TKA centers. Level of Evidence: III., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study.

Aim: Delirium is common and dangerous among elderly inpatients; yet, it is underdiagnosed and thus undertreated. This study aimed to test the diagnostic characteristics of a noninvasive point-of-care device with two-channel (bispectral) electroencephalography (EEG) for the screening of delirium in the hospital., Methods: Patients admitted to the University of Iowa Hospitals and Clinics were assessed for the presence of delirium with a clinical assessment, the Confusion Assessment Method for Intensive Care Unit and Delirium Rating Scale. Subsequently, we obtained a 10-min bispectral EEG (BSEEG) recording from a hand-held electroencephalogram device during hospitalization. We performed power spectral density analysis to differentiate between those patients with and without delirium., Results: Initially 45 subjects were used as a test dataset to establish a cut-off. The BSEEG index was determined to be a significant indicator of delirium, with sensitivity 80% and specificity 87.7%. An additional independent validation dataset with 24 patients confirmed the validity of the approach, with a sensitivity of 83.3% and specificity of 83.3%., Conclusion: In this pilot study, the BSEEG method was able to distinguish delirious patients from non-delirious patients. Our data showed the feasibility of this technology for mass screening of delirium in the hospital., (© 2018 The Authors. Psychiatry and Clinical Neurosciences © 2018 Japanese Society of Psychiatry and Neurology.)

Objectives: Although the majority of patients undergoing total knee arthroplasty (TKA) report substantial improvement in pain and function, a significant subset experience persistent postsurgical pain and dysfunction. Better understanding of the longitudinal postoperative course is needed, including the association between patient status following physical rehabilitation at 6-weeks post-TKA, to 6-months outcomes. This study aims to described the postoperative course of TKA and examine variables associated with change in pain and functioning between 6-weeks and 6-months post-TKA., Methods: In this longitudinal study of 223 participants, assessments of analgesic intake, depression, anxiety, pain catastrophizing, dysfunction, resting and range of motion pain, and pain sensitivity were completed at 6-weeks post-TKA. Analgesic intake, pain ratings, and dysfunction data were also collected at 6-months post-TKA. Pain and dysfunction ratings were divided into none-mild and moderate-severe categories., Results: Between 6-weeks and 6-months post-TKA, 75% of the sample stayed in the same pain category, 20% improved, and 5% worsened. In terms of functional changes between 6 weeks and 6 months, 65% of the sample stayed in the same functional category, whereas 31% improved and 5% worsened., Discussion: These findings demonstrate that the majority of patients' pain and functioning remains stable between 6 weeks and 6 months post-TKA. However, a notable subset continues to improve or worsen in pain and functioning and the current study identifies variables associated with these changes.

Background: Many clinical factors are known to increase an individual patient's risk of perioperative complications and hospital readmission. Several novel risk calculators have been created to predict the risk of postoperative complications for specific procedures that rely entirely on objective measurements. Our goal was to determine if surgeon intuition (an estimate of the percent likelihood of minor and major medical and surgical complications and 30-day readmission) could provide an additional source of data in the preoperative setting that may enhance the prediction of complications after surgery., Methods: We targeted the operative practices of three subspecialized orthopedic surgeons over a 6-month period (February 1 to July 31, 2015). We administered surveys to attending surgeons and assisting residents or nurse practitioners prior to each operation. Surgeons were asked to predict each patient's likelihood, on a scale from <1-100, for experiencing a complication. Following the procedure, we analyzed each patient's electronic medical record to determine any adverse events and readmissions. We then looked at levels of association between predictor variables and complications. Analysis of maximum likelihood estimates for complication outcome was performed comparing objective variables and surgeon prediction., Results: A total of 417 surveys in 270 patients were available for analysis. Defining the predicted likelihood of minor medical complications as <10% (low), 10-40% (intermediate), and >40% (high), provided discrimination of postoperative complications for a single observer in the first three month. These cutoff ranges showed inter-observer consistency and a trend towards intra-observer consistency. The only three variables predictive of minor medical complications were ASA class (OR=3.63, 95%CI=1.76-7.52, p=0.0005; comparing >2 vs ≤2), age (β=0.034±0.012, p=0.0032) and surgeon prediction when comparing high to low risk (β=0.034±0.008 (0.018-0.049), p<0.0001)., Conclusions: Quantitative surgeon preoperative risk assessment was able to accurately discriminate between low- and high-risk groups of minor medical complications. We did not find a similar association between major complications and readmissions.Level of Evidence: IV.

Background: Automated mobile phone messaging has not been reported in total joint arthroplasty (TJA). Our purpose was to compare Press Ganey (PG) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores between TJA patients who did and did not receive perioperative automated mobile phone messages., Methods: Patients were prospectively enrolled and received messages for 1 week prior until 2 weeks after TJA. Message content included reminders, activity, and pain control. Patients answered select PG/HCAHPS and questions regarding their experience with the automated communication platform. Average PG/HCAHPS scores were compared to historical TJA patients in the 3-year window prior (control group) with significance P < .05., Results: Thirty-seven consecutive patients were approached and 92% (n = 34) were enrolled. The experimental group was 47% male, with 80% patients between 51 and 75 years. The experimental (n = 30) and control groups (n = 26) were similar. Patients receiving messages were more likely to have a good understanding of health responsibilities (P = .024) and feel that the care team demonstrated shared decision-making (P = .024). Of patients enrolled, 87% felt messages helped them be more prepared for surgery, 100% felt messages kept them better informed, and 97% would participate again., Conclusion: TJA patients who received perioperative communication via automated mobile phone messaging had improved patient satisfaction scores postoperatively. Patients perceived this form of communication was useful and kept them better informed. Automated mobile phone messaging can be an easily integrated, helpful adjunct to surgeons, healthcare systems, and case managers to more effectively communicate with patients undergoing TJA in this era of value-based care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Multiple assessments are used clinically after total knee arthroplasty (TKA) including self-report, performance tasks, and physical activity levels. It is unclear if these different functional assessments are interchangeable or if they measure different constructs. The objective of this study was to characterize different functional measures before and after TKA. We characterized function before and after TKA using perceived function (KOOS ADL), physical performance (gait speed), and daily activity (steps/day via accelerometry); compared function in people undergoing TKA to age-matched healthy controls; and examined characteristics of those undergoing TKA for potential predictors of postoperative function. Prior to TKA, all three functional assessments were significantly lower for participants than those of healthy controls and each measure remained lower for participants than for controls postoperatively. All three functional assessments developed differently over time postoperatively. Each functional outcome had a unique set of predictors. Perceived function was predicted primarily by anxiety and depression, physical performance was most strongly predicted by age, and daily activity was chiefly predicted by BMI. Pressure pain threshold was a common predictor across all models. Functional limitations exist preoperatively and persist postoperatively across different measures in people undergoing TKA when compared to those measures in healthy controls. Functional outcomes after TKA are different depending on the functional measure utilized, implying that different constructs underlie each measure. Multiple functional measures should be assessed to provide a more comprehensive assessment of function after TKA. Further work should assess the impact of interventions designed to treat modifiable predictors of postoperative TKA function. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2790-2798, 2017., (© 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: The reliability of patient-reported penicillin allergies has been disputed. A Drug Allergy Clinic (DAC) was established at our institution in combination with an electronic best practice alert (BPA) in the Orthopedic Clinic. Joint arthroplasty patients with a reported history of beta-lactam allergy (HOBA) were preoperatively referred via the BPA to the DAC. The purpose of this study was to determine the effectiveness of beta-lactam allergy screening in enabling the surgical team to optimize antimicrobial prophylaxis., Methods: Between February 2013 and May 2015, 161 patients with a HOBA were referred to the DAC where they underwent penicillin skin testing (PST), a drug challenge to a beta-lactam antibiotic, and/or had no intervention depending on the history obtained., Results: PST was performed on 140 of 161 (87%) patients. A negative PST was noted in 139 (99%) patients, indicating no penicillin allergy. Cefazolin was safe to use in 145 (90%) patients evaluated. Significantly more patients evaluated in the DAC vs those not seen got cefazolin in any surgical prophylaxis regimen (90% vs 77%) without any adverse perioperative reactions. Concurrently, the use of non-beta-lactam antibiotics was significantly less in the patients evaluated vs not evaluated (16% vs 27%). The overall use of cefazolin in orthopedic surgeries in patients with HOBA was >84% over the course of the study period., Conclusion: Beta-lactam allergy screening using a BPA and a DAC promotes the use of standard surgical prophylaxis with cefazolin. Joint arthroplasty surgeons should consider implementing allergy screening programs to promote antimicrobial stewardship., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Case: A 30-year-old man sustained an obturator dislocation of a left total hip prosthesis with a concomitant ipsilateral fracture of the greater trochanter following a high-energy motor-vehicle accident. With the patient under general anesthesia, the hip was successfully treated with closed reduction, as confirmed with intraoperative fluoroscopy and postoperative radiographs. Postreduction, the patient was able to mobilize with abduction restrictions and had no additional instability. Short-term follow-up showed evidence of healing of the greater trochanter., Conclusion: Obturator dislocation of a total hip prosthesis is an exceedingly rare injury. Closed reduction can be considered as a treatment option in the appropriate patient, with a satisfactory short-term outcome.

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r s  = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Introduction: As the United States healthcare system evolves towards improved value delivery, patient outcomes and healthcare costs are increasingly used to evaluate physicians and provider organizations. One such metric is hospital length of stay, which has the potential to be influenced by a variety of patient characteristics and comorbidities. Determining factors influencing length of stay represents an opportunity to increase value in healthcare delivery., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2006-2012) was utilized to identify a cohort of 92,266 patients having one of 14 common orthopaedic procedures. A generalized linear model was utilized to identify patient factors that increase hospital length of stay., Results: During the six-year study period, length of stay decreased significantly in the total joint arthroplasty population. Nine variables were independently associated with increased length of stay. Congestive heart failure and underweight status increased length of stay the most, at 1.46 and 1.01 days, respectively. Other factors increasing length of stay include: non-white race (0.69 days), chronic obstructive pulmonary disease (0.50 days), diabetes mellitus (0.25 days), morbid obesity (0.23 days), hypertension (0.10 days), and patient age (0.02 days for each additional year)., Discussion: In conclusion, congestive heart failure and underweight status are the greatest predictors of increased length of stay. COPD, diabetes, morbid obesity, and hypertension represent other modifiable risk factors that increase length of stay. This data can be used to counsel patients and their families regarding anticipated duration of hospitalization. Systematic targeting of patient factors known to increase length of stay represents an opportunity for cost reduction and improved value delivery. When utilizing hospital length of stay as a metric for evaluation, it is important to incorporate the factors that increase length of stay, so that orthopaedic surgeons and provider organizations can be evaluated based on representative patient population characteristics.

Objective: To evaluate the extent to which elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA) restore normal patient-reported physical function in men and women., Methods: Pain and physical function (WOMAC-PF) were prospectively measured pre- and post-operatively. The relationship between surgical procedure and achieving physical function equivalent to age and sex-matched adults with no hip or knee joint problems was modeled using sex-specific logistic regression. Percent change in function was also compared between groups using sex-specific generalized linear models adjusted for age, BMI, pain, comorbid conditions, time from surgery, and subsequent surgery., Results: Individuals with pre- and post-operative WOMAC data were classified exclusively into either THA (287M:306F) or TKA (239M:424F) groups. The median follow-up was 476 (THA) and 474 (TKA) days for men, and 495 (THA) and 526 (TKA) days for women., Main Outcome: women with THA compared with TKA were more likely to achieve a normal level of postoperative PF while there were no significant differences between procedures in men. Additional analyses: we found slightly lower preoperative PF in THA compared with TKA. This difference resolved postoperatively in men, but women who underwent THA reported greater improvement and better PF than those who had TKA., Conclusion: In women, THA results in greater improvement in WOMAC-PF at approximately 1-year follow-up and better approximates physical function of community-dwelling older adults without OA than TKA does. In contrast, in men, a lack of between-group post-operative WOMAC-PF differences suggests that procedures result in a similar degree of improvement., (Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

The development of patient profiles to subgroup individuals on a variety of variables has gained attention as a potential means to better inform clinical decision making. Patterns of pain sensitivity response specific to quantitative sensory testing (QST) modality have been demonstrated in healthy subjects. It has not been determined whether these patterns persist in a knee osteoarthritis population. In a sample of 218 participants, 19 QST measures along with pain, psychological factors, self-reported function, and quality of life were assessed before total knee arthroplasty. Component analysis was used to identify commonalities across the 19 QST assessments to produce standardized pain sensitivity factors. Cluster analysis then grouped individuals who exhibited similar patterns of standardized pain sensitivity component scores. The QST resulted in 4 pain sensitivity components: heat, punctate, temporal summation, and pressure. Cluster analysis resulted in 5 pain sensitivity profiles: a "low pressure pain" group, an "average pain" group, and 3 "high pain" sensitivity groups who were sensitive to different modalities (punctate, heat, and temporal summation). Pain and function differed between pain sensitivity profiles, along with sex distribution; however, no differences in osteoarthritis grade, medication use, or psychological traits were found. Residualizing QST data by age and sex resulted in similar components and pain sensitivity profiles. Furthermore, these profiles are surprisingly similar to those reported in healthy populations, which suggests that individual differences in pain sensitivity are a robust finding even in an older population with significant disease.

Background: Approximately 600,000 total knee arthroplasties (TKA) are performed every year in the United States and the number of procedures has increased substantially every year. These demands may further strain the government, insurers, and patients struggling with increasing healthcare spending. A delay in proceeding to surgery after hospital admission may affect the overall healthcare costs. To our knowledge, the current literature has not addressed the incidence of, and preoperative risk factors for, a surgical delay in TKA., Methods: The ACS-NSQIP 2011 database was reviewed to identify patients undergoing elective primary total knee arthroplasty (TKA) using the Current Procedural Terminology (CPT) code 27447. 14,881 cases were no delay in proceeding to surgery after hospital admission while 139 cases were delayed for TKA. Risk factors or comorbidities contributing to surgical delay in TKA were identified. A univariate analysis of all patient parameters was conducted to measure the difference between the two cohorts. Finally, a multivariate logistic regression analysis was then conducted to identify risk factors or comorbidities for surgical delay., Results: There were 139 cases of surgical delay in TKA (0.93%). Congestive heart failure (P = 0.017), bleeding disorder (P <0.0001), sepsis (P <0.0001), a prior operation in the past 30 days (P <0.0001), dependent functional status (P <0.0001), ASA class 3 (P = 0.046), and hematocrit <38% (P <0.0001) were independent risk factors for a surgical delay. Postoperative medical complication (2.2% vs 0.8%, P < 0.0001) in surgical delay was significantly higher than non-delayed cohort., Conclusion: The optimization of preoperative modifiable risk factors appears to be one of the best strategies to reduce delayed surgery and therefore costs in TKA., (Copyright © 2015. Published by Elsevier Inc.)

Background: Obesity is increasingly common in patients having total hip arthroplasty, and previous studies have shown a correlation with increased operative time in total hip arthroplasty. Decreasing operative time and room time is essential to meeting the increased demand for total hip arthroplasty, and factors that influence these metrics should be quantified to allow for targeted reduction in time and adjusted reimbursement models. This is the first study to use a multivariate approach to identify which factors increase operative time and room time in total hip arthroplasty., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify a cohort of 30,361 patients having total hip arthroplasty between 2006 and 2012. Patient demographics, comorbidities including body mass index, and anesthesia type were used to create generalized linear models identifying independent predictors of increased operative time and room time., Results: Morbid obesity (body mass index >40) independently increased operative time by 13 minutes and room time 18 by minutes. Congestive heart failure led to the greatest increase in overall room time, resulting in a 20-minute increase. Anesthesia method further influenced room time, with general anesthesia resulting in an increased room time of 18 minutes compared with spinal or regional anesthesia., Conclusion: Obesity is the major driver of increased operative time in total hip arthroplasty. Congestive heart failure, general anesthesia, and morbid obesity each lead to substantial increases in overall room time, with congestive heart failure leading to the greatest increase in overall room time., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We introduced a multimodal, multidisciplinary approach to perioperative blood management aimed at reducing blood transfusions in primary knee (TKA) and hip (THA) arthroplasty. The protocol included (1) preoperative hemoglobin optimization through a multidisciplinary approach, (2) minimization of perioperative blood loss, and (3) adherence to evidence-based transfusion guidelines., Methods: Evaluation of 1010 consecutive patients undergoing primary TKA (488) or THA (522) was performed., Results: A significant reduction in the overall transfusion rate (1.4% vs 17.9%, P<.0001) resulted after algorithm introduction, when compared with the 1814 previous patients. Zero (0%) TKA and 4 (0.8%) THA patients adherent to protocol, and 4/488 (0.8%) TKA and 10/522 (1.9%) THA patients overall received transfusions., Conclusion: Adoption of a multimodal blood management algorithm can significantly reduce blood transfusions in primary joint arthroplasty., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Safe and effective perioperative analgesia is instrumental to patient satisfaction and decreasing LOS after TJA. We evaluated rates of acute kidney injury (AKI) in primary and revision TJA using a multimodal pain control regimen including scheduled celecoxib and PRN ketorolac. Postoperative AKI was identified in 43/903 (4.8%) of 903 of patients with adequate preoperative renal function. Those who developed AKI had significantly increased LOS (P < .01), were older, more obese, and more likely to have diabetes (P < .05). With a protocol incorporating NSAIDs in patients without evidence of preoperative renal impairment, there is a 4.8% rate of AKI, which is 2.7 times higher than the reported literature. Acute postoperative kidney injury was significantly correlated with increased LOS and has important patient safety and healthcare-related cost implications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking., Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses., Results: We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk., Conclusions: On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The purpose of this study was to determine the early outcomes of 599 cases of revision THA performed using a porous tantalum cup., Methods: Clinical and radiographic data was sought in all patients at a minimum two years follow-up, after acetabular revision performed with a porous tantalum cup., Results: Of the 599 cases identified, there were 51 re-operations in 47 patients (7.8 percent). Cup removal was required in 14 of these cases (2.3 percent). The most common cause for cup removal was a septic joint (12). No cups were revised for aseptic loosening during the study period. There was one case of early cup migration. There were 17 incomplete lucencies not initially seen on post-operative films, but identified later, all were non-progressive on subsequent x-rays., Conclusions: Early results of porous tantalum acetabular components in the revision setting demonstrate good initial stability and low re-operation rates at two years follow-up., Level of Evidence: Level 4: Case series.

Background: Medial protrusio is a recognized complication of total hip arthroplasty, but it is not known if a medial wall breach during cup implantation increases the risk. We thus investigated the effect of up to a 2 cm defect in the medial acetabular wall in a cadaveric model. Separately, we investigated the ability of acetabular screws to rescue the construct., Methods: Nine human fresh-frozen hemipelves were reamed medially to create the defect, implanted with acetabular cups, and then loaded to failure. The nine contralateral hemipelves were reamed in a standard fashion and served as controls. Separately, nine hemipelves with a medial defect were augmented with two acetabular screws each, then loaded to failure, with the contralateral side as a control. Load-to-failure, stiffness, and energy were recorded., Findings: The presence of a medial wall defect decreased the load-to-failure by a mean of 26% (5710 v. 4221 N, p=0.024). The addition of two acetabular screws did not rescue the construct (mean 27% decrease, 4082 v. 2985 N, p=0.024). The majority of specimens failed in a supra-physiologic range of force. Bone density correlated with failure loads (R(2) range of 0.54-0.78), and osteoporotic specimens were more likely to fail at a physiologic range, consistent with forces experienced during minor stumbles or falls., Interpretation: Osteoporotic patients with a medial wall defect after hip arthroplasty may be susceptible to fracture during activities of daily living. Protected weight bearing with an assistive device may be reasonable in order to minimize fall risk until cup ingrowth is achieved.

This study evaluated the efficacy of transcutaneous electrical nerve stimulation (TENS) in reducing pain and hyperalgesia and increasing function after total knee arthroplasty (TKA). We hypothesized that participants using TENS during rehabilitation exercises would report significantly lower pain during range-of-motion (ROM) activity and fast walking but not at rest, would have less hyperalgesia, and would have better function than participants receiving placebo-TENS or standard care. We also hypothesized that change in ROM pain would differ based on psychological characteristics (trait anxiety, pain catastrophizing, and depression) and treatment group. This prospective, randomized study used intent-to-treat analyses in 317 participants after primary, unilateral TKA. Assessors, blinded to treatment allocation, measured pain, function (ROM and gait speed), and hyperalgesia (quantitative sensory tests) postoperatively and 6 weeks after surgery. Analgesic intake, anxiety, depression, and pain catastrophizing were also assessed. TENS participants used it 1 to 2 times per day at 42 mA (on average) and had less pain postoperatively during active knee extension (P=.019) and fast walking (P=.006) than standard care participants. TENS and placebo-TENS were not significantly different. TENS participants who scored low on anxiety and pain catastrophizing had a greater reduction in ROM pain at 6 weeks than those who scored high on these factors (P=.002 and P=.03). Both TENS and placebo-TENS participants had less postoperative mechanical hyperalgesia (P=.03-.01) than standard care participants. Supplementing pharmacologic analgesia with TENS during rehabilitation exercises reduces movement pain postoperatively, but a placebo influence exists and the effect is gone by 6 weeks. Patients with low anxiety and pain catastrophizing may benefit most from TENS., (Published by Elsevier B.V.)

Background: The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification., Methods: We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate., Results: There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while "trauma" subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001)., Conclusions: The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Total knee arthroplasty has provided dramatic improvements in function and pain for the majority of patients with knee arthritis, yet a significant proportion of patients remain dissatisfied with their results. We performed a prospective analysis of 215 patients undergoing TKA who underwent a comprehensive array of evaluations to discover whether any preoperative assessment could predict high pain scores and functional limitations postoperatively. Patients with severe pain with a simple knee range-of-motion test prior to TKA had a 10 times higher likelihood of moderate to severe pain at 6 months. A simple test of pain intensity with active flexion and extension preoperatively was a significant predictor of postoperative pain at 6 months after surgery. Strategies to address this particular patient group may improve satisfaction rates of TKA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Uncemented tantalum acetabular components were introduced in 1997. The purpose was to determine the 2- to 10-year results with this implant material in primary total hip arthroplasty. Our registry identified all primary total hip cases with porous tantalum cups implanted from 1997 to 2004. Clinical outcomes and radiographs were studied. 613 cases were identified. Seventeen percent of patients were lost to follow-up. Twenty-five reoperations were performed (4.4%). Acetabular cup removal occurred in 6 cases (1.2%). No cups were revised for aseptic loosening. Incomplete radiolucent lines were found on 9.3% of initial postoperative radiographs. At 2 years, 67% had resolved. Zero new radiolucent lines were detected. Two- to 10-year results of porous tantalum acetabular components for primary total hip arthroplasty demonstrate high rates of initial stability and apparent ingrowth., (© 2014.)

We present the first case of infection in a native or prosthetic joint by Propionibacterium granulosum in which a patient developed symptoms of prosthetic hip infection 5 years after primary surgery. The patient required multiple operative debridements to eradicate the infection and was successfully reimplanted despite an ongoing purulent-appearing, although sterile, fluid collection at the time of reimplantation. There is no clinical or laboratory evidence of infection at 3 years post-reimplantation, and the patient has a well-functioning total hip arthroplasty. P granulosum is a low-virulence but highly-inflammatory organism. It seems to produce a large fluid collection that may require multiple debridements. To our knowledge, there are no reported cases of native or prosthetic joint infection from P granulosum. We present the first case here., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Previous studies have shown that lower-extremity malalignment increases the risk and rate of progression of knee osteoarthritis. The authors of such studies have used full-length lower-extremity radiographs to quantify alignment. However, a radiograph that includes only the knee is commonly ordered for a patient with early symptoms of knee osteoarthritis. The purpose of this study was to investigate whether local malalignment, as determined with use of a standing short knee radiograph, is associated with an increased risk of having osteoarthritis and having more severe compartmental disease., Methods: Short fluoroscopically guided standing anteroposterior knee radiographs of 306 patients (608 knees) with radiographic evidence of knee osteoarthritis were used to determine the compartment-specific Kellgren-Lawrence grade of osteoarthritis and the local (distal femoral to proximal tibial) knee alignment. The relationship between local alignment and compartmental patterns of osteoarthritis was assessed., Results: Each degree of increase in the local varus angle was associated with a significantly increased risk of having predominantly medial compartment osteoarthritis, even when we adjusted for age, sex, and body mass index (odds ratio, 1.39; 95% confidence interval, 1.29 to 1.49; p < 0.001). A similar association was found between valgus angulation and lateral compartment osteoarthritis (odds ratio, 1.55; 95% confidence interval, 1.36 to 1.75; p < 0.001). Analysis of the 362 knees with predominantly medial compartment osteoarthritis showed that each degree of increase in the varus angle was associated with a significantly increased adjusted risk of having severe medial disease (odds ratio, 1.52, p < 0.001). In the forty-seven knees with predominantly lateral compartment osteoarthritis, a similar trend was found between an increase in the valgus angle and the severity of the lateral disease, with the results approaching but not reaching significance., Conclusions: In patients with early symptomatic knee osteoarthritis, there is a clear relationship between local knee alignment, as determined from short standing knee radiographs, and the compartmental pattern and severity of the knee osteoarthritis. This study provides data with which physicians can assess how knee alignment contributes to the observed patterns and severity of osteoarthritis in an individual patient.