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Background: The primary purpose of this study was to evaluate how utilization, physician reimbursement, and patient populations have changed for primary total knee arthroplasty (TKA) from 2013 to 2021 at both a regional and national level within the Medicare population. Methods: The Medicare Physician and Other Practitioners database was queried for all episodes of primary TKA between years 2013 and 2021. TKA utilization per 10,000 beneficiaries, inflation-adjusted physician reimbursement per TKA, and patient demographics of each TKA surgeon were extracted each year. Data were stratified geographically, and Kruskal-Wallis tests were utilized. Results: Between 2013 and 2021, TKA utilization per 10,000 beneficiaries increased at the greatest rate in the Northeast (+15.1%). In 2021, TKA utilization was highest in the Midwest (97.6/10,000; P < .001). The Midwest had the greatest decline in average physician reimbursement per TKA between 2013 and 2021 (−26.3%) and the lowest average reimbursement ($988.70, P < .001) in 2021. Alternatively, the Northeast had the smallest decline in average TKA reimbursement (−22.6%). Nationally, the average number of beneficiaries per TKA surgeon declined (−6.8%), while the average number of TKAs per surgeon (+5.7%) and average services per beneficiary (+24.3%) both increased. The average number of patient comorbidities and proportion of patients with dual Medicare-Medicaid eligibility decreased over time across all regions. Conclusions: This study demonstrates that TKA utilization is increasing and average physician reimbursement per TKA is declining at varying rates across the country, with the Northeast and Midwest most affected. These findings should be addressed in policy discussions to ensure equitable arthroplasty care.

Background: Patella baja is a known complication of total knee arthroplasty (TKA). There is a limited understanding of the association between patellar resurfacing and the incidence of patella baja. We aimed to compare rates of patella baja between unresurfaced and resurfaced patellas in patients undergoing TKA. Methods: A retrospective review of patients who underwent TKA between October 2009 and January 2020 was performed. Patients were included if they had at least one preoperative radiograph and a 1-year follow-up radiograph. Blackburne-Peel index (BPI) and Insall-Salvati ratios (ISRs) were measured on preoperative and 1-year postoperative radiographs and were used to define patella baja vs pseudopatella baja. Statistical analysis was performed using a linear model analysis of variance and the Fisher’s exact test. Results: Three hundred eighteen TKAs were included, with 176 being resurfaced and 142 unresurfaced patellas. Of the resurfaced group, 4% (7/176) had true patella baja, compared to 5.6% (8/142) of the unresurfaced patellas. Of the resurfaced patellas, 8% (14/176) had pseudopatella baja, compared to 7% (10/142) in the unresurfaced group. Patellar resurfacing was not associated with a higher incidence of patella baja (P = .60) or pseudopatella baja (P = .83). Lower preoperative ISRs (P = .04) and BPIs (0.03) were highly predictive of a higher incidence of patella baja post-TKA. Conclusions: Patellar resurfacing in TKA is not associated with a higher incidence of patella baja in TKA when compared to unresurfaced patellas. Lower preoperative ISRs and BPIs are highly predictive of a higher incidence of postoperative patella baja.

Background: Social determinants of health are implicated in the experience of knee osteoarthritis, a key component of which is access to care and healthcare utilization. The objective of this study was to describe difficulties in access to care and healthcare utilization in the United States knee osteoarthritis population. Methods: The publicly available All of Us Database was utilized to conduct a retrospective cohort study. Patients with a diagnosis of knee osteoarthritis were included and matched to a control group who did not have knee osteoarthritis. The association of knee osteoarthritis and patient-specific demographic features with self-reported domains of access to care was analyzed. Results: Among 15,718 patients with knee osteoarthritis, 27.6% reported delayed care (n = 4343), 25.6% reported inability to afford care (n = 4015), 12.8% reported skipped medications (n = 2011), and 1.6% reported not seeing a healthcare provider in over 1 year (n = 247). Patients with knee osteoarthritis were more likely to be unable to afford care (odds ratio 1.21, P < .001) or skip medications (odds ratio 1.12, P = .004) in comparison to matched patients without knee osteoarthritis. Among the knee osteoarthritis cohort, low income and nonheterosexual orientation were both associated with increased rates of delayed care and an inability to afford care. Conclusions: Patients with knee osteoarthritis report significant challenges with delayed care, affordability of care, and medication adherence. Among patients with knee osteoarthritis, patients who are younger age, female sex, low-income, low-education, nonheterosexual orientation, or have poor physical and mental health are at increased risk of having decreased access to treatment.

Background: Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively. Methods: Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics. Results: Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02). Conclusions: PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Conclusion: Care should be taken to prevent drills from plunging beyond the medial femoral cortex during surgery. Cautious observation of patient’s vitals and clinical course can allow for early detection of vascular complication.

Abstract Background Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. Discussion The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. Conclusions DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

Background:. While previously used in other specialties, the preference signaling program (PSP) was implemented in the 2022 to 2023 orthopaedic surgery residency application process for the first time. The PSP allowed for 30 signaling tokens to be sent by applicants to programs of their choice to indicate particular interest in a program. It remains unknown how the PSP affects applicants and programs in the orthopaedic surgery residency match. Thus, this study's purpose was to assess the utility of preference signaling within the orthopaedic surgery residency application process in its inaugural year of use. Methods:. An anonymous electronic survey was emailed to all orthopaedic surgery residency applicants who applied to the authors' institution during the 2022 to 2023 application cycle. The survey was sent after match lists were submitted and closed before the release of match results. The survey collected information regarding applicant demographics, preference signaling habits, and attitude toward preference signaling. Results:. The survey was completed by 101 applicants. Applicants applied to a mean of 90 programs (range: 10-197) and received an average of 12 interview invitations (range: 0-39). Applicants almost uniformly used all 30 signals, with nearly two-thirds signaling their home programs (65%, 49/76), and nearly all applicants sending signals to programs at which they performed away rotations (95.7%, 88/92). Applicants received a mean of 9 invitations from programs they signaled, compared with 2 invitations from programs they did not signal. Applicants were significantly more likely to receive an interview invite at a program they signaled than one they did not (p < 0.01). Overall, 57% of applicants (57/101) found the PSP to be helpful, whereas 28% (28/101) found it to be unhelpful, and 16% (16/101) had a neutral opinion. Conclusions:. This study reports that the PSP in the 2022 to 2023 orthopaedic surgery match was an effective method of expressing interest in a program because applicants were significantly more likely to receive interview invites to signaled programs. More than half of respondents felt PSP to be helpful; however, the effect on application numbers is still unclear. Level of Evidence:. III

Background: The use of robotics in arthroplasty surgery has increased substantially in recent years. The purpose of this study was to objectively identify the 100 most influential studies in the robotic arthroplasty literature and to conduct a bibliometric analysis of these studies to describe their key characteristics. Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics for robotic arthroplasty research using Boolean queries. The search list was sorted in descending order by the number of citations, and articles were included or excluded based on clinical relevance to robotic arthroplasty. Results: The top 100 studies were cited a total of 5770 times from 1997 to 2021, with rapid growth in both citation generation and the number of articles published occurring in the past 5 years. The top 100 robotic arthroplasty articles originated from 12 countries, with the United States being responsible for almost half of the top 100. The most common study types were comparative studies (36) followed by case series (20), and the most common levels of evidence were III (23) and IV (33). Conclusions: Research on robotic arthroplasty is rapidly growing and originates from a wide variety of countries, academic institutions, and with significant industry influence. This article serves as a reference to direct orthopaedic practitioners to the 100 most influential studies in robotic arthroplasty. We hope that these 100 studies and the analysis we provide aid healthcare professionals in efficiently assessing consensus, trends, and needs within the field.

Background: The effect of spinopelvic pathology on femoral version is unclear. This study investigated variability in native femoral anteversion in patients undergoing total hip arthroplasty (THA) and its relationship to the patient’s underlying spinopelvic pattern. Methods: A retrospective chart review was performed to include in the study all patients undergoing robot-assisted THA over a 3-year period. Native femoral version was measured for each patient using a preoperative computed tomography scan and categorized as excessive, normal, or retroverted. Additionally, a subset analysis was performed for all patients with sit-to-stand dynamic pelvic radiographs available, and cases were classified by spinopelvic pattern. Results: A total of 119 patients were included in the study with a mean age of 68.6 years; 61 (51%) were female. The median femoral anteversion for the entire study group was 6.0° (−32° to 40°, interquartile range 13.5°). Eleven patients (9.2%) had excessive femoral anteversion, 54 of the 119 (45.4%) had normal femoral version, and 54 of the 119 (45.4%) had native retroversion. Forty-two patients (35.3%) had sit-to-stand radiographs available and were subclassified by femoral version type and spinopelvic parameters. Welch’s analysis of variance demonstrated a significant difference in femoral version among spinopelvic patterns (F = 7.826, P = .003), with Games-Howell post hoc analysis showing increased retroversion in deformity-stiff patients compared to deformity-normal mobility patients (P = .003). Conclusions: This study demonstrates that native femoral retroversion is present in a significant number of patients undergoing THA and is more common in patients with stiff spine deformities. Based on this observation, currently available spinopelvic classification systems should be modified to account for native femoral version.

Background: The purpose of this analysis was to assess the public interest in total hip arthroplasty (THA) based on approach by analyzing Google Trends online search volume trends between 2007 and 2021. Methods: Data were obtained by querying the Google Trends online search tool for key terms and phrases relating to anterior, posterior, lateral, and minimally invasive approaches to THA. Data from January 2007 to December 2021 were utilized. Relative search volume (RSV) was generated for each THA approach group based on historical search volume trends in the United States. Results: Over the 15-year period, Google Trends Search Data demonstrated a statistically significant increase (P < .001) in the RSV for all 4 major hip arthroplasty approaches. The growth in public interest for anterior hip arthroplasty was significantly greater than the growth for posterior (P = .02) and minimally invasive hip arthroplasty (P = .02). The difference in RSV growth between lateral and anterior approaches was not significant (P = .88). The average RSV for anterior hip arthroplasty was 59.0, which was significantly greater than the average RSV of all other groups. Conclusions: The anterior approach to hip arthroplasty has demonstrated a consistent and statistically significant increase in RSV over the past 15 years that has outpaced the increases observed in the posterior and minimally invasive approaches. Despite the increase in public awareness and interest for anterior approach hip arthroplasty, it is yet to demonstrate any long-term clinical benefits over other approaches.

Background: When used appropriately, the minimal clinically important difference (MCID) provides a powerful tool for identifying meaningful improvements brought about by a given treatment, offering more clinically relevant information than frequentist statistical analysis. However, recent studies have shown inconsistent derivation methods and use of MCIDs. The goal of this study was to report the rate of patient-reported outcome measures (PROMs) and MCIDs use in the literature and assess how this rate has changed over time. Methods: All articles published in 2010 and 2020 reporting on total hip arthroplasty or total knee arthroplasty in The Journal of Clinical Orthopaedics and Related Research, The Journal of Bone and Joint Surgery, and The Journal of Arthroplasty were reviewed. In each reviewed article, every reported PROM and, if present, its corresponding MCID was recorded. These data were used to calculate the rate of reporting of each PROM and MCID. Results: While the total number of articles on total hip arthroplasty and total knee arthroplasty reporting PROMs increased over time, the proportion of articles reporting PROMs decreased from 49.8% (131/263) in 2010 to 35.5% (194/546) in 2020 (P = .011). Of these articles that report PROMs, the proportion of articles reporting any MCID increased from 2.3% (3/131) in 2010 to 16.5% (32/194) in 2020 (P = .002). Conclusions: The rate of reporting of MCIDs among articles relating to total hip arthroplasty and total knee arthroplasty that report PROMs has increased significantly between 2010 and 2020 but remains low. Continued emphasis on appropriate inclusion and value of MCIDs when PROMS are reported in clinical outcomes studies is needed.

Abstract Background Over the last decade, cementless total knee arthroplasty has demonstrated improved outcomes and survivorship due to advances in technologies of implant design, manufacturing capabilities, and biomaterials. Due to increasing interest in cementless implant design for TKA, our aim was to perform a systematic review of the literature to evaluate the clinical outcomes and revision rates of the Triathlon Total Knee system over the past decade. Methods A systematic review of the literature was conducted following PRISMA guidelines for patients who underwent total knee arthroplasty with cementless Triathalon Total Knee System implants. Patients had a minimum of two-year follow-up and data included clinical outcome scores and survivorship data. Results Twenty studies were included in the final analysis. The survivability of the Stryker Triathlon TKA due to all causes was 98.7%, with an aseptic survivability of 99.2%. The overall revision incidence per 1,000 person-years was 3.4. Re-revision incidence per 1,000 person-years was 2.2 for infection, and 1.3 for aseptic loosening. The average KSS for pain was 92.2 and the average KSS for function was 82.7. Conclusions This systematic review demonstrated excellent clinical outcomes and survivorship at a mean time of 3.8 years. Additional research is necessary to examine the long-term success of the Stryker Triathlon TKA and the use of cementless TKAs in obese and younger populations. Level of evidence III.

Background: The use of robotics in arthroplasty continues to increase. Patient demand, patient expectations, and patient-directed marketing by industry and care providers each likely contributes to its increasing popularity. Trends in patient interest have not been well described. We used the online Google Trends tool to analyze trends in national public interest toward robotic and nonrobotic arthroplasty between 2011 and 2021. Material and methods: Google Trends online was queried for search terms related to nonrobotic hip and knee arthroplasty in addition to robotic hip, robotic knee, and general robotic arthroplasty between January 1, 2011, and December 31, 2021. Results: Google Trends Data demonstrated a significant linear increase in online searches related to nonrobotic total knee and hip arthroplasty. Online search volume for robotic hip arthroplasty was significant and linear, while that of robotic knee arthroplasty was significant and exponential. When combined, robotic joint arthroplasty demonstrated an exponential trend over the 10-year period. This increase was noted to be statistically significant when compared with nonrobotic arthroplasty search volume. Conclusion: Our study demonstrates that public interest in robotic total joint arthroplasty has increased significantly from 2011 through 2020. When compared with online search volume for conventional arthroplasty, this increasing growth is statistically significant. Public interest in robotic arthroplasty is anticipated to continue to increase, and care providers should be aware of this trend that impacts patient perceptions and expectations. Despite significant growth in interest for robotic arthroplasty, there is incomplete evidence supporting its use over nonrobotic arthroplasty. Additional high-quality studies are needed to inform provider decision-making and appropriately guide public interest in robot-assisted arthroplasty.

Purpose: To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods: We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow-up (6 weeks) and 1-year (or most recent) follow-up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results: In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow-up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow-up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow-up (P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow-up. Conclusions: In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow-up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence: Level III, case–control study.

Background: Routine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty. Methods: A practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status. Results: A total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50. Conclusions: Discontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.

Strings of local excitations are interesting features of a strongly correlated topological quantum matter. Here, the authors show that Boltzmann-distributed strings of local excitations also describe the topological physics of the Santa Fe geometry of artificial spin ice, which is a classical thermal system.

Background: Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty. Methods: A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision. Results: Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective. Conclusions: A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.

Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients >18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients (p). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic (>0.96) vs. acute () PJI. The sensitivity at this value was 0.74 (95 % CI 0.62–0.83) and the specificity was 0.90 (95 % CI 0.81–0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.

Engineering efforts have focused on acyltransferase (AT) domains of modular polyketide synthases (PKSs) to site-selectively modify the resulting polyketides, but critical AT residues involved in substrate selection have not been fully elucidated. Here, the authors use molecular dynamics to pinpoint mutations that impact AT domain selectivity and exchange structural motifs to obtain chimeric PKS modules with expanded substrate specificity.

Introduction:. Away rotations have become a critical factor for a successful orthopaedic surgery residency match. Away rotations significantly improve an applicant's chance of matching into an orthopaedic residency. Away rotations were limited during the 2020 to 2021 academic year because of the COVID-19 pandemic. During the 2021 to 2022 academic year, the American Association of Medical Colleges coalition recommended students only complete 1 rotation outside their home institution, whereas the American Orthopaedic Association Council of Residency Directors argued that multiple rotations should be allowed. We sought to quantify the impact of these restrictions on orthopaedic surgery applicants during the 2020 to 2021 residency application cycle. Methods:. An online survey was sent to all applicants applying to the authors' home orthopaedic surgery program. The survey asked respondents to indicate how many away rotations they completed and how many they planned to complete but were unable to complete in the 2020 to 2021 application cycle. Historical match data were obtained from the National Resident Matching Program's publicly accessible Main Residency Match Data and Reports. Results:. Survey responses were collected from 650 of 812 applicants (80%) to our program. Over a third of respondents (38.1%) reported completing 3 subinternship rotations during the 2020 to 2021 application cycle. Nearly a quarter of respondents (24.0%) reported completing 4 rotations. Most applicants (50.9%) were unable to complete 5 previously planned rotations because of pandemic-related restrictions, and 25.2% reported an inability to complete 4 rotations. Fewer applicants reported canceling 3 rotations (9.2%), 2 rotations (6.8%), or 1 (7.8%) rotation. Conclusions:. Away rotations have been a traditional component of the orthopaedic surgery application process. Restrictions on away rotations in the 2020 to 2021 residency application cycle had affected the number of rotations that applicants were able to complete. However, despite those restrictions, over a third of applicants were able to complete at least 3 rotations. This suggests that the away rotation experience is variable for students and may be multifactorial; however, our study did not investigate the reasons for this. Accordingly, limiting away rotations may support an inequitable environment for medical students applying to orthopaedic surgery, and creating a consensus definition among medical schools, program directors, and orthopaedic chairs of away rotations, their duration, and the maximum number allowed would enhance fairness and reduce inconsistencies.

Purpose: The purpose of this study was to assess the price variation of various Medicare severity diagnosis-related group codes for orthopaedic upper extremity procedures for the top 20 orthopaedic hospitals using chargemaster price listings from each hospital. Methods: The top 20 orthopaedic hospitals in the United States were determined by querying the U.S. News and World Report’s 2020 orthopaedic hospital ranking. This report ranks orthopaedic hospitals according to 4 major domains: outcomes, structure, process/expert opinion, and patient experience. Chargemaster data for the top 20 orthopaedic hospitals was compiled from their websites. Five DRG codes that represented orthopaedic upper extremity procedures were selected, and the pricing information for each was extracted from hospital chargemasters. The median income and cost-of-living index were also compiled for the county that each hospital is located in so that pricing data could be compared to economic measures through regression analysis. Results: Of the top 20 orthopaedic hospitals, 18 had publicly available pricing information in DRG format on their websites. The DRG code with the highest pricing variability was Hand Injury Procedures (DRG 906; range, $12,832-$253,633). The procedure with the least pricing variability was Hand or Wrist Procedures (DRG 514; range, $24,533-$128,403). Additionally, only the cost of living index was a statistically significant predictor of procedure pricing with a weak correlation. Conclusion: Hospital chargemaster listings are lacking in 2 major areas: true price transparency and standardization/consistency between hospitals. Chargemaster data are often difficult to find, confusing to patients, and inaccurate. Additionally, the price range for a single DRG code can also vary substantially depending on the hospital. It is possible that hospitals located in areas with high costs of living and median incomes would charge higher prices, but these factors were not found to support this hypothesis.

Background:. Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown. Methods:. Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation. Results:. Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency. Conclusion:. Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.

Although the coronavirus disease 2019 (COVID‐19) pandemic has been associated with increased psychological distress globally, it poses unique challenges to persons who are potentially more vulnerable to its effects, including patients with autoimmune disease. In this article, we review the published literature and media reports to determine factors that may contribute to mental health challenges in persons with autoimmune disease. We then explore existing mental health interventions that have been developed for use in COVID‐19 and in patients with autoimmune disorders in general. We identified several potential contributors to psychological distress in patients with autoimmune disease during the pandemic, as follows: feelings of discrimination related to societal response to COVID‐19, fear of infection and uncertainty related to immunosuppressive medication, diminished access to usual care and resources, previous health‐related trauma, and the exacerbating effect of social isolation. Drawing from existing literature, we synthesize the identified evidence to develop a proposed framework for researching and managing mental health challenges in autoimmune disease during the pandemic and its aftermath.

Background: Despite decreasing transfusion rates, routine type and screens are frequently used before primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aims of this study were to characterize transfusion rates and identify any factors that affect the likelihood of transfusion to determine if it is safe to discontinue routine preoperative type and screens at an academic hospital. Methods: A retrospective chart review was performed for all patients who underwent primary THA or TKA in 2019 at an academic institution by a fellowship-trained arthroplasty surgeon. Data on preoperative type and screens, transfusion rates, bleeding disorders, and anticoagulation status were obtained. Patients were considered to have a preoperative type and screen if it was performed within 30 days before surgery. Results: Overall, 379 patients were included in the study. Of these, 210 underwent primary THA and 169 underwent primary TKA. Four patients received transfusions during their hospitalization for a cumulative transfusion rate of 1.06%. No patients received an intraoperative transfusion. One (0.59%) patient received a postoperative transfusion after TKA, and 3 (1.43%) patients received a postoperative transfusion after THA. The mean preoperative hemoglobin of the 4 transfused patients was 10.8 g/dL. Conclusions: In summary, performing a preoperative routine type and screen is likely unnecessary at academic medical centers. Consideration for obtaining a type and screen may include complex primary surgeries or when patients have preoperative hemoglobin of less than 11 g/dL. Ultimately, preoperative type and screen should be considered on a case-by-case basis using clinical judgment.

In the setting of total hip arthroplasty (THA), pseudoaneurysms are extremely rare and can be difficult to diagnose, as clinical symptoms can mimic symptoms of other more common complications, such as periprosthetic joint infection, hematoma, and nerve damage. We present a case of a 69-year-old male with a history of slipped capital femoral epiphysis 56 years prior and subsequent right THA. The right hip primary arthroplasty was subsequently complicated by multiple dislocations and recurrent prosthetic joint infections. The most recent infection was treated with debridement, antibiotics, and implant retention (DAIR) in 2017. The patient later presented in 2019 with right thigh pain. Upon further analysis, he was diagnosed with Streptococcus bovis positive periprosthetic joint infection. The patient underwent a two-stage revision of the hip using an antibiotic spacer. Two weeks following the second stage, he presented with a sudden onset of uncontrolled atrial fibrillation with rapid ventricular response and a low hemoglobin. The computed tomography scan revealed a large hematoma involving both the anterior and posterior thigh compartments with lab markers that were questionable for infection. An operation to remove the hematoma revealed no purulence, and a large pulsatile pseudoaneurysm on the posterolateral aspect at the mid femur was found. A sharp bone fragment was noted next to the pseudoaneurysm. The pseudoaneurysm was repaired by a vascular surgeon, and the bone fragment was removed. Following this procedure, the patient developed a subsequent periprosthetic joint infection requiring a double DAIR procedure six weeks following the pseudoaneurysm repair and is now on chronic antibiotic suppression. Orthopedic surgeons should be aware of the potential for pseudoaneurysm in the setting of total joint arthroplasty when treating a postsurgical hematoma of sudden onset.

In the setting of below-knee amputation, compartment syndrome is a rare complication. Early clinical symptoms of an acute compartment syndrome following below-knee amputation can mimic or be masked by postoperative pain management. We present the case of a 38-year-old male with a significant past medical history of Proteus syndrome who underwent an elective transtibial below-knee amputation. Following surgery, the patient had extensive postoperative pain and high pain medication requirements and returned to the operating room for irrigation and debridement due to suspicion of an infection. Upon return to the operating room to manage the infection, the necrotic tissue was discovered and removed which had developed due to a suspected missed acute compartment syndrome. The necrotic tissue secondary to the compartment syndrome subsequently resulted in infection. Multiple irrigation and debridement procedures were performed to further manage the infection, and ultimately, the patient was deemed stable for discharge. Acute compartment syndrome (ACS) following below-knee amputation (BKA) is a rarely documented but critical complication. This case describes the unique setting in which a compartment syndrome can be masked due to postoperative pain management and infection. Orthopedic surgeons should be aware of the varying risk factors and presentations of an acute compartment syndrome (ACS) as it can occur and is a devastating complication.

Introduction. This case report adds to current literature on management of a subdural hematoma following total knee arthroplasty and is particularly important as joint replacement moves into outpatient surgery centers where the orthopedic surgery team becomes the sole patient contact point. Case Presentation. A 66-year-old male presented to the emergency department five days after elective robotic-assisted left total knee arthroplasty performed with spinal epidural with the symptoms of a persistent nonpostural headache. CT of the head revealed a small bifrontal acute subdural hematoma. He was admitted for overnight monitoring as a precaution. No vascular abnormalities or underlying pathology was found on further advanced imaging. He was discharged the following morning after follow-up CT showed no focal changes. Magnetic resonance imaging (MRI) one month later confirmed resolution of the subdural hematoma. Conclusion. Orthopedic surgeons should be aware of the signs and symptoms, as well as the risk factors for subdural hematomas following lumbar puncture, as it is a rare, but potentially life-threatening complication of spinal epidural.

Purpose: To determine the 50 most frequently cited studies in the orthopaedic shoulder arthroscopy literature and to conduct a bibliometric analysis of these studies. Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics using Boolean queries to capture all possible iterations of shoulder arthroscopy research. The search list was sorted so that articles were organized in descending order based on the number of citations and included or excluded based on relevance to shoulder arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence. Results: For these 50 studies, the total number of citations was calculated to be 13,910, with an average of 278.2 citations per paper. The most-cited article was cited 1134 times, whereas the second- and third-most cited articles were cited 920 and 745 times, respectively. All 50 articles were published in English and came from 7 different orthopaedic journals. The United States was responsible for most of the included articles (31), followed by France (9) and Japan (3). Conclusions: The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. In addition, more than one half of the top 50 most-cited studies were published after 2004, which suggests that article age may be less important in the accumulation of citations for a rapidly growing field like shoulder arthroscopy. Clinical Relevance: The top 50 most-cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to shoulder arthroscopy.

Significant progress has been made toward model-based prediction of neral tissue activation in response to extracellular electrical stimulation, but challenges remain in the accurate and efficient estimation of distributed local field potentials (LFP). Analytical methods of estimating electric fields are a first-order approximation that may be suitable for model validation, but they are computationally expensive and cannot accurately capture boundary conditions in heterogeneous tissue. While there are many appropriate numerical methods of solving electric fields in neural tissue models, there isn't an established standard for mesh geometry nor a well-known rule for handling any mismatch in spatial resolution. Moreover, the challenge of misalignment between current sources and mesh nodes in a finite-element or resistor-network method volume conduction model needs to be further investigated. Therefore, using a previously published and validated multi-scale model of the hippocampus, the authors have formulated an algorithm for LFP estimation, and by extension, bidirectional communication between discretized and numerically solved volume conduction models and biologically detailed neural circuit models constructed in NEURON. Development of this algorithm required that we assess meshes of (i) unstructured tetrahedral and grid-based hexahedral geometries as well as (ii) differing approaches for managing the spatial misalignment of current sources and mesh nodes. The resulting algorithm is validated through the comparison of Admittance Method predicted evoked potentials with analytically estimated LFPs. Establishing this method is a critical step toward closed-loop integration of volume conductor and NEURON models that could lead to substantial improvement of the predictive power of multi-scale stimulation models of cortical tissue. These models may be used to deepen our understanding of hippocampal pathologies and the identification of efficacious electroceutical treatments.

Advances in computation and neuronal modeling have enabled the study of entire neural tissue systems with an impressive degree of biological realism. These efforts have focused largely on modeling dendrites and somas while largely neglecting axons. The need for biologically realistic explicit axonal models is particularly clear for applications involving clinical and therapeutic electrical stimulation because axons are generally more excitable than other neuroanatomical subunits. While many modeling efforts can rely on existing repositories of reconstructed dendritic/somatic morphologies to study real cells or to estimate parameters for a generative model, such datasets for axons are scarce and incomplete. Those that do exist may still be insufficient to build accurate models because the increased geometric variability of axons demands a proportional increase in data. To address this need, a Ruled-Optimum Ordered Tree System (ROOTS) was developed that extends the capability of neuronal morphology generative methods to include highly branched cortical axon terminal arbors. Further, this study presents and explores a clear use-case for such models in the prediction of cortical tissue response to externally applied electric fields. The results presented herein comprise (i) a quantitative and qualitative analysis of the generative algorithm proposed, (ii) a comparison of generated fibers with those observed in histological studies, (iii) a study of the requisite spatial and morphological complexity of axonal arbors for accurate prediction of neuronal response to extracellular electrical stimulation, and (iv) an extracellular electrical stimulation strength–duration analysis to explore probable thresholds of excitation of the dentate perforant path under controlled conditions. ROOTS demonstrates a superior ability to capture biological realism in model fibers, allowing improved accuracy in predicting the impact that microscale structures and branching patterns have on spatiotemporal patterns of activity in the presence of extracellular electric fields.

We present a case of an 82-year-old female with a history of right total knee arthroplasty 11 years prior. She was admitted after a ground-level fall and developed progressive pain and swelling of her right knee. She had no history of complications with her total knee replacement. Radiographs of the knee and hip were negative for acute fracture, dislocation, or hardware malalignment. Knee aspiration was performed and revealed inflammatory exudate, synovial fluid consistent with crystal arthropathy, and no bacterial growth. She was diagnosed with an acute gout flare, and her symptoms significantly improved with steroids and anti-inflammatory treatment. Orthopedic surgeons should be aware of the potential for crystal arthropathy in the setting of total joint arthroplasty and evaluate for crystals before treating a presumed periprosthetic joint infection.

We have performed a detailed study on thermal annealing of the moment configuration in artificial spin ice. Permalloy (Ni80Fe20) artificial spin ice samples were examined in the prototypical square ice geometry, studying annealing as a function of island thickness, island shape, and annealing temperature and duration. We also measured the Curie temperature as a function of film thickness, finding that thickness has a strong effect on the Curie temperature in regimes of relevance to many studies of the dynamics of artificial spin ice systems. Increasing the interaction energy between island moments and reducing the energy barrier to flipping the island moments allow the system to more closely approach the collective low energy state of the moments upon annealing, suggesting new channels for understanding the thermalization processes in these important model systems.

Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P < .001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P = .002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits. Keywords: Total joint arthroplasty (TJA), Periprosthetic joint infection (PJI), International normalized ratio (INR), Warfarin, Venous thromboembolism (VTE), Pulmonary emboli (PE)