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With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p

Background: The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon. Methods: A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs. Results: Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS. Conclusions: Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

The present study aimed to determine the distribution of Veterans RAND 12-Item Health Survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher healthcare utilizations and 1-year patient-reported outcome measures (PROMs).A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (non-home discharge, prolonged length of stay [LOS](i.e.≥3 days), all-cause readmission), attainment of Patient Acceptable Symptom State (PASS) at 1-year postoperative and Substantial Clinical Benefit (SCB) in the Hip Disability Osteoarthritis Outcome Score (HOOS)-pain and HOOS-physical short form (PS).Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all p0.001). Preoperative VR-12 MCS20 was associated with more than twice the odds of non-home discharge (odds ratio [OR]:2.31) and prolonged LOS (OR:3.46). VR-12 MCS60 was associated with higher odds of achieving PASS (OR:2.00), and SCB in HOOS-JR (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes.Low preoperative VR-12 MCS, specifically less than 40, may predict increased healthcare utilization. Furthermore, preoperative VR-12 MCS60 predicts greater satisfaction at 1-year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared-decision making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal–Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p

The purpose of this study is to assess how unicompartmental knee arthroplasty (UKA) patient demographics, comorbidities, and episode of care outcomes have changed from 2008 to 2018 in order to better understand the impact of recent changes in healthcare ideology on UKA. The National Surgical Quality Improvement Program was queried to identify demographics, comorbidities, and episode of care outcomes in patients undergoing primary UKA from 2008 to 2013 (n = 3096) vs 2014–2018 (n = 9073). Trends were analyzed using Student’s t-tests for continuous variables and Chi-squared tests and Fisher’s exact tests for categorical variables. When comparing the years 2008–2013 to 2014–2018, there was no clinically significant difference in age, body mass index (BMI), proportion of patients with a BMI > 40 kg/m2, percentage of diabetes (15.0% vs 15.5; p = 0.715), smoking status (10.2% vs 9.4%; 0.177), COPD (3.0% vs 2.8%; p = 0.645), CHF within 30 days (

Total knee arthroplasty (TKA) is increasing in the elderly population; however, some patients, family members, and surgeons raise age-related concerns over expected improvement and risks. This study aimed to (1) evaluate the relationship between age and change in patient-reported outcome measures (PROMs); (2) model how many patients would be denied improvements in PROMs if hypothetical age cutoffs were implemented; and (3) assess length of stay (LOS), readmission, reoperation, and mortality per age group. A prospective cohort of 4,396 primary TKAs (August 2015–August 2018) was analyzed. One-year PROMs were evaluated via Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, -physical function short form (-PS), and -quality of life (-QOL), as well as Veterans Rand-12 (VR-12) physical (-PCS) and mental component (-MCS) scores. Positive predictive values (PPVs) of the number of postoperative “failures” (i.e., unattained minimal clinically important difference in PROMs) relative to number of hypothetically denied “successes” from a theoretical age-group restriction was estimated. KOOS-PS and QOL median score improvements were equivalent among all age groups (p = 0.946 and p = 0.467, respectively). KOOS-pain improvement was equivalent for ≥80 and 60–69-year groups (44.4 [27.8–55.6]). Median VR-12 PCS improvements diminished as age increased (15.9, 14.8, and 13.4 for the 60–69, 70–79, and ≥80 groups, respectively; p = 0.002) while improvement in VR-12 MCS was similar among age groups (p = 0.440). PPV for failure was highest in the ≥80 group, yet remained 2, non-home discharge, and 90-day readmission were highest in the ≥80 group (8.11% [n = 24], p

Aims Thresholds for operative eligibility based on body mass index (BMI) alone may restrict patient access to the benefits of arthroplasty. The purpose of this study was to evaluate the relationship between BMI and improvements in patient-reported outcome measures (PROMs), and to determine how many patients would have been denied improvements in PROMs if BMI cut-offs were to be implemented. Methods A prospective cohort of 3,449 primary total hip arthroplasties (THAs) performed between 2015 and 2018 were analyzed. The following one-year PROMs were evaluated: hip injury and osteoarthritis outcome score (HOOS) pain, HOOS Physical Function Shortform (PS), University of California, Los Angeles (UCLA) activity, Veterans Rand-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (VR-12 MCS). Positive predictive values for failure to improve and the number of patients denied surgery in order to avoid a failed improvement were calculated for each PROM at different BMI cut-offs. Results There was a trend to improved outcomes in terms of pain and function improvements with higher BMI. Patients with BMI ≥ 40 kg/m2 had median (Q1, Q3) HOOS pain improvements of 58 points (interquartile range (IQR) 41 to 70) and those with BMI 35 to 40 kg/m2 had median improvements of 55 (IQR 40 to 68). With a BMI cut-off of 30 kg/m2, 21 patients would have been denied a meaningful improvement in HOOS pain score in order to avoid one failed improvement. At a 35 kg/m2 cut-off, 18 patients would be denied improvement, at a 40 kg/m2 cut-off 21 patients would be denied improvement, and at a 45 kg/m2 cut-off 21 patients would be denied improvement. Similar findings were observed for HOOS-PS, UCLA, and VR-12 scores. Conclusion Patients with higher BMIs show greater improvements in PROMs. Using BMI alone to determine eligibility criteria did not improve the rate of clinically meaningful improvements. BMI thresholds prevent patients who may benefit the most from surgery from undergoing THA. Surgeons should consider PROMs improvements in determining eligibility for THA while balancing traditional metrics of preoperative risk stratification. Cite this article: Bone Joint J 2020;102-B(6):683–692.

Three patients presented with recurrent hemarthrosis secondary to erosive patellofemoral arthritis. Recurrent hemarthrosis from the eroded patellofemoral subchondral bone has not been well described. Each patient presented with symptoms secondary to painful effusions that were identified by aspiration. Each patient was successfully treated with patellofemoral or total knee arthroplasty.Spontaneous or recurrent effusions in the setting of erosive patellofemoral arthritis should prompt orthopaedic surgeons to consider hemarthrosis as the cause of such effusions. Patellofemoral or total knee arthroplasty is effective in resolving the hemarthroses, resolving pain, and restoring function in these patients.

Patient satisfaction is indicative of the quality of care in the value-driven healthcare model. The Patient Acceptable Symptom State (PASS) is a dichotomous outcome tool measuring the highest level of symptom beyond which a patient considers him/herself well. The purpose of the present study was to identify combined preoperative phenotypes of PROMs associated with not achieving PASS at 1 year following total hip arthroplasty (THA) and to associate such phenotypes with hospital utilization parameters.A prospective institutional cohort of 4,034 patients who underwent primary THA for osteoarthritis (OA) with 1-year follow-up was included. Preoperative scores on Hip Disability and Osteoarthritis Outcome Score (HOOS)-pain, HOOS physical short form-(PS), and Veteran's Rand-12 (VR-12) mental component summary-(MCS) were used to develop phenotypes. Associations between preoperative 'phenotype' and 1-year PASS, discharge disposition, prolonged length of stay, 90-day readmission, and 1-year reoperation were evaluated using multivariate regression.10.6% (427/4,043) reported their state as 'not satisfactory' at 1 year. The phenotypes were the only preoperative factors to demonstrate the increased likelihood of 1-year dissatisfaction. Only phenotypes with lower than average preoperative MCS demonstrated this association. Low scores in all presently measured PROMs (Pain-PS-MCS-) was associated with double the odds of 1-year dissatisfaction (P.001), 2.43 times the odds of nonhome discharge and 2.2 times the odds of prolonged LOS.Patients with lower preoperative scores across multiple PROMs have increased odds of dissatisfaction after THA; and assessing pain, function, and MCS concomitantly (as phenotypes) may support identifying patients at risk for not achieving a satisfactory outcome.

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015–August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Background The Centers for Medicare and Medicaid Services has recently added primary total joint arthroplasty (TJA) codes to the 2019 Potentially Misvalued Codes List. The American Association of Hip and Knee Surgeons and the American Medical Association have called for contemporary data that would assess operative time to inform the decision on reimbursement valuation. Therefore, the purpose of this study was to report total hip arthroplasty (THA) and total knee arthroplasty (TKA) operative times within a large multihospital and physician organizational enterprise to assess stability over time. Methods The study was a retrospective review (2015-2019) of a prospectively maintained multihospital health system database. A total of 12,567 consecutive TJAs were included (5742 THAs by 16 surgeons; 6825 TKAs by 20 surgeons). Operative time was between incision and completion of wound closure. Descriptive statistics were performed for categorical/continuous variables, and trend analysis was performed to assess if there was a change in time over the study period. Results For THA, 43.1% were male, with a mean age of 64.1 ± 11.8 years and a mean BMI of 30.1 ± 6.6. The mean operative time was 96.4 ± 36.8 minutes. For TKA, 39.4% were male, with a mean age of 66.2 ± 9.4 years and a mean BMI of 32.7 ± 6.8. The mean operative time was 103.6 ± 29.9 minutes. Trend analysis demonstrated no significant difference in operative time across the study period. Conclusion Our analysis demonstrated that operative time has remained stable, with mean time for THA and TKA consistently within 3.6 minutes of the historical benchmark of 100 minutes. Given these findings in a large institutional cohort, there is no definitive evidence to support changing current procedural valuation for TJA based on operative time.

Background The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge. Methods A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls. Results The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004). Conclusion These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.

Often, differences in length of stay after total knee arthroplasty are solely attributed to patient factors. Therefore, our aim was to determine the influence of patient-related and procedure or structural-related risk factors as predictors of length of stay after total knee arthroplasty.A prospective cohort of 4,509 patients (54.6% of whom had Medicare for insurance) underwent primary total knee arthroplasty across 4 facilities in a single health-care system (from January 1, 2016, to September 30, 2017). Risk factors were categorized as patient-related risk factors (demographic characteristics, smoking status, Veterans RAND 12 Item Health Survey Mental Component Summary score [VR-12 MCS], Charlson Comorbidity Index, surgical indication, Knee injury and Osteoarthritis Outcome Score [KOOS], deformity, range of motion, and discharge location probability assessed by a nomogram predicting location after arthroplasty) or as procedure or structural-related risk factors (hospital site, surgeon, day of the week when the surgical procedure was performed, implant type, and surgical procedure start time). Multivariable cumulative link (proportional odds logistic regression) models were built to identify significant predictors from candidate risk factors for 1-day, 2-day, and ≥3-day length of stay. Performance was compared between a model containing patient-related risk factors only and a model with both patient-related and procedure or structural-related risk factors, utilizing the Akaike information criterion (AIC) and internally validated concordance probabilities (C-index) for discriminating a 1-day length of stay compared with1-day length of stay.Patient-related risk factors were significant predictors of length of stay (p0.05). A longer length of stay was predicted by older age, higher body mass index (BMI), higher Charlson Comorbidity Index, lower VR-12 MCS, and female sex. However, when the procedure or structural factors were added to the patients' risk factors, the AIC decreased by approximately 1,670 units. This indicates that procedure or structural-related risk factors provide clinically relevant improvement in explaining length of stay in addition to patient-related risk factors.Despite patient-related factors such as age, sex, and comorbidities providing substantial predictive value for length of stay after total knee arthroplasty, the main driving predictors of single-day length of stay after total knee arthroplasty were procedure or structural-related factors, including hospital site and surgeon. Understanding the risk factors that affect outcomes after total knee arthroplasty provides the opportunity to influence and potentially modify them favorably to optimize care.

Background The association of postoperative complications and obesity after total knee arthroplasty (TKA) has been well described. However, the effect of an increased body-mass index (BMI) on postoperative complications after unicompartmental knee arthroplasty (UKA) is controversial. Therefore, our aim was to assess the influence of BMI on 30-day postoperative complications after UKA when analyzed as both a categorical and continuous variable. Methods The American College of Surgeons National Quality Improvement Program (NSQIP) database was used to identify a total of 8029 patients who underwent UKA from January 1, 2008, to December 31, 2016. The database was queried for over 30 unique complications occurring within 30 days. The impact of BMI on short-term outcomes was assessed as a categorical variable using univariate and multivariate regression. Additionally, BMI was assessed as a continuous variable using spline regressions. Results Univariate regression analysis revealed that compared to normal weight patients, overweight patients had a lower risk of major complication (odds ratio [OR], 0.506; 95% confidence interval [CI], 0.279–0.918; p = 0.025), and any complication ([OR] 0.632; 95% CI, 0.423–0.944; p = 0.025) Multivariate regression analysis found no statistically significant relationship between categorical BMI and complications or outcomes, except for morbidly obese patients who had a greater risk of superficial SSI (p = 0.026). Spline regression found no statistically significant non-linear relationships between BMI and any complication (p = 0.4687), major complications (p = 0.1567), or minor complications (p = 0.4071). Conclusion Overweight and obese individuals who undergo UKA may not have an increased risk of 30-day postoperative complications compared to normal weight individuals.

The multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions.Two thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios.In the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P.001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001).Higher ADI is associated with an increased healthcare utilization within 90 days of THA.

Simultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA.A prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated.Compared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P.001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P.001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12).Staged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.

» As smoking increases the risk of adverse events and leads to increased hospital costs following total joint arthroplasty (TJA), many institutions have introduced perioperative smoking cessation initiatives. Although such programs have been demonstrated to improve outcomes for smokers undergoing TJA, the optimal approach, duration, and timing of smoking cessation models have not been well-defined. » Overall, initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA, although longer periods of cessation should be encouraged if feasible. » Patients brought in for emergency surgical treatment who cannot participate in a preoperative intervention may still benefit from an intervention instituted in the immediate postoperative period. » Cotinine testing may provide some benefit for encouraging successful smoking cessation and validating self-reported smoking status, although its utility is limited by its short half-life. Further study is needed to determine the value of other measures of cessation such as carbon monoxide breath testing. » Smoking cessation programs instituted prior to TJA have been demonstrated to be cost-effective over both the short and long term.

Accurate component orientation and restoration of hip biomechanics remains a continuing challenge in total hip arthroplasty (THA). The goal of this study was to analyze the accuracy/reproducibility of a novel CT-free and pin-less robotic-assisted THA (RA-THA) platform compared to manual THA (mTHA). This matched-pair cadaveric study compared this RA-THA system to mTHA (n = 33/arm), both using the assistance of fluoroscopic imaging, in a group of 14 high-volume arthroplasty surgeons. In both groups, surgeons were asked to aim for 40°/15° for cup inclination/version, and 0 mm of leg length discrepancy (LLD). A validated and accurate method using radio-opaque markers measured cup inclination/version and LLD. The accuracy and reproducibility (fewer outliers) of cup inclination was significantly improved in the robotic group (1.8° ± 1.3° vs 6.4° ± 4.9°, respectively, robotic vs manual; p p = 0.003). For all parameters studied, the robotic group had an improved accuracy and lower variance (fewer outliers). The percentage of cases within the more restrictive Callanan safe zone was 100% for RA-THA vs 73% for mTHA (p = 0.002). The CT-free RA-THA platform, using only fluoroscopic imaging, demonstrated more accurate acetabular cup positioning, when compared to the mTHA procedures performed by high-volume hip surgeons (naive to this RA-THA platform), with respect to cup inclination and placement within the Lewinnek/Callanan safe zones. Future study must incorporate economic factors, lower volume surgeons, clinical and patient-centric outcomes, and other radiographic parameters in controlled studies in large sample sizes.

Background: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study’s purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches. Methods: A prospective consecutive series of primary THA for osteoarthritis ( n = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA ( n = 913; 38%), AL/DL ( n = 505; 21%), or PL ( n = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed. Results: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain ( p = 0.002). Approach was not a significant factor for 1-year HOOS-PS ( p = 0.16) or 1-year UCLA activity ( p = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach ( p > 0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively ( p Conclusions: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

Patient-related and surgery-related factors have been shown to be drivers of outcomes after total hip arthroplasty (THA); however, the impact of intersurgeon variability is poorly understood. The purpose of this study is to assess the following: (1) overall effect of surgeon on 1-year patient-reported outcome measures (PROMs), length of stay (LOS), discharge disposition, and 90-day readmission following THA; and (2) variability in 1-year PROMs among surgeons.A prospective cohort of 3,695 patients who underwent THA between 2016 and 2018 was included. Seventy-eight percent of patients completed 1-year follow-up. Thirty-one surgeons from a large healthcare system were included. Likelihood ratio tests analyzed the relationship among surgeon and 1-year Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, HOOS-Physical Function Short-Form, HOOS-Joint Replacement, University of California, Los Angeles activity score, Patient Acceptable Symptom State, LOS, discharge disposition, and 90-day readmission. Mixed-effect proportional odds and logistic regression models were used to determine variable importance for each outcome.In total, 90.5% of patients responded positively to 1-year Patient Acceptable Symptom State. There was a significant association among surgeon and 1-year PROMs, LOS, discharge disposition (P.001), and readmission (P = .002). For HOOS-Pain, Physical Function Short-Form, and Joint Replacement, surgeon (Akaike information criterion increase: 34.6, 18.7, 17.1, respectively) was a greater contributor to outcome than patient-level factors, including age, gender, and comorbidity. Differences in the highest and lowest median probability of achieving any given score on 1-year PROMs ranged from 11% to 18.5%. Variability was not explained by approach (P = .431) or case volume (correlation coefficient, ρ = 0.19).Surgeon-level variability appears to be a greater driver of 1-year PROMs than some patient-level characteristics. Incorporating surgeon as a variable is beneficial for model-fitting and important for increasing value in THA.

Value-driven healthcare models prioritize patient-perceived benefits to quantify the quality of care through patient-reported outcome measures (PROMs). The Patient Acceptable Symptom State (PASS) is the highest level of symptom beyond which a patient considers his/her condition satisfactory. We identified preoperative phenotypes of PROMs associated with not achieving PASS at 1 year following total knee arthroplasty (TKA) and explored the relationships between such phenotypes with hospital utilization parameters.A prospective institutional cohort of 5,274 primary TKAs for osteoarthritis from 2016 to 2019 with 1-year follow-up were included. Preoperative scores on Knee Disability and Osteoarthritis Outcome Score (KOOS) Pain, KOOS-Physical function Short form (PS), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were used to develop patient phenotypes. Associations between preoperative "phenotype" and 1-year PASS, discharge disposition, length of stay, 90-day readmission, and 1-year reoperation were evaluated using multivariate regression.In total, 16.3% (n = 862) of patients reported their state as "not acceptable" at 1 year. A combination of low scores in each of the presently examined PROMs was associated with the highest odds of 1-year dissatisfaction (odds ratio 2.18, 95% confidence interval 1.74-2.74). The PROM phenotypes were the greatest drivers compared to sociodemographic variables in predicting satisfaction. Combinations of low scores in VR-12 MCS and KOOS-PS were significantly associated with both non-home discharge status and prolonged length of stay.Patients with combined lower preoperative scores across multiple PROMs (KOOS-Pain41.7, KOOS-PS51.5, and VR-12 MCS52.8) have increased odds of dissatisfaction after TKA. Measuring pain, function, and mental health concurrently as phenotypes may help identify TKA patients at risk for not achieving a satisfactory outcome at 1 year.

With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade.From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT 35.5% for females and 38.5% for males), thrombocytopenia (platelet count 150,000/µL), INR 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions.There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007).Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors.III.

Background Operative eligibility thresholds based on body mass index (BMI) alone may risk restricting access to improved pain control, function, and quality of life. This study evaluated the use of BMI-cutoffs to offering TKA in avoiding: 1) 90-day readmission, 2) one-year mortality, and 3) failure to achieve clinically important one-year PROMS improvement (MCID). Methods A total of 4126 primary elective unilateral TKA patients from 2015 to 2018 were prospectively collected. For specific BMI(kg/m2) cutoffs: 30, 35, 40, 45, and 50, the positive predictive value (PPV) for 90-day readmission, one-year mortality, and failure to achieve one-year MCID were calculated. The number of patients denied complication-free postoperative courses per averted adverse outcome/failed improvement was estimated. Results Rates of 90-day readmission and one-year mortality were similar across BMI categories (P > .05, each). PPVs for preventing 90-day readmission and one-year mortality were low across all models of BMI cutoffs. The highest PPV for 90-day readmission and one-year mortality was detected at cutoffs of 45 (6.4%) and 40 (0.87%), respectively. BMI cutoff of 40 would deny 18 patients 90-day readmission-free, and 194 patients one-year mortality-free postoperative courses for each averted 90-day readmission/one-year mortality. Such cutoff would also deny 11 patients an MCID per avoided failure. Implementing BMI thresholds alone did not influence the rate of improvements in KOOS-PS, KRQOL, or VR-12. Conclusion Utilizing BMI cutoffs as the sole determinants of TKA ineligibility may deny patients complication-free postoperative courses and clinically important improvements. Shared decision-making supported by predictive tools may aid in balancing the potential benefit TKA offers to obese patients with the potentially increased complication risk and cost of care provision.

Background The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes. Methods This study includes data from the first 100 primary THAs and 100 revision THAs performed by 15 surgeons at a single institution from January through April 2016. Surgeons prospectively entered procedural details into OME following surgery. The OME database and operative notes were compared to evaluate completion rates and agreement. Completion rates were compared using McNemar’s test (with continuity correction), while agreement was analyzed using Cohen’s kappa (κ) and concordance correlation coefficient. Results The OME database had significantly higher completion rates for 41% (39/96) of the variables. Proportion of data points that matched between the operative notes and OME data revealed that 54% (52/96) had a proportion agreement >0.90, and 79% (76/96) had a proportion agreement >0.80. In regard to measured agreement, 25% (24/96) of variables had almost perfect agreement, 29% (28/96) had substantial agreement, and 14% (13/96) had moderate agreement. Only 4% (4/96) had fair agreement, 8% (8/96) had slight agreement, and 6% (6/96) had poor agreement. Conclusion The OME data capture system is an efficient tool to document procedural details following THA. The system is user-friendly, comprehensive, and accurate. It has the potential to be a valuable tool for future orthopedic research.

Our goal was to determine whether readmissions within 30 or 90 days following discharge are associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for total hip arthroplasty (THA) patients.HCAHPS surveys from all patients who underwent THA between January 2016 and September 2016 in our institution were analyzed. Readmissions, demographics, baseline joint pain, joint function, and Veterans RAND-12 scores were collected. Statistical analyses involved Pearson's chi-squared tests for categorical variables and Student's t-tests for continuous variables. Multivariable logistic regression models were used to determine whether 30-day or 90-day readmissions were independently associated with HCAHPS scores.A total of 1868 patients were identified, the survey was sent to 969 patients and 578 completed the survey (59.6%). Eight patients (1.4%) were readmitted within 30 days, and 28 patients (4.8%) within 90 days. These patients were more likely to undergo revision THA (P.001). For the 30-day readmission cohort, 4 of 8 patients (50.0%) rated the hospital a 9 or 10 out of 10 compared to 466 of 567 patients (82.2%) of the non-readmitted cohort (P = .019). Thirty-day readmissions were associated with significantly lower likelihood of rating the hospital a 9 or 10 out of 10 (odds ratio 0.18).Our results demonstrate a significant negative association between readmission and HCAHPS scores under several dimensions of the survey including nurse communication, doctor communication, pain management, and global satisfaction with the hospital experience.

Primary total hip arthroplasty (THA) and conversion THA may result in substantial blood loss, sometimes necessitating transfusion. Despite the complexities of the latter, both are grouped in the same category for quality assessment and reimbursement. This study's purpose was to compare both blood loss and transfusion risk in primary and conversion THA and identify their associated predictors.A total of 1616 patients who underwent primary and conversion THA at a single hospital from 2009-2013 were reviewed (primary THA = 1575; conversion THA = 41). Demographics, comorbidities, and perioperative data were collected from electronic records. Blood loss was calculated using a validated method. Transfusion triggers were based on standardized criteria. Separate multivariable regression models for blood loss and transfusion were performed.Conversion THA patients were younger (P = .002), had lower age-adjusted Charlson scores (P = .006), longer surgeries (P.001), higher blood loss (P.001), and more transfusions (P.001). Primary and conversion THA groups were different in terms of surgical approach (P.001), anesthesia type (P = .002), and venous thromboembolism prophylaxis (P = .01). Compared to primary THA, conversion THA had an average 478.9 mL higher blood loss (P = .003) and increased adjusted odds ratio of 3.2 (P = .019) for transfusion.Conversion THA leads to higher blood loss and transfusion compared with primary THA. These differences were quantified in the present study and showed consistent results between the 2 metrics. The differences between these procedures should be addressed during quality assurance because conversion THA is associated with higher resource utilization, which is important in the allocation of resources and tiered reimbursement strategies.

Background Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience. Methods A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Results In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (−8.501%, 95% confidence interval [CI] −9.639 to −7.350), a decrease in LOS (−26.966%, 95% CI −28.516 to −25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient. Conclusion TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

Background Removing total hip arthroplasty (THA) from the Centers for Medicare & Medicaid Services (CMS) inpatient-only list allows Medicare to cover outpatient THA, driving hospitals to recommend outpatient surgery for appropriate patients and raising safety concerns over which patients’ admissions should remain inpatient. Thus, we aimed to determine the influence of patient-related and procedure-related risk factors as predictors of >1-day Length of Stay (LOS) after THA. Methods A prospective cohort of 5281 patients underwent primary THA from 2016 to 2019. Risk factors were categorized as patient-related or procedure-related. Multivariable cumulative link models identified significant predictors for 1-day, 2-day, and ≥3-day LOS. Discriminating 1-day LOS from >1-day LOS, we compared performance between two regression models. Results A>1-day LOS was significantly associated with age, female gender, higher body mass index, higher Charlson Comorbidity Index, Medicare status, and higher Hip disability and Osteoarthritis Outcome Physical Function Shortform(HOOS-PS) and lower Veterans RAND12 Mental Component (VR-12 MCS) scores via the initial regression model that contained patient factors only. A second regression model included procedure-related risk factors and indicated that procedure-related risk factors explain LOS more effectively than patient-related risk factors alone, as Akaike information criterion (AIC) increased by approximately 1100 units upon removal from the model. Conclusion Although patient-related risk factors alone provide predictive value for LOS following THA, procedure-related risk factors remain the main drivers of predicting LOS. These findings encourage examination of which specific procedural risk factors should be targeted to optimize LOS when choosing between inpatient and outpatient THA, especially within a Medicare population.

Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS.Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P.0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P.001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P.001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P.001).Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.

Background Periprosthetic joint infection is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of certain agents to prevent deep vein thrombosis after arthroplasty has been linked to an increased risk of adverse effects including wound drainage and infection. Adverse effects of one alternative, rivaroxaban, was studied in a single community hospital. Methods International Classification of Diseases, Clinical Modification 9 codes were used to identify primary THAs and TKAs in an administrative database at one large-volume community hospital performed in 2012. Patients were divided into 2 groups: the study group received rivaroxaban, whereas the control group received another form of chemical thromboprophylaxis for at least 2 weeks postoperative. Demographics, risk factors, and illness severity scores were collected for each group. The primary measured outcome was the incidence of deep surgical site infection (SSI) within 30 days postoperative. Results A total of 639 TKA or THA patients were included, with 159 patients who received rivaroxaban and 480 who received another form of chemical thromboprophylaxis. There were no significant differences between groups regarding demographics, risk factors, or illness severity scores. Incidence of early deep SSI in the rivaroxaban group was higher than in the control group (2.5% vs 0.2%; P Conclusion The use of rivaroxaban for thromboprophylaxis led to a significantly increased incidence of deep SSI in a continuous series of patients undergoing primary THA and TKA in a single institution.

Press Ganey administration of Hospital Consumer Assessment of Healthcare Providers and Systems Survey after discharge is sometimes used to monitor hospital performance and adjust reimbursements.significant differences exist between responders and nonresponders. We assessed baseline characteristic differences between responders and nonresponders; sampling bias; responding predictability in total joint arthroplasty patients; and differences in sampling and response rates among different hospitals.A prospective database of arthroplasty patients from January 1, 2016 to September 30, 2016 was used to compare responders' and nonresponders' baseline characteristics at 4 hospitals. A univariate analysis between groups was performed. A multiple logistic regression model was used to assess whether Press Ganey sampling was predictable. We identified receiving and responding predictors.We captured 96.6% (3255 of 3369) of hip and knee arthroplasties. Hospital Consumer Assessment of Healthcare Providers and Systems Survey sampling rate was 60% and response rate was 36% (1157). Responders were more likely Caucasians, nonsmokers, discharged home, have shorter hospital stays, have higher baseline joint pain and physical composite scores, and have better mental health composite scores. Concordance indices suggest reasonable-to-very-strong model predictability for those sampled (range 0.56-0.91) and those responding (range 0.61-0.78). Completion predictors were Caucasian race (P.0001), younger ages (P.0001), discharged home (P.0001), negative smoking status (P = .02), quit smoking (P = .0026), higher baseline mental health composite scores (P = .0096), and diagnoses of femoroacetabular impingement (P = .0056), osteoarthritis (P = .0111), or prosthesis failure (P = .0036).Responders/nonresponders were significantly different in several characteristics. It can be predicted who will likely be sampled and who will complete. Responders were not representative of arthroplasty population. Research is needed for more representative sampling methods.Level III.

BACKGROUND Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. METHODS A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive debridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. RESULTS Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). CONCLUSIONS Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Simultaneous bilateral total knee arthroplasty (SBTKA) may present a higher risk for postoperative complications than unilateral surgery. The authors retrospectively identified 561 patients who underwent SBTKA between 2013 and 2015. The cohort was stratified according to the following appropriateness of care criteria (AOCC): (1) age younger than 70 years; (2) absence of cardiac disease; (3) controlled diabetes; and (4) body mass index less than 30 kg/m 2 . The authors created an AOCC score, with 0 representing the most ideal candidates and 4 representing the least ideal candidates. The cohort included 140 (25%) ideal candidates with a score of 0; the cohort also included 299 (53%) non-ideal candidates with a score of 1, 105 (19%) with a score of 2, 14 (2%) with a score of 3, and 3 (1%) with a score of 4. Ideal candidates had the shortest mean length of stay at 3.6±1.2 days. Length of stay was longer for patients with an AOCC score of greater than 2 compared with those with an AOCC score of 2 or less (5.2±4.3 vs 3.8±1.6 days, P P P =.400), medical complications trended strongly (6% vs 11%, P =.086). Appropriateness of care criteria for SBTKA patients were associated with shorter length of stay, higher rates of home discharge, and a trend toward lower complication rates. Simultaneous bilateral total knee arthroplasty can offer better outcomes in a subgroup of patients appropriately selected for surgery. Physicians can use these results to counsel their patients about risks and benefits of undergoing SBTKA. [ Orthopedics. 2018; 41(5):293–298.]

Protocols for the screening and decolonization ofStaphylococcus aureusprior to total joint arthroplasty (TJA) have become widely adopted. The goals of this study were to determine: (1) whether implementation of a screening protocol followed by decolonization with mupirocin/vancomycin and chlorhexidine reduces the risk of revision compared with no screening protocol (i.e., chlorhexidine alone) and (2) whether clinical criteria could reliably predict colonization with MSSA and/or MRSA. Electronic medical records of primary patients undergoing TJA that were screened (n=3,927) and were not screened (n=1,751) forStaphylococcus aureusat least 4 days prior to surgery, respectively, were retrospectively reviewed. All patients received chlorhexidine body wipes preoperatively. Patients carrying MSSA and MRSA were treated preoperatively with mupirocin and vancomycin, respectively, along with the standard preoperative antibiotics and chlorhexidine body wipes. Screened patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened (p=0.04). Multivariate regression models were poorly accurate in predicting colonization with MSSA (AUC = 0.58) and MRSA (AUC = 0.62). These results support the routine screening and decolonization ofS. aureusprior to TJA.

One potential strategy to decrease the risk of dislocation after revision total hip arthroplasty (THA) is the use of an abduction brace to limit flexion and adduction. The purpose of this study was to compare the dislocation rate after revision THA between patients treated with or without an abduction brace. Data were obtained from 1211 revision THAs performed in 610 women and 518 men who had a mean age of 64.7 years (range, 22-95 years) and were followed up for a minimum of 90 days. Five hundred two patients were braced, whereas 650 were not. The 90-day dislocation rate among patients who wore a brace was 5.2% compared with 5.7% in the nonbrace group (P = .70). Multivariate regression found no benefit to bracing (P = .37), while controlling for factors found to significantly affect dislocation rate in this population. Our data do not support the routine use of an abduction brace to aid in the prevention of dislocation.

Pain secondary to instability in total knee arthroplasty (TKA) has been shown to be major cause of early failure. In this study, we focused on the effect of instability in TKA on the proximal tibiofibular joint (PTFJ). We used a robotics model to compare the biomechanics of the PTFJ in the native knee, an appropriately balanced TKA, and an unbalanced TKA. The tibia (n=5) was mounted to a six-degree of freedom force/torque sensor and the femur was moved by a robotic manipulator. Motion at the PTFJ was recorded with a high resolution digital camera system. After establishing a neutral position, loading conditions were applied at varying flexion angles (0, 30, and 60°). These included: internal/external rotation (0 Nm, ± 5 Nm), varus/valgus (0 Nm, ± 10 Nm), compression (100 N, 700 N), and posterior drawer (0 N, 100 N). With respect to anterior displacement, external rotation had the largest effect (coefficient = 0.650; p < 0.0001). Polyethylene size as well as the interaction between polyethylene size and flexion consistently showed substantial anterior motion. Flexion and mid-flexion instability in TKA have been difficult to quantify. While tibiofemoral kinematics is the main aspect of TKA performance, the effects on adjacent tissues should not be overlooked. Our data show that PTFJ kinematics are affected by the balancing of the TKA.

Distally fixed modular implants have seen a recent increase in use, to manage proximal femoral bone loss often encountered during revision total hip arthroplasty (THA). Forty-three distally fixed modular stems implanted at our institution between 1999 and 2006 were clinically and radiographically reviewed. These patients had either a minimum 2-year follow-up (average, 2.4 years; range, 2-5.6 years) or failure (ie, explant or rerevision required). Eleven stems subsided, and 4 were rerevised (n = 4), for a rate of 9.3%. All revised stems were radiographically undersized, emphasizing the importance of the technique. Although being a valuable option in revision THA, these stems are not free of complications. The high rate of subsidence encountered in our early experience shows that there is a learning curve. This complication is preventable by avoiding undersizing.

The purpose of this study was to develop an easily administered tool to preoperatively predict patient discharge disposition after total joint arthroplasty in the United States. Data were collected in a retrospective review of 517 medical charts and analyzed using logistic regression to develop a model for predicting the likelihood that a patient will not be discharged directly home. The resulting regression model was the basis for the nomogram, named the Predicting Location after Arthroplasty Nomogram. This model demonstrated a bootstrap-corrected concordance index of 0.867, excellent calibration, and external validation as demonstrated by a concordance index of 0.861. Preoperative knowledge that a patient is likely to require an extended care facility allows the clinical care team to make appropriate arrangements and avoid potential delays in patient discharge.

Postoperative care after total knee arthroplasty has focused on decreasing patients' length of stay and increasing function at discharge. The purpose of this study was to determine whether implementing Rapid Recovery in total knee arthroplasty patients has an effect on length of stay and early postoperative pain and function. A retrospective review was conducted for surgeries between January 2005 and August 2006 (traditional; n=62) and September 2006 and December 2007 (Rapid Recovery; n=54). Patients treated with Rapid Recovery are able to ambulate farther ( P = 0.01), have decreased length of stay ( P = 0.01), are discharged directly home at an increased frequency ( P = 0.01), and have greater Knee Society function scores at 4 weeks postoperatively ( P = 0.01).

Total hip arthroplasty is one of the most successful procedures performed. Despite its success, there is an increasing burden of revision surgery. Revision surgeries can be complex and are often complicated by severe bone loss. Implant designs are constantly evolving to address problems encountered in revision surgery. The distally fixed modular stem has been designed to help the orthopedic surgeon adequately address proximal femoral bone loss in the revision setting. As with any technology, distally fixed modular stems must be correctly used in the appropriate patient. Short- to midterm data show early clinical success for these stems, but long-term data are needed.

Aseptic loosening is the most common cause for revision total hip arthroplasty (THA). Due to poor long-term results with cemented acetabular components, cementless implants that rely on biologic fixation became popular in the United States for both primary and revision procedures in the early 1980s. Cementless acetabular components used in THA have been reported to have superior radiographic performance compared with cemented fixation, although the optimal method of acetabular fixation remains controversial. Cementless acetabular components require initial implant stability to allow for bone ingrowth and remodeling into the acetabular shell, providing long-term durability of the prosthesis. Many improved implant materials are available to facilitate bone growth and remodeling, including the 3 most common surface treatments; fibermesh, sintered beads, and plasma spray coatings. Recently added to these are porous metal surfaces, which have increased porosity and optimal pore sizes when compared with titanium fibermesh. The most studied of these materials is the titanium fibermesh fixation surface, which has demonstrated a mechanical failure rate of 1% at 10 to 15 years. This technology utilizes the diffusion bonding process to attach fiber metal pads to a titanium substrate using heat and pressure. The sintered bead fixation surface offers a porous coating of various sizes of spherical beads, achieved by the sintering process, and has been shown to provide long-term fixation. While there are less long-term published data regarding the titanium plasma spray surface, its early results have provided evidence of its durability, even in the face of significant osteolysis. The most recently added alternative fixation surface is porous tantalum metal, which offers potentially greater bone ingrowth and bone graft incorporation due to its high porosity (80%) and low modulus of elasticity (3 MPa). Porous tantalum implants have shown early favorable clinical results and have been reported to have excellent bone graft incorporation of the acetabular component based on serial radiograph data at a minimum 1-year follow-up. Tritanium is a porous metal, which has emerged as a promising new surface technology for acetabular shells. While no clinical data are yet available, basic science research has demonstrated enhanced bone ingrowth and mechanical strength.

Background: Extensor mechanism disruption following total knee arthroplasty is a rare but devastating complication. The purpose of this study was to report our experience with extensor mechanism allograft reconstruction for chronic extensor mechanism failure. Methods: Fifty consecutive extensor mechanism allograft reconstructions were performed in forty-seven patients with a mean age of 67.6 years who were followed for a mean time of 57.6 months (range, twenty-four to 125 months). The operative technique included the use of a fresh-frozen, correctly sized full extensor mechanism allograft that was tensioned tightly in full extension. Patients were evaluated clinically with use of the Knee Society score, and reconstructions were considered failures if the patient had a score of 30° or if they required revision or removal of the allograft. Results: Nineteen reconstructions (38%) were considered failures, including four revised to a second extensor mechanism allograft due to failure of the allograft, five for deep infection, and ten considered clinical failures secondary to a Knee Society score of 30°. The mean Knee Society score improved from 33.9 to 75.9 points (p < 0.0001). The estimated Kaplan-Meier survivorship with failure for any reason as the end point was 56.2% (95% confidence interval, 39.4% to 70.1%) at ten years. Conclusions: Extensor mechanism disruption following total knee arthroplasty is a difficult complication to treat, with modest outcomes. Extensor mechanism allograft reconstruction is a reasonable option; however, patients must be informed regarding the substantial risk of complications, and although initial extensor mechanism function may be restored, expectations regarding longer-term outcomes are more guarded. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Despite dislocation being the most frequent complication after revision THA, risk factors for its occurrence are not completely understood.We therefore (1) determined the overall risk of dislocation after revision THA in a large series of revision THAs using contemporary revision techniques, (2) identified patient-related risk factors predicting dislocation, and (3) identified surgical variables predicting dislocation.We performed 1211 revision THAs between June 2004 and October 2010 in 576 women and 415 men who had a mean age of 64.7 years (range, 25-95 years) at time of surgery. Forty-six (4%) were lost to followup and 13 died (1%), leaving 1152 hips followed for a minimum of 90 days (mean, 2 years; range, 90 days to 7.1 years). Multivariate logistic regression was performed to identify risk factors for dislocation. The model was also tested on patients followed for a minimum 1 year to assess any difference in longer followup.One hundred thirteen patients dislocated over the followup period (9.8%). Factors that were different between patients who dislocated and those who remained stable included a history of at least one previous dislocation (odds ratio [OR] = 2.673), abductor deficiency (OR = 2.672), and Paprosky acetabulum class (OR = 1.522). Use of a constrained liner (OR = 0.503) and increased femoral head size (OR = 0.942) were protective against dislocation, while with longer followup a constrained liner was no longer significant.Dislocation remains a common problem after revision THA. Identifying these risk factors can assist in patient education and surgical planning. Recognition of these risk factors in both patient type and surgical strategy is important for the surgeon performing revision THA and for minimizing these risks.Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background: Blood loss during total hip arthroplasty can be substantial and may lead to adverse patient outcomes and increased health-care costs. Many blood-management options are available for these procedures. The purpose of the present study was to test the hemostatic efficacy of a bipolar sealer used during total hip arthroplasty in order to determine whether its use results in significantly lower transfusion requirements and/or improved clinical, functional, and health-related quality-of-life outcomes in healthy patients. Methods: This prospective, single-center, randomized, double-blinded study was designed to enroll a total of 140 patients. Patients with a low preoperative hemoglobin level or a history of bleeding abnormalities and other medical conditions were excluded. Patients were randomized to either the treatment arm (radiofrequency energy with use of the Aquamantys 6.0 bipolar sealer) or control arm (standard Bovie electrocautery). The primary outcome measure was the transfusion requirement, and the secondary outcome measures were intraoperative estimated blood loss, postoperative hemoglobin levels, perioperative narcotic usage, length of hospital stay, postoperative pain scores, and postoperative function as measured with the Harris hip score and the Short Form-12 quality-of-life score. Results: Seventy-one patients were assigned to the treatment arm, and sixty-nine were assigned to the control arm. The mean number of units of blood transfused for all patients in the study and control arms were 0.38 and 0.44, respectively (p = 0.72). The transfusion requirements were similar in the two groups, with fifteen of seventy-one patients in the treatment arm and fourteen of sixty-nine patients in the control arm requiring a transfusion (p = 0.9). No significant differences were detected between the groups in terms of estimated blood loss, postoperative hemoglobin levels, perioperative narcotic usage, length of hospital stay, postoperative pain scores, Harris hip scores, or Short Form-12 scores. Conclusions: In this patient population, there were no significant differences between the treatment and control groups in terms of the need for blood transfusions or overall blood loss. Given these findings, we have discontinued the use of this bipolar sealing device in uncomplicated primary total hip arthroplasty patients at our institution. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.