Does Race Affect Outcomes in Total Joint Arthroplasty?

Variation in Demographics, Hospital, and Patient-Reported Outcomes following Total Hip Arthroplasty According to Biological Sex

BACKGROUND

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

METHODS

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-week, 6-month, and 1-year Single Assessment Numeric Evaluation (SANE), Visual Analog Scale (VAS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), University of California, Los Angeles (UCLA), and Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical scores, as well as satisfaction scores.

RESULTS

A total of 6,418 patients were included (55% women). Women were older (P < 0.001), had a lower body mass index (P < 0.001), and were more likely to have public insurance (P < 0.001). Fewer women were discharged to home or self-care (P < 0.001). Women had higher rates of cementation (P < 0.001) and fracture within 90 days (P < 0.001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

CONCLUSION

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.

Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty

INTRODUCTION

Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications.

METHODS

A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors.

RESULTS

After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05).

CONCLUSION

Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient

BACKGROUND

Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care.

METHODS

A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant.

RESULTS

High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI.

CONCLUSIONS

Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.

LEVEL OF EVIDENCE

III.

The Utility of the Area Deprivation Index in Assessing Complications After Total Joint Arthroplasty

Background

Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year.

Methods

A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128).

Results

Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications.

Conclusions

Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Culturally Adapting Mind-Body Interventions for Black Individuals with Chronic Pain: Arguments and Recommendations Towards a Task-Sharing Approach

Compared to non-Hispanic White individuals, non-Hispanic Black Individuals report worse chronic pain from a variety of medical issues. Among the options for non-pharmacological pain treatment, mind-body interventions (MBI) are a promising modality to help Black individuals manage their chronic pain effectively. MBIs such as mindfulness meditation improve chronic pain and chronic pain-related outcomes by shifting the individual's perception of pain away from stress-related cognitive appraisals, emotional reactions, and behaviors. MBIs may also address disparities in chronic pain outcomes between Black and White individuals because of their contextual overlap with (1) centering and contemplative prayer, (2) racial empowerment, and (3) social support. Despite this overlap, the demand for MBIs among Black individuals has generally been low due to lingering access and acceptability barriers. To reduce these barriers for Black individuals with chronic pain, we must adopt a community-engaged approach and culturally adapt MBIs for the specific historic, environmental, financial, and psychosocial needs of Black individuals. Example adaptations include increasing Black representation among MBI instructors, reducing geographical access barriers, accommodating the financial and personal realities of Black adults, and explicitly allowing relevant attitudes, practices, and terms.

Marital Status, Race, Insurance Type, and Socioeconomic Status-Assessment of Social Predictors for Outcomes After Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to investigate the effect of various social determinants of health on outcomes and dispositions after total knee arthroplasty (TKA).

METHODS

A retrospective review was conducted on 14,462 consecutive TKA procedures between 2013 and 2021 at a multicenter hospital system. Data abstraction was done by inquiry to the Michigan Arthroplasty Registry Collaborative Quality Initiative. Data points requested included basic demographics, marital status, race, insurance status, socioeconomic status measured by the Area of Deprivation Index, perioperative course, and incidence of emergency department (ED) visits and readmissions within 3 months of surgery. Subsequent multivariate analyses were conducted.

RESULTS

Unmarried patients required markedly greater lengths of hospital stay and had an increased rate of discharge to skilled nursing facilities and a higher likelihood of any purpose ED visit within 90 days of surgery compared with married patients, who had a significantly greater rate of same-day discharge ( P < 0.001). Race did not markedly correlate with outcomes. Medicare patients showed a greater rate of same-day discharge, nonhome discharge, and 90-day ED visits compared with privately insured patients ( P < 0.001). Medicaid patients were more likely than privately insured patients to have a 90-day ED visit ( P < 0.001). Socioeconomic status had a minimal clinical effect on all studied outcomes.

CONCLUSION

Social factors are important considerations in understanding outcomes after TKA. Additional investigations are indicated in identifying at-risk patients and subsequent optimization of these patients.

Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort

PURPOSE

The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort.

DESIGN

A single-center, retrospective analysis.

METHODS

This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared.

FINDINGS

There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively.

CONCLUSIONS

In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Evaluating the association between race and complications following pediatric upper extremity surgery

Race can influence perioperative care and outcomes in adult and pediatric orthopedic surgery. However, no prior study has evaluated any associations between race and complications following upper extremity surgery in pediatric patients. Thus, the purpose of this study was to evaluate whether there are any differences in risks for complications, readmission, or mortality following upper extremity surgery between African American and Caucasian pediatric patients. Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were categorized into two cohorts: patients who were Caucasian and patients who were African American. Differences in demographics, comorbidities, and postoperative complications were assessed and compared between the two-patient population using bivariate and multivariable regression analyses. Of the 25 848 pediatric patients who underwent upper extremity surgeries, 21 693 (83.9%) were Caucasian, and 4155 (16.1%) were African American. Compared to Caucasian patients, African American patients were more likely to have a higher American Society of Anesthesiologists classification ( P  < 0.001), as well as pulmonary comorbidities ( P  < 0.001) and hematologic disorders ( P  = 0.004). Following adjustment on multivariable regression analysis to control for baseline characteristics, there were no differences in any postoperative complications between Caucasian and African American patients. In conclusion, African American pediatric patients are not at an increased risk for postoperative complications compared to Caucasian patients following upper extremity surgery. Race should not be used independently when evaluating patient risk for postoperative complications. Level of Evidence: III.

Race Associated With Increased Complication Rates After Total Knee Arthroplasty

BACKGROUND

Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications.

METHODS

A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients.

RESULTS

The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455).

CONCLUSION

Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.

Does interaction occur between risk factors for revision total knee arthroplasty?

INTRODUCTION

Several risk factors for revision TKA have previously been identified, but interactions between risk factors may occur and affect risk of revision. To our knowledge, such interactions have not been previously studied. As patients often exhibit multiple risk factors for revision, knowledge of these interactions can help improve risk stratification and patient education prior to TKA.

MATERIALS AND METHODS

The State Inpatient Databases (SID), part of the Healthcare Cost and Utilization Project (HCUP), were queried to identify patients who underwent TKA between January 1, 2006 and December 31, 2015. Risk factors for revision TKA were identified, and interactions between indication for TKA and other risk factors were analyzed.

RESULTS

Of 958,944 patients who underwent TKA, 33,550 (3.5%) underwent revision. Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA were significantly associated with revision (p < 0.05). Age was the strongest predictor (p  < 0.0001), with younger patients exhibiting higher revision risk. Risks associated with age were modified by an interaction with indication for TKA (p < 0.0001). There was no significant interaction between sex and indication for TKA (p = 0.535) or race and indication for TKA (p = 0.187).

CONCLUSIONS

Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA are significantly associated with revision TKA. Interaction occurs between age and indication.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database

BACKGROUND

The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups.

METHODS

This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates.

RESULTS

Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites.

CONCLUSION

There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Pipeline to Military Orthopaedic Leadership: 20 Years of Race and Gender Diversity Trends Within Military Orthopaedic Surgery Fellowship Training

Background

The lack of trainees from underrepresented race and gender backgrounds in orthopaedic surgery fellowship training has been well reported in the literature. The purpose of this study was to investigate the demographic trends of federally sponsored military orthopaedic surgery fellows in the Army, Navy, and Air Force. We hypothesize that there has been an increase in women selected for fellowship but that there has been no change in the race demographics of military fellows over the past 2 decades.

Methods

A retrospective review of all available demographic data collected by the Army, Air Force, and Navy since the beginning of tracking federally funded fellowship training in orthopaedic surgery was completed (1998-2021). Data were grouped into 4-year periods for analysis to closely mirror the military assignment cycle.

Results

Three hundred sixty-two military orthopaedic surgery fellowship board selectees were included in our analysis. The proportion of women fellows increased from 3% (n = 2/69) over 2001 to 2004 to 21% (n = 17/82) during 2017 to 2020 (p < 0.05). Fellows who identified as White comprised 82% (n = 297) of the cohort during the study period. Individuals who identified as Asian were the next highest proportion of fellows at 4% (n = 16), followed by Black (n = 14, 4%) and Hispanic (n = 13, 3%). Individuals who identified as Native Hawaiian/Pacific Islander represented 1% (n = 3), and an additional 6% (n = 20) fellows identified as "other" or "undeclared." Over the 20-year study period, representation of Asian, Black, Native Hawaiian, and Hispanic fellows did not increase (p = 0.79, 0.81, 0.45, 0.34, respectively).

Conclusions

Within military orthopaedics, there has been increased representation of women in fellowship training over the past 20 years. However, the proportion of fellows from underrepresented racial and ethnic groups has remained stagnant. One barrier to improving gender and race representation is the currently imprecise and inconsistent collection of demographic information. Importantly, fellowship training has a direct effect on future leadership opportunities within the military orthopaedic surgery community. A more diverse leadership may help to inspire future generations of military orthopaedic surgeons.

Level of Evidence

IV.

Patient Designation Prior to Total Knee Arthroplasty: How Can Preoperative Variables Impact Postoperative Status?

BACKGROUND

Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively.

METHODS

We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion.

RESULTS

Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion.

CONCLUSION

Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.

In Vitro Evaluation of Ag- and Sr-Doped Hydroxyapatite Coatings for Medical Applications

Osseointegration plays the most important role in the success of an implant. One of the applications of hydroxyapatite (HAp) is as a coating for metallic implants due to its bioactive nature, which improves osteoconduction. The purpose of this research was to assess the in vitro behavior of HAp undoped and doped with Ag and/or Sr obtained by galvanostatic pulsed electrochemical deposition. The coatings were investigated in terms of chemical bonds, contact angle and surface free energy, electrochemical behavior, in vitro biomineralization in acellular media (SBF and PBS), and biocompatibility with preosteoblasts cells (MC3T3-E1 cell line). The obtained results highlighted the beneficial impact of Ag and/or Sr on the HAp. The FTIR spectra confirmed the presence of hydroxyapatite within all coatings, while in terms of wettability, the contact angle and surface free energy investigations showed that all surfaces were hydrophilic. The in vitro behavior of MC3T3-E1 indicated that the presence of Sr in the HAp coatings as a unique doping agent or in combination with Ag elicited improved cytocompatibility in terms of cell proliferation and osteogenic differentiation. Therefore, the composite HAp-based coatings showed promising potential for bone regeneration applications.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

Risk factors for pain after total hip arthroplasty: a systematic review

BACKGROUND

Approximately 23% of patients develop hip pain after total hip arthroplasty (THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgical planning.

METHODS

Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preoperative modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently.

RESULTS

Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes.

CONCLUSIONS

Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management.

The Use of Race in Risk Assessment Tools Contributes to Systemic Racism

Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.

Race and Socioeconomic Status Are Associated With Inferior Patient-Reported Outcome Measures Following Rotator Cuff Repair

PURPOSE

To investigate the impact social determinants of health (SDOH) have on National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test scores and postoperative health care use in patients who undergo rotator cuff repair (RCR).

METHODS

All patients who underwent RCR surgery by 3 shoulder and/or sports medicine fellowship-trained orthopaedic surgeons between July 2017 and January 2020 were included. The electronic medical record (EMR) was used to identify SDOH for each patient. PROMIS computer adaptive test measures of Upper Extremity function, Pain Interference, and Depression were completed preoperatively and postoperatively (6 months and 1 year). Postoperative health care use (clinical visits, virtual encounters, imaging encounters, and physical therapy visits) were recorded as well. Univariate associations, multiple linear regressions, and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH.

RESULTS

Three hundred thirty-eight patients who underwent RCR were included. Patients who were Black, in lower median household income quartiles, had public insurance, and female reported lower PROMIS scores compared with their counterparts. Smokers and White patients attended fewer postoperative office visits whereas Black patients had more physical therapy and nonvisit encounters compared with their respective counterparts.

CONCLUSIONS

Black race and lower socioeconomic status are associated with worse function and pain outcomes post-RCR compared with White race. Similarly, Black race and positive smoking status are associated with differential use of health care following RCR. Further attention may be required for these patients to address health care disparities.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty

BACKGROUND

Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk.

QUESTIONS/PURPOSES

(1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization?

METHODS

Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included.

RESULTS

When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization.

CONCLUSION

We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Disparities in Elective and Nonelective Total Hip Arthroplasty

BACKGROUND

Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.

METHODS

Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.

RESULTS

After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.

CONCLUSION

Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.

Hemoglobinopathy is Associated With Total Hip Arthroplasty Indication Even Beyond Sickle Cell Anemia

Background

The extent to which hemoglobinopathies other than sickle anemia (HbSS) are associated with hip osteonecrosis is unknown. Sickle cell trait (HbS), hemoglobin SC (HbSC), and sickle/β-thalassemia (HbSβTh) may also predispose to osteonecrosis of the femoral head (ONFH). We sought to compare the distributions of indications for a total hip arthroplasty (THA) in patients with and without specific hemoglobinopathies.

Methods

PearlDiver, an administrative claims database, was used to identify 384,401 patients aged 18 years or older undergoing a THA not for fracture from 2010 to 2020, with patients grouped by diagnosis code (HbSS N = 210, HbSC N = 196, HbSβTh N = 129, HbS N = 356). β-Thalassemia minor (N = 142) acted as a negative control, and patients without hemoglobinopathy as a comparison group (N = 383,368). The proportion of patients with ONFH was compared to patients without it by hemoglobinopathy groups using chi-squared tests before and after matching on age, sex, Elixhauser Comorbidity Index, and tobacco use.

Results

The proportion of patients with ONFH as the indication for THA was higher among those with HbSS (59%, P < .001), HbSC (80%, P < .001), HbSβTh (77%, P < .001), and HbS (19%, P < .001) but not with β-thalassemia minor (9%, P = .6) than the proportion of patients without hemoglobinopathy (8%). After matching, the proportion of patients with ONFH remained higher among those with HbSS (59% vs 21%, P < .001), HbSC (80% vs 34%, P < .001), HbSβTh (77% vs 26%, P < .001), and HbS (19% vs 12%, P < .001).

Conclusions

Hemoglobinopathies beyond sickle cell anemia were strongly associated with having osteonecrosis as the indication for THA. Further research is needed to confirm whether this modifies THA outcomes.

Impact of social disadvantage among total knee arthroplasty places of service on procedural volume: a nationwide Medicare analysis

INTRODUCTION

As recent analyses have indicated that low-volume hospitals experience higher rates of complications following total knee arthroplasty (TKA), it remains important to evaluate how area deprivation index (ADI) of hospitals impacts the quantity of TKA performed. Our analysis sought to evaluate how the ADI of orthopedic surgeon's place of service influences TKA utilization.

MATERIALS AND METHODS

The Medicare Provider Utilization and Payment Data Public Use File (MPUP-PUF) was queried to identify claims between 2013 and 2019 associated with Healthcare Common Procedure Coding System (HCPCS) code 27447 (TKA). The MPUP-PUF file was linked with publicly available ADI information as well as information regarding each provider's practice location. The Mann-Kendall trend test was used to analyze significant differences in TKA volume between ADI quintiles and differences in TKA volume overall between the years 2013 and 2019. An adjusted multivariable linear regression analysis was conducted to evaluate how ADI, and practice-specific characteristics, influenced TKA utilization volume.

RESULTS

When isolating by ADI quintiles, no significant changes in TKA volume were demonstrated for Quintile 4 (Kendall's τ = 0.524; p = 0.13) and Quintile 5 (Kendall's τ = 0.524; p = 0.13) between 2013 and 2019. However, a significant increase in TKA volume over the study period was observed in Quintile 1 (Kendall's τ = 0.714 p = 0.034), Quintile 2 (Kendall's τ = 0.714 p = 0.034), and Quintile 3 (Kendall's τ = 0.905 p = 0.007). The adjusted multivariable linear regression model demonstrated that each increase in ADI quintile was associated with significantly lower TKA utilization (β-estimate - 1.16; 95% CI - 2.04 to - 0.29; p = 0.009).

CONCLUSIONS

Our findings suggest that resource deprivation contributes to disparities in TKA utilization. With the ongoing recognition of how social and neighborhood-level deprivation may influence access to end-stage osteoarthritis care and related perioperative outcomes, the present study serves to encourage continued efforts at ensuring equity in orthopedic care.

Association Between Race/Ethnicity and Total Joint Arthroplasty Utilization in a Universally Insured Population

INTRODUCTION

Previous studies have documented racial and ethnic disparities in total joint arthroplasty (TJA) utilization in the United States. A potential mediator of healthcare disparities is unequal access to care, and studies have suggested that disparities may be ameliorated in systems of universal access. The purpose of this study was to assess whether racial/ethnic disparities in TJA utilization persist in a universally insured population of patients enrolled in a managed healthcare system.

METHODS

This retrospective cohort study used data from a US integrated healthcare system (2015 to 2019). Patients aged 50 years and older with a diagnosis of hip or knee osteoarthritis were included. The outcome of interest was utilization of primary total hip arthroplasty and/or total knee arthroplasty, and the exposure of interest was race/ethnicity. Incidence rate ratios (IRRs) were modeled using multivariable Poisson regression controlling for confounders.

RESULTS

There were 99,548 patients in the hip analysis and 290,324 in the knee analysis. Overall, 10.2% of the patients were Black, 20.5% were Hispanic, 9.6% were Asian, and 59.7% were White. In the multivariable analysis, utilization of primary total hip arthroplasty was significantly lower for all minority groups including Black (IRR, 0.55, 95% confidence interval [CI], 0.52-0.57, P < 0.0001), Hispanic (IRR, 0.63, 95% CI, 0.60-0.66, P < 0.0001), and Asian (IRR, 0.64, 95% CI, 0.61-0.68, P < 0.0001). Similarly, utilization of primary total knee arthroplasty was significantly lower for all minority groups including Black (IRR, 0.52, 95% CI, 0.49-0.54, P < 0.0001), Hispanic (IRR, 0.72, 95% CI, 0.70-0.75, P < 0.0001), and Asian (IRR, 0.60, 95% CI, 0.57-0.63, P < 0.0001) (all in comparison with White as reference).

CONCLUSIONS

In this study of TJA utilization in a universally insured population of patients enrolled in a managed healthcare system, disparities on the basis of race and ethnicity persisted. Additional research is required to determine the reasons for this finding and to identify interventions which could ameliorate these disparities.

Low Rates of Reporting Race, Ethnicity, and Socioeconomic Status in Studies Published in Top Orthopaedic Journals

BACKGROUND

Although there have been calls for the routine reporting of patient demographics associated with health disparities, including race, ethnicity, and socioeconomic status (SES), in published research, the extent to which these variables are reported in orthopaedic journals remains unclear.

METHODS

We identified and examined all research articles with human cohorts published in 2019 in the 2 highest-ranked U.S. general orthopaedics journals, Clinical Orthopaedics and Related Research and The Journal of Bone & Joint Surgery. Excluded from analysis were studies with no U.S.-based institution and those that did not report any demographic data. Articles were reviewed to determine study type; reporting of race, ethnicity, and any of 3 SES variables (i.e., income, education, and health-care insurance); and the inclusion of these demographics in multivariable analyses.

RESULTS

A total of 156 articles met the inclusion criteria. Of these, 56 (35.9%) reported patient race and 24 (15.4%) reported patient ethnicity. Income was reported in 13 (8.3%) of the articles, education in 23 (14.7%), and health insurance in 18 (11.5%). Of the 97 papers that reported results of multivariable analyses, 30 (30.9%) included race in the analysis and 21 (21.6%) reported significance associated with race. Income, education, and health insurance were included in multivariable analyses in 7 (7.2%), 11 (11.3%), and 10 (10.3%) of the articles, respectively.

CONCLUSIONS

Race, ethnicity, and SES were infrequently reported and analyzed within articles published in 2 of the top orthopaedic journals. This problem may be remedied if orthopaedic journals impose standards for the reporting and analysis of patient demographics in studies with human cohorts.

CLINICAL RELEVANCE

Failure to report key demographics makes it difficult for practitioners to determine whether study results apply to their patient populations. In addition, when orthopaedic interventions are evaluated without accounting for potential disparities by demographics, clinicians may incorrectly assume that the overall benefits and risks reported in studies apply equally to all patients.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities

BACKGROUND

Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States.

METHODS

A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data.

RESULTS

A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05).

CONCLUSIONS

This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Time to Reflect and Take Action on Health Disparities and Health Inequities

The United States healthcare system underperforms in healthcare access, quality, and cost resulting in some of the poorest health outcomes among comparable countries, despite spending more of its gross national product on healthcare than any other country in the world. Within the United States, there are significant healthcare disparities based on race, ethnicity, socioeconomic status, education level, sexual orientation, gender identity, and geographic location. COVID-19 has illuminated the racial disparities in health outcomes. This article provides an overview of some of the main concepts related to health disparities generally, and in orthopaedics specifically. It provides an introduction to health equity terminology, issues of bias and equity, and potential interventions to achieve equity and social justice by addressing commonly asked questions and then introduces the reader to persistent orthopaedic health disparities specific to total hip and total knee arthroplasty.

Predictors of Disparities in Patient-Reported Outcomes before and after Arthroscopic Meniscectomy

The purpose of this study is to identify predictors of disparities in patient-reported outcome measures (PROMs) before and after arthroscopic meniscectomy. Knee injury and Osteoarthritis Outcome Score (KOOS) was used in this study. All patients who underwent single-knee arthroscopic meniscectomy from January 2012 to March 2018 performed by a single surgeon at an academic safety-net hospital were identified. We excluded patients who had undergone ipsilateral previous knee surgery, bilateral meniscectomy, or concomitant ligament, cartilage, or osteotomy procedures, and those with severe radiographic osteoarthritis in the operated knee, missing preoperative data, or military insurance. Data abstracted from medical records included demographics (age, sex, race, insurance type), clinical characteristics (body mass index, Charlson comorbidity index, and Kellgren-Lawrence [KL] grade), procedure codes, and KOOS assessed before and 90 days after surgery. Multivariable analyses investigated the associations between patient characteristics and the KOOS Pain, other Symptoms, and Function in activities of daily living (ADL) subscales. Among 251 eligible patients, most were female (65.5%), half were of nonwhite race (50.2%), and almost one third were insured by Medicaid (28.6%). Medicaid and black race were statistically significant (p < 0.05) predictors of worse preoperative values for all three KOOS subscales. Medicaid insurance also predicted a lower likelihood of successful surgery, defined as meeting the 10-point minimal clinically important difference, for the KOOS symptoms (p < 0.05) and KOOS ADL (p < 0.05) subscales. Compared with patients without definitive evidence of radiographic osteoarthrosis (KL grade 1), those with moderate radiographic osteoarthritis (KL grade 3) were less likely to have a successful surgical outcome (p < 0.05 for all subscales). Worse preoperative KOOS values predicted worse postoperative KOOS values (p < 0.001 for all subscales) and a lower likelihood of surgical success (p < 0.01 for all subscales). Insurance-based disparities in access to orthopaedic care for meniscus tears may explain worse preoperative PROMs and lower success rates of meniscectomy among Medicaid patients. Patients with meniscus tears and radiological and/or magnetic resonance imaging evidence of osteoarthritis should be carefully evaluated to determine the appropriateness of arthroscopic meniscectomy.

Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine–Related Hip Disabilities

Background:

Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine–related hip disabilities.

Purpose:

To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses.

Results:

African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance.

Conclusion:

Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine–related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.

Measuring appropriate need for unicompartmental knee arthroplasty: results of the MANUKA study

PURPOSE

Indications for unicompartmental knee arthroplasty (UKA) are controversial. Studies based solely on radiographic criteria suggest up to 49% of patients with knee osteoarthritis (OA) are suitable for UKA. In contrast, the 'Appropriate use criteria' (AUC), developed by the AAOS, apply clinical and radiographic criteria to guide surgical treatment of knee OA. The aim of this study was to analyze patient suitability for TKA, UKA and osteotomy using both radiographic criteria and AUC in a cohort of 300 consecutive knee OA patients.

METHODS

Included were consecutive patients with clinical and radiographic signs of knee OA referred to a specialist clinic. Collected were demographic data, radiographic wear patterns and clinical findings that were analyzed using the AUC. A comparison of the radiographic wear patterns with the treatment suggested by the AUC as well as the Surgeon Treatment Decision was performed.

RESULTS

There were 397 knees in 300 patients available for analysis. Median age was 68 [IQR 15], BMI 30 [6] with 55% females. Excellent consistency for both the radiographic criteria and the AUC criteria was found. Based on radiological criteria, 41% of knees were suitable for UKA. However, when using the AUC criteria, UKA was the appropriate treatment in only 13.3% of knees. In 19.1% of knees, no surgical treatment was appropriate at the visit, based on the collected data.

CONCLUSION

Application of isolated radiologic criteria in patients with knee OA results in a UKA candidacy is misleadingly high. AUC that are based on both radiological and clinical criteria suggest UKA is appropriate in less than 15% of patients.

LEVEL OF EVIDENCE

III retrospective study.

Comorbidity Burden Contributing to Racial Disparities in Outpatient Versus Inpatient Total Knee Arthroplasty

INTRODUCTION

Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes.

RESULTS

A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery.

DISCUSSION

Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.

Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

BACKGROUND

Although frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.

METHODS

The National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.

RESULTS

We identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.

CONCLUSION

Disparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.

Does racial background influence outcomes following total joint arthroplasty?

BACKGROUND

The purpose of this study is to assess whether racial differences influence patient-reported outcome measures (PROMs) following primary total hip (THA) and knee (TKA) arthroplasty.

METHODS

We retrospectively reviewed patients who underwent primary THA or TKA from 2016 to 2020 with available PROMs. Both THA and TKA patients were separated into three groups based on their ethnicity: Caucasian, African-American, and other races. Patient demographics, clinical data, and PROMs at various time-periods were collected and compared. Demographic differences were assessed using chi-square and ANOVA. Univariate ANCOVA was utilized to compare outcomes and PROMs while accounting for demographic differences.

RESULTS

This study included 1999 THA patients and 1375 TKA patients. In the THA cohort, 1636 (82%) were Caucasian, 177 (9%) were African-American, and 186 (9%) were of other races. In the TKA cohort, 864 (63%) were Caucasian, 236 (17%) were African-American, and 275 (20%) were of other races. Surgical-time significantly differed between the groups that underwent THA (88.4vs.100.5vs.96.1; p < 0.001) with African-Americans requiring the longest operative time. Length-of-stay significantly differed in both THA (1.5vs.1.9vs.1.8; p < 0.001) and TKA (2.1vs.2.5vs.2.3; p < 0.001) cohorts, with African-Americans having the longest stay. Caucasians reported significantly higher PROM scores compared to non-Caucasians in both cohorts. All-cause emergency-department (ED) visits, 90-day postoperative events (readmissions&revisions), and discharge-disposition did not statistically differ in both cohorts.

CONCLUSION

Non-Caucasian patients demonstrated lower PROM scores when compared to Caucasian patients following TJA although the differences may not be clinically relevant. LOS was significantly longer for African-Americans in both THA and TKA cohorts. Further investigation identifying racial disparity interventions is warranted.

LEVEL OF EVIDENCE

Prognostic Level III.

Minority Race and Ethnicity is Associated With Higher Complication Rates After Revision Surgery for Failed Total Hip and Knee Joint Arthroplasty

BACKGROUND

Racial and ethnic disparities in access to hip and knee total joint arthroplasty (TJA) and postoperative outcomes have wide-reaching implications for patients and the health care system. The aim of this study is to evaluate the effect of ethnicity on clinical outcomes and complications following revision hip and knee TJA.

METHODS

A single-institution, retrospective analysis of a consecutive series of 4424 revision hip and knee TJA patients was evaluated. Student's t-test and chi-squared analysis were used to identify significant differences in patient demographics and clinical outcomes between Caucasians and various ethnic minorities, including African Americans, Hispanics, and Asians.

RESULTS

When compared with white patients, African American patients demonstrated a significantly higher BMI (P = .04), ASA score (P = .04), length of hospital stay (P = .06), and postoperative infection rates (P = .04). Hispanics demonstrated a significantly higher BMI (P = .04), when compared with white patients, alongside a significantly higher risk for postoperative infection (P < .01). African American demonstrated a significantly higher ASA score (P = .02; P = .03), when compared with Hispanics and Asians, alongside a significantly increased length of stay (P = .01) and higher risk for postoperative infection (P = .02).

CONCLUSION

The study findings demonstrate an underutilization of revision TJA by ethnic minority groups, suggesting that disparities in access to orthopedic surgery increase from primary to revision surgery despite higher failure rates of minority ethnic groups reported after primary TJA surgery. In addition, inferior postoperative outcomes were associated with African Americans and Hispanics, when compared to white patients, with African Americans demonstrating the highest risk of postoperative complications.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Where Do We Stand Today on Racial and Ethnic Health Disparities? An Analysis of Primary Total Hip Arthroplasty From a 2011-2017 National Database

Background

Little is known about the persistence of health disparities in joint arthroplasty. The objective of this study was to update our knowledge on the state of racial and ethnic disparities in total hip arthroplasty (THA).

Methods

Patients undergoing primary, elective THA using the 2011-2017 American College of Surgeons National Surgical Quality Improvement Program were retrospectively reviewed. Five minority groups (non-Hispanic black or African American, Hispanic or Latino, Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander) were compared with non-Hispanic whites. The primary outcomes were in the differences in demographic characteristics, comorbidities, perioperative characteristics, THA utilization, length of stay (LOS), and 30-day adverse events (mortality, readmission, reoperation, and complications).

Results

A total of 155,870 patients were identified with racial and ethnic data available on 134,961 (86.6%) of them. Non-Hispanic white patients comprised 74.5% of all THA procedures. Except for Asians, all minority groups were more likely to be younger, have a higher body mass index, and smoke tobacco (P < .001). There were higher rates of nonprimary osteoarthritis, procedure length exceeding 100 minutes, and comorbidities among all minority groups. All minority groups, except Asian and Hawaiians or Pacific Islanders, were more likely to require an LOS >2 days. Blacks were more likely to develop surgical or medical complications (odds ratio [OR]: 1.21 and 1.2, respectively), whereas Hispanics or Latinos were more likely to develop surgical complications (OR: 1.28). American Indians or Alaska Natives were more likely to undergo reoperations (OR: 1.91).

Conclusions

Health disparities persist among minority groups with respect to comorbidities, THA utilization, LOS, and complications. Blacks and Hispanics or Latinos appear to be the most impacted by these disparities.

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans

BACKGROUND

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients.

METHODS

Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery.

RESULTS

On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty.

CONCLUSION

Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population

BACKGROUND

Prior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population.

METHODS

A US integrated health system's total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders.

RESULTS

Of 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78).

CONCLUSION

We observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities.

LEVEL OF EVIDENCE

Level III.

Racial/Ethnic Disparities in Physical Function Before and After Total Knee Arthroplasty Among Women in the United States

IMPORTANCE

Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated.

OBJECTIVE

To examine trajectories of PF by race/ethnicity before and after TKA among older women.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among the prospective Women's Health Initiative with linked Medicare claims data. A total of 10 325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017.

EXPOSURES

Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively).

MAIN OUTCOMES AND MEASURES

Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time.

RESULTS

In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, -5.8 [95% CI, -8.0 to -3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, -7.8 [95% CI, -10.8 to -4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, -3.0 [95% CI, -5.3 to -0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods.

CONCLUSIONS AND RELEVANCE

This study suggests that black women had significantly poorer PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises.

The association between race/ethnicity and outcomes following primary shoulder arthroplasty

BACKGROUND

Although prior studies have reported health disparities in total knee and hip arthroplasty, few have evaluated the effect of race/ethnicity on total shoulder arthroplasty, particularly in a setting in which patients have uniform access to care. Because the procedural volume of shoulder arthroplasty has increased dramatically over the past decade, evaluating the association between race/ethnicity and postoperative outcomes is warranted. We sought to evaluate racial/ethnic disparities in adverse postoperative events within a universally insured shoulder arthroplasty cohort in an integrated health care system.

METHODS

An integrated health care system's registry was used to identify patients who underwent elective primary (total or reverse) shoulder arthroplasty from 2005 to 2016. Four mutually exclusive race/ethnicity groups were investigated: white, Asian, black, and Hispanic. Racial differences were evaluated using Cox proportional hazards regression for all-cause revision and conditional logistic regression for 90-day unplanned readmissions and 90-day emergency department (ED) visits while adjusting for confounders.

RESULTS

Of the 8360 shoulder procedures, 2% were performed in Asian patients; 5%, black patients; 9%, Hispanic patients; and 84%, white patients. Compared with white patients, Hispanic patients had a 44% lower revision risk (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97). Black patients had a 45% higher likelihood of a 90-day ED visit (odds ratio, 1.45; 95% confidence interval, 1.12-1.89).

CONCLUSION

We found minority groups to have revision and unplanned readmission risks that were similar to or lower than those of white patients. However, black patients had a higher likelihood of ED visits. Further investigation is needed to determine the reasons for this disparity and identify interventions to mitigate unnecessary ED visits.

Racial Differences in Pain and Function Following Knee Arthroplasty: A Secondary Analysis From a Multicenter Randomized Clinical Trial

OBJECTIVE

The assessment of racial differences in pain and function outcome following knee arthroplasty (KA) has received little attention despite very substantial literature exploring a variety of other prognostic factors. The present study was undertaken to determine whether race was associated with KA outcome after accounting for potential confounding factors.

METHODS

We conducted a secondary analysis of a randomized clinical trial of 384 participants with moderate-to-high pain catastrophizing who underwent KA. Preoperative measures included race/ethnicity status as well as a variety of potential confounders, including socioeconomic status, comorbidity, and bodily pain. Outcome measures were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scales as well as performance measures. Linear mixed-effects models compared outcomes over a 1-year follow-up period for African American versus non-African American participants.

RESULTS

WOMAC pain scores differences for African American versus non-African American participants averaged ~2 points in unadjusted analyses and 1-1.5 points in adjusted analyses. In adjusted analyses, follow-up WOMAC function scores differed by 6 points for African Americans compared to non-African Americans (P = 0.002).

CONCLUSION

African Americans generally had worse pain, function, and performance prior to KA and worse scores after surgery, but differences were small and attenuated by ~25-50% after adjustment for potential confounding. Only WOMAC function scores showed clinically important postsurgical differences in adjusted analyses. Clinicians should be aware that after adjustment for potential confounders, African Americans have approximately equivalent outcomes compared to others, with the exception of WOMAC function score.

Using Cluster Analysis to Identify Patient Factors Linked to Differential Functional Gains After Total Knee Arthroplasty

BACKGROUND

The basis of poor outcomes following total knee arthroplasty (TKA) is multifactorial. Previous research aimed at predicting outcome following TKA focuses largely on outcomes measured between two specific time points (pre-to post-TKA). Analysis of outcomes measured over multiple time points (trajectory) may expose relationships between patients' characteristics and longitudinal outcome patterns that may otherwise remain obscured.

METHODS

The current study analyzed Short Form 36 Physical Component Score (PCS) trajectories of 656 patients composed of 3 time points over a 1-year period. Clusters were constructed utilizing MultiExperiment Viewer hierarchical clustering algorithm. Statistical significance of these clusters was assessed using MeV's built-in bootstrapping method. Patient characteristics of the resulting statistically conserved clusters were summarized and compared using Wilcoxon rank-sum test or chi-squared test as appropriate.

RESULTS

Two distinct clusters of outcome trajectory were identified. Cluster 1 included 550 patients (84%) who demonstrated persistent PCS improvement at 6 and 12 months. Cluster 2 included 106 patients (16%) who demonstrated decline in PCS at 6 months followed by improvement at 12 months. Cluster 1 achieved earlier success, greater absolute mental and physical health scores as compared to Cluster 2 (P < .05), and demonstrated higher baseline mental health scores, lower baseline PCS, and a significantly higher proportion of non-Hispanic Whites (P ≤ .05).

CONCLUSION

Cluster analysis identified distinct functional outcome trajectories following TKA. Specific differentiating patient factors were associated with differing trajectories. Future studies should focus on this method's ability to inform predictive models regarding patient outcomes.