Association between abductor tears and hip pathology: A nationwide large cohort study

Introduction

Although gluteal tears have been observed in a substantial percentage of total hip arthroplasty (THA) patients and hip osteoarthritis (OA) has been shown to alter the function of the gluteal muscles, the association between gluteal tears and hip OA has not been characterized. Therefore, we evaluated (1) the overlap between hip OA and gluteal tears, (2) the relative risks of gluteal tears in patients who have hip OA, and (3) gluteal tear-free survival after diagnosis or treatment for hip osteoarthritis.

Methods

This retrospective study sourced data from TriNetX, a research network that aggregates data from over 92 million patients. Relative risks for gluteal tears were calculated for known risk factors for gluteal tears, age ≥45 years, female sex, and obesity, as well as for hip OA, hip injections, and THA. A subgroup analysis was performed utilizing a Cox proportional hazard model for patients who were diagnosed with hip OA, received a hip injection, or underwent THA in 2015 to assess gluteal tear-free survival over a 9-year timeframe.

Results

There was a large degree of overlap between patients with hip OA and gluteal tears, as 17.9% of patients with hip OA and 27.5% of patients with a gluteal tear also had the other pathology. Hip OA was associated with a markedly increased risk of a gluteal tear compared to healthy controls (Relative risk: 26.75, 95% CI: 26.64-26.86). Upon controlling for the established risk factors of gluteal tears, patients with hip OA had a markedly more likely to subsequently be diagnosed with an abductor tear (Hazard ratio: 12.46, 95% CI: 11.75-13.22).

Conclusion

Overall, these findings suggest a strong association between hip OA and the development of gluteal tears, in which further investigation is merited to determine the biomechanical pathophysiology underlying this potential relationship to inform prevention and treatment strategies.

Are robotic-assisted and computer-navigated total hip arthroplasty associated with superior outcomes in patients who have hip dysplasia?

Introduction

Robotic-assisted (RA) and computer-navigated (CN) total hip arthroplasty (THA) have been demonstrated to improve component placement accuracy compared to manual THA (mTHA) for primary osteoarthritis. As hip dysplasia presents several additional challenges in component placement accuracy and leg length discrepancy (LLD) correction during THA, a systematic review was conducted to evaluate whether utilizing these platforms may be associated with superior outcomes over mTHA in patients who have hip dysplasia.

Methods

PubMed, Medline, EBSCOhost, and Google Scholar were searched on September 13, 2023 to identify comparative studies published after January 1, 2000 that evaluated outcomes of RA-THA or CN-THA in patients who have hip dysplasia. The query yielded 197 unique articles, which were screened for alignment with the study aims. After screening, 10 studies fulfilled all inclusion criteria, comprising 946 patients. Risk of bias was evaluated via the Methodological Index for Nonrandomized Studies tool, and the mean score was 21.2 ± 1.5.

Results

Both RA-THA and CN-THA were not associated with improved acetabular anteversion and inclination when evaluating Crowe I-IV types altogether compared to mTHA, but studies reported improved accuracy for each Crowe I and II cases when assessed individually. While studies reporting acetabular cup placement within the Lewinnek and Callanan safe zones consistently found higher odds of accurate positioning for RA-THA versus mTHA, accuracy in achieving targeted center of rotation was mixed. Also, studies reported no difference in LLD restoration for RA-THA and CN-THA compared to mTHA. While operative time may be increased when utilizing these platforms, they may also expedite specific sequences, offsetting most of the increase in operative time.

Conclusion

This review highlights the advantages of RA-THA and CN-THA for patients who have DDH, particularly when treating Crowe I and II types as superior radiographic outcomes were achieved with these intraoperative technologies. However, there remains a need for studies to investigate whether this results in patient-reported outcome measures.

Stepping Up Recovery: Integrating Patient Reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty

BACKGROUND

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.

METHODS

Analysis of a multicenter prospective longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N=1,844 TKA patients and N=489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multi-level home environment (N=896 TKA patients and N=258 PKA patients) were included in analysis of stair flight counts Pearson correlation coefficients were calculated to determine correlations between variables.

RESULTS

Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r=-0.14, p<0.0001) and 1-month follow-up (r=-0.14, p<0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r=-0.16, p<0.0001) and 1-month follow-up (r=-0.11, p=0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r=0.19, p<0.0001) and 1-month postoperative (r=0.17, p<0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r=0.13, p=0.0002) and at 1-month postoperatively (r=0.10, p=0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.

CONCLUSION

Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, healthcare providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

Resilience as a psychiatric factor affecting outcomes after total joint arthroplasty: a systematic review

INTRODUCTION

Mental and psychiatric status continue to be underscreened prior to total joint arthroplasty (TJA). Research on the role of resilience as a psychiatric factor affecting TJA outcomes remains limited. Therefore, our systematic review sought to evaluate the impact of patient resilience in TJA.

METHODS

A systematic review of the literature from the Pubmed, MEDLINE, EBSCOhost, and Google Scholar online databases was performed in abidance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting on outcomes following primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) segregated by patient resilience were included. Case reports, reviews, meta-analyses, and conference abstracts were excluded. Primary outcomes of interest included patient-reported outcomes (PROs), surgical outcomes, and postoperative opioid consumption.

RESULTS

Twelve articles were included reporting on a total of 1,577 TJAs. There was a strong agreement that the Patient Reported Outcomes Measurement Information System (PROMIS)-Physical Health and Mental Health components were strongly predicted by patient resilience. However, there was inconclusive evidence regarding the impact of resilience on UCLA Activity Scales (UCLA) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcomes as well as postoperative hip and knee function. Similarly, conflicting evidence was presented regarding the effect of resilience on length of stay (LOS). Greater resilience was associated with reduced opioid usage in the immediate inpatient postoperative period. However, resilience had no significant effect on opioid requirements in the postoperative outpatient follow-up time frame.

CONCLUSION

The present analysis demonstrated mixed, inconclusive evidence regarding the impact of resilience on postoperative outcomes. The paucity of research evaluating this relationship warrants further investigation, examining both short and long-term outcomes. Due to the limited literature evaluating resilience as a predictor of outcomes following TJA, we cannot definitively rule out resilience as a valuable metric and must further examine its utility as a preoperative screening tool.

LEVEL OF EVIDENCE

III.

Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies

Robotic assisted (RA) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting novel platforms challenging. Therefore, we conducted a systematic review to assess the learning curve associated with RA-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA). PubMed, MEDLINE, EBSCOhost, and Google Scholar were searched on June 16, 2023, to identify studies published between January 1, 2000 and June 16, 2023 (PROSPERO registration: CRD42023437339). The query yielded 655 unique articles, which were screened for eligibility. The final analysis included 11 articles, evaluating 1351 THA procedures. Risk of bias was assessed via the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 21.3 ± 0.9. RA-THA provided immediate improvements in acetabular component placement accuracy and radiographic outcomes compared to M-THA, with little to no experience required to achieve peak proficiency. A modest learning curve (12-17 cases) was associated with operative time, which was elevated compared to M-THA (+ 9-13 min). RA-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes. Surgeons should expect to experience increased operative times, which become less pronounced or equivalent to M-THA after a modest caseload.

5-Factor Modified Frailty Index as a Predictor of Outcomes After Hemiarthroplasty or Total Hip Arthroplasty for Femoral Neck Fracture

INTRODUCTION

Although the 5-factor modified frailty index (mFI-5) has been shown to be an independent predictor of complications after primary total hip arthroplasty (THA), its predictive value has not been evaluated in the setting of hip fracture. We therefore assessed the utility of mFI-5 score as an independent predictor of morbidity and mortality in patients who underwent THA or hemiarthroplasty for femoral neck fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients with femoral neck fractures treated with THA or hemiarthroplasty between 2006 and 2020. A multivariate logistic regression analysis was done using mFI-5 as a predictor while controlling for baseline demographic and clinical variables.

RESULTS

In total, 45,185 patients (hemiarthroplasty: 37,645; THA: 7,540) were identified. For hemiarthroplasty patients, the mFI-5 strongly predicted risk of any complication (OR, 1.1; 95% CI, 1.1 to 1.2; P < 0.001), bleeding (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001), and readmission (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001). For THA patients, the mFI-5 was a strong predictor of any complication (OR, 1.2; 95% CI, 1.0 to 1.3; P = 0.023), pneumonia (OR, 1.4; 95% CI, 1.0 to 2.0; P = 0.047), and readmission (OR, 1.3; 95% CI, 1.1 to 1.6; P = 0.004).

DISCUSSION

The mFI-5 is an independent predictor of morbidity and complications after hemiarthroplasty and THA for femoral neck fracture. Importantly, readmission risk was predicted by the mFI-5. The mFI-5 may present a valuable clinical tool for assessment of high-risk patients who might require additional resources and specialized care after femoral neck fracture.

Association Between Digitally Provided Education and 90-Day Return to Sexual Activity Following Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Contemporary total knee arthroplasty patients have increased expectations of returning to predisease function, including sexual activity (SA). The purpose of this study was to determine whether patients using a digital care management platform (DCMP) were more likely to have a higher rate and frequency of return to SA.

METHODS

We conducted an exploratory analysis of a prospective, multicenter, randomized controlled trial that enrolled patients undergoing total knee arthroplasty. A total of 304 patients were randomized to a DCMP (n = 119) providing preoperative and postoperative education regarding return to SA or standard postoperative care (control group; n = 185). Return to SA, assessed via questionnaire, patient-reported outcome measures, Timed Up and Go test, single leg stance, active range of motion and need for manipulation under anesthesia were assessed at 90 days postoperatively.

RESULTS

More patients in the DCMP group returned to SA compared to control at 90 days (58.4 versus 39.6%, P = .018); however, the control group resumed SA sooner (33.1 versus 42.0 days, P = .023). Patients who returned to SA were younger (61.6 versus 65.9 year), more often men (56 versus 35%) (P < .001), higher performing on the Timed Up and Go and single leg stance tests (P < .001), and had greater active range of motion (P = .007). There were no differences in patient-reported outcome measures or need for manipulation under anesthesia between patients that returned to SA and those who did not.

CONCLUSIONS

More patients using a DCMP resumed SA at 90 days; however, patients in the control group returned to SA sooner. Those who returned to SA were younger, possessed greater physical function, and were more often men.

Assessing the Readability of Clinical Trial Consent Forms for Surgical Specialties

INTRODUCTION

To evaluate the readability of surgical clinical trial consent forms and compare readability across surgical specialties.

METHODS

We conducted a cross-sectional analysis of surgical clinical trial consent forms available on ClinicalTrials.gov to quantitatively evaluate readability, word count, and length variations among different specialties. The analysis was performed between November 2022 and January 2023. A total of 386 surgical clinical trial consent forms across 14 surgical specialties were included.

RESULTS

The main outcomes were language complexity (measured using Flesch-Kincaid Grade Level), number of words (measured as word count), time to read (measured at reading speeds of 240 per min), and readability (measured by Flesch Reading Ease Score, Gunning Frog Index, Simple Measures of Gobbledygook Index, FORCAST, and Automated Readability Index). The surgical consent forms were a mean (standard deviation) of 2626 (1668) words long, with a mean of 12:53 min to read at 240 words per min. None of the surgical specialties had an average readability level of sixth grade or lower across all six indices, and only 16 out of 386 (4%) clinical trials met the recommended reading level. Furthermore, there was no significant difference in reading grade level between surgical specialties based on the Flesch-Kincaid Grade Level and Flesch Reading Ease indices.

CONCLUSIONS

Our findings suggest that current surgical clinical trial consent documents are too long and complex, exceeding the recommended sixth-grade reading level. Ensuring readable clinical trial consent forms is not only ethically responsible but also crucial for protecting patients' rights and well-being by facilitating informed decision-making.

An In-Depth Analysis of Public and Private Research Funding in Orthopaedic Surgery from 2015 to 2021

BACKGROUND

Understanding the trends and patterns of research funding can aid in enhancing growth and innovation in orthopaedic research. We sought to analyze financial trends in public orthopaedic surgery funding and characterize trends in private funding distribution among orthopaedic surgeons and hospitals to explore potential disparities across orthopaedic subspecialties.

METHODS

We conducted a cross-sectional analysis of private and public orthopaedic research funding from 2015 to 2021 using the Centers for Medicare & Medicaid Services Open Payments database and the National Institutes of Health (NIH) RePORTER through the Blue Ridge Institute for Medical Research, respectively. Institutions receiving funds from both the NIH and the private sector were classified separately as publicly funded and privately funded. Research payment characteristics were categorized according to their respective orthopaedic fellowship subspecialties. Descriptive statistics, Wilcoxon rank-sum tests, and Mann-Kendall tests were employed. A p value of <0.05 was considered significant.

RESULTS

Over the study period, $348,428,969 in private and $701,078,031 in public research payments were reported. There were 2,229 unique surgeons receiving funding at 906 different institutions. The data showed that a total of 2,154 male orthopaedic surgeons received $342,939,782 and 75 female orthopaedic surgeons received $5,489,187 from 198 different private entities. The difference in the median payment size between male and female orthopaedic surgeons was not significant. The top 1% of all practicing orthopaedic surgeons received 99% of all private funding in 2021. The top 20 publicly and top 20 privately funded institutions received 77% of the public and 37% of the private funding, respectively. Private funding was greatest (31.5%) for projects exploring adult reconstruction.

CONCLUSION

While the amount of public research funding was more than double the amount of private research funding, the distribution of public research funding was concentrated in fewer institutions when compared with private research funding. This suggests the formation of orthopaedic centers of excellence (CoEs), which are programs that have high concentrations of talent and resources. Furthermore, the similar median payment by gender is indicative of equitable payment size. In the future, orthopaedic funding should follow a distribution model that aligns with the existing approach, giving priority to a nondiscriminatory stance regarding gender, and allocate funds toward CoEs.

CLINICAL RELEVANCE

Securing research funding is vital for driving innovation in orthopaedic surgery, which is crucial for enhancing clinical interventions. Thus, understanding the patterns and distribution of research funding can help orthopaedic surgeons tailor their future projects to better align with current funding trends, thereby increasing the likelihood of securing support for their work.

Photodynamic bone stabilization for traumatic and pathologic fractures: a systematic review of utilization, complications, and patient-reported outcomes

INTRODUCTION

The photodynamic bone stabilization system (PBSS) was was developed in 2010, and in 2018 gained FDA approval in the United States. Given its relative novelty, our analysis sought to analyze the available literature exploring the indications, outcomes, and complications of the PBSS.

METHODS

We performed a systematic review (PROSPERO registration of study protocol: CRD42022363065, October 8th, 2022). PubMed, EBSCOHost, and Google Scholar electronic databases were queried to identify articles evaluating PBSS in the treatment of pathologic or traumatic fractures between January 1 2010 and 15 October 2022. The quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies tool.

RESULTS

Our initial search yielded 326 publications, which were then screened for appropriate studies that aligned with the purpose of our review. A total of thirteen studies, comprising seven case series, four case reports, and two cohort studies. The total sample size of the included studies consisted of 345 patients, with 242 females (70%) and 103 males (30%). The implants were most commonly utilized in the humerus (41%), radius (12%), and metacarpal (12%). The most common complications were related to broken implants (5%) and dislocation (1%). Most studies reported complete fracture healing and return of full strength and range of motion.

CONCLUSION

Despite being a relatively novel technology, PBSS appears to be a viable option for fracture stabilization. Most studies included in our analysis reported complete fracture healing and return of function with minimal complications.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis

BACKGROUND

As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort.

METHODS

A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission.

RESULTS

A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001).

CONCLUSION

There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique

INTRODUCTION

The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA).

MATERIALS AND METHODS

A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs.

RESULTS

Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID).

CONCLUSIONS

Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

Are orthopedic clinical trials representative? An analysis of race and ethnicity reported in clinical trials between 2007 and 2022 : Running title: representation of clinical trials in orthopedic surgery

INTRODUCTION

Prior studies investigating the racial and ethnic representation of orthopedic trial participants have found low rates of reporting, but these studies are dated due to the passing of the National Institutes of Health Final Rule in 2017 requiring the reporting of racial and ethnic data among clinical trials. Therefore, we evaluated the representativeness of orthopedic clinical trials before and after the Final Rule.

METHODS

A cross-sectional survey of orthopaedic clinical trials registered at ClinicalTrials.gov between October 1, 2007 and May 20, 2023 was conducted. After identifying and screening 23,752 clinical trials, 1564 trials were included in the analysis. Trials started before the implementation of the Final Rule on January 18, 2017 were grouped and compared to trials that began after. Odds ratios (OR) were utilized to identify trial characteristics associated with reporting race/ethnicity data. One-proportion z tests compared the representation of each racial and ethnic category to the 2020 United States Census.

RESULTS

In total, 34% (544 of 1564) of orthopedic clinical trials evaluated reported the race of participants, while 28% (438 of 1564) reported ethnicity. Trials registered after the Final Rule were more likely to report racial (OR: 5.15, 95%CI: 3.72-7.13, p < 0.001) and ethnic (OR: 3.23, 95%CI: 2.41-4.33, p < 0.001) representation of participants. Compared with the distribution of race and ethnicity reported by the United States 2020 Census, orthopedic trials had 16.6% more White participants (95% CI 16.4%, 16.8%; p < 0.001), 3.2% fewer Black participants (95%CI 3.1%, 3.3%; p < 0.001), and 5.7% fewer Hispanic/Latino participants (95%CI 5.2%, 6.2%; p < 0.001). Trials with enrollment sizes over 100 participants were also more likely to report race and ethnicity, with odds increasing with increased sample size.

CONCLUSIONS

The Final Rule marginally improved the reporting of race and ethnicity in orthopedic clinical trials, and underrepresentation of Black or African American, Multiracial, and Hispanic populations persists.

LEVEL OF EVIDENCE

III.

Navigating the learning curve: assessing caseload and comparing outcomes before and after the learning curve of computer-navigated total hip arthroplasty

PURPOSE

Computer-navigated (CN) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting a novel platform challenging. Therefore, we conducted a systematic review to assess the learning curve associated with CN-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA).

METHODS

A search was conducted using PubMed, MEDLINE, EBSCOhost, and Google Scholar on June 16, 2023 to find research articles published after January 1, 2000 (PROSPERO registration: CRD4202339403) that investigated the learning curve associated with CN-THA. 655 distinct articles were retrieved and subsequently screened for eligibility. In the final analysis, nine publications totaling 847 THAs were evaluated. The Methodological Index for Nonrandomized Studies (MINORS) tool was utilized to evaluate the potential for bias, with the mean MINORS score of 21.3 ± 1.2.

RESULTS

CN-THA showed early advantages to M-THA for component placement accuracy and radiographic outcomes but longer operative times (+ 3- 20 min). There was a learning curve required to achieve peak proficiency in these metrics, though mixed methodologies made the required caseload unclear.

CONCLUSIONS

CN-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes, though CN-THA's advantages become more pronounced with experience. Surgeons should anticipate longer operative times during the learning curve for CN-THA, which lessen following a modest caseload. A more thorough evaluation of novel computer-navigated technologies would be enhanced by adopting a more uniform method of defining learning curves for outcomes of interest. Registration PROSPERO registration of the study protocol: CRD42023394031, 27 June 2023.

Early radiological outcomes of a fully porous bridging collar in lower-limb endoprosthetic reconstructions: a case-matched retrospective series to assess osseointegration

BACKGROUND

Limb-salvage surgery involving the utilization of endoprosthetic replacements is commonly employed following segmental bone resection for primary and secondary bone tumors. This study aimed to evaluate whether a fully porous bridging collar promotes early osseous integration in endoprosthetic replacements.

METHODS

We undertook a retrospective review of all lower-limb endoprostheses utilizing a fully porous endosteal bridging collar design. We matched this cohort with a conventional extra-osteal non-porous fully hydroxyapatite-coated grooved collar cohort according to surgical indication, implant type, resection length, age, and follow-up time. At 6, 12, and 24 months post-implantation, radiographs were assessed for the number of cortices with or without osseointegration on orthogonal radiographs. Each radiograph was scored on a scale of -4 to + 4 for the number of cortices bridging the ongrowth between the bone and the collar of the prosthesis. Implant survival was estimated using the Kaplan-Meier method, and the mean number of osseointegrated cortices at each time point between the collar designs was compared using a paired t-test.

RESULTS

Ninety patients were retrospectively identified and analyzed. After exclusion, 40 patients with porous bridging collars matched with 40 patients with conventional extra-osteal non-porous collars were included in the study (n = 80). The mean age was 63.4 years (range 16-91 years); there were 37 males and 43 females. The groups showed no difference in implant survival (P = 0.54). The mean number of cortices with radiographic ongrowth for the porous bridging collar and non-porous collar groups was 2.1 and 0.3, respectively, at 6-month (P < 0.0001), 2.4 and 0.5, respectively, at 12-month (P = 0.044), and 3.2 and -0.2, respectively, at 24-month (P = 0.18) radiological follow-up.

CONCLUSION

These findings indicate that fully porous bridging collars increased the number of cortices, with evidence of bone ongrowth between 6 and 24 months post-implantation. By contrast, extra-osteal collars exhibited reduced evidence of ongrowth between 6 and 24 months post-implantation. In the medium term, the use of a fully porous bridging collar may translate to a reduced incidence of aseptic loosening.

Automated digital templating of component sizing is accurate in robotic total hip arthroplasty when compared to predicate software

Accurate pre-operative templating of prosthesis components is an essential factor in successful total hip arthroplasty (THA), including robotically-assisted THA (RA-THA) techniques. We sought to validate the accuracy of a novel, robotic-optimized THA planning software compared to a predicate THA planner for component sizing. We analyzed a series of 199 patients who received manual THA (mTHA) and fluoroscopy-based RA-THA at a single institution. All cases were templated using a predicate pre-operative templating software. For RA-THA cases, the novel robotic-optimized pre-operative planner software was also used for templating. The differences between templated and implanted acetabular cup, femoral head, and stem component sizes were compared based on matching within 1, 2, and ≥3 sizes. Differences in templated and implanted femoral stem implant geometry were also compared. The robot-optimized pre-operative RA-THA plans demonstrated equivalent accuracy to that of predicate pre-operative plans for both RA-THA and mTHA cases. Templated acetabular cups (90.4 vs. 86.8 vs. 82.8; p = 0.421), femoral stems (76.0 vs. 65.1 vs. 67.7; p = 0.096), and femoral heads (91.3 vs. 96.2 vs. 88.2; p = 0.302) were within +/-1 size of implanted components. No significant differences were detected in the proportion of matching templated and implanted stem geometry across the study cohorts.

Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance

BACKGROUND

While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated.

METHODS

This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores.

RESULTS

No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468).

CONCLUSION

Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.

Impact of external beam radiation on total shoulder arthroplasty outcomes: a propensity-matched cohort study

BACKGROUND

External beam radiation therapy has a number of deleterious effects on the body, and a number of post-operative complications have been reported for several surgeries including total knee arthroplasty. However, few studies have investigated the impact of external beam radiation therapy for total shoulder arthroplasty (TSA). Our study aimed to assess the systemic and joint complications associated with TSA in patients with prior radiation exposures, as well as evaluate the surgical outcomes of radiation patients compared to non-radiation TSA patients.

MATERIALS AND METHODS

A retrospective cohort analysis was conducted using the TriNetX Analytics Network. A 1:1 propensity score matching function was utilized to create two cohorts with matched baseline characteristics within the TriNetX network. Comparisons of the primary and secondary outcomes between the two cohorts were made using odds ratios. A p value of < 0.05 was determined to be significant.

RESULTS

A total of 75,510 patients that received TSA were identified with 1505 having a history of radiation therapy (RT) and 73,605 with no radiation therapy (non-RT). After propensity matching, both groups contained 1484 patients. RT patients were at higher risk for developing prosthetic joint infection, acute renal failure, altered mental state, cerebrovascular event, DVT, PE, pneumonia, respiratory failure, and UTI compared to non-RT patients at different time points (p < 0.5).

CONCLUSION

Patients with prior history of external beam radiation undergoing TSA had a higher risk of systemic complications and prosthetic joint infection compared to patients without a prior history. These complications suggest a more complicated post-operative management course for these patients.

No clinically significant differences in patient-reported outcome measures across total hip arthroplasty approaches

INTRODUCTION

As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes.

METHODS

5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs).

RESULTS

No differences between the DAA and other approaches were observed when evaluating HOOS (MD -0.28; 95% CI, -1.98-1.41; p = 0.74), HHS (MD 2.38; 95% CI, -0.27-5.03; p = 0.08), OHS (MD 1.35; 95% CI, -2.00-4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, -0.36-12.12; p = 0.06), VAS-pain (MD -0.32; 95% CI, -0.68-0.04; p = 0.08), and WOMAC-pain (MD -0.73; 95% CI, -3.85-2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54-4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01-0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis.

CONCLUSIONS

Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

Is Discharge Within a Day Following Total Hip Arthroplasty Safe in the Septuagenarian and Octogenarian Population? A Propensity-Matched Cohort Study

BACKGROUND

Limited data exists on whether patients older than 70 can safely be discharged within a day (rapid discharge (RD)) following primary total hip arthroplasty (THA). The purpose of this study was to compare perioperative complications and readmission rates associated with RD in patients ≥70 years compared to longer lengths of stay following THA.

METHODS

A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients ≥70 years undergoing RD following THA were propensity matched to patients ≥70 years who had longer hospital stays (nonrapid discharge). Sub-analyses were performed for septuagenarians and octogenarians. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmissions. Following propensity matching, both groups contained 2,192 patients.

RESULTS

The RD patients were found to have shorter operative times (P < .001), less bleeding complications (P < .001), and were more likely to have home discharges (P < .001). The 2 cohorts did not differ in the remaining complications or 30-day postoperative period readmissions among all patients and when evaluating septuagenarians and octogenarians.

CONCLUSION

Patients ≥70 years undergoing RD following THA had comparable complication and readmission rates to patients older than 70 undergoing nonrapid discharge. Furthermore, RD patients were more likely to have home discharges and have shorter operations with less bleeding complications. Septuagenarians receiving RD were more likely to have an unplanned readmission. These data suggest that RD following THA can be performed safely in select patients older than 70.

Complications in Osteonecrosis Patients Following Total Knee Arthroplasty: A Propensity-Matched Cohort Study

BACKGROUND

Several studies have demonstrated high complication rates in osteonecrosis (ON) patients undergoing total hip arthroplasty. However, there is a paucity of literature regarding outcomes of total knee arthroplasty (TKA) in ON patients. Our study aimed to assess preoperative risk factors associated with the development of ON and determine the incidence of postoperative complications up to one year following TKA.

METHODS

A retrospective cohort study was conducted using a large national database. Patients who had a primary TKA and ON were isolated using Current Procedural Terminology code 27447 and ICD-10-CM code M87, respectively. A total of 185,045 patients were identified, including 181,151 patients who had a TKA and 3,894 patients who had a TKA and ON. After propensity matching, both groups each contained 3,758 patients. Intercohort comparisons of primary and secondary outcomes after propensity score matching were made using the odds ratio. A P value of < .01 was determined to be significant.

RESULTS

The ON patients were found to have an increased risk for prosthetic joint infection, urinary tract infection, deep vein thrombosis, pulmonary embolism, wound dehiscence pneumonia, and the development of heterotopic ossification at different time points. Osteonecrosis patients had an increased risk of revision at the 1-year time point (odds ratio = 2.068, P < .0001).

CONCLUSION

The ON patients had a higher risk of systemic and joint complications than non-ON patients. These complications suggest a more complicated management course for patients who have ON prior to and after TKA.

Total Hip Arthroplasty Outcomes in Patients Who Have a History of Prior Radiation

BACKGROUND

The purpose of this study was to assess the odds of developing medical and surgical adverse events following total hip arthroplasty (THA) in patients who have a history of radiation therapy (RT) for cancer.

METHODS

A retrospective cohort study was conducted using a national database to identify patients who underwent primary THA (Current Procedural Terminology code 27130) from 2002 to 2022. Patients who had a prior RT were identified by International Classification of Diseases, Tenth Revision, Clinical Modification codes Z51.0 (encounter for antineoplastic RT), Z92.3 (personal history of irradiation), or Current Procedural Terminology code 101843 (radiation oncology treatment). One-to-one propensity score matching was conducted to generate 3 pairs of cohorts: 1) THA with/without a history of RT; 2) THA with/without a history of cancer; and 3) THA patients who have a history of cancer treated with/without RT. Surgical and medical complications were assessed at the 30-day, 90-day, and 1-year postoperative periods.

RESULTS

Patients who have a history of RT had higher odds of developing anemia, deep vein thrombosis, pneumonia, pulmonary embolism, and prosthetic joint infection at all intervals. When controlling for a history of cancer, RT was associated with an increased risk of pulmonary embolism, heterotrophic ossification, prosthetic joint infection, and periprosthetic fracture at all postoperative time points. There was additionally an increased risk of aseptic loosening at 1 year (odds ratio: 2.0, 95% confidence interval: 1.2 to 3.1).

CONCLUSION

These findings suggest that patients who have a history of antineoplastic RT are at an increased risk of developing various surgical and medical complications following THA.

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform

Robotic-assisted total hip arthroplasty (THA) using a computerized-tomography (CT) based workflow increases surgical time relative to traditional manual technique. The purpose of this investigation was to compare the intra-operative efficiencies of two robotic THA systems: a fluoroscopy-based platform (FL-RTHA) and a contemporary, CT-based (CT-RTHA) platform. A review of 107 consecutive FL-RTHA and 159 CT-RTHA primary, direct anterior approach (DAA) THA procedures was conducted. All cases were performed by one of two surgeons operating at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included averages and consistencies (variances) for surgical times and operating room (OR) times. A secondary outcome was to quantify the duration of robot-active phases in the FL-RTHA workflow. The FL-RTHA cohort experienced shorter surgical times (38.71 min ± 7.00 vs. 75.33 min ± 11.38; p < 0.001) and OR times (101.35 min ± 12.22 vs. 156.74 min ± 17.79; p < 0.001) compared to the CT-RTHA cohort. Surgical times and OR times were both more consistent in the FL-RTHA cohort compared to the CT-RTHA cohort (p < 0.001). Patients who underwent DAA THA with the assistance of a fluoroscopy-based robotic system experienced shorter and more consistent surgical times and OR times compared to patients who underwent similar DAA THA procedures with a contemporary, CT-based robotic platform.

Implant Selection Strategies for Total Joint Arthroplasty: The Effects on Cost Containment and Physician Autonomy

BACKGROUND

With continued declines in reimbursement for total joint arthroplasty, health systems have explored implant cost containment measures to generate sustainable margins. This review evaluated how implementation of (1) implant price control programs, (2) vendor purchasing agreements, and (3) bundled payment models affected implant costs and physician autonomy in implant selection.

METHODS

PubMed, EBSCOhost, and Google Scholar were searched to identify studies that evaluated the efficacy of total hip or total knee arthroplasty implant selection strategies. The review included publications between January 1, 2002, and October 17, 2022. The mean Methodological Index for Nonrandomized Studies score was 18.3 ± 1.8.

RESULTS

A total of 13 studies (32,197 patients) were included. All studies implementing implant price capitation programs found decreased implant costs, ranging 2.2 to 26.1% and increased utilization of premium implants. Most studies found bundled payments models reduced total joint arthroplasty implant costs with greatest reduction being 28.9%. Additionally, while absolute single vendor agreements had higher implant costs, preferred single vendor agreements had reduced implant costs. When given price constraints, surgeons tended to select more premium implants.

CONCLUSION

Alternative payment models that incorporated implant selection strategies saw reduced costs and surgeon utilization of premium implants. The study findings encourage further research on implant selection strategies, which must balance the goals of cost containment with physician autonomy and optimized patient care.

LEVEL OF EVIDENCE

Level III.

Is Penicillin Allergy a Clinical Problem? A Systematic Review of Total Joint Arthroplasty Procedures With Implications for Patient Safety and Antibiotic Stewardship

BACKGROUND

Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection.

METHODS

PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection).

RESULTS

All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients.

CONCLUSIONS

Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Fluoroscopy-based robotic assistance for total hip arthroplasty improves acetabular cup placement accuracy for obese patients compared to the manual, fluoroscopic- assisted technique

BACKGROUND

Patient obesity is a risk factor for poor acetabular cup positioning in total hip arthroplasty (THA).

OBJECTIVE

To assess the impact of using a novel, fluoroscopy-based robotic THA system on acetabular cup placement in obese versus non-obese patients.

METHODS

A review of 105 consecutive manual unassisted (mTHA) (47 Obese/58 Non-obese) and 102 robotic-assisted (RA-THA) (50 Obese/52 Non-obese) primary, direct anterior approach THA procedures was conducted. All cases were performed by a single surgeon, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Obesity was defined as a Body Mass Index (BMI) ⩾ 30 kg/m2. Outcomes included acetabular cup inclination and anteversion, and the proportion of cups within the Lewinnek safe-zone.

RESULTS

Obese patients in the mTHA cohort had larger cup inclination angles on average compared to non-obese patients (44.82∘± 6.51 vs. 41.39∘± 6.75; p= 0.009). Obese mTHA patients were less likely to have cup placement within the Lewinnek zone compared to non-obese mTHA patients (0.48 vs. 0.67; p= 0.027). Obesity had no effect on the accuracy of RA-THA.

CONCLUSION

Obesity affects the placement of the acetabular component in manual THA. The novel, fluoroscopy-based robotic THA system in this study demonstrated accurate cup placement regardless of obesity status.

Fluoroscopy-based robotics in total hip arthroplasty mitigates laterality-based differences in acetabular cup placement when compared to the manual, fluoroscopic- assisted technique

BACKGROUND

Robotic assistance in total hip arthroplasty (RA-THA) has been shown to minimize laterality-based differences in acetabular cup positioning.

OBJECTIVE

To determine if the use of a novel, fluoroscopy-based RA-THA system mitigates differences in acetabular cup placement between left (L) and right (R) side hip procedures, when compared to manual, fluoroscopic-assisted technique.

METHODS

We conducted a retrospective review of 106 consecutive mTHA (40 L/66 R) and 102 RA-THA (48 L/54 R) primary direct anterior approach procedures. All cases were performed by a single right-hand-dominant surgeon, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included acetabular cup inclination and anteversion, and the proportion of cups within the Lewinnek safe-zone.

RESULTS

The average inclination of mTHA L cases was smaller than that of mTHA R cases (41.10∘± 7.38 vs. 43.97∘± 6.27; p= 0.04). For RA-THA, L and R cup angles were similar. There were fewer overall mTHA hips within the Lewinnek safe-zone compared to RA-THA (0.59 vs. 0.78; p= 0.003), as well as fewer mTHA R cases than RA-THA R cases (0.59 vs. 0.80; p= 0.03) within safe zone.

CONCLUSION

Use of a novel, fluoroscopy-based robotic system mitigates laterality-based differences in acetabular cup placement that were observed in a manual, fluoroscopic-assisted cohort.

Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty

BACKGROUND

Robot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique.

METHODS

Retrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients.

RESULTS

The RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups.

CONCLUSIONS

Fluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care.

Understanding the use of artificial intelligence for implant analysis in total joint arthroplasty: a systematic review

INTRODUCTION

In recent years, there has been a significant increase in the development of artificial intelligence (AI) algorithms aimed at reviewing radiographs after total joint arthroplasty (TJA). This disruptive technology is particularly promising in the context of preoperative planning for revision TJA. Yet, the efficacy of AI algorithms regarding TJA implant analysis has not been examined comprehensively.

METHODS

PubMed, EBSCO, and Google Scholar electronic databases were utilized to identify all studies evaluating AI algorithms related to TJA implant analysis between 1 January 2000, and 27 February 2023 (PROSPERO study protocol registration: CRD42023403497). The mean methodological index for non-randomized studies score was 20.4 ± 0.6. We reported the accuracy, sensitivity, specificity, positive predictive value, and area under the curve (AUC) for the performance of each outcome measure.

RESULTS

Our initial search yielded 374 articles, and a total of 20 studies with three main use cases were included. Sixteen studies analyzed implant identification, two addressed implant failure, and two addressed implant measurements. Each use case had a median AUC and accuracy above 0.90 and 90%, respectively, indicative of a well-performing AI algorithm. Most studies failed to include explainability methods and conduct external validity testing.

CONCLUSION

These findings highlight the promising role of AI in recognizing implants in TJA. Preliminary studies have shown strong performance in implant identification, implant failure, and accurately measuring implant dimensions. Future research should follow a standardized guideline to develop and train models and place a strong emphasis on transparency and clarity in reporting results.

LEVEL OF EVIDENCE

Level III.

The quality of online information on Legg-Calvé-Perthes disease: can we do better?

INTRODUCTION

As patients increasingly utilize the Internet to obtain health-related information, the accuracy and usability of information prove critical, especially for patients and parents seeking care for relatively common orthopedic childhood disorders such as Legg-Calvé-Perthes (LCP) disease. Therefore, the purpose of this study is to evaluate available online health information regarding LCP disease. The study specifically seeks to (1) examine the accessibility, usability, reliability, and readability of online information, (2) compare the quality of sites from different sources, and (3) determine whether Health on the Net Foundation Code (HON-code) certification guarantees higher quality of information.

MATERIALS AND METHODS

Websites from a query of both Google and Bing were compiled and scored using the Minervalidation tool (LIDA), an appraisal tool quantifying website quality, along with the Flesch-Kinkaid (FK) analysis, a metric assessing readability of content. All sites were organized based on source category [academic, private physician/physician group, governmental/non-profit organization (NPO), commercial, and unspecified] and HON-code certification.

RESULTS

Physician-based and governmental/NPO sites had the highest accessibility, the unspecified site group were the most reliable and usable, and the physician-based group was found to require the least education to comprehend. Unspecified sites had a significantly higher rating of reliability than physician sites (p = 0.0164) and academic sites (p < 0.0001). HON-code-certified sites were found to have greater scores across quality domains along with being easier to read compared to sites without certification, with significantly higher reliability scoring (p < 0.0001).

CONCLUSIONS

As a whole, information on the Internet regarding LCP disease is of poor quality. However, our findings also encourage patients to utilize HON-code-certified websites due to their significantly higher reliability. Future studies should analyze methods of improving this publicly available information. Additionally, future analyses should examine methods for patients to better identify reliable websites, as well as the best mediums for optimized patient access and comprehension.

Management of acetabular bone loss in revision total hip replacement: a narrative literature review

Background and Objective

Due to growing numbers of primary total hip replacement (THR), the revision THR burden is also increasing. Common indications for revision are osteolysis, infection, instability, and mechanical failure of implants, which can cause acetabular bone loss. Massive acetabular bone defects and pelvic discontinuity are extremely challenging problems. Many techniques have been utilized to address bone loss while maintaining a stable revision THR. Structural allografts, cemented prosthesis, reconstruction cages, and custom triflanged implants have all been used successfully albeit with relatively high complications rates. We have tried to highlight emerging trends to utilize Custom Made Monoflange or Triflange Acetabular Components to reconstruct massive acetabular defects with favourable midterm implant survival, better functional outcomes, relatively lesser complications, and almost similar cost of prosthesis as compared to conventional reconstruction techniques. However, long-term data and study is still recommended to draw a definitive conclusion.

Methods

In this narrative review article, we searched PubMed and Cochrane for studies on managing acetabular bone loss in revision THR with a focus on recent literature for mid to long-term outcomes and compared results from various studies on different reconstruction methods.

Key Content and Findings

Hemispherical cementless acetabular prosthesis with supplemental screws are commonly utilized to manage mild to moderate acetabular bone loss. Recent trends have shown much interest and paradigm shift in patient specific custom triflange acetabular components (CTAC) for reconstructing massive acetabular defects and pelvic discontinuity. Studies have reported high patient satisfaction, improved patient reported daily functioning, high mid-term implant survival, similar complications, and encouraging all cause re-revision rate. However, more prospective and quality studies with larger sample sizes are needed to validate the superiority of CTACs over conventional acetabular implants.

Conclusions

There is no consensus regarding the best option for reconstructing massive acetabular defects. Thorough preoperative workup and planning is an absolute requirement for successful revision THR. While most of the moderate acetabular bone loss can be managed with cementless hemispherical acetabular shells with excellent long-term outcomes, reconstructing massive acetabular bone defects in revision THR remains a challenge. Depending on the size and location of the defect, various constucts have demonstrated long-term success as discussed in this review, but complications are not negligible. CTACs provide a treatment for massive bone loss that may be otherwise difficult to achieve anatomic stability with other constructs. Although long-term data is sparse, the cost and complication rate is comparable to other reconstruction methods.

What Factors Are Associated with Clinical Trial Discontinuation in Orthopaedic Surgery: An Analysis of Clinical Trials Between 2007 and 2022

BACKGROUND

Clinical trials play a crucial role in advancing medical knowledge and have the potential to change standards of care. The present study evaluated the prevalence of discontinued clinical trials in orthopaedic surgery. Additionally, we sought to identify the study characteristics associated with and the rationale behind trial discontinuation.

METHODS

A cross-sectional survey of orthopaedic clinical trials using the ClinicalTrials.gov registry and results database was performed for trials between October 1, 2007, and October 7, 2022. Interventional trials listed as "completed," "terminated," "withdrawn," or "suspended" were included. Study characteristics were collected and clinical trial abstracts were reviewed in order to assign the appropriate subspecialty category. A univariate linear regression analysis was performed to determine whether the percentage of discontinued trials changed between 2008 and 2021. Univariate and multivariable hazard ratios (HRs) were calculated to identify factors associated with trial discontinuation.

RESULTS

A total of 8,603 clinical trials were included in the final analysis, of which 1,369 (16%) were discontinued, with the highest rates of discontinuation found in oncology (25%) and trauma (23%). The most common rationales for discontinuation were insufficient patient accrual (29%), technical or logistical issues (9%), business decision (9%), and lack of funding or resources (9%). Industry-funded studies were more likely than government-funded studies to be discontinued (HR: 1.81; p < 0.001). There was no change in the percentage of discontinued trials for each orthopaedic subspecialty between 2008 and 2021 (p = 0.21). As shown on multivariable regression analysis, trials for devices (HR: 1.63 [95% confidence interval, 1.20 to 2.21]; p = 0.002) and drugs (HR: 1.48 [1.10 to 2.02]; p = 0.013) as well as Phase-2 trials (HR: 1.35 [1.09 to 1.69]; p = 0.010), Phase-3 trials (HR: 1.39 [1.09 to 1.78]; p = 0.010), and Phase-4 trials (HR: 1.44 [1.14 to 1.81]; p = 0.010) had a higher likelihood of early discontinuation. However, pediatric trials were less likely to be discontinued (HR: 0.58 [0.40 to 0.86]; p = 0.007).

CONCLUSIONS

The results of the present study suggest the need for continued efforts to ensure the completion of orthopaedic clinical trials in order to limit publication bias and to employ resources and patient contributions more efficiently for research.

CLINICAL RELEVANCE

Discontinued trials contribute to publication bias, which limits the comprehensiveness of the literature available to support evidence-based patient care interventions. Therefore, identifying the factors associated with and the prevalence of orthopaedic trial discontinuation encourages orthopaedic surgeons to design future trials to be more resistant to early discontinuation.

Improved accuracy of a novel fluoroscopy-based robotically assisted THA system compared to manual THA

Accurate acetabular cup position remains a persistent challenge in total hip arthroplasty (THA). Studies investigating the early outcomes of robotic-assisted THA (RA-THA) systems have shown improved cup placement compared to manual THA (mTHA) approaches, however, contemporary robotic platforms are reliant on pre-operative CT imaging. The goal of this study was to analyze the accuracy of a novel, fluoroscopy-based RA-THA system compared to an unassisted mTHA approach and determine the effect of the robotic system on operative time. We performed a retrospective cohort analysis on a consecutive series of 198 patients who received mTHA and RA-THA between March 2021 and July 2022. The primary outcome of interest was the accuracy of acetabular component placement, defined by average cup inclination and anteversion. Secondary outcomes included the proportion of acetabular cups positioned within the Lewinnek safe zone, operative time, and overall room time. The RA-THA group demonstrated significantly higher accuracy of acetabular anteversion to target compared to the manual group (18.5 vs. 21.7˚; p < 0.001), and had a significantly greater proportion of acetabular cups placed within the Lewinnek safe zone (81.6 vs. 59.0%; p < 0.001). The RA-THA cohort had longer operative times compared to mTHA group (39.0 vs. 35.3 min; p = 0.003), but no difference was seen in total operating room time (101.2 vs. 101.2 min; p = 0.982). This study demonstrates that the use of a novel, fluoroscopy-based, pin-less THA robotic platform increased the accuracy of acetabular cup placement, including a 22.6% improvement in safe zone placement, compared to mTHA approach, with no increase in overall case time.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study

BACKGROUND

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized.

QUESTIONS/PURPOSES

(1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states?

METHODS

We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions.

RESULTS

A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08).

CONCLUSION

As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately.

CLINICAL RELEVANCE

To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Cost-effectiveness of a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system: A Markov analysis

BACKGROUND

The purpose of this study was to assess the cost-effectiveness of a novel, fluoroscopy-based robotic-assisted total hip arthroplasty (RA-THA) system compared to a manual unassisted technique (mTHA) up to 5 years post-operatively.

METHODS

A Markov model was constructed to compare the cost-effectiveness of RA-THA and mTHA. Cost-effectiveness was defined as an Incremental Cost-Effectiveness Ratio (ICER) <$50 000 or $100 000 per Quality Adjusted Life Year (QALY).

RESULTS

RA-THA patients experienced lower costs compared to mTHA patients at 1 year ($20 865.12 ± 9897.52 vs. $21 660.86 ± 9909.15; p < 0.001) and 5 years ($23 124.57 ± 10 045.48 vs. $25 756.42 ± 10 091.84; p < 0.001) post-operatively. RA-THA patients also accrued more QALYs (1-year: 0.901 ± 0.117 vs. 0.888 ± 0.114; p < 0.001; 5-years: 4.455 ± 0.563 vs. 4.384 ± 0.537 p < 0.001). Overall, RA-THA was cost-effective (1-year ICER: $-61 210.77; 5-year ICER: $-37 068.31).

CONCLUSIONS

The novel, fluoroscopy-based RA-THA system demonstrated cost-effectiveness when compared to manual unassisted THA.

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty

BACKGROUND

Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions.

METHODS

A large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons.

RESULTS

For knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures.

CONCLUSION

The MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.

Characterization and Reach of Orthopaedic Research Posted to Preprint Servers: Are We "Undercooking" Our Science?

BACKGROUND

Although biomedical preprint servers have grown rapidly over the past several years, the harm to patient health and safety remains a major concern among several scientific communities. Despite previous studies examining the role of preprints during the Coronavirus-19 pandemic, there is limited information characterizing their impact on scientific communication in orthopaedic surgery.

QUESTIONS/PURPOSES

(1) What are the characteristics (subspecialty, study design, geographic origin, and proportion of publications) of orthopaedic articles on three preprint servers? (2) What are the citation counts, abstract views, tweets, and Altmetric score per preprinted article and per corresponding publication?

METHODS

Three of the largest preprint servers (medRxiv, bioRxiv, and Research Square) with a focus on biomedical topics were queried for all preprinted articles published between July 26, 2014, and September 1, 2021, using the following search terms: "orthopaedic," "orthopedic," "bone," "cartilage," "ligament," "tendon," "fracture," "dislocation," "hand," "wrist," "elbow," "shoulder," "spine," "spinal," "hip," "knee," "ankle," and "foot." Full-text articles in English related to orthopaedic surgery were included, while nonclinical studies, animal studies, duplicate studies, editorials, abstracts from conferences, and commentaries were excluded. A total of 1471 unique preprints were included and further characterized in terms of the orthopaedic subspecialty, study design, date posted, and geographic factors. Citation counts, abstract views, tweets, and Altmetric scores were collected for each preprinted article and the corresponding publication of that preprint in an accepting journal. We ascertained whether a preprinted article was published by searching title keywords and the corresponding author in three peer-reviewed article databases (PubMed, Google Scholar, and Dimensions) and confirming that the study design and research question matched.

RESULTS

The number of orthopaedic preprints increased from four in 2017 to 838 in 2020. The most common orthopaedic subspecialties represented were spine, knee, and hip. From 2017 to 2020, the cumulative counts of preprinted article citations, abstract views, and Altmetric scores increased. A corresponding publication was identified in 52% (762 of 1471) of preprints. As would be expected, because preprinting is a form of redundant publication, published articles that are also preprinted saw greater abstract views, citations, and Altmetric scores on a per-article basis.

CONCLUSION

Although preprints remain an extremely small proportion of all orthopaedic research, our findings suggest that nonpeer-reviewed, preprinted orthopaedic articles are being increasingly disseminated. These preprinted articles have a smaller academic and public footprint than their published counterparts, but they still reach a substantial audience through infrequent and superficial online interactions, which are far from equivalent to the engagement facilitated by peer review. Furthermore, the sequence of preprint posting and journal submission, acceptance, and publication is unclear based on the information available on these preprint servers. Thus, it is difficult to determine whether the metrics of preprinted articles are attributable to preprinting, and studies such as the present analysis will tend to overestimate the apparent impact of preprinting. Despite the potential for preprint servers to function as a venue for thoughtful feedback on research ideas, the available metrics data for these preprinted articles do not demonstrate the meaningful engagement that is achieved by peer review in terms of the frequency or depth of audience feedback.

CLINICAL RELEVANCE

Our findings highlight the need for safeguards to regulate research dissemination through preprint media, which has never been shown to benefit patients and should not be considered as evidence by clinicians. Clinician-scientists and researchers have the most important responsibility of protecting patients from the harm of potentially inaccurate biomedical science and therefore must prioritize patient needs first by uncovering scientific truths through the evidence-based processes of peer review, not preprinting. We recommend all journals publishing clinical research adopt the same policy as Clinical Orthopaedics and Related Research® , The Bone & Joint Journal, The Journal of Bone and Joint Surgery, and the Journal of Orthopaedic Research , removing any papers posted to preprint servers from consideration.

What Are the Trends in Women's Representation Among Lead Investigators of Orthopaedic Clinical Trials?

BACKGROUND

Serving as a principal investigator for a clinical trial can bring national visibility and recognition to physicians, and it can have a substantial impact on their promotion and tenure. In the field of orthopaedics, there is a well-known gender gap in terms of representation and leadership. Examining the representation of women in clinical trial leadership may help to inform and enable the design of targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership.

QUESTIONS/PURPOSES

(1) What is the proportion of women principal investigators in orthopaedic clinical trials, and has this changed over time? (2) Are there trial characteristics (trial phase, status, funding source, and intervention) associated with women principal investigators? (3) What is the geographic distribution globally and regionally within the United States of clinical trials led by women principal investigators?

METHODS

A cross-sectional survey of clinical trials using the ClinialTrials.gov registry and results database provided by the NIH was performed on August 22, 2022. Trial characteristics included principal investigator names and gender, trial phase, type, funding source, intervention, and location (defined by continent and US Census region). Our primary outcome was the overall proportion of women orthopaedic principal investigators over time. We assessed this by comparing the proportion of women principal investigators from 2007 to 2022. Our secondary outcomes were trial characteristics (trial phase, status, funding source, and intervention) and geographic distribution (globally and within the United States) associated with women principal investigators. Baseline characteristics of the clinical trials were calculated using frequencies and percentages for categorical variables. Fisher exact tests were conducted to evaluate differences in gender proportions based on the included clinical trial characteristics. Univariate linear regression was applied to analyze trends in the annual proportion of women principal investigators over time.

RESULTS

The overall proportion of women principal investigators was 18% (592 of 3246), and this proportion increased over the study period. Specifically, the proportion of women leading clinical trials was 13% (16 of 121) in 2007 and 22% (53 of 242) in 2022 (r2 = 0.68; p < 0.001). This trend was also observed when evaluating only US women principal investigators (r2 = 0.47; p = 0.003) and non-US women principal investigators over the study period (r2 = 0.298; p = 0.03). There was no difference in the distribution of trial phases between men and women principal investigators. Most men and women were involved in "not applicable" or Phase IV trials. Similarly, there was no difference in trial status or funding source. However, women principal investigators had a higher proportion of studies involving behavioral interventions (11% [67 of 592]) compared with men principal investigators (3% [74 of 2654]; p = 0.03). The proportion of women principal investigators over the study period by world region revealed a higher proportion of women principal investigators in Asia (23% [88 of 391]), followed by South America (24% [12 of 49]), North America (18% [306 of 1746]), and Europe (16% [136 of 833]). Among all US trials over the study period, the proportion of women principal investigators across the US Census region was Northeast (19% [62 of 329]), South (18% [90 of 488]), West (20% [97 of 492]), and Midwest (13% [22 of 168]).

CONCLUSION

Although there has been a notable increase in the proportion of women principal investigators over time, the overall representation remains relatively low. The disparities observed in trial characteristics and geographic distribution of women principal investigators further emphasize the need for targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership.

CLINICAL RELEVANCE

These results underscore the importance of adopting practices and strategies that foster gender equity in the leadership of orthopaedic clinical trials. By establishing mentorship and sponsorship programs, early-career women surgeons can be connected with experienced leaders, cultivating a supportive network and offering valuable career guidance. Additionally, addressing geographic disparities in the representation of women principal investigators can involve the implementation of mentorship and sponsorship programs in regions with lower representation.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis

BACKGROUND

While trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood.

METHODS

The Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions.

RESULTS

The number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (β = 109.07, P ≤ .001) and revision (β = -13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111).

CONCLUSION

The present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

Is prematurity a risk factor for developmental dysplasia of the hip? A systematic review and meta-analysis

Developmental dysplasia of the hip (DDH) is the most common orthopedic disorder in newborns. Early recognition and diagnosis are critical to prevent long-term complications. While several risk factors have been established, the association between prematurity and DDH remains unclear. Our analysis sought to analyze the literature exploring the relationship between prematurity and DDH. Articles evaluating the relationship between prematurity and DDH published between 1 January 2000 and 1 February 2022 were queried, with 11 studies included for analysis. Overall, a total of 8720 patients were included. The gestational age ranged from 23 to 36 weeks for preterm and ≥37 weeks for term births. Seven studies agreed that gestational age did not have a significant impact on DDH. Pooled analysis of available data demonstrated no significant difference in DDH among preterm and term infants (OR, 1.11; 95% CI, 0.82-1.51; P  = 0.49). Sub-group analysis of two studies reporting data on very preterm (≤32 weeks) and term infants revealed no significant difference in the occurrence of DDH (OR, 4.58; 95% CI, 0.09-244.78; P  = 0.45). Four studies found early gestational age is associated with a significantly higher incidence of mature hips compared to late preterm or term babies. Similarly, pooled analysis demonstrated significantly lower Graf classification among preterm infants (OR, 0.13; 95% CI, 0.03-0.61; P  = 0.009). Based on the current literature, our analysis found that prematurity is not strongly associated with DDH. Furthermore, early gestational age was associated with a significantly higher incidence of mature hips measured by Graf classification.

What Are the Trends in Research Publication Misrepresentation Among Orthopaedic Residency and Fellowship Applicants From 1996 to 2019? A Systematic Review

BACKGROUND

Because research experience is increasingly important in ranking orthopaedic residency and fellowship applicants, determining the accuracy of candidates reporting their scholarly activity is essential. However, disparate and inconsistent findings have made it difficult to draw meaningful conclusions from individual studies.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) What percentage of research publications are misrepresented among orthopaedic residency and fellowship applicants? (2) What percentage of applications contain one or more example of academic misrepresentation? (3) Is research misrepresentation associated with any individual applicant characteristics? (4) What is the publication status of articles listed by applicants as having been submitted to journals?

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were searched on March 10, 2022, to identify all studies that evaluated research misrepresentation in orthopaedic residency and fellowship applications between January 1, 1995, and March 1, 2022. Articles were included if full-text articles in English were available and the study reported on research misrepresentation among orthopaedic residency or fellowship applicants. Studies investigating nonorthopaedic publications, systematic reviews, case studies, duplicate studies among databases, and gray literature were excluded. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. This is a validated assessment tool that grades noncomparative studies from 0 to 16 and studies with control groups from 0 to 24, based on eight criteria related to study design, outcomes assessed, and follow-up. All included articles were noncomparative studies, so the maximum score here was 16, with higher scores indicating better study quality. The mean MINORS score was 13 ± 1 in the studies we included. The final analysis included 10 studies with 5119 applicants. Eight studies evaluated orthopaedic residency applicants and two evaluated fellowship applicants. The applicant classes ranged from 1996 to 2019. Research misrepresentation was defined among studies as nonauthorship of an existing article, claimed authorship of a nonexistent article, or incorrect listing of authorship order for an existing article. Each study's findings and definition of research misrepresentation were considered to allow for a discussion of overall trends. The percentage of misrepresentation was further broken down by the misrepresentation type. Applicant characteristics and destination of submitted articles were also evaluated. Given the potential overlap between applicants among the studies, no pooled analysis was conducted, and results are presented as a narrative summary.

RESULTS

The percentage of overall publication misrepresentation was estimated to range between 1% (13 of 1100) and 21% (27 of 131), with more-recent studies reporting a lower proportion of overall articles misrepresented. Most studies we found claimed that authorship of a nonexistent article was the most common type of misrepresentation. Nonauthorship of an existing article and incorrect authorship order were less common. The percentage of applications with at least one misrepresentation was approximately 20% between 1998 and 2017. Most studies found no applicant characteristics, such as match outcomes, demographic markers, or academic records, that were consistently associated with a higher odds of the candidate misrepresenting his or her research credentials. Finally, approximately half of the articles listed as submitted to journals went on to publication, with one-third going to a different journal with a lower Impact Factor.

CONCLUSIONS

Our systematic review found that the percentage of overall publication misrepresentations among orthopaedic residency and fellowship applicants has generally been low over the past 20 years. However, approximately one-fifth of applications had at least one research misrepresentation, with 2% having multiple misrepresentations on reported publications. There were no consistent applicant characteristics associated with higher odds of research misrepresentation. Additionally, most of the articles listed as submitted to journals for publication were ultimately published.

CLINICAL RELEVANCE

Although the decrease in overall publication misrepresentation is encouraging, our finding that one-fifth of applicants have research misrepresentation is a cause for concern. In light of a continually evolving application process, orthopaedic residency and fellowship programs must ensure there is integrity related to information that is self-reported by applicants. These findings also serve to encourage faculty members involved in the application screening and decision process to limit biases related to applicant demographics perceived to be associated with a high odds of misrepresentation. Furthermore, governing agencies and program leadership should evaluate methods of verifying unpublished work and provide opportunities for applicants to give publication updates throughout the application cycle.

Gender Differences in Reimbursement Among Orthopaedic Surgeons: A Cross-sectional Analysis of Medicare Claims

INTRODUCTION

Inequalities involving women across orthopaedic subspecialties continue to be highlighted in the literature. Previous analyses exploring reimbursement differences between sexes have not controlled for confounding factors or have been limited by small sample sizes. Our study used Medicare data on a national sample of orthopaedic surgeons to better evaluate these disparities.

METHODS

This cross-sectional analysis used publicly available data from the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File. Using each provider's National Provider Identifier number, this data set was linked to the National Plan and Provider Enumeration System downloadable file and the 2019 National Provider Compare Database. Mean differences were calculated using the Welch t-test. Multivariate linear regression analysis was conducted to determine the effect of sex on total Medicare payments per physician, controlling for years in practice, practice diversity, clinical productivity, and subspecialty.

RESULTS

Nineteen thousand six orthopaedic surgeons were included in our analysis. Of these providers, 1,058 were female (5.6%) and 17,948 were male (94.4%). Male orthopaedic surgeons billed an average of 19.40 unique billing codes per provider and female orthopaedic surgeons billed 14.4 per provider (P < 0.001). Female orthopaedic surgeons billed an average of 1,245.5 services per physician while male orthopaedic surgeons billed 2,360.7 services per physician. The mean difference in payment between male and female orthopaedic surgeons was $59,748.7 (P < 0.001). Multivariate linear regression showed that female sex was a significant predictor of lower total yearly Medicare reimbursement (P < 0.001).

DISCUSSION

These findings emphasize the need for additional efforts to help ensure reimbursement differences do not deter women from pursuing orthopaedics. Healthcare organizations should use this information to ensure equal salary negotiating power among their employees while additionally addressing potential biases and misconceptions related to referrals and surgeon aptitude, respectively.

What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

BACKGROUND

Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary.

QUESTION/PURPOSE

Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?

METHODS

The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively.

RESULTS

Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness.

CONCLUSION

Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.

The learning curve for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system

BACKGROUND

Adoption of robotic-assisted total hip arthroplasty (RA-THA) systems can improve the accuracy of acetabular cup placement, but no group has reported the learning curve of novel, fluoroscopy-based RA-THA systems.

METHODS

A learning-curve cumulative summation (LC-CUSUM) analysis was performed on a consecutive series of the first 100 patients who received fluoroscopy-based RA-THA by the study surgeon. Operative times and specific robotic timepoints were compared between learning and proficiency phases.

RESULTS

Implementation of fluoroscopy-based RA-THA was associated with a learning curve of 12 cases. A 6-min increase in operative time was seen during the learning phase compared to the proficiency phase (44.3 ± 4.4 vs. 38.0 ± 7.1 min; p < 0.001), with a 3-min longer robotic cup impaction sequence during the learning phase (7.8 ± 1.9 vs. 4.8 ± 1.3 min; p < 0.001).

CONCLUSION

Adoption of fluoroscopy-based RA-THA is associated with a brief learning curve of 12 cases, with the most significant improvements in surgical efficiency realised during acetabular cup placement.

Do patient-reported outcome measures improve after aseptic revision total hip arthroplasty?

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 Markup on Orthopaedic Services: An Analysis of 2014-2019 Medicare Data and the Potential for Surprise Billing

BACKGROUND

Markups on charges for medical services have the potential to result in "surprise billing," especially for out-of-network and uninsured patients. Although previously analyzed in other surgical subspecialties, the distribution and level of cost-to-charge ratios (CCRs) for orthopaedic services have yet to be studied. Therefore, our analysis sought to evaluate the CCRs for orthopaedic surgery services provided to Medicare beneficiaries throughout the United States.

METHODS

Orthopaedic services provided to Medicare Part B beneficiaries between 2014 and 2019 were identified in the Physician & Other Practitioners database of the Centers for Medicare & Medicaid Services (CMS). CCRs, representing the ratio between the actual payment provided by CMS and the charge submitted by the provider, were calculated for each service. Descriptive statistics were calculated for CCRs at the national, state, and service-code levels. The coefficient of variation (CoV) was utilized to evaluate variability in CCRs across services and states. Additionally, Mann-Kendall tests were performed to evaluate trends in CCRs for included services over the time frame.

RESULTS

Our analysis included an annual mean of 47,247,928 services provided by a mean of 23,185 orthopaedic surgeons over the study period. In the non-facility setting, there was a decrease in median CCRs for orthopaedic surgery services (0.29 to 0.27; p = 0.024). No changes were demonstrated for facility-based services. Service codes related to trigger finger procedures (0.18 to 0.17; p = 0.004), physical therapy (0.40 to 0.36; p = 0.035), and new patient visits (0.52 to 0.46; p = 0.035) demonstrated significant decreases in median CCRs. Only shoulder arthroscopy demonstrated a significant increase in median CCR (0.09 to 0.10; p = 0.003). High dispersion in CCRs was demonstrated for 16 (80%) of the 20 evaluated services. Wide variations in CCRs were demonstrated across individual states (median, 0.57; interquartile range width, 0.53).

CONCLUSIONS

Our analysis demonstrated low and variable CCRs for commonly performed orthopaedic services in the U.S. These findings serve to inform and help improve related price transparency policies. Additionally, our analysis encourages increased efforts at preventing these low CCRs from limiting care in vulnerable populations.