How Many Patients Qualify for Extended Oral Antibiotic Prophylaxis Infection Following Primary and Revision Hip and Knee Arthroplasties?

Extended oral antibiotic prophylaxis (EOAP) has been suggested to reduce rates of periprosthetic joint infection (PJI) postoperatively after total joint arthroplasty (TJA). The purpose of this multicenter study is to define how many TJA patients are considered high risk for developing PJI based on published EOAP criteria and determine whether this status is associated with socioeconomic or demographic factors. All primary and aseptic revision TJAs performed in 2019 at three academic medical centers were reviewed. High-risk status was defined based on prior published EOAP criteria. Area deprivation index (ADI) was calculated as a measure of socioeconomic status. Data were reported as means with standard deviation. Both overall and institutional differences were compared. Of the 2,511 patients (2,042 primary and 469 revision) in this cohort, 73.3% met criteria for high risk (primary: 72.9% [1,490] and revision: 74.6% [350]). Patient's race or age did not have a significant impact on risk designation; however, a larger proportion of high-risk patients were women (p = 0.002) and had higher Elixhauser scores (p < 0.001). The mean ADI for high-risk patients was higher (more disadvantaged) than for standard-risk patients (64.0 [20.8] vs. 59.4 [59.4]) (p < 0.001). Over 72% of primary and revision TJA patients at three medical centers met published criteria for EOAP. These patients were more often women, had more comorbidities, and lived in more disadvantaged areas. Our findings suggest that most patients qualify for EOAP, which may call for more stringent criteria on who would benefit extended antibiotic prophylaxis.

Diaphyseal Impaction Grafting Combined with Metaphyseal Cones: Outcomes in 88 Revision Total Knee Arthroplasties

BACKGROUND

Metaphyseal cones with cemented stems can be successfully utilized in most revision total knee arthroplasties (TKAs). However, if the diaphysis has been previously violated, fixation of the cemented stem, which is important for cone ingrowth and construct survival, can be compromised. The initial results of our novel technique combining diaphyseal impaction bone-grafting with a metaphyseal cone were promising but required additional study. The purpose of the present study was to assess results of this technique in a larger cohort.

METHODS

A metaphyseal cone combined with diaphyseal impaction grafting and a cemented stem was utilized in 88 revision TKAs at our institution, including 35 from our prior study. The mean age at the time of revision was 67 years, and 67% of patients were male. Patients had had a mean of 4 prior knee arthroplasty procedures. The 2 most common reasons for revision were aseptic loosening (78%) and 2-stage reimplantation for periprosthetic joint infection (PJI) (19%). The mean follow-up was 4 years.

RESULTS

At the time of the latest follow-up, no cone-impaction grafting constructs required re-revision for aseptic loosening. Five-year survivorship free from any revision of the cone-impaction grafting construct and free from any reoperation was 95% and 65%, respectively. A total of 25 knees (28%) underwent reoperation, with the 2 most common indications being PJI and periprosthetic fracture. All cones were osseointegrated, and all bone graft appeared stable or incorporated. One patient had radiographic evidence of tibial component loosening despite a well-fixed cone; however, this patient was asymptomatic and had not undergone revision at 9 years.

CONCLUSIONS

When presented with a sclerotic, polished diaphyseal canal with deficient cancellous bone and concomitant metaphyseal bone loss, our technique of combining diaphyseal impaction grafting with a metaphyseal cone proved extremely durable in this larger series of patients. No cone-impaction grafting constructs required re-revision for aseptic loosening.

LEVEL OF EVIDENCE

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

Contemporary Aseptic Revision Total Hip Arthroplasty in Patients ≤50 Years of Age: Results of >500 Cases

BACKGROUND

There has been a paucity of long-term outcomes data on aseptic revision total hip arthroplasties (THAs) in the young adult population. The purpose of this study was to evaluate implant survivorship, complications, and clinical outcomes in a large cohort of contemporary aseptic revision THAs in patients ≤50 years of age at the time of the surgical procedure.

METHODS

We identified 545 aseptic revision THAs performed at a single academic institution from 2000 to 2020 in patients who were 18 to 50 years of age. Patients who underwent conversion THAs and patients with a history of any ipsilateral hip infection were excluded. The mean age was 43 years, the mean body mass index (BMI) was 29 kg/m2, and 63% were female. The index indication for revision THA was aseptic loosening in 46% of cases, polyethylene wear or osteolysis in 28% of cases (all revisions of conventional polyethylene), and dislocation in 11% of cases. There were 126 hips (23%) that had undergone at least 1 previous revision (median, 1 revision [range, 1 to 5 revisions]). The mean follow-up was 10 years.

RESULTS

In the entire cohort, the 20-year survivorship free of any re-revision was 76% (95% confidence interval [95% CI], 69% to 82%). There were 87 re-revisions, with 31 dislocations, 18 cases of aseptic loosening of the femoral component, and 16 periprosthetic joint infections (PJIs) being the most common reasons for re-revision. Dislocation as the indication for the index revision was associated with an increased risk of re-revision (hazard ratio, 2.9; p < 0.001). The 20-year survivorship free of any reoperation was 73% (95% CI, 66% to 78%). There were 75 nonoperative complications (14%), including 32 dislocations. The mean Harris hip score significantly improved (p < 0.001) from 65 preoperatively to 81 at 10 years postoperatively.

CONCLUSIONS

Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. Dislocation, aseptic loosening of the femoral component, and PJI were the most common reasons for re-revision. Index revision THAs for dislocation had a 3 times higher risk of re-revision.

LEVEL OF EVIDENCE

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

What's New in Periprosthetic Femur Fractures?

BACKGROUND

Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty.

METHODS/RESULTS

This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons 2023 annual meeting, including an overview of the Vancouver classification and its implications on treatment and subsequent complications, an updated approach to the management of intraoperative fractures, and finally, contemporary strategies for both osteosynthesis as well as revision arthroplasty for PFFs.

CONCLUSION

As the incidence of PPF continues to increase, arthroplasty and trauma surgeons must be prepared to address this challenging complication with a contemporary understanding of the treatment options and their outcomes.

Association Between Tranexamic Acid and Decreased Periprosthetic Joint Infection Risk in Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Over 2 Million Patients

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis to evaluate the association between tranexamic acid (TXA) use during primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA), and the risk of developing periprosthetic joint infection (PJI) after these procedures.

METHODS

A systematic review was carried out from inception to October 17, 2022. There were 6 studies that were ultimately included in the meta-analysis. The association between the development of PJI and TXA was analyzed using odds ratios (ORs) with 95% confidence intervals (CIs) and estimates of risk difference (RD). Subgroup analysis was performed to evaluate only studies reporting out to 90 days of follow-up versus more than 90 days of follow-up.

RESULTS

Among 2,098,469 arthroplasties, TXA utilization was associated with an overall lower risk of PJI (OR = 0.63 [95% CI 0.42 to 0.96], P < .001) and a 0.4% lower incidence of PJI (RD = -0.0038, 95% CI [-0.005 to -0.002], P < .001). When subgrouping the studies according to length of follow-up, TXA was associated with a lower risk of PJI (OR = 0.43 [95% CI 0.35 to 0.53], P < .001) and a 1% lower incidence of PJI (RD = -0.0095 [95% CI -0.013 to -0.005], P < .001) in patients followed for more than 90 days.

CONCLUSIONS

This meta-analysis demonstrates that TXA use is associated with a reduced risk of PJI, with our RD analysis identifying an approximately 0.4% reduction in PJI rates with TXA use. These findings provide even more data to support the routine use of TXA during primary THA and primary TKA.

Highly Porous Acetabular Cup and Augment Constructs in Complex Revision Total Hip Arthroplasty: What Predicts 10-Year Implant Survivorship?

BACKGROUND

Porous tantalum acetabular cup and augment constructs have demonstrated favorable outcomes up to 5 years postsurgery despite severe bone loss during revision total hip arthroplasty (THA). Prior literature lacks long-term studies with substantial case numbers. This study aims to assess long-term clinical and radiographic outcomes 10 years postsurgery in patients undergoing revision THA with porous tantalum acetabular cup-augment constructs and determine factors associated with long-term survivorship.

METHODS

Between 2000 and 2012, 157 revision THAs were performed in cases with major acetabular defects (mainly Paprosky type IIIA and IIIB) utilizing porous tantalum cup-augment constructs. Pelvic discontinuity was noted intraoperatively in 17 hips (11%). Postoperative radiographs were evaluated at regular intervals for implant stability and radiolucent lines. There were 49 patients who had complete radiographic follow-up at 10 years or longer postsurgery.

RESULTS

The 10-year survivorship free of revision of the cup-augment construct for aseptic loosening was 93%, free of any acetabular construct revision was 91%, free of any hip rerevision was 77%, and free of any reoperation was 75%. Pelvic discontinuity was associated with increased risk of reoperation (hazard ratio [HR] = 2.8), any hip rerevision (HR = 3.2), any cup-augment construct revision (HR = 11.8), and aseptic construct revision (HR = 10.0). Of unrevised cases with radiographs at 10 years, 4 hips showed radiographic loosening. Mean Harris hip scores improved from 47 preoperatively to 79 at 10 years.

CONCLUSIONS

Porous tantalum acetabular cup-augment constructs used in revision THA with severe acetabular bone loss provide excellent implant survivorship at 10 years when the acetabulum is intact. Due to lower survivorship of cup-augment constructs in cases of pelvic discontinuity, additional construct fixation or stabilization methods are recommended, when a discontinuity is present.

LEVEL OF EVIDENCE

IV.

Marlex Mesh Reconstruction of the Extensor Mechanism: A Concise 5-Year Follow-up of 2 Previous Reports

LEVEL OF EVIDENCE

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

Cemented dual-mobility constructs in uncemented revision acetabular components

Aims

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

Methods

We identified 64 patients (65 hips) who had a single-design cemented DM cup cemented into an uncemented acetabular shell during revision THA between 2018 and 2020 at our institution. Cups were cemented into either uncemented cups designed for liner cementing (n = 48; 74%) or retained (n = 17; 26%) acetabular components. Median outer head diameter was 42 mm. Mean age was 69 years (SD 11), mean BMI was 32 kg/m2 (SD 8), and 52% (n = 34) were female. Survival was assessed using Kaplan-Meier methods. Mean follow-up was two years (SD 0.97).

Results

There were nine cemented DM cup revisions: three for periprosthetic joint infection, three for acetabular aseptic loosening from bone, two for dislocation, and one for a broken cup-cage construct. The two-year survivals free of aseptic DM revision and dislocation were both 92%. There were five postoperative dislocations, all in patients with prior dislocation or abductor deficiency. On radiological review, the DM cup remained well-fixed at the cemented interface in all but one case.

Conclusion

While dislocation was not eliminated in this series of complex revision THAs, this technique allowed for maximization of femoral head diameter and optimization of effective acetabular component position during cementing. Of note, there was only one failure at the cemented interface.

Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years

BACKGROUND

To make an informed decision about total hip arthroplasty (THA), surgeons and patients need to understand the absolute and relative risks of periprosthetic joint infection (PJI). We sought to evaluate the long-term risk of PJI following primary THA stratified by body mass index (BMI) and PJI-related risk factors.

METHODS

We identified 21,550 primary THAs performed from 2000 to 2021 at a single institution. Patients were stratified as having 0, 1, or ≥ 2 PJI risk factors (diabetes, chronic kidney disease, nonprimary osteoarthritis, immunosuppression, or active smoking) and into BMI categories. The 15-year cumulative risk of PJI was evaluated by BMI and PJI risk factors.

RESULTS

For the entire cohort, the 15-year absolute risk of PJI was 2%. For patients who did not have PJI risk factors, the absolute risk of PJI at 15 years was 1% in normal weight, 2% in class III obesity, and 4% in class IV obesity. Patients who had class III and IV obesity had a 3-times and 9-times higher relative risk of PJI, respectively (P = .03, P < .001). Among patients who had ≥ 2 PJI risk factors, the absolute risk of PJI at 15 years was 2% in normal weight, 4% in class III obesity, and 18% in class IV obesity.

CONCLUSIONS

Healthy patients who had class III and IV obesity had a 3-times and 9-times increased risk of PJI at 15 years relative to normal weight patients. However, the absolute risk of PJI at 15 years was 2 and 4%, respectively. Given emerging data questioning whether BMI modification decreases PJI risk, surgeons and patients must consider both a 3-times to 9-times increased relative risk of PJI and a 2 to 4% absolute risk of PJI at 15 years for healthy patients who had a BMI ≥ 40.

LEVEL OF EVIDENCE

IV.

Periprosthetic Hip and Knee Infection: Is an Ipsilateral Uninfected Total Joint Arthroplasty at Risk?

BACKGROUND

Periprosthetic joint infections (PJIs) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) may occur in the setting of an uninfected ipsilateral prosthetic joint. However, the risk to that uninfected ipsilateral joint is unknown. We analyzed the survivorship free from PJI in at risk THAs and TKAs following treatment of an ipsilateral knee or hip PJI, respectively.

METHODS

Using our institutional total joint registry, we identified 205 patients who underwent treatment for PJI (123 THAs and 83 TKAs) with an at-risk ipsilateral in situ knee or hip, respectively, between 2000 and 2019. In total, 54% of index PJIs were chronic and 46% were acute. The mean age was 70 years, 47% were female, and the mean body mass index was 32. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 6 years.

RESULTS

The 5-year survivorship free of PJI in an at-risk THA after an ipsilateral TKA was treated for PJI was 97%. The 5-year survivorship free of PJI in an at-risk TKA when the ipsilateral THA was treated for PJI was 99%. Three PJIs occurred (2 THAs and 1 TKA), all over 1 year from the index ipsilateral PJI treatment. One hip PJI was an acute hematogenous infection that resulted from pneumonia. The other 2 new PJIs were caused by the same organism as the index PJI and were due to a failure of source control at the index joint.

CONCLUSIONS

When diagnosed with PJI in a single joint, the risk of developing PJI in an ipsilateral prosthetic joint within 5 years was low (1 to 3% risk). In the rare event of an ipsilateral infection, all occurred greater than one year from the index PJI and 2 of 3 were with the same organism when source infection control failed.

LEVEL OF EVIDENCE

Prognostic Level III.

Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship

INTRODUCTION

Arthroplasty registries often utilize traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data.

METHODS

We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation were calculated for patients who have TM. The same survivorship endpoints was re-calculated with censoring performed when a patient transitioned to a MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years.

RESULTS

From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90 and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio (HR) = 1.16, P = 0.033), and there was a trend towards higher survivorship free from any revision (95 versus 93% at 15-years; HR = 1.16, P = 0.074).

CONCLUSION

Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.

New Ceramic Heads With Titanium Sleeves on Retained Femoral Components: Results of Over 500 Revision Total Hip Arthroplasties

BACKGROUND

Ceramic heads are frequently combined with titanium sleeves in revision total hip arthroplasties (THAs), ostensibly to protect the ceramic head from existing damage to the retained trunnion. Although widely adopted, data on the performance and safety of this construct are minimal. The purpose of this study was to describe implant survivorships, radiographic results, and clinical outcomes of patients who underwent revision THA with a ceramic head and titanium sleeve on a retained femoral component.

METHODS

We identified 516 revision THAs with femoral component retention (328 acetabular-only revisions and 188 bearing surface exchanges) treated with a new ceramic head and titanium sleeve between 2000 and 2020. Mean age at revision was 64 years, 56% were women, and mean body mass index was 30. The indications for revision THA were adverse local tissue reaction (25%), acetabular loosening (24%), dislocation (17%), infection (5%), and other (29%). Kaplan-Meier survivorships were analyzed, radiographs reviewed, and Harris Hip Scores evaluated. Mean follow-up was 4 years (range, 2 to 10).

RESULTS

There were no reoperations or failures for ceramic head fracture, taper corrosion, or head/sleeve disengagement. The 10-year survivorship free of any re-revision was 85%. Indications for the 57 re-revisions included dislocation (33), infection (13), acetabular component loosening (7), periprosthetic fracture (2), psoas impingement (1), and sciatic nerve irritation (1). The 10-year survivorship free of any reoperation was 82%. There were an additional 14 reoperations. Radiographically, 1.9% had progressive femoral radiolucent lines, and 4.7% had progressive acetabular radiolucent lines. Mean Harris Hip Score was 81 at 2 years.

CONCLUSIONS

New ceramic heads with titanium sleeves in revision THAs with retained femoral components were durable and reliable with no cases of ceramic head fracture or taper complications at mean 4-year follow-up, including those revised for adverse local tissue reaction.

LEVEL OF EVIDENCE

IV.

Precision or Pitfall? Evaluating the Accuracy of ICD-10 Coding for Cemented Total Hip Arthroplasty: A Multicenter Study

BACKGROUND

The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Procedure Coding System (ICD-10-PCS) was adopted in the U.S. in 2015. Proponents of the ICD-10-PCS have stated that its granularity allows for a more accurate representation of the types of procedures performed by including laterality, joint designation, and more detailed procedural data. However, other researchers have expressed concern that the increased number of codes adds further complexity that leads to inaccurate and inconsistent coding, rendering registry and research data based on ICD-10-PCS codes invalid and inaccurate. We aimed to determine the accuracy of the ICD-10-PCS for identifying cemented fixation in primary total hip arthroplasty (THA).

METHODS

We retrospectively reviewed all cemented primary THAs performed at 4 geographically diverse, academic medical centers between October 2015 and October 2020. Cemented fixation was identified from the ICD-10-PCS coding for each procedure. The accuracy of an ICD-10-PCS code relative to the surgical record was determined by postoperative radiograph and chart review, and cross-referencing with institution-level coding published by the American Joint Replacement Registry (AJRR) was also performed.

RESULTS

A total of 552 cemented THA cases were identified within the study period, of which 452 (81.9%) were correctly coded as cemented with the ICD-10-PCS. The proportion of cases that were correctly coded was 187 of 260 (72%) at Institution A, 158 of 185 (85%) at Institution B, 35 of 35 (100%) at Institution C, and 72 of 72 (100%) at Institution D. Of the 480 identified cemented THA cases at 3 of the 4 institutions, 403 (84%) were correctly reported as cemented to the AJRR (Institution A, 185 of 260 cases [71%]; Institution B, 185 of 185 [100%]; and Institution C, 33 of 35 [94%]). Lastly, of these 480 identified cemented THA cases, 317 (66%) were both correctly coded with the ICD-10-PCS and correctly reported as cemented to the AJRR.

CONCLUSIONS

Our findings revealed existing discrepancies within multiple institutional data sets, which may lead to inaccurate reporting by the AJRR and other registries that rely on ICD-10-PCS coding. Caution should be exercised when utilizing ICD-10 procedural data to evaluate specific details from administrative claims databases as these inaccuracies present inherent challenges to data validity and interpretation.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Defining Clinically Meaningful Subgroups for Risk Stratification in Patients Undergoing Revision Total Hip Arthroplasty: A Combined Unsupervised and Supervised Machine Learning Approach

BACKGROUND

Studies developing predictive models from large datasets to risk-stratify patients under going revision total hip arthroplasties (rTHAs) are limited. We used machine learning (ML) to stratify patients undergoing rTHA into risk-based subgroups.

METHODS

We retrospectively identified 7,425 patients who underwent rTHA from a national database. An unsupervised random forest algorithm was used to partition patients into high-risk and low-risk strata based on similarities in rates of mortality, reoperation, and 25 other postoperative complications. A risk calculator was produced using a supervised ML algorithm to identify high-risk patients based on preoperative parameters.

RESULTS

There were 3,135 and 4,290 patients identified in the high-risk and low-risk subgroups, respectively. Each group significantly differed by rate of 30-day mortalities, unplanned reoperations/readmissions, routine discharges, and hospital lengths of stay (P < .05). An Extreme Gradient Boosting algorithm identified preoperative platelets < 200, hematocrit > 35 or < 20, increasing age, albumin < 3, international normalized ratio > 2, body mass index > 35, American Society of Anesthesia class ≥ 3, blood urea nitrogen > 50 or < 30, creatinine > 1.5, diagnosis of hypertension or coagulopathy, and revision for periprosthetic fracture and infection as predictors of high risk.

CONCLUSION

Clinically meaningful risk strata in patients undergoing rTHA were identified using an ML clustering approach. Preoperative labs, demographics, and surgical indications have the greatest impact on differentiating high versus low risk.

LEVEL OF EVIDENCE

III.

Femoral Head Length Impact on Outcomes Following Total Hip Arthroplasty in 36 Millimeter Cobalt Chrome-on-Highly Crosslinked Polyethylene Articulations

BACKGROUND

Despite concerns for corrosion, dislocation, and periprosthetic femur fractures, minimal literature has investigated the effect of adjusting femoral head length on outcomes after primary total hip arthroplasty (THA). Therefore, we aimed to investigate the effect of femoral head length on the risk of any revision and reoperation following cobalt chromium (CoCr)-on-highly crosslinked polyethylene (HXLPE) THAs.

METHODS

Between 2004 and 2018, we identified 1,187 primary THAs with CoCr-on-HXLPE articulations using our institutional total joint registry. The mean age at THA was 71 years (range, 19-97), 40% were women, and mean body mass index was 30 (range, 10-68). All THAs using 36 mm diameter femoral heads were included. Neutral (0 mm), positive, or negative femoral head lengths were used in 42, 31, and 27% of the THAs, respectively. Kaplan-Meier survivorship was assessed. The mean follow-up was 7 years (range, 2-16).

RESULTS

The 10-year survivorships free of any revision or reoperation were 94 and 92%, respectively. A total of 47 revisions were performed, including periprosthetic femur fracture (17), periprosthetic joint infection (8), dislocation (7), aseptic loosening of either component (6), corrosion (4), and other (5). Nonrevision reoperations included wound revision (11), open reduction and internal fixation of periprosthetic femur fracture (4), and abductor repair (2). Multivariable analyses found no significant associations between femoral head length and revision or reoperation.

CONCLUSION

Altering femoral head lengths in 36 mm CoCr-on-HXLPE THAs did not affect outcomes. Surgeons should select femoral head lengths that optimize hip stability and center of rotation.

LEVEL OF EVIDENCE

III.

What is the Impact of Social Deprivation on Mental and Physical Health Before and After Primary Total Knee Arthroplasty?

Background

The purpose of the present study was to investigate the relationship between socioeconomic status and Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) scores before and after primary total knee arthroplasty (TKA). We hypothesized that patients with greater social deprivation would have lower PROMIS-GH scores at 3 months and 1 year following primary TKA.

Methods

We retrospectively reviewed data from patients who underwent unilateral primary TKA and completed PROMIS-GH preoperatively and at 3 months (n = 257) or 1 year (n = 154) postoperatively. Area Deprivation Index (ADI), calculated from 9-digit zip codes, was used to measure social deprivation. Participants were grouped into quartiles by ADI score. Minimal clinically important difference in PROMIS-GH mental (PROMIS-MH) and physical health (PROMIS-PH) component scores were compared between ADI groups.

Results

Participants in the highest ADI quartile (most disadvantaged) had significantly lower PROMIS-MH and PROMIS-PH scores at every time point relative to the lowest ADI quartile (least disadvantaged) (P < .05 for all). Both ADI groups experienced significant improvements in PROMIS-PH following TKA (P < .001 for all), but not in PROMIS-MH (P > .05 for all) at 3-months and 1-year postoperatively. Magnitude of improvement in PROMIS-PH and rates of achievement of minimal clinically important difference did not significantly differ between ADI groups (P > .05 for all).

Conclusions

Socially disadvantaged patients benefit equally from primary TKA but are more likely to have persistently lower 1-year postoperative PROMIS-GH scores relative to less disadvantaged patients. Social deprivation should be accounted for when using PROMIS-GH to assess clinical outcomes for research and quality measures.

Level of Evidence

IV, retrospective cohort study.

Can the American Joint Replacement Registry Utilize Administrative Claims Data to Accurately Classify Revision THA Surgical Diagnoses?

INTRODUCTION

The American Joint Replacement Registry (AJRR) is a valuable tool for studying revision total hip arthroplasty (rTHA). Currently, International Classification of Diseases-10 (ICD-10) codes are utilized by AJRR for classifying surgical diagnoses. However, the validity of this methodology is unknown. The purpose of this study was to determine the accuracy of these codes, as used by AJRR, in classifying rTHA diagnoses.

METHODS

We identified 908 rTHAs performed at our institution from 2015 to 2021 using our total joint registry (TJR). Revision diagnoses were obtained from TJR, which contains prospectively recorded surgical diagnoses collected by trained abstractors, independent from ICD-10 data. The ICD-10 diagnosis codes, as submitted to AJRR, were retrieved for the same procedures. The accuracy of ICD-10 codes for classifying rTHA diagnoses as septic versus aseptic, instability, aseptic loosening, and periprosthetic fracture was assessed using Cohen's Kappa statistic, sensitivity, and specificity.

RESULTS

Concordance between AJRR submitted data and TJR for classifying rTHA as septic or aseptic was excellent (96.9%; k=0.87). Agreement for aseptic diagnoses varied from very good for instability (k=0.76) and loosening (k=0.67) to moderate for periprosthetic fracture (k=0.54). Specificity was high (>96%) for all three aseptic diagnoses, but sensitivity was lower at 74, 68, and 44% for instability, loosening, and periprosthetic fracture, respectively.

CONCLUSION

The AJRR submitted ICD-10 data correctly classifies the infection status of rTHA procedures with outstanding accuracy, but the accuracy for more granular diagnoses was variable. These data demonstrate the potential for diagnosis specific limitations when utilizing ICD-10 administrative claims for registry reporting.

What Is the Fate of Total Joint Arthroplasty Patients Who Are Asked to Quit Smoking Prior to Surgery?

Background

Smoking is a known risk factor for complications following primary total joint arthroplasty (TJA). Little is known regarding the fate of patients who are asked to quit smoking before surgery. The purpose of this study was to evaluate the success of smoking cessation prior to primary TJA and the impact of smoking cessation on perioperative outcomes.

Methods

This is a retrospective review of patients who presented between 2008 and 2020 to a single academic medical center with a documented smoking history and were asked to quit smoking prior to receiving a date for primary TJA. The cohort was surveyed about smoking cessation, smoking history, use of quit aids, seeking surgery elsewhere due to the cessation policy, and postoperative complications. Descriptive statistics evaluated the relationship between demographics, smoking cessation, and postoperative complications.

Results

A total of 101 patients completed the survey with an overall response rate of 48%. Sixty-two percent of patients quit smoking before surgery, and 51% of these patients reported remaining smoke-free at 6 months postoperatively. The average time to quit before TJA was 45 days (range: 1-365 days), and 62% quit without quit aids. The wound complication/infection rate was significantly higher for patients who did not stop smoking prior to TJA (4 of 16; 27%) than for those who did quit prior to surgery (3 of 63; 5%; P = .02).

Conclusions

This study demonstrates that most patients (62%) will stop smoking, if required, prior to primary TJA. Furthermore, 51% of patients reported abstinence from smoking at 6 months following TJA. TJA appears to be an effective motivator for smoking cessation.

Level of Evidence

III (retrospective cohort study).

Projected Prevalence of Obesity in Aseptic Revision Total Hip and Knee Arthroplasty

Background

The purpose of this study was to develop projections of the prevalence of obesity in aseptic revision THA and TKA patients through the year 2029.

Methods

The National Surgical Quality Improvement Project (NSQIP) was queried for years 2011-2019. Current procedural terminology (CPT) codes 27134, 27137, and 27138 were used to identify revision THA and CPT codes 27486 and 27487 were used to identify revision TKA. Revision THA/TKA for infectious, traumatic, or oncologic indications were excluded. Participant data were grouped according to body mass index (BMI) categories: underweight/normal weight, <25 kg/m2; overweight, 25-29.9 kg/m2; class I obesity, 30.034.9 kg/m2; class II obesity, 35.0-39.9 kg/m2; morbid obesity ≥ 40 kg/m2. Prevalence of each BMI category was estimated from year 2020 to year 2029 through multinomial regression analyses.

Results

38,325 cases were included (16,153 revision THA and 22,172 revision TKA). From 2011 to 2029, prevalence of class I obesity (24% to 25%), class II obesity (11% to 15%), and morbid obesity (7% to 9%) increased amongst aseptic revision THA patients. Similarly, prevalence of class I obesity (28% to 30%), class II obesity (17% to 29%), and morbid obesity (16% to 18%) increased in aseptic revision TKA patients.

Conclusion

Prevalence of class II obesity and morbid obesity demonstrated the largest increases in revision TKA and THA patients. By 2029, we estimate that approximately 49% of aseptic revision THA and 77% of aseptic revision TKA will have obesity and/or morbid obesity. Resources aimed at mitigating complications in this patient population are needed. Level of Evidence: III.

Outcomes Vary Significantly Using a Tiered Approach To Define Success After Total Hip Arthroplasty

Background

Clinical outcomes following primary total hip arthroplasty (THA) are commonly assessed through patient-reported outcome measures (PROM). The purpose of this study was to use progressively more stringent definitions of success to evaluate clinical outcomes of primary THA at 1-year postoperatively and to determine if demographic variables were associated with achievement of clinical success.

Methods

The American Joint Replacement Registry (AJRR) was queried from 2012-2020 for primary THA. Patients that completed the following PROMs preoperatively and 1-year postoperatively were included: Western Ontario and McMaster Universities Arthritis Index (WOMAC), Hip Injury and Osteoarthritis Outcome Score (HOOS) and HOOS for Joint Replacement (HOOS, JR). Mean PROM scores were determined for each visit and between-visit changes were evaluated using paired t-tests. Rates of achievement of minimal clinically important difference (MCID) by distribution-based and anchor-based criteria, patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) were calculated. Logistic regression was used to evaluate associations between demographic variables and odds of success.

Results

7,001 THAs were included. Mean improvement in PROM scores were: HOOS, JR, 37; WOMAC-Pain, 39; WOMAC-Function, 41 (p<0.0001 for all). Rates of achievement of each metric were: distribution-based MCID, 88-93%; anchor-based MCID, 68-90%; PASS, 47-84%; SCB, 68-84%. Age and sex were the most influential demographic factors on achievement of clinical success.

Conclusion

There is significant variability in clinical outcomes at 1 year after primary THA when using a tiered approach to define success from the patient's perspective. Tiered approaches to interpretation of PROMs should be considered for future research and clinical assessment. Level of Evidence: III.

The Rise of Medicare Advantage: Effects on Total Joint Arthroplasty Patient Care and Research

BACKGROUND

Medicare Advantage (MA) plans are popular among Medicare-eligible patients, but little is known about MA in lower-extremity total joint arthroplasty (TJA). The purpose of this study was to describe trends in MA utilization and analyze differences in patient characteristics and postoperative outcomes between patients undergoing primary TJA using traditional Medicare (TM) or MA plans.

METHODS

Patients ≥65 years of age who underwent primary total knee or total hip arthroplasty were identified using the Premier Healthcare Database. Patients were categorized into TM and MA cohorts. Data from 2004 to 2020 were used to describe trends in insurance coverage. Data from 2015 to 2020 were used to identify differences in patient characteristics and postoperative complications using ICD-10 codes. Multivariate analyses were performed using 2015 to 2020 data to account for potential confounders.

RESULTS

From 2004 to 2020, the proportion of patients with MA increased from 7.9% to 34.4%, while those with TM decreased from 83.7% to 54.0%. Of the 697,317 patients who underwent primary elective TJA from 2015 to 2020, 471,439 (67.6%) had TM coverage and 225,878 (32.4%) had MA coverage. The cohorts were similar in terms of age and sex. However, a higher proportion of Black patients (8.29% compared with 4.62%; p < 0.001) and a lower proportion of White patients (84.0% compared with 89.2%; p < 0.001) were enrolled in MA compared with TM. After controlling for confounders, patients with MA had higher odds of surgical site infection (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.47; p = 0.031), periprosthetic joint infection (aOR: 1.10; 95% CI: 1.03 to 1.18; p = 0.006), stroke (aOR: 1.15; 95% CI: 1.02 to 1.31; p = 0.026), and acute kidney injury (aOR: 1.08; 95% CI: 1.04 to 1.11; p < 0.001), but lower odds of urinary tract infection (aOR: 0.94; 95% CI: 0.90 to 0.98; p = 0.003).

CONCLUSIONS

From 2004 to 2020, the number of patients utilizing MA increased markedly such that 1 in 3 were covered by MA in 2020. From 2015 to 2020, patients who were non-White were more likely to have MA than TM, and the MA group had a higher rate of several postoperative complications compared with the TM group. As TM claims data inform health-care policy and clinical decisions, this change portends future challenges, including limitations in arthroplasty registry research, an increase in the administrative burden of surgeons, and a potential worsening of social disparities in health care.

Rates of Antimicrobial Resistance With Extended Oral Antibiotic Prophylaxis After Total Joint Arthroplasty

Background

There is increased interest and utilization of extended oral antibiotic prophylaxis (EOAP) following primary and revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). The purpose of this study was to look for potential associations between EOAP and differential rates of antimicrobial resistance or epidemiology of organisms causing periprosthetic joint infection (PJI) following primary and aseptic revision THAs/TKAs.

Methods

Patients who developed PJI following a primary or aseptic revision TKA/THA at a single institution from 2009 to 2020 were retrospectively identified. Patients who received at least 7 days of EOAP following the surgery were noted. Rates of antimicrobial resistance were compared between standard antibiotic prophylaxis and EOAP cohorts using the Fisher's exact test.

Results

One hundred twenty-eight cultures were obtained from 119 patients with PJI. Fourty-four cases (37%) developed PJI after EOAP. Staphylococcus aureus was the most frequently isolated organism (30% of all cultures; 78% were methicillin-sensitive). Rates of antimicrobial resistance were similar between standard antibiotic prophylaxis and EOAP cohorts in all but 2 instances: Increased resistance to erythromycin and trimethoprim-sulfamethoxazole was observed in coagulase-negative Staphylococci isolates in the EOAP cohort (89% vs 21%, P < .01; 44% vs 0%, P = .02). An increased frequency of gram-negative organisms was observed in the EOAP group (22% vs 8%, P = .03).

Conclusions

Rates of antimicrobial resistance were not significantly different between EOAP and standard antibiotic prophylaxis cohorts except in coagulase-negative Staphylococci. The increased frequency of gram-negative infections was present in the EOAP cohort. Larger, multicenter studies are needed to better understand the impact of EOAP on antimicrobial resistance and PJI epidemiology.

Level of Evidence

Level III; retrospective cohort study.

Administrative Data Use in National Registry Efforts: Blessing or Curse?

"Big data" refers to a growing field of large database research. Administrative data, a subset of big data, includes information from insurance claims, electronic medical records, and registries that can be useful for investigating novel research questions. While its use provides salient advantages, potential researchers relying on big data would benefit from knowing about how these databases are coded, common errors they may encounter, and how to best use large data to address various research questions. In the first section of this paper, Dr. Nicholas A. Bedard addresses the four major pitfalls to avoid with diagnosis and procedure codes in administrative data. In the next section, Dr. Jeffrey N. Katz et al. focus on the strengths and limitations of administrative data, suggesting methods to mitigate these limitations. Lastly, Dr. Elena Losina et al. review the uses and misuses of large databases for cost-effectiveness research, detailing methods for careful economic evaluations.

Analysis of New Orthopaedic Technologies in Large Database Research

Improvements in orthopaedic surgery go hand in hand with technological advances. The present article outlines the historical and current uses of large databases and registries for the evaluation of new orthopaedic technologies, providing insights for future utilization, with robotic-assisted surgery as the example technology.

Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal.

METHODS

PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism.

RESULTS

A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms).

CONCLUSIONS

Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.

Not all Total Hip and Knee Arthroplasties Are the Same: What Are the Implications in Large Database Studies?

BACKGROUND

The use of claims databases for research after total hip and knee arthroplasty (THA, TKA) has increased exponentially. These studies rely on accurate coding, and inadvertent inclusion of patients with nonroutine indications may influence results. The purpose of this study was to evaluate the complexity of THA and TKA captured by CPT code and determine if complication rates vary based on the indication.

METHODS

The NSQIP database was queried using CPT codes 21730 and 27447 to identify patients undergoing THA and TKA from 2018 to 2019. The surgical indication was classified based on the ICD-10 diagnosis code as routine primary, complex primary, inflammatory, fracture, oncologic, revision, infection, or indeterminant. Patient factors and 30-day complications, readmission, reoperation, and wound complications were compared.

RESULTS

A total of 86,009 THA patients had 703 ICD-10 diagnosis codes and 91.4% were routine primary indications. Complication rates were: routine primary 7.4%, complex primary 11.3%, inflammatory 12.5%, fracture 23.9%, oncologic 32.4%, revision 26.9%, infection 38.7%, and indeterminant 10.3% (P < .0001). 137,500 TKA patients had 552 ICD-10 diagnosis codes and 96.1% were routine primary cases. Complication rates were: routine primary 5.9%, complex primary 8.0%, inflammatory 7.2%, fracture 38.9%, oncologic 32.7%, revision 13.3%, infection 37.7%, and indeterminant 9.6% (P < .0001). Routine primary arthroplasty had significantly lower rates of reoperation, readmission, and wound complications.

CONCLUSION

Using CPT code alone captures 10% of THA and 4% of TKA patients with procedures for nonroutine primary indications. It is essential to recognize identification of patients simply by CPT code has the potential to inadvertently introduce bias, and surgeons should critically assess methods used to define the study populations.

Perioperative Opioid Counseling Reduces Opioid Use Following Primary Total Joint Arthroplasty

BACKGROUND

Preoperative counseling may reduce postoperative opioid requirements; however, there is a paucity of randomized controlled trials (RCTs) demonstrating efficacy. The purpose of this study was to perform an interventional, telehealth-based RCT evaluating the effect of peri-operative counseling on quantity and duration of opioid consumption following primary total joint arthroplasty (TJA).

METHODS

Participants were randomized into three groups: 1. Control group, no perioperative counseling; 2. Intervention group, preoperative educational video; 3. Intervention group, preoperative educational video and postoperative acceptance and commitment therapy (ACT). Opioid consumption was evaluated daily for 14 days and at 6 weeks postoperatively. Best-case and worse-case intention to treat analyses were performed to account for non-responses. Bonferroni corrections were applied.

RESULTS

183 participants were analyzed (63 in Group 1, 55 in Group 2, and 65 in Group 3). At 2 weeks postoperatively, there was no difference in opioid consumption between Groups 1, 2, and 3 (p>0.05 for all). At 6 weeks postoperatively, Groups 2 and 3 had consumed significantly less opioids than Group 1 (p=0.04, p<0.001) (Table 1). Group 3 participants were less likely to obtain an opioid refill relative to Group 1 participants (p=0.04). Participants in groups 2 and 3 ceased opioid consumption a median of 6 days and 2 days sooner than Group 1, respectively (p<0.001, p=0.03) (Table 2).

CONCLUSION

Perioperative opioid counseling significantly decreases the quantity and duration of opioid consumption at 6 weeks following primary TJA. Level of Evidence: I.

Operative Time and Risk of Surgical Site Infection and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis on the association between operative time and peri-prosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

PubMed, Embase, and Cochrane CENTRAL databases were searched for relevant articles dating 2000-2020. Relationship of operative time and PJI rate in primary total joint arthroplasty (TJA) was evaluated by pooled odds ratios (OR) and 95% confidence intervals.

RESULTS

Six studies were identified for meta-analysis. TJA lasting greater than 120 minutes had greater odds of PJI (OR, 1.63 [1.00-2.66], p=0.048). Similarly, there were greater odds of PJI for TJA procedures lasting greater than 90 minutes (OR, 1.65 [1.27-2.14]; p<0.001). Separate analyses of TKA (OR, 2.01 [0.76-5.30]) and THA (OR, 1.06 [0.80-1.39]) demonstrated no difference in rates of PJI in cases of operative time ≥ 120 minutes versus cases < 120 minutes (p>0.05 for all). Using any surgical site infection (SSI) as an endpoint, both TJA (OR, 1.47 [1.181.83], p<0.001) and TKA (OR, 1.50 [1.08-2.08]; p=0.016) procedures lasting more versus less than 120 minutes demonstrated significantly higher odds of SSI.

CONCLUSION

Following TJA, rates of SSI and PJI are significantly greater in procedures ≥120 minutes in duration relative to those < 120 minutes. When analyzing TKA separately, higher rates of SSI were observed in procedures ≥ 120 minutes in duration relative to those <120 minutes. Rates of PJI in TKA or THA procedures alone were not significantly impacted by operative time. Level of Evidence: V.

Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?

BACKGROUND

Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data.

RESULTS

Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis.

CONCLUSION

Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.

Are Body Mass Index Cutoffs Creating Racial, Ethnic, and Gender Disparities in Eligibility for Primary Total Hip and Knee Arthroplasty?

BACKGROUND

Unabated increases in the prevalence of obesity among American adults have disproportionately affected women, Black persons, and Hispanic persons. The purpose of this study was to evaluate for disparity in rates of patient eligibility for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on race and ethnicity and gender by applying commonly used body mass index (BMI) eligibility criteria to two large national databases.

METHODS

We retrospectively reviewed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2015-2019 for primary THA and TKA and the National Health and Nutrition Examination Survey (NHANES) from 2011-2018. Designations of race and ethnicity were standardized between cohorts. BMI cutoffs of <50 kg/m², <45 kg/m², <40 kg/m², and <35 kg/m² were then applied. Rates of eligibility for surgery were examined for each respective BMI cutoff and stratified by age, race and ethnicity, and gender.

RESULTS

143,973 NSQIP THA patients, 242,518 NSQIP TKA patients, and 13,255 NHANES participants were analyzed. Female patients were more likely to be ineligible for surgery across all cohorts for all modeled BMI cutoffs (P < .001 for all). Black patients had relatively lower rates of eligibility across all cohorts for all modeled BMI cutoffs (P < .0001 for all). Hispanic patients had disproportionately lower rates of eligibility only at a BMI cutoff of <35 kg/m².

CONCLUSION

Using BMI cutoffs alone to determine the eligibility for primary THA and TKA may disproportionally exclude women, Black persons, and Hispanic persons. These data raise concerns regarding further disparity and restriction of arthroplasty care to vulnerable populations that are already marginalized.

LEVEL OF EVIDENCE

Retrospective Cohort Study, Level III.

Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get?

BACKGROUND

Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029.

METHODS

Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m²) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029.

RESULTS

A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese.

CONCLUSION

By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Increased Risk of Short-Term Complications in Smokers Undergoing Primary Unicompartmental Knee Arthroplasty

The effects of smoking on unicompartmental knee arthroplasty (UKA) are unknown. The purpose of this study was to evaluate the effects of smoking on short-term outcomes following primary UKA. A query of the National Surgical Quality Improvement Project (NSQIP) database was used to identify cases of primary UKA performed during years 2006 to 2017. Patient demographics, operative times, and postoperative complications were compared between smoking and nonsmoking cohorts. Descriptive statistics, univariate analyses, and multivariate analyses were conducted to evaluate the effects of smoking on primary UKA. A total of 10,593 cases of UKA were identified; 1,046 of these patients were smokers. Univariate analysis demonstrated smokers to have higher rates of any complication (4.6 vs. 3.3%, p = 0.031), any wound complication (1.82 vs. 0.94%, p = 0.008), deep wound infection (0.57 vs. 0.13%, p = 0.006), and reoperation (1.34 vs. 0.68%, p = 0.018) relative to nonsmokers. Multivariate analysis demonstrated smokers to have higher rates of any wound complication (odds ratio [OR] = 1.79; 95% confidence interval [CI]: 1.06-2.95) and reoperation (OR = 2.11; 95% CI: 1.12-3.97). Smokers undergoing primary UKA are at higher risk for any wound complication and reoperation relative to nonsmokers in the first 30 days postoperatively. Further studies evaluating the long-term effects of smoking on outcome following UKA, as well as the impact of smoking cessation on outcomes following UKA, are needed.

What is the Impact of Body Mass Index Cutoffs on Total Knee Arthroplasty Complications?

BACKGROUND

Body mass index (BMI) cutoffs are commonly used to decide whether to offer obese patients elective total knee arthroplasty (TKA). However, weight loss goals may be unachievable for many patients who are consequentially denied complication-free surgery. The purpose of this study was to assess the impact of different BMI cutoffs on the rates of complication-free surgery after TKA.

METHODS

Patients undergoing elective, primary TKA from 2015 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27447. The BMI and rates of any thirty-day complication were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m² were applied to model the incidence of complications if TKA would have been allowed or denied based on the BMI.

RESULTS

A total of 314,719 patients underwent TKA, and 46,386 (14.7%) had a BMI ≥40 kg/m². With a BMI cutoff of 40 kg/m², 268,333 (85.3%) patients would have undergone TKA. A total of 282,552 (94.8%) would experience complication-free surgery, and 17.3% of all complications would be prevented. TKA would proceed for 309,479 (98.3%) patients at a BMI cutoff of 50 kg/m². A total of 293,108 (94.7%) would not experience a complication, and 2.8% of complications would be prevented. A BMI cutoff of 35 kg/m² would prevent 36.6% of all complications while allowing 94.8% of complication-free surgeries to proceed.

CONCLUSION

Lower BMI cutoffs can reduce complications, but will limit access to complication-free TKA for many patients. These data do not indicate TKA should be performed without consideration of risks from obesity; however, a holistic assessment and shared decision-making may be more valuable when deciding on appropriate goal weight reduction.

Can Abnormal Spinopelvic Relationships be Identified by Anteroposterior Pelvic Radiographs?

BACKGROUND

Abnormal spinopelvic relationships may place patients at an increased risk for instability after primary total hip arthroplasty. The purpose of this study was to determine if radiographic markers on a standing anteroposterior (AP) pelvis radiograph could identify patients with sagittal spinopelvic imbalance or spinal stiffness.

METHODS

Patients undergoing primary total hip arthroplasty at a single institution from 2017 to 2020 with standing AP pelvis radiographs and sitting/standing lateral radiographs were identified. AP pelvis radiographs were assessed for the following: lumbosacral hardware, spine osteophytes, disc space narrowing, scoliosis>5°, pelvic obliquity>5°, and overlap of the sacrococcygeal junction/pubic symphysis. Patients with spinopelvic imbalance and/or spinopelvic stiffness were identified. Univariate and multivariate analyses were performed. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Four hundred eighty-six patients were included. Prevalence of isolated sagittal spinopelvic imbalance and isolated spinopelvic stiffness was 12% and 21%, respectively; 11% of patients had sagittal imbalance and stiffness. Overlap of the sacrococcygeal junction/pubic symphysis (OR = 10.2, 95% CI = 5.3-19.8) and presence of lumbosacral hardware (OR = 4.4, 95% CI = 2.0-9.4) were markers of an increased risk of combined sagittal imbalance and stiffness. Seventy-nine percent of patients with overlap of the sacrococcygeal junction and pubic symphysis and 82% of patients with lumbosacral hardware had an abnormal spinopelvic relationship.

CONCLUSION

Isolated sagittal imbalance and stiffness were difficult to predict on standing AP pelvis radiographs. Overlap of the sacrococcygeal junction/pubic symphysis and presence of lumbosacral hardware associated with a higher risk of combined sagittal imbalance/stiffness and were present in ≥79% of patients with an abnormal spinopelvic relationship.

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Are Morbidly Obese Patients Equally Benefitting From Care Improvements in Total Hip Arthroplasty?

BACKGROUND

Morbidly obese patients have increased rates of complications following primary total hip arthroplasty (THA) and it is not clear whether improvements in THA care pathways are equally benefitting these patients. The purpose of this study is to assess if reductions in complications have similarly improved for both morbidly obese and non-morbidly obese patients after THA.

METHODS

Patients undergoing primary THA between 2011 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 and ≥40 kg/m². Thirty-day rates of infectious complications, readmissions, reoperation, and any complication were assessed. Trends in complications were compared utilizing odds ratios and multivariate analyses.

RESULTS

In total, 234,334 patients underwent THA and 16,979 (7.8%) had BMI ≥40 kg/m². Patients with BMI ≥40 kg/m² were at significantly higher odds for readmission, reoperation, and infectious complications. Odds for any complication were lower for morbidly obese patients in 2011, not different from 2012 to 2014, and higher from 2015 to 2019 compared to lower BMI patients. Odds for any non-transfusion complication were higher for morbidly obese patients and there was no improvement for either group over the study period. There were improvements in rates of readmission and reoperation for patients with BMI <40 kg/m² and readmission for BMI >40 kg/m².

CONCLUSION

Odds for readmission and reoperation for non-morbidly obese patients and readmission for morbidly obese patients improved from 2011 to 2019. Reductions in transfusions are largely responsible for improvements in overall complication rates. Although morbidly obese patients remain at higher risk for complications, there does not appear to be a growing disparity in outcomes between morbidly obese and non-morbidly obese patients.

Use of Cementless Metaphyseal Fixation in Revision Total Knee Arthroplasty in the United States

BACKGROUND

Fixation options for revision total knee arthroplasty (rTKA) have expanded and now include cementless metaphyseal fixation. The utilization rates of these implants in the United States are not well known. The purpose of this study was to analyze trends in cementless metaphyseal fixation for rTKA within the American Joint Replacement Registry (AJRR).

METHODS

The AJRR was queried for the years 2015-2019 to identify all rTKA with implant data. Trends in the use of cementless sleeves, metaphyseal cones, and any cementless metaphyseal fixation (sleeves + cones) were examined over the study period using logistic regression analysis.

RESULTS

Twenty thousand two hundred and eighty rTKA were analyzed. Cementless metaphyseal fixation was used in 16% of rTKA and significantly increased over the study period (14% to 19%, P < .0001). Cementless metaphyseal fixation was more frequently utilized during revision for aseptic loosening than other diagnoses (OR 1.014, 95% CI 1.001-1.027). Cementless sleeve utilization decreased over time (11% to 9%, P = .004), driven by decreased use on the femur (4% to 2%, P < .0001). The use of cones increased significantly over time (3% to 9%, P < .0001), driven by increased use on the tibia (2% to 9%, P < .0001). Cones were 22 times more likely to be utilized on the tibia relative to the femur (P < .0001) and were more likely to be used in revisions for infection (OR 1.103, 95% CI 1.089-1.117) and aseptic loosening (OR 1.764, 95% CI 1.728-1.800).

CONCLUSION

Cementless metaphyseal fixation has grown in popularity yet, still comprised only 16% of rTKA over a 5-year period. Most of the increase was due to the utilization of tibial metaphyseal cones.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BACKGROUND

We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.

METHODS

Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.

RESULTS

Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).

CONCLUSION

A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.

LEVEL OF EVIDENCE

1.

Is There a Time-Dependent Contamination Risk to Open Surgical Trays During Total Hip and Knee Arthroplasty?

Background

Periprosthetic joint infection (PJI) after total hip and knee arthroplasty (TJA) is a devastating complication and intraoperative contamination can be a source for PJI. Currently, many measures are performed intraoperatively to reduce the risk of contamination. The primary purpose of this study was to determine if there is a time-dependent risk of contamination to open sterile surgical trays during TJA cases.

Methods

A prospective intraoperative culture swab study was performed. Standard sterile operating room trays without instruments were utilized as the experimental trays. These were opened simultaneously with all other surgical instrumentation needed for the procedure. These trays were left on an isolated Mayo stand next to the scrub tech's table and swabbed at 30-minute intervals. The first swab was performed immediately after opening all sets and the last swab performed on closure of the incision. A new section of the grid-lined tray was swabbed for each data point and the culture analysis was conducted by our institutions' microbiology lab for both quantitative and qualitative analysis. Operating suite room temperature and humidity data was also gathered.

Results

Twenty-three consecutive primary TJA cases in high air turnover rooms were included. 13 of the 23 (57%) cases demonstrated culture positive bacterial growth on at least one time point. Of the 109 independent swabs collected, 19 (17%) had bacterial growth. The most common bacterial species isolated was Staphylococcus epidermidis. There were no statistically significant associations between time (p= 0.35), operating room (OR) temperature (p = 0.99), and OR humidity (p = 0.07) and with bacterial growth.

Conclusion

In spite of isolating an organism in 57% of cases, we could not identify a time-dependent increase in bacterial contamination throughout our operative cases. We were unable to associate OR environmental temperature and humidity to bacterial growth. Level of Evidence: II.

Longer Length of Stay Is Associated With More Early Complications After Total Knee Arthroplasty

Background

Length of stay (LOS) following total knee arthroplasty (TKA) has decreased over recently years. In 2018, the Centers for Medicare and Medicaid Services removed TKA from Inpatient-Only List (IPO), incentivizing further expansion of outpatient TKA. However, many patients may still require postsurgical hospitalization. The purpose of this study was to assess early outcomes for TKA based on length of stay (LOS).

Methods

We identified patients undergoing elective, primary TKA in the National Surgical Quality Improvement Program database using CPT code 27447 between 2015 and 2018. Patients were stratified by length of stay (LOS) 0 days, 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmission, and reoperation were assessed. Multivariate analysis was performed to adjust for confounding variables.

Results

5,655 (3%) patients underwent outpatient TKA, 130,543 (59%) had LOS 1-2 days, and 84,986 (38%) had LOS ≥3 days. Any complication was experienced in 4.1% of those with LOS 0 days, 4.3% for those with LOS of 1-2 days, and 10.5% for patients with LOS ≥3 days (p<0.0001). Readmission occurred in 2.2%, 2.6%, and 4.0% for the 3 groups, respectively (p<0.0001). After multivariate analysis, there was no significant difference in any outcome measure between patients with LOS 0 and 1-2 days, however those with LOS ≥3 days had higher odds of complications, reoperation, and readmission.

Conclusion

A significant number of patients had LOS ≥3 days following TKA and had more comorbidities and complications. Outpatient TKA was not associated with increased early complication compared to those with LOS of 1-2 days. Despite expansion of outpatient surgery, postsurgical hospitalization remains an integral part of care following TKA. Level of Evidence: III.

What is the Level of Evidence Substantiating Commercial Payers' Coverage Policies for Total Joint Arthroplasty?

BACKGROUND

The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States.

METHODS

The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease.

RESULTS

282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA.

CONCLUSION

Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.

Do Extended Oral Postoperative Antibiotics Prevent Early Periprosthetic Joint Infection in Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty?

BACKGROUND

Extended oral antibiotic prophylaxis after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) in patients with body mass index (BMI) ≥40 kg/m² may reduce the rate of early periprosthetic joint infection (PJI); however, existing data are limited. The purpose of this study was to examine rates of wound complications and PJI in patients with BMI ≥40 kg/m² treated with and without extended oral antibiotic prophylaxis after surgery.

METHODS

We retrospectively identified all primary THA and TKA performed since 2015 in patients with a BMI ≥40 kg/m² at a single institution. Extended oral antibiotic prophylaxis for 7-14 days after surgery was prescribed at the discretion of each surgeon. Wound complications and PJI were examined at 90 days postoperatively.

RESULTS

In total, 650 cases (205 THA and 445 TKA) were analyzed. Mean age was 58 years and 62% were women. Mean BMI was 44 kg/m². Extended oral antibiotic prophylaxis was prescribed in 177 cases (27%). At 90 days, there was no difference between prophylaxis and nonprophylaxis groups in rate of wound complications (11% vs 8%; P = .41) or PJI (1.7% vs 0.6%; P = .35). The univariate analysis demonstrated increased operative time (odds ratio (OR) 1.01; 95% confidence interval (95% CI) 1.01-1.02) and diabetes mellitus (OR 1.88; 95% CI 1.03-3.46) to be associated with increased risk of 90-day wound complications. No patient factors were associated with increased risk of PJI at 90 days postoperatively.

CONCLUSION

Extended oral antibiotic prophylaxis after primary THA and TKA did not reduce rates of wound complications or early PJI in a morbidly obese patient population.

Has Removal From the Inpatient-Only List Increased Complications After Outpatient Total Knee Arthroplasty?

BACKGROUND

On 1/1/2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient-Only (IPO) list. This change allowed expansion of outpatient TKA, potentially to include older, more frail patients at greater risk for perioperative complications. The purpose of this study was to evaluate the impact of removing TKA from the IPO list on early complications.

METHODS

Patients undergoing TKA in the National Surgical Quality Improvement Program database were identified using CPT code 27447. Only cases with length of stay of zero days were included. Rates of 30-day complications, readmissions, and reoperation were compared before and after TKA was removed from the IPO list (2015-2017 vs 2018). The analysis was performed both with and without propensity score matching.

RESULTS

212,313 patients underwent TKA during the study period. 2466 (1.5%) were outpatient TKA in 2015-2017 and 3189 (5.6%) in 2018. After propensity matching, there were 2458 patients in each cohort. Rates of total 30-day complications were significantly lower in 2018 (3.7%) than the years TKA remained on the IPO (4.5%, P = .04). Similarly, rates of any reoperation decreased from 1.2% during 2015-2017 to 0.6% in 2018 (P = .03). There were no significant changes in rates of readmission (2.5% vs 2.2%, P = .5) or wound complications (0.8% vs 0.8%, P = 1.0).

CONCLUSION

Removal of TKA from the IPO list did not result in an increase in complications or readmissions. These data suggest, despite the regulatory change, surgeons have continued to exercise sound judgment as to what patients can safely undergo outpatient TKA.

Are surgeons still performing primary total knee arthroplasty in the morbidly obese?

AIMS

The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred.

METHODS

Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m² and ≥ 40 kg/m² and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses.

RESULTS

In total, 314,695 patients underwent TKA and 46,362 (15%) had BMI ≥ 40 kg/m². The prevalence of morbid obesity among TKA patients did not change greatly, ranging between 14% and 16%. Reoperation rate decreased from 1.16% to 0.96% (odds ratio (OR) 0.81 (95% confidence interval (CI) 0.66 to 0.99)) for patients with BMI < 40 kg/m², as did rates of readmission (4.46% to 2.87%; OR 0.61 (0.55 to 0.69)). Patients with BMI ≥ 40 kg/m² also had fewer readmissions over the study period (4.87% to 3.34%; OR 0.64 (0.49 to 0.83)); however, the rate of reoperation did not change (1.37% to 1.41%; OR 0.99 (0.62 to 1.56)). Significant improvements were not observed for infective complications over time for either group; patients with BMI ≥ 40 kg/m² had increased risk of both deep infection and wound complications compared to non-morbidly obese patients. Rate of any complication decreased for all patients.

CONCLUSION

The proportion of TKAs in morbidly obese patients has not significantly changed over the past decade. Although readmission rates improved for all patients, reductions in reoperation in non-morbidly obese patients were not experienced by the morbidly obese, resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infective complications in the morbidly obese. Cite this article: Bone Joint J 2021;103-B(6 Supple A):38-44.

Early Emergency Department Visits Following Primary Hip and Knee Arthroplasty

BACKGROUND

Postoperative emergency department (ED) utilization remains an understudied aspect of total joint arthroplasty (TJA). The purpose of this study is to characterize 30-day ED visits following TJA.

METHODS

We reviewed 4061 primary unilateral total hip and knee arthroplasty cases performed at our hospital from 2013 to 2017. The primary outcome was presentation to our institution's ED within 30 days of surgery. Chief complaints and their association to the TJA encounter, as well as readmissions and reoperations, were recorded. One-to-three propensity score matched analysis was used to identify index admission variables associated with early ED visits.

RESULTS

There were 253 recorded ED visits within 30 days of TJA (218 cases, 5.4%). Nearly 60% of ED visits were directly related to the TJA encounter. The remainder were medically related, most commonly for gastrointestinal complaints. The most common TJA-related complaints were surgical limb pain (28%), wound concerns (20%), and swelling (20%). These complaints comprised two-thirds of TJA-related ED visits, though accounted for only 19.4% and 9.5% of readmissions and reoperations observed in this cohort, respectively. Perioperative transfusion, length of stay, primary insurer, and discharge disposition were not associated with an ED visit.

CONCLUSION

ED visits within 30 days of TJA were common (5.4%). Most visits related to the index procedure were due to surgical limb pain, wound concerns, and swelling. These complaints accounted for a minority of readmissions and reoperations. This study suggests that perioperative strategies addressing common postoperative concerns are warranted to mitigate acute care use after TJA.