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With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA. A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation. There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The odds ratio associated with anemia as a predictor of transfusion increased from 3.1 (95% confidence interval: 2.1 to 4.6) in 2010 to 14.0 (95% confidence interval: 8.9 to 24) in 2021. The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA. III. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients. This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed. Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients. Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation. [ABSTRACT FROM AUTHOR]

There has been considerable interest in the use of GLP-1 receptor analogs (GLP-1 RAs) for weight optimization in patients undergoing elective arthroplasty. As there is limited data regarding the implications of their use, our study aimed to evaluate the association between preoperative GLP-1 RA use and postoperative outcomes in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The TrinetX research network was queried to identify all patients undergoing primary THA or TKA between May 2005 and December 2023 across 84 health care organizations. Patients were stratified based on preoperative GLP-1 RA use. Propensity score matching (1:1) was performed to account for baseline differences in demographics, laboratory investigations, and comorbidities. Subsequently, risk ratios were evaluated for postoperative outcomes. A total of 268,504 and 386,356 patients underwent THA and TKA, of which 1,044 and 2,095 used preoperative GLP-1 RAs. After matching, GLP-1 RA use was associated with a decreased 90-day risk of periprosthetic joint infection (2.1 versus 3.6%, RR = 0.58, P =.042) and readmission (1.1 versus 2.0%, RR = 0.53, P =.017) following THA and TKA, respectively. There was no difference in the risk of all other outcomes between comparison groups. Preoperative GLP-1 RA use is associated with a 42% decreased risk of periprosthetic joint infection and 47% decreased risk of readmission in the 90-day postoperative period following THA and TKA, respectively, with no difference in other risks, including aspiration. Our findings indicate that GLP-1 RAs may be safe to use in patients undergoing elective arthroplasty; however, further studies are warranted to inform the routine use of GLP-1 RAs for weight management in THA and TKA patients. [ABSTRACT FROM AUTHOR]

As publishing with open access is becoming increasingly popular within orthopaedics, understanding the types of publishing options available and what each may deliver is critically important. Hybrid articles require a high article processing charge. Open journal articles have a lower fee, while closed license articles are freely accessible at no charge. Open repository articles are peer-reviewed manuscripts posted freely online. The purpose of this study was to determine the relationship between article type and resulting citations, social media attention, and readership in total knee arthroplasty (TKA) literature. Open access TKA journal articles published since 2016 were found using the Altmetric Explorer Database. Data gathered included the Altmetric Attention Score (attention), Mendeley Readership Score (readership), and citations per article. Articles were grouped by type: open journal, hybrid, closed license, and open repository. Results were analyzed using descriptive statistics and Tukey's analysis; α = 0.05. A total of 9,606 publications were included. The open repository had the greatest mean citations (14.40), while open journal (9.55) had fewer than all other categories (P <.001). Hybrid had the greatest mean attention (10.35), and open journal (6.16) had a lower mean attention than all other categories (P ≤.002). Open repository had the greatest mean readership (44.68), and open journal (34.00) had a lower mean readership than all other categories (P ≤.012). The mean publication fee for paid publication options was $1,792 United States dollars. In open access TKA literature, free-to-publish open repositories had the greatest mean citations and readership. Free publication options, open repositories and closed licenses, had greater readership compared to paid publication options. [ABSTRACT FROM AUTHOR]

Preoperative anemia is common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Several definitions of anemia have been described, with no clear consensus on the optimal one for preoperative screening. We hypothesized that depending on the definition used preoperatively, the proportion of anemic patients identified who would require a postoperative allogeneic blood transfusion would vary significantly. A total of 681,141 patients were identified in a national database who underwent either THA or TKA. Preoperative anemia was classified according to the World Health Organization (WHO) definition, Cleveland Clinic (CC) definition, or race, age, and sex-specific definition described by Beutler et al in 2006. The optimal preoperative (OP) hemoglobin thresholds to predict perioperative transfusions were also calculated using receiver operating characteristic curves. When using the WHO definition, 18% of anemic patients required a transfusion versus 14% (OP definition), 12% (CC definition), and 16% (Beutler definition). Similarly, 0.69% of anemic patients sustained a periprosthetic joint infection within 30 days using the WHO definition versus 0.59% (OP definition), 0.60% (CC definition), or 0.66% (Beutler definition). Using the WHO definition, 5.3% of patients would have sustained a major complication versus 4.5% (OP definition), 4.4% (CC definition), and 5.0% (Beutler definition). Variation in the definition of anemia for preoperative screening in THA and TKA results in substantial differences in discriminative ability to predict perioperative transfusions. The WHO definition identified the largest proportion of patients who ultimately received a perioperative transfusion. [ABSTRACT FROM AUTHOR]

Social media platforms are often used for research dissemination and collaboration. Given the increased prevalence of online-only publications, understanding what drives research dissemination is important. Here, we analyzed factors associated with increased social media attention among peer-reviewed publications in total knee arthroplasty, total hip arthroplasty, and unicompartmental knee arthroplasty. We analyzed publications about total knee arthroplasty, total hip arthroplasty, or unicompartmental knee arthroplasty from 2010 to 2022 using a national database. We analyzed a weighted count of social media mentions, using negative binomial regressions adjusting for days since publication. Publications on "hot topics" in arthroplasty were examined including navigation/robotics, COVID-19, race/ethnicity, body mass index, and reimbursement. There were 9,542 publications included, 4,216 (44%) were open access (OA), 338 (3.5%) included navigation, 32 (0.34%) discussed race/ethnicity, 20 (0.2%) discussed COVID-19, 3,840 (40%) were randomized studies, 30 (0.3%) discussed reimbursement, and 2,867 (30%) were in top-10 orthopaedic journals. Factors associated with higher weighted score included studies about COVID-19 (50 versus 6.0, P <.001), race/ethnicity (15.8 versus 6.0, P <.001), OA status (6.3 versus 5.8, P =.001), and randomized studies (6.5 versus 5.7, P <.001). Studies from top-10 journals had a lower score (5.8 versus 6.2, P =.025), as did studies about body mass index (3.4 versus 6.1, P =.001). Studies about navigation and reimbursement did not have significantly different scores. Studies on COVID-19, race/ethnicity, randomized studies, and OA publication were associated with increased social media while those in top-10 orthopaedic journals had lower scores. Level IV, Prognostic Study. [ABSTRACT FROM AUTHOR]

Open access (OA) publication is growing in total joint arthroplasty literature. While OA manuscripts are free to view, these publications require a fee from authors. This study aimed to compare social media attention and citation rates between OA and non-OA publications in the total knee arthroplasty (TKA) literature. There were 9,606 publications included, with 4,669 (48.61%) as OA articles. The TKA articles were identified from 2016 to 2022. Articles were grouped as OA or non-OA and Altmetric Attention Score (AAS), a weighted count of social media attention, and the Mendeley readership were analyzed using negative binomial regressions while adjusting for days since publication. The OA articles had greater mean AAS (13.45 versus 8.42, P =.012) and Mendeley readership (43.91 versus 36.72, P <.001). OA was not an independent predictor of number of citations when compared to non-OA articles (13.98 versus 13.63, P =.914). Subgroup analysis of studies in the top 10 arthroplasty journals showed OA was not an independent predictor of AAS (13.51 versus 9.53, P =.084) or number of citations (19.51 versus 18.74, P =.495) but was an independent predictor of Mendeley readership (49.05 versus 40.25, P <.003). The OA publications in the TKA literature were associated with increased social media attention, but not overall citations. This association was not observed among the top 10 journals. Authors may use these results to weigh the relative importance of readership, citations, and online engagement to the cost of OA publication. [ABSTRACT FROM AUTHOR]

Racial and ethnic minorities are under-represented in orthopaedic surgery despite efforts to promote diversity and inclusion in the specialty. The purpose of this study was to determine the proportion of international medical graduates (IMGs) in the surgical workforce and future residency pipeline. We further analyze IMG applicant qualifications relative to their US-based counterparts to assess the viability of recruiting IMG candidates as one strategy to advance diversity and inclusion in orthopaedic surgery. Physician workforce data from the American Medical Association and residency match data from the National Resident Match Program were analyzed for Orthopaedic Surgery. Trends in the proportion of IMG applicants were compared with those from other specialties. Qualifications of applicants were compared including board exam scores, number of abstracts/publications, and additional graduate degrees. In 2020, orthopaedic surgery had the lowest percentage of IMGs relative to otolaryngology (5.8 %, p < 0.001), neurosurgery (12.1 %, p < 0.001), obstetrics & gynecology (14.0 %, p < 0.001), and general surgery (19.1 %, p < 0.001). From 1986 to 2021, IMG Graduates who matched into orthopaedic surgery increased from 1 (0.3 %) to 8 (0.9 %). Compared to other surgical specialties, orthopaedic surgery had among the lowest annual rates of incoming IMG residents. In 2021, most respondents to the orthopaedic surgery residency program directors survey reported never selecting IMG applicants for interview (74 % for non-US IMG applicants and 53 % for US IMG applicants). From 2020 to 2021, non-US IMG applicants (17 %) and US IMG applicants (26 %) had lower match rates than DO Senior (74 %) and MD Senior (80 %) applicants (p < 0.001). In 2020, matched non-US IMGs had similar board scores as matched US MD Senior applicants, but more abstracts/publications. The recruitment of IMGs into orthopaedic surgery residency remains limited and lower than other surgical specialties. IMGs have similar board scores and more abstracts/publications, thus representing a potential pipeline for workforce diversity. More research is needed to understand the special needs of IMGs in the orthopaedic surgery match. [ABSTRACT FROM AUTHOR]

Background: In January 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient Only (IPO) list. This study aimed to compare patient-level payments in TKA cases with a length of stay (LOS) <2 midnights before and after removal of TKA from IPO list.Methods: In this retrospective cohort study, all Medicare patients who received a primary elective TKA from 2016-2019 with a LOS <2 midnights at an academic tertiary center were identified. Total and itemized charges and patient-level payments were compared between eligible TKA cases performed in 2016-2017 and those in 2018-2019. There were 351 eligible TKA cases identified: 151 in 2016-2017 and 200 in 2018-2019.Results: The percentage of patients making any out-of-pocket payment increased in 2018-2019 from 2016-2017 (51.0% versus 10.6%), as did median patient-level payment ($7.30 [range, $0.00-$3,389] versus $0.00 [range, $0.00-$1,248], P < .001 for both). A greater proportion of patients in 2018-2019 paid $1-$50 than in 2016-2017 (37.5% versus 1.3%, P < .001) with no change in the proportion of patients who made payments >$50. Total charges were less in 2018-2019 than in 2016-2017 (P = .001). Charges for drugs, laboratory tests, admissions/floor, and therapies decreased in 2018-2019, whereas charges for the operating room and radiology increased (P < .001 for all).Conclusion: Patients receiving outpatient TKA in 2018-2019 were more likely to have out-of-pocket payments than patients with comparable hospital stay who were designated as inpatients, although most of these payments were less than $50. [ABSTRACT FROM AUTHOR]

Diarrhea is a prevalent gastrointestinal problem associated with fatal implications. It is a huge public health concern that requires better alternatives to current drugs. This study investigated the mechanisms involved in the antidiarrheal activity of Anacardium occidentale (Ao) stem bark extract, a plant commonly used in the management of diarrhea in Nigeria. Methanolic stem bark extract of the plant was partitioned into three fractions: hexane fraction, ethyl acetate fraction (AoEF) and methanol fraction. In vitro studies on the effect of these fractions on guinea pig ileum (GPI) strips, as well as the modulatory effect of AoEF on standard agonists- and antagonists-induced GPI contraction and relaxation, revealed AoEF as the most active fraction. In vivo studies to assess the effect of AoEF on the dopaminergic, muscarinic, and serotonergic pathways were carried out using gastric emptying (GE) and gastrointestinal transit (GT) as experimental end points. AoEF was subjected to GC-MS analysis, while the identified compounds were docked with the muscarinic acetylcholine receptor M3 (CHRM3) using AutodockVina. Results indicated that AoEF inhibited GE and GT via inhibition of CHRM3. In addition, GC-MS analysis revealed the presence of 24 compounds in AoEF, while docking indicated that octadecanoic acid 2-(2-hydroxylethoxy) ethyl ester exhibited the highest binding affinity to CHRM3. This study indicated that the antidiarrheal activity of Ao is through its antimotility effect via the inhibition of the muscarinic pathway. And since none of the identified compounds exhibited higher binding affinity to CHRM3 relative to loperamide, the antimotility activity of these phytoconstituents may be via synergism. [Display omitted] • Ethyl acetate fraction of Anacardium occidentale methanolic stem bark extract inhibited guinea pig ileal muscle motility. • The ethyl acetate fraction inhibited gut motility via inhibition of muscarinic acetylcholinesterase receptor. • GC-MS analysis identified 24 compounds in the fraction. • Molecular docking revealed that the anti-motility activity of these compounds is possibly through synergism. • Anacardium occidentale extracts modulate gut motility via inhibition of muscarinic acetylcholinesterase receptor. [ABSTRACT FROM AUTHOR]

Background: Falls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA.Methods: We queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05.Results: Patients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts.Conclusion: Falls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: As the incidence of total joint arthroplasty (TJA) increases, identifying methods for cost reduction is essential. Basic metabolic panels (BMPs) are obtained routinely after TJA. We aimed at assessing the prevalence of intervention secondary to abnormal BMPs after primary TJA and at identifying predictors of the need for postoperative BMPs.Methods: We reviewed 802 cases (758 patients) of primary lower-extremity TJA performed from January 1 through December 31, 2018, at our tertiary care medical center. Patient characteristics, preoperative and postoperative BMPs, comorbidities, current medications, and in-hospital interventions were recorded. Age-adjusted Charlson Comorbidity Index (AA-CCI) values were calculated. Institutional costs of 1 BMP and of all BMPs not prompting intervention were calculated. We used multiple regression to identify independent predictors of in-hospital interventions secondary to abnormal postoperative BMPs.Results: Our institutional BMP cost was $36. A total of 1032 postoperative BMPs were ordered; 958 (93%) prompted no intervention. This equated to $34,488 of avoidable BMP costs. We identified 27 cases (3.4%) requiring intervention secondary to abnormal BMPs. Independent predictors of intervention were preoperative renal dysfunction (ie, abnormal creatinine or glomerular filtration rate <60 mL/min) (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.8-22), number of current nephrotoxic medications (OR, 1.9; 95% CI, 1.3-2.9), and AA-CCI value (OR, 1.2; 95% CI, 1.0-1.5).Conclusion: Routine postoperative BMPs are unwarranted for most patients undergoing primary TJA. Testing may be reserved for those with renal dysfunction, those taking multiple nephrotoxic medications, or those with a high AA-CCI value. [ABSTRACT FROM AUTHOR]

Objectives: Postoperative delirium, associated with negative consequences including longer hospital stays and worse cognitive and physical outcomes, is frequently accompanied by sleep-wake disturbance. Our objective was to evaluate the efficacy and short-term safety of ramelteon, a melatonin receptor agonist, for the prevention of postoperative delirium in older patients undergoing orthopedic surgery.Design: A quadruple-masked randomized placebo-controlled trial (Clinical Trials.gov NCT02324153) conducted from March 2017 to June 2019.Setting: Tertiary academic medical center.Participants: Patients aged 65 years or older, undergoing elective primary or revision hip or knee replacement.Intervention: Ramelteon (8 mg) or placebo MEASUREMENTS: Eighty participants were randomized to an oral gel cap of ramelteon or placebo for 3 consecutive nights starting the night before surgery. Trained research staff conducted delirium assessments for 3 consecutive days starting on postoperative day (POD) 0, after recovery from anesthesia, and on to POD2. A delirium diagnosis was based upon DSM-5 criteria determined by expert panel consensus.Results: Of 80 participants, five withdrew consent (one placebo, four ramelteon) and four were excluded (four ramelteon) after randomization. Delirium incidence during the 2 days following surgery was 7% (5 of 71) with no difference between the ramelteon versus placebo: 9% (3 of 33) and 5% (2 of 38), respectively. The adjusted odds ratio for postoperative delirium as a function of assignment to the ramelteon treatment arm was 1.28 (95% confidence interval: 0.21-7.93; z-value 0.27; p-value = 0.79). Adverse events were similar between the two groups.Conclusion: In older patients undergoing elective primary or revision hip or knee replacement, ramelteon was not efficacious in preventing postoperative delirium. [ABSTRACT FROM AUTHOR]

Background: Nutritional optimization before total joint arthroplasty (TJA) may improve patient outcomes and decrease costs. However, the utility of serologic laboratory markers, including albumin, transferrin, and total lymphocyte count (TLC), as primary indicators of nutrition is unclear. We analyzed the prevalence of abnormal nutritional values before TJA and identified factors associated with them.Methods: We retrospectively reviewed 819 primary cases of TJA performed at 1 institution from January to December 2018. Patient demographic characteristics were assessed for associations with abnormal preoperative nutritional values (albumin <3.5 g/dL, transferrin <200 mg/dL, and TLC <1.5 cells/μL3). Associations of comorbidities, American Society of Anesthesiologists Physical Status classification, and age-adjusted Charlson Comorbidity Index (CCI) with abnormal values were assessed with logistic regression.Results: Values were abnormal for albumin in 21 cases (2.6%), transferrin in 26 cases (5.6%), and TLC in 185 cases (25%). Thirteen cases (1.7%) had abnormal values for 2 markers. Age was associated with abnormal albumin and TLC, and race with abnormal transferrin. Congestive heart failure, chronic kidney disease, pancreatic insufficiency, gastroesophageal reflux disease, osteoporosis, dementia, and CCI were associated with abnormal albumin; Parkinson disease and American Society of Anesthesiologists Physical Status with abnormal transferrin; and dementia, body mass index, cancer history, and CCI with abnormal TLC.Conclusion: We report low prevalence of and a low concordance rate among abnormal nutritional values before primary TJA. Our results suggest that routine testing of all healthy patients is not warranted before TJA. [ABSTRACT FROM AUTHOR]

Background: As the world struggles with the COVID-19 pandemic, health care providers are on the front lines. We highlight the value of engaging in humanitarian medical work, contributions of the hip and knee arthroplasty community to date, and future needs after the resolution of the pandemic. We sought to understand how the arthroplasty community can contribute, based on historical lessons from prior pandemics and recessions, current needs, and projections of the COVID-19 impact.Methods: We polled members of medical mission groups led by arthroplasty surgeons to understand their current efforts in humanitarian medical work. We also polled orthopedic colleagues to understand their role and response. Google Search and PubMed were used to find articles relevant to the current environment of the COVID-19 pandemic, humanitarian needs after previous epidemics, and the economic effects of prior recessions on elective surgery.Results: Hip and knee arthroplasty surgeons are not at the center of the pandemic but are providing an invaluable supportive role through continued care of musculoskeletal patients and unloading of emergency rooms. Others have taken active roles assisting outside of orthopedics. Arthroplasty humanitarian organizations have donated personal protective equipment and helped to prepare their partners in other countries. Previous pandemics and epidemics highlight the need for sustained humanitarian support, particularly in poor countries or those with ongoing conflict and humanitarian crises.Conclusion: There are opportunities now to make a difference in this health care crisis. In the aftermath, there will be a great need for humanitarian work both here and throughout the world. [ABSTRACT FROM AUTHOR]

Background: Current estimates of operative time (OT) for total hip arthroplasty (THA) are reported as the mean OT across all procedures. This method does not reflect variability among surgeons and surgical settings and should not be used to infer individual surgeon work. We hypothesized that this method would underestimate the time it takes individual surgeons to perform THA. Therefore, we compared the mean OT for all THA cases ("overall OT") with the mean OT for individual surgeons ("individual surgeon OT") and examined which factors were associated with each.Methods: Mean OT was calculated for 3972 primary THA cases ("overall OT") by 41 surgeons from 2015 to 2018 in a single health system. The mean OT for each surgeon was determined ("individual surgeon OT"), averaged across surgeons, and compared with overall OT. Overall OT and individual surgeon OT were assessed for associations with surgeon-related (adult reconstruction fellowship training, THA volume, years' experience), hospital-related (hospital type, trainee presence), and patient-related (age, body mass index category, American Society of Anesthesiologists physical status classification) factors (alpha = 0.05).Results: Mean individual surgeon OT was significantly longer (106 ± 21 minutes) than overall OT (96 ± 28 minutes) (P = .03), with 73% of individual surgeon OTs being greater than overall OT. Although all surgeon-, hospital-, and patient-related factors were associated with significant differences in overall OT, only hospital type was associated with differences in individual surgeon OT.Conclusion: Individual surgeon OT was longer than overall OT for most surgeons and provides a better estimate of surgeon work. [ABSTRACT FROM AUTHOR]

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Background: Public domain physician review websites (PRWs) and personal websites are extremely popular measures that patients use to evaluate physicians before receiving care. Few studies have examined how orthopedic surgeons are rated on PRWs and personal websites. This study examines the online ratings of hip and knee replacement subspecialists.Methods: The American Association of Hip and Knee Surgeons (AAHKS) fellow's ratings were examined from October 1st, 2018 to December 31st, 2018, on Healthgrades.com, Vitals.com, RateMDs.com, Google.com, and personal websites. Number of responses and average ratings (0.0-5.0) were recorded, along with provider gender, years in practice (0-10, 11-20, and 21+), practice type (academic, private), geographic region (NE, SE, MW, SW, W), degree (MD, DO), and fellowship training (yes, no). The Kruskal-Wallis testing was performed to determine factors affecting positive surgeon ratings.Results: 98.3% (483) of 490 AAHKS surgeons were rated at least once. No significant differences in average ratings were identified between websites. Surgeons in practice 1-10 years had significantly higher ratings than those in practice 11-20 and 21+ years (P < .01). Fellowship-trained surgeons in practice 1-10 years also showed significantly higher ratings. No differences in average ratings were found between gender, practice type, and geographic region.Conclusions: AAHKS surgeons have high average ratings and are rated online frequently. Surgeons in practice 1-10 years had statistically higher overall average ratings. Adult reconstruction fellowship training was also associated with higher average ratings for surgeons in practice 1-10 years. Public domain PRWs and personal websites showed no difference in average ratings. [ABSTRACT FROM AUTHOR]

Body mass index (BMI) impacts risk for revision total knee arthroplasty (rTKA), but the relationship between BMI and cause for revision remains unclear. We hypothesized that patients in different BMI classes would have disparate risk for causes of rTKA. There were 171,856 patients who underwent rTKA from 2006 to 2020 from a national database. Patients were classified as underweight (BMI < 19), normal-weight, overweight/obese (BMI 25 to 39.9), or morbidly obese (BMI > 40). Multivariable logistic regressions adjusted for age, sex, race/ethnicity, socioeconomic status, payer status, hospital geographic setting, and comorbidities were used to examine the effect of BMI on risk for different rTKA causes. Compared to normal-weight controls, underweight patients were 62% less likely to undergo revision due to aseptic loosening, 40% less likely due to mechanical complications, 187% more likely due to periprosthetic fracture, 135% more likely due to periprosthetic joint infection (PJI). Overweight/obese patients were 25% more likely to undergo revision due to aseptic loosening, 9% more likely due to mechanical complications, 17% less likely due to periprosthetic fracture, and 24% less likely due to PJI. Morbidly obese patients were 20% more likely to undergo revision due to aseptic loosening, 5% more likely due to mechanical complications, and 6% less likely due to PJI. Mechanical reasons were more likely to be the cause of rTKA in overweight/obese and morbidly obese patients, compared to underweight patients, for whom revision was more likely to be infection or fracture related. Increased awareness of these differences may promote patient-specific management to reduce complications. III. [ABSTRACT FROM AUTHOR]

Posterior-stabilized (PS) and cruciate-retaining (CR) have been the most common tibial designs used in total knee arthroplasty. Ultra-congruent (UC) inserts are becoming popular because they preserve bone without relying on the posterior cruciate ligament balance and integrity. Despite increasing use, there is no consensus on how UC inserts perform versus PS and CR designs. A comprehensive literature search of 5 online databases was performed for articles from January 2000 to July 2022 comparing the kinematic and clinical outcomes of PS or CR tibial inserts to UC inserts. There were nineteen studies included. There were 5 studies comparing UC to CR and 14 comparing UC to PS. Only one randomized controlled trial (RCT) was rated "good quality". For CR studies, pooled analyses showed no difference in knee flexion (n = 3, P =.33) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (n = 2, P =.58). For PS studies, meta-analyses showed better anteroposterior stability (n = 4, P <.001) and more femoral rollback (n = 2, P <.001) for PS but no difference in knee flexion (n = 9, P =.55) or medio-lateral stability (n = 2, P =.50). There was no difference with WOMAC (n = 5, P =.26), Knee Society Score (n = 3, P =.58), Knee Society Knee Score (n = 4, P =.76), or Knee Society Function Score (n = 5, P =.51). Available data demonstrates there are no clinical differences between CR or PS and UC inserts in small short-term studies ending around 2 years after surgery. More importantly, high-quality research comparing all inserts is lacking, demonstrating a need for more uniform and longer-term studies beyond 5 years after surgery to justify increased UC usage. [ABSTRACT FROM AUTHOR]

Background: High-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT.Methods: This retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed.Results: Among the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons' OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time.Conclusions: Operative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT. [ABSTRACT FROM AUTHOR]

Purpose: Hypsarrhythmia is the interictal EEG pattern most often associated with infantile spasms. We set out to evaluate the metabolic impact of hypsarrhythmia among patients with infantile spasms by contrasting regional cerebral metabolic activity among children with and without hypsarrhythmia.Methods: Patients with video-EEG confirmed infantile spasms who underwent simultaneous interictal EEG and FDG-PET as part of a surgical evaluation were retrospectively identified. Pons-normalized relative cerebral metabolic activity (RCA) was ascertained in 18 cortical and 6 subcortical pre-specified regions of interest (ROIs).Results: We identified 63 patients with infantile spasms who underwent simultaneous EEG/PET, including children with hypsarrhythmia (n = 9), high-voltage EEG background (n = 20), and multifocal independent spike discharges (MISD) (n = 34). Among them, a putative epileptogenic zone was identified within the left-hemisphere only (n = 27), right-hemisphere only (n = 20), or assumed to be bilateral (n = 16). After adjustment for age at PET, the presence of hypsarrhythmia was associated with hypermetabolism in 11 of 18 cortical ROI's. After adjustment for lateralized epileptogenic zones, the association between hypsarrhythmia and hypermetabolism was generally stronger within the left hemisphere.Conclusion: Hypsarrhythmia is associated with widespread-and curiously left more than right-elevations in pons-normalized RCA, which is not evident on routine clinical review of individual PET studies. This study suggests that hypsarrhythmia may be a quasi-ictal phenomenon based on widespread and usually bilateral cortical hypermetabolism. [ABSTRACT FROM AUTHOR]

Congenital talipes equinovarus (CTEV), more commonly known as clubfoot, is a deformity of the foot that is not well understood. The tarsal navicular is at the center of the disease process and exhibits abnormal development and delayed ossification. However, its role in the pathologic process is not clear. The aim of the present study was to better understand the role of the tarsal navicular in CTEV by correlating the presence of the navicular ossification center and relapse of clubfoot deformity after surgical treatment. The medical records and radiographs of 34 patients (41 feet) with surgically treated CTEV were reviewed for the presence of the navicular ossification center and the lateral talocalcaneal angles. Of the 41 feet, 17 (41.46%) did not have the tarsal navicular ossification center present before surgery, and 24 (58.54%) did have the ossification center present. The talocalcaneal angles were similar between those with and without the navicular ossification center present. No significant difference was found in the incidence of relapse between the nonossified navicular group (17.6%) and the ossified navicular group (16.7%; p = .63). The presence of the navicular ossification center before surgery does not appear to have prognostic value for the relapse of CTEV after surgical intervention. [ABSTRACT FROM AUTHOR]

Patellofemoral arthroplasty has been described as an ap-propriate treatment for isolated patellofemoral arthritis. With the aging population and the increasing number of total joint arthroplasties, both patients and surgeons are on the lookout for alternatives to total joint arthroplasty. With appropriate patient selection, well-designed implants, and precise surgical technique, the outcomes of patellofemoral arthroplasty can be excellent. The main indication for patel-lofemoral arthroplasty is isolated patellofemoral arthritis. [ABSTRACT FROM AUTHOR]

Periprosthetic fractures of the femur after total hip replacement can present some unique challenges to the treating reconstructive orthopedic surgeon. Treatment may differ depending on fracture location, bone condition, implant stability, patient characteristics, and surgeon experience. It is imperative that adequate and sufficient mechanical fixation be achieved in the treatment of these patients. It is crucial that the treating orthopaedic surgeon have a clear and effective treatment plan to manage these complex cases. The patient's final outcome is dependent on fracture union, implant stability, early functional recovery, and return to pre-injury independence. This review presents an overview of the current diagnostic and treatment approaches, with the goal of providing a template for optimal decision-making when dealing with these complex injuries. [ABSTRACT FROM AUTHOR]

Distance university education has come a long way in Nigeria. It started as a dual mode and today has both the dual and single modes. However, the system has been faced majorly with the challenge of inadequate funding. This has hampered the success rate of the system. Therefore for the purpose of appropriate utilisation of the available fund, it is necessary that the knowledge of the unit cost of cost drivers is gained. This will help in re-directing and prioritising the available fund. To meet this purpose, five research questions were raised and answered. Descriptive survey research design was used. Checklist served as the instrument used to obtained data from the sampled institutions. The data collected were analysed using econometric formulas and charts. The findings revealed that cost drivers in Nigerian distance education programmes have not attained adequate unit costs. High enrolment and proper planning before commencement of programmes were recommended. [ABSTRACT FROM AUTHOR]

Abstract: Phytochemical studies on the methanolic extract of Drypetes gossweileri afforded N-β-d-glucopyranosyl-p-hydroxyphenylacetamide (1), p-hydroxyphenylacetic acid (2), p-hydroxyphenyl-acetonitrile (3), p-hydroxyacetophenone (4), 3,4,5-trimethoxyphenol (5), dolichandroside A (6), and β-amyrone (7). Compounds 1–7 were identified with the aid of extensive NMR and MS spectroscopic studies. Compound 1 was a new natural product and was isolated for the first time from plant containing N-glucose moiety incorporated in its structure. Compounds 1–7 exhibited moderate to the weak source anti-α-glucosidase inhibitory activity. Compound 7 exhibited moderate anti-acetylcholinesterase (AChE) activity while the rest of the isolates were weakly active in this bioassay. Compounds 1–7 also showed moderate anti-fungal activity. [Copyright &y& Elsevier]

Spontaneous intramural duodenal haematoma (IDH) is an uncommon pathology and it is usually related to anticoagulant therapy. Other causes include various pancreatic diseases, connective tissue disease, peptic ulcer disease and pancreaticoduodenal aneurysm. IDH of pancreatic origin has been infrequently reported. The disease course can be life-threatening and serious complications may occur, including gastric outlet obstruction, duodenal perforation and septicaemia. A case of pancreatic-induced IDH is presented, for which pancreaticoduodenectomy was performed as definitive treatment. In general, medical treatment with continuous nasogastric aspiration and total parenteral nutrition is recommended as initial management strategy. Surgical interventions (evacuation of blood clot or surgical resection) are reserved for patients in whom medical treatment fails or complications occur. [Copyright &y& Elsevier]