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The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA. Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov : NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups. Postoperative GMH improved (P <.05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement. Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) has been associated with decreased blood loss and transfusion after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to examine both transfusion utilization and the economic impact of a Process Improvement Project implementing TXA for THA and TKA.Methods: After standardization of TXA administration in THA and TKA patients, retrospective data were compared from 12 consecutive months before (group A, n = 336 procedures) and after (group B, n = 436 procedures) project initiation.Results: TXA administration increased with project implementation (group A = 3.57%, group B = 86.01%) and was associated with reductions in perioperative hemoglobin decrement (20.2%), patients transfused (45%), and number of units transfused per patient (61.9%). Cost savings were notable per patient ($128) and annually program wide ($55,884) with the primary THA subgroup contributing the most to the savings. No increase in adverse effects was observed.Conclusion: Standardized administration of TXA is an effective and economically favorable blood-reduction strategy for patients undergoing elective THA or TKA. Although reduction in transfusions with TXA may be greater after TKA, the economic and clinical impact of transfusion reduction is more substantial in THA patients. [ABSTRACT FROM AUTHOR]

Background: The number of obese patients seeking a total joint arthroplasty (TJA) continues to increase. Weight loss is often recommended to treat joint pain and reduce risks associated with TJA. We sought to determine the effectiveness of an orthopedic surgeon's recommendation to lose weight.Methods: We identified morbidly obese (body mass index (BMI) 40-49.9 kg/m2) and super obese (BMI ≥50 kg/m2) patients with hip or knee osteoarthritis. Patients with less than 3-month follow-up were excluded. Patient characteristics (age, gender, BMI, comorbidities), disease characteristics (joint affected, radiographic osteoarthritis grading), and treatments were recorded. Clinically meaningful weight loss was defined as weight loss greater than 5%.Results: Two hundred thirty morbid and 50 super obese patients were identified. Super obese patients were more likely to be referred to weight management (52.0% vs 21.7%, P < .001) and were less likely to receive TJA (20.0% vs 41.7%, P = .004). Each 1 kg/m2 increase in BMI decreased the odds of TJA by 10.9% (odds ratio = 0.891, 95% confidence interval: 0.833-0.953, P = .001). Forty (23.0%) of the nonoperatively treated patients achieved clinically meaningful weight loss, and 19 (17.9%) patients who underwent TJA lost weight before surgery. After surgery, the number of patients who achieved a clinically meaningful weight loss grew to 32 (30.2%).Conclusion: In morbid and super obese patients, increasing BMI reduces the likelihood that a patient will receive TJA, and when counseled by their orthopedic surgeon, few patients participate in weight-loss programs or are otherwise able to lose weight. Weight loss is an inconsistently modifiable risk factor for joint replacement surgery. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes after hip and knee arthroplasty based on hospital participation in Medicare's bundled payment programs.Methods: We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively.Results: Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (-1.8 point relative difference at 6 months; 95% confidence interval -3.2 to -0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (-2.3 point relative difference at 6 months; 95% confidence interval -4.0 to -0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference.Conclusions: Patients receiving care at hospitals participating in Medicare's bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Comparisons of patient-reported outcomes (PROs) based on surgical approach for total hip arthroplasty (THA) in the United States are limited to series from single surgeons or institutions. Using prospective data from a large, multicenter study, we compare preoperative to postoperative changes in PROs between posterior, transgluteal, and anterior surgical approaches to THA.Methods: Patient-reported function, global health, and pain were systematically collected preoperatively and at 1, 3, and 6 months postoperatively from patients undergoing primary THA at 26 sites participating in the Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (ClinicalTrials.gov: NCT02810704). Outcomes consisted of the brief Hip disability and Osteoarthritis Outcome Score, the Patient-Reported Outcomes Measurement Information System Physical Health score, and the Numeric Pain Rating Scale. Operative approaches were grouped by surgical plane relative to the abductor musculature as being either anterior, transgluteal, or posterior.Results: Between 12/12/2016 and 08/31/2019, outcomes from 3018 eligible participants were examined. At 1 month, the transgluteal cohort had a 2.2-point lower improvement in Hip disability and Osteoarthritis Outcomes Score (95% confidence interval, 0.40-4.06; P = .017) and a 1.3-point lower improvement in Patient-Reported Outcomes Measurement Information System Physical Health score (95% confidence interval, 0.48-2.04; P = .002) compared to posterior approaches. There was no significant difference in improvement between anterior and posterior approaches. At 3 and 6 months, no clinically significant differences in PRO improvement were observed between groups.Conclusion: PROs 6 months following THA dramatically improved regardless of the plane of surgical approach, suggesting that choice of surgical approach can be left to the discretion of surgeons and patients without fear of differential early outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To compare interference screw fixation to Pulvertaft weave fixation in a cadaveric basal joint abductor pollicis longus (APL) suspensionplasty model with an early range of motion protocol. We asked whether the interference screw fixation would provide comparable initial stability while minimizing the dorsal incision and eliminating the prominent dorsal mass associated with the traditional Pulvertaft weave. Methods: Six matched cadaveric forearms underwent suspensionplasty with tendon fixation via an interference screw or a Pulvertaft weave. We then loaded the specimens to 10,000 cycles and used a modification of a previously validated cyclic pinch model. One third of the load required for maximal pinch strength was used. The APL was not loaded because we used the tendon for ligament reconstruction. We obtained measurements of residual trapezial space with feeler gauges after trapeziectomy, after suspensionplasty, and at 1,000-cycle intervals. Results: Suspensionplasty with interference screw fixation maintained statistically significantly larger trapezial space heights compared with the Pulvertaft weave. Moreover, after the first 1,000 cycles, none of the specimens fixed with the interference screw lost further height up to the 10,000th cycle. All of the specimens fixed with the Pulvertaft weave continued to lose height with cycling, and 1 specimen showed contact of the first metacarpal with the scaphoid after only 1,000 cycles. With interference screw fixation, the height achieved initially and maintained through 10,000 cycles was an average of 5.5 mm. When the Pulvertaft weave was used, the height achieved was 3.0 mm initially, declining to 2.3 mm after 10,000 cycles. The polylactic acid interference screw was placed through a 5-mm dorsal stab incision and the extra tendon graft was cut flush as it exited the bone tunnel, eliminating the dorsal prominence associated with the Pulvertaft weave. Conclusions: Although traditional APL suspensionplasty with a Pulvertaft weave provides good initial stability, it requires a large dorsal incision and leaves a prominent dorsal mass that may be bothersome to some patients. Clinical relevance: Fixation of the suspensionplasty with an interference screw appears to offer several advantages. [Copyright &y& Elsevier]

Background: Length of stay (LOS) following total joint arthroplasty (TJA) continues to decrease. The effects of this trend on readmission risk and total cost are unclear. We hypothesize that optimal LOS following TJA minimizes index hospitalization, early readmission risk, and total cost.Methods: Retrospective data from the South Carolina Department of Revenue and Fiscal Affairs was reviewed for patients who underwent primary TJA in South Carolina from 2000 to 2015 (n = 172,760). Data for readmissions within 90 days were included. Severity of illness was estimated by Elixhauser score (EH). Index LOS is defined as the surgery and the subsequent hospital stay.Results: Patients with more significant medical comorbidities (EH ≥ 4) had significantly longer LOS than healthier patients (4.0 vs 3.4 days, P < .001). Independent of EH, readmitted patients had a significantly longer index LOS than those never readmitted (4.3 vs 3.6 days, P < .001). For healthier patients (EH ≤ 3), each additional inpatient day increased readmission risk, while among sicker patients, staying 2 days vs 1 day was protective against readmission risk. Since 2000, the total index cost of TJA has doubled and average cost per inpatient day has tripled, but readmission rates remain essentially unchanged (7.4% to 7.0%).Conclusion: Increased LOS was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal LOS after TJA is highly influenced by the patient's overall health. Despite a 300% increase in TJA daily cost, readmission rate has changed minimally over the last 15 years. [ABSTRACT FROM AUTHOR]

Abstract Background aims Previous studies identified a circulating human osteoblastic population that expressed osteocalcin (OCN), increased following fracture and pubertal growth, and formed mineralized colonies in vitro and bone in vivo. A subpopulation expressed CD34, a hematopoietic/endothelial marker. These findings led to our hypothesis that hematopoietic-derived CD34+OCN+ cells exist in the circulation of mice and are modulated after fracture. Methods Flow cytometry was used to identify CD34+OCN+ cells in male B6.SJL-PtprcaPepcb/BoyJ and Vav-Cre/mTmG (VavR) mice. Non-stabilized tibial fractures were created by three-point bend. Fractures were longitudinally imaged by micro-computed tomography, and immunofluorescent staining was used to evaluate CD34+OCN+ cells within fracture callus. AMD3100 (10 mg/kg) was injected subcutaneously for 3 days and the CD34+OCN+ population was evaluated by flow cytometry. Results Circulating CD34+OCN+ cells were identified in mice and confirmed to be of hematopoietic origin (CD45+; Vav1+) using two mouse models. Both circulating and bone marrow-derived CD34+OCN+ cells peaked three weeks post-non-stabilized tibial fracture, suggesting association with cartilage callus transition to bone and early mineralization. Co-expression of CD34 and OCN in the fracture callus at two weeks post-fracture was observed. By three weeks, there was 2.1-fold increase in number of CD34+OCN+ cells, and these were observed throughout the fracture callus. AMD3100 altered CD34+OCN+ cell levels in peripheral blood and bone marrow. Discussion Together, these data demonstrate a murine CD34+OCN+ circulating population that may be directly involved in fracture repair. Future studies will molecularly characterize CD34+OCN+ cells, determine mechanisms regulating their contribution, and examine if their number correlates with improved fracture healing outcomes. [ABSTRACT FROM AUTHOR]

Abstract: A survey was mailed to a representative sample of US orthopedic surgeons to assess protocols for the prevention of venous thromboembolism after lower extremity total joint arthroplasty. Practices were examined by type of operation, annual surgical volume, and opinions of consensus guidelines issued by the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians. Although there was near-unanimous agreement that routine thromboprophylaxis should be the standard practice for patients who undergo hip or knee arthroplasty, surgeons were divided as to the exact management approach. [Copyright &y& Elsevier]