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Background: Over the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors., Methods: We retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1, 2013, to December 31, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson comorbidity index, insurance, and socioeconomic status, as determined by median income by patients' zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test., Results: Over the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = .001), BMI (2013: 29.0 to 2022: 29.5, P = .020), and mean Charlson comorbidity index (2013: 2.4 to 2022: 3.1, P = .001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = .001). The proportion of African American patients among the THA population increased from 11.3% in 2013 to 13.0% in 2022 (P = .012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = .107 and P = .136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < .001)., Conclusions: In the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Debridement, antibiotics, and implant retention (DAIR) are the mainstays surgical treatment for acute periprosthetic joint infection (PJI). However, reoperation following DAIR is common and the risk factors for DAIR failure remain unclear. This study aimed to assess the perioperative characteristics of patients who failed initial DAIR treatment., Methods: A retrospective review was conducted on 83 patients who underwent DAIR for acute PJI within 3 months following index surgery from 2011 to 2022, with a minimum one-year follow-up. Surgical outcomes were categorized using the Musculoskeletal Infection Society outcome reporting tool (Tiers 1 to 4). Patient demographics, laboratory data, and perioperative outcomes were compared between patients who had failed (Tiers 3 and 4) (n = 32) and successful (Tiers 1 and 2) (n = 51) DAIR treatment. Logistic regression was also performed., Results: After logistic regression, Charlson Comorbidity Index (odds ratio [OR]: 1.57; P = .003), preoperative C-reactive protein (OR: 1.06; P = .014), synovial white blood cell (OR: 1.14; P = .008), and polymorphonuclear cell (PMN%) counts (OR: 1.05; P = .015) were independently associated with failed DAIR. Compared with total hip arthroplasty, total knee arthroplasty patients (OR: 6.08; P = .001) were at increased risk of DAIR failure. The type of organism and time from primary surgery were not correlated with DAIR failure., Conclusions: Patients who had failed initial DAIR tended to have significantly higher Charlson Comorbidity Index, C-reactive protein, synovial white blood cell, and PMN%. The total knee arthroplasty DAIRs were more likely to fail than the total hip arthroplasty DAIRs. These characteristics should be considered when planning acute PJI management, as certain patients may be at higher risk for DAIR failure and may benefit from other surgical treatments., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: With the increasing utilization of total hip arthroplasty (THA) in patients who have a high comorbidity burden (HCB), coinciding with modifications to reimbursement models over the past decade, an evaluation of the financial impact of HCB on THA over time is warranted. This study aimed to investigate trends in revenue and cost associated with THA in HCB patients., Methods: Of 13,439 patients who had primary, elective THA between 2013 and 2021 at our institution, we retrospectively reviewed 978 patients considered to have HCB (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores 3 or 4). We collected patient demographics, perioperative data, revenue, cost, and contribution margin (CM) of the inpatient episode. We analyzed changes as a percentage of 2013 values over time for these financial markers. Linear regression determined trend significance. The final analysis included 978 HCB patients who had complete financial data., Results: Between 2013 and 2021, direct costs increased significantly (P = .002), along with a nonsignificant increase in total costs (P = .056). While revenue remained steady during the study period (P = .486), the CM decreased markedly to 38.0% of 2013 values, although not statistically significant (P = .222). Rates of 90-day complications and home discharge remained steady throughout the study period., Conclusions: Increasing costs for HCB patients undergoing THA were not matched by an equivalent increase in revenue, leading to dwindling CMs throughout the past decade. Re-evaluation of reimbursement models for THA that account for patients' HCB may be necessary to preserve broad access to care., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB)., Methods: We retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group)., Results: Total (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049)., Conclusions: Increased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Though previous studies have demonstrated improved cost benefits associated with simultaneous versus staged bilateral total hip arthroplasty (simBTHA and staBTHA), further investigation is needed regarding the revenues and contribution margins (CMs) of these procedures. In this study, we compared revenue, CM, and surgical outcomes between simBTHA and staBTHA., Methods: All patients who underwent simBTHA (both procedures completed the same day) and staBTHA (procedures completed on different days within one year) between 2011 and 2021 at a single high-volume orthopedic specialty hospital were identified. Of the 1,517 identified patients (n = 139 simBTHA, n = 1,378 staBTHA), 232 were included in a 1:1 propensity match based on baseline demographics (116 per cohort). Revenue, costs, CM, and surgical outcomes were compared between cohorts., Results: Compared to staBTHA, simBTHA procedures had significantly lower total costs (P < .001), direct costs (P < .001), and patient revenue. There was no significant difference in CM between groups (P = .361). Additionally, there were no significant differences in length of stay (P = .173), operative time (P = .438), 90-day readmissions (P = .701), 90-day revisions (P = .313), or all-cause revisions (P = .701) between cohorts., Conclusions: Though simBTHA procedures have lower revenues than staBTHA, they also have lower costs, resulting in similar CM between procedures. As both procedures have similar postoperative complication rates, further research is required to evaluate specifically which patients may benefit from simBTHA versus staBTHA regarding clinical and patient-reported outcomes., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status., Methods: We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion., Results: Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12 pm (P < 0.001), with a BMI > 30 kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP., Conclusion: Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older., Level Iii Evidence: Retrospective Cohort Study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons., Methods: A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases., Results: The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056)., Conclusions: Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification., Methods: Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99 kg/m 2 ), overweight (25-29.99 kg/m 2 ), obese (30-39.99 kg/m 2 ), and morbidly obese (> 40 kg/m 2 ). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders., Results: We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR., Conclusions: Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years., Methods: We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests., Results: In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ., Conclusion: More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment., Level Evidence: III, Retrospective Review., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Aims: Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons., Methods: Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period., Results: Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group., Conclusion: The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes., Competing Interests: R. I. Davidovitch reports receipt of royalties or licences from Radlink and Schaerer Medical, consulting fees from Radlink, Exactech Inc, and Schaerer Medical, and stock or stock options in Radlink, all of which are unrelated to this study. J. C. Rozell reports receipt of consulting fees from Aerobiotix, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Foundation for Physician Advancement, Depuy Synthes, and Zimmer Biomet, and membership of the AAOS Hip and Knee Evaluation Committee, all of which are unrelated to this study. R. Schwarzkopf reports receipt of royalties or licences from Smith & Nephew, consulting fees from Smith & Nephew, Zimmer Biomet, and Intellijoint, leadership or fiduciary role in AAOS, AAHKS, Arthroplasty Today, and The Journal of Arthroplasty, and stock or stock options in Gauss Surgical and Intellijoint, all of which are unrelated to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Background: Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients., Methods: A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications., Results: The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval., Conclusion: Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status., Methods: We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group)., Results: The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately., Conclusion: Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants., Methods: We retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions., Results: Of the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups., Conclusion: Comparable outcomes following implantation of DM constructs may be achievable irrespective of the surgical approach employed. The incidence of iliopsoas injections for groin pain did not significantly differ between anterior and posterior approaches. Future investigation is needed to determine whether surgical approach influences long-term outcomes in patients receiving DM implants. Level of Evidence: III ., (Copyright © The Iowa Orthopaedic Journal 2022.)