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Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay.In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching.PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE.Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN Retrospective cohort study. SETTING Twelve Level 1 North American trauma centers. PATIENTS Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To determine if the relative distance between the acetabular teardrops on unstressed and lateral compressive stress examination under anesthesia (EUA) pelvic fluoroscopic images is reproducible between independent reviewers. DESIGN Retrospective database review. SETTING Level 1 trauma center. PATIENTS/INTERVENTION Fifty-eight patients with a lateral compression type 1 pelvic ring injury who underwent EUA. MAIN OUTCOME MEASURE Validation of EUA objective measurements between blinded, independent reviewers using interclass and intraclass correlation coefficients. RESULTS There was excellent interobserver and intraobserver reliability between all reviewers. Values for each intraclass correlation coefficients (including 95% confidence intervals) were between 0.96 (0.95-0.098) and 0.99 (0.99-0.99) for all measurements. P values were

Objectives To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. Design Retrospective cohort study with radiograph and chart review. Setting Twelve Level 1 North American trauma centers. Patients Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. Intervention Open or closed reduction technique during internal fixation. Main outcome Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. Results Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. Conclusions Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Removal of internal fixation implants previously placed to stabilize posterior pelvic ring injuries may be technically challenging. Described techniques for extraction require specialized equipment, extensile measures, or purchase of additional implants. We describe a technique for removal of large diameter cannulated screws and washers from the posterior pelvic ring, which requires no additional equipment or implants beyond the instrumentation used for implant insertion, as well as a series of 15 cases in which the technique was applied.

Background Wearable sensors can track patient activity after surgery. The optimal data sampling frequency to identify an association between patient-reported outcome measures (PROMs) and sensor data is unknown. Most commercial grade sensors report 24-hour average data. We hypothesize that increasing the frequency of data collection may improve the correlation with PROM data. Methods Twenty-two total joint arthroplasty (TJA) patients were prospectively recruited and provided wearable sensors. Second-by-second (Raw) and 24-hour average data (24Hr) were collected on 7 gait metrics on the 1st, 7th, 14th, 21st, and 42nd days postoperatively. The average for each metric as well as the slope of a linear regression for 24Hr data (24HrLR) was calculated. The R2 associations were calculated using machine learning algorithms against individual PROM results at 6 weeks. The resulting R2 values were defined having a mild, moderate, or strong fit (R2 ≥ 0.2, ≥0.3, and ≥0.6, respectively) with PROM results. The difference in frequency of fit was analyzed with the McNemar’s test. Results The frequency of at least a mild fit (R2 ≥ 0.2) for any data point at any time frame relative to either of the PROMs measured was higher for Raw data (42%) than 24Hr data (32%; P = .041). There was no difference in frequency of fit for 24hrLR data (32%) and 24Hr data values (32%; P > .05). Longer data collection improved frequency of fit. Conclusion In this prospective trial, increasing sampling frequency above the standard 24Hr average provided by consumer grade activity sensors improves the ability of machine learning algorithms to predict 6-week PROMs in our total joint arthroplasty cohort.

Background: The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening—grouped as triceps surae lengthening (TSL) procedures—in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma. Methods: A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma. Results: A total of 258 surgeons with median 14 years’ experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (β = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL. Conclusion: Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice. Level of Evidence: Level V, therapeutic.

A prospective observational cohort of 20 primary total hip arthroplasty (n = 12) and total knee arthroplasty (n = 8) patients (mean age: 63 ± 6 years) was passively monitored with a consumer-level wearable activity sensor before and 6 weeks after surgery. Patients were clustered by minimal change or decreased activity using sensor data. Decreased postoperative activity was associated with greater pain reduction (−5.5 vs −2.0, P = .03). All patients surpassed minimal clinical benefit thresholds of total joint arthroplasty (TJA) (Hip Disability and Osteoarthritis Score Junior 30.5 vs 20.8, P = .23; Knee Injury and Osteoarthritis Outcome Score Junior 23.3 vs 18.2, P = .77) within 6 weeks. Patients who objectively “take it easy” after TJA may experience less pain with no difference in early subjective outcome. Remote, passive analysis of outpatient wearable sensor data may permit real-time detection of early problems after TJA. Keywords: Hip arthroplasty, Knee arthroplasty, Activity tracking, Sensors, Wearable, Pain

Limited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients.Retrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non-dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences.Six hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P.001), discharge to facility (RR = 1.3, P.001), and longer admission (1.5×, P.001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P.001), ICU care (RR = 6.0, P .001), stroke (RR = 7.6, P.001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P.001).Dialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models.

The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD).Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group.A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P.001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021).Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care.

Data from wearable technology may correlate with patient-reported outcome measures (PROMs). The objective of this prospective pilot study of 22 total joint arthroplasty patients was to determine if sensor-generated data are predictive of short-term PROMs in total joint arthroplasty. Data on “average daily step count” and “average daily minutes active” were generated by the provided wearable sensor preoperatively and up to 6 weeks postoperatively. PROMs were collected preoperatively and at 6 weeks postoperatively. Changes in PROMs were calculated as “Δ”. Linear regression of the sensor data and PROMs generated R2 values. Changes in the average daily step count from preop to 6-week postop strongly associated with changes in Veterans Rand 12 Physical Component Score (R2 = 0.4532) from preop to 6 weeks. Changes in average daily minutes active from preop to 6-weeks postop were strongly associated with ΔHOOS/KOOS (R2 = 0.4858). Keywords: Technology, Sensors, Outcome, Patient-reported outcome, Arthroplasty

Objectives Clinical practice has shifted from therapeutic anticoagulation of any lower extremity venous thromboembolism (VTE) to only thromboses with risk of proximal extension or embolization-clinically important VTE (CIVTE). Isolated operative fractures of the tibia or distal bone of the lower extremity are associated with low-to-intermediate VTE risk, and there is wide variability in the choice to anticoagulate as well as anticoagulant. We sought to evaluate the role for chemoprophylaxis of VTE and CIVTE in these injuries by meta-analysis of Level I evidence. Data sources Articles in English, Chinese, French, and German in MEDLINE, Biosis, and EMBASE from 1988 to 2016. Study selection Randomized controlled trials describing chemoprophylaxis of VTE after operative management of fractures of the tibia and distal bones. Independent review of 1502 citations yielded 5 studies (1181 patients) meeting inclusion criteria. Data extraction Chemoprophylaxis regimen, VTE, CIVTE, and major bleeding events were recorded. Study quality was assessed with regard to randomization, outcome assessment allocation and treatment concealment, and commercial funding. Data synthesis A random-effects model meta-analysis determined that chemoprophylaxis with a low-molecular-weight heparin (LMWH) compared with placebo or no intervention significantly reduced the risk of any VTE [pooled relative risk (RR) = 0.696, 95% confidence interval (0.490-0.989), P = 0.043; homogeneity P = 0.818, I = 0%]. However, chemoprophylaxis with a LMWH compared with placebo did not significantly reduce the risk of CIVTE [RR = 0.865, 95% confidence interval (pooled RR = 0.112-3.863), P = 0.790; homogeneity P = 0.718, I = 0%]. No major bleeding events occurred. Funnel plots did not suggest publication bias. The number needed to treat was 31 patients treated with chemoprophylaxis using a LMWH to prevent 1 VTE and 584 patients to prevent 1 CIVTE. Conclusions Meta-analysis of Level I evidence suggests that routine postoperative anticoagulation after surgical management of an isolated fracture of the tibia or distal bone in patients without risk factors for VTE is unlikely to provide a clinical benefit, based on the absence of a treatment effect for preventing VTE warranting therapeutic anticoagulation. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION Tailoring opioid prescriptions to inpatient use after orthopaedic procedures may effectively control pain while limiting overprescription but may not be common in the current orthopaedic practice. METHODS A retrospective review identified opioid-naive patients admitted after any orthopaedic procedure. Daily and total prescription quantities as well as patient-specific factors were collected. The total opioids used the day before discharge was compared with the total opioids prescribed for the day after discharge. Refill rates were then compared between patients whose daily discharge prescription regimen far exceeded or approximated their predischarge opioid consumption. RESULTS Six hundred thirteen patients were included (ages 18 to 95 years). The total opioids prescribed for the 24 hours after discharge significantly exceeded the opioids consumed the 24 hours before discharge for each orthopaedic subspecialty. The excessive-prescription group (409 patients) received greater daily opioid (120 oral morphine equivalents [OMEs] versus 60 OMEs; P < 0.01) and total opioid (750 OMEs versus 512.5 OMEs; P < 0.01) at discharge but was more likely to refill their opioid prescription within 30 days of discharge (27.6% versus 20.1%; P = 0.043). DISCUSSION Opioid regimens prescribed after an orthopaedic surgery frequently exceed inpatient opioid use. Opioid regimens that approximate inpatient use may help curb overprescription and are not associated with higher refill rates compared with more excessive prescriptions. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.

OBJECTIVE To investigate an association between a surgeon's choice of a cephalomedullary nail (CMN) or sliding hip screw (SHS) with the cost of treating a pertrochanteric hip fracture. DESIGN Multicenter retrospective cohort study. SETTING US Veterans Health Administration Sierra Pacific Network. PATIENTS/PARTICIPANTS Two hundred ninety-four consecutive US veterans admitted for a principal diagnosis of an OTA/AO 31A-type pertrochanteric hip fracture of a native hip from 2000 to 2015. INTERVENTION Internal fixation using a CMN or an SHS. MAIN OUTCOME MEASUREMENTS Veterans Administration Health Economic Resource Center average national cost estimate of combined acute and postacute care episode cost, excluding implant cost, normalized to 2015 US dollars by the Consumer Price Index. RESULTS Median episode cost was $8223 lower with a CMN than an SHS (95% confidence interval, $5700-$10,746, P < 0.001) after matching on a propensity score for treatment with a CMN based on age, sex, body mass index, Charlson Comorbidity Index, fracture characteristics, study site, and admission year. A subgroup propensity-matched analysis excluding reverse obliquity pertrochanteric fractures was not sufficiently powered to detect a difference in episode cost (β = 0.76, P = 0.311). CONCLUSIONS Implant choice significantly affected the episode cost of care of hip fracture at Veterans Health Administration facilities. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Tracking patient-generated health data (PGHD) following total joint arthroplasty (TJA) may enable data-driven early intervention to improve clinical results. We aim to demonstrate the feasibility of combining machine learning (ML) with PGHD in TJA to predict patient-reported outcome measures (PROMs). Methods Twenty-two TJA patients were recruited for this pilot study. Three activity trackers collected 35 features from 4 weeks before to 6 weeks following surgery. PROMs were collected at both endpoints (Hip and Knee Disability and Osteoarthritis Outcome Score, Knee Osteoarthritis Outcome Score, and Veterans RAND 12-Item Health Survey Physical Component Score). We used ML to identify features with the highest correlation with PROMs. The algorithm trained on a subset of patients and used 3 feature sets (A, B, and C) to group the rest into one of the 3 PROM clusters. Results Fifteen patients completed the study and collected 3 million data points. Three sets of features with the highest R2 values relative to PROMs were selected (A, B and C). Data collected through the 11th day had the highest predictive value. The ML algorithm grouped patients into 3 clusters predictive of 6-week PROM results, yielding total sum of squares values ranging from 3.86 (A) to 1.86 (C). Conclusion This small but critical proof-of-concept study demonstrates that ML can be used in combination with PGHD to predict 6-week PROM data as early as 11 days following TJA surgery. Further study is needed to confirm these findings and their clinical value.

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Purpose To test the hypothesis that clinical assessment reliably identifies patients with radiographic changes (including loss of reduction, hardware failure, and hardware migration) at the initial visit following operative repair of distal radius fractures. Methods We identified 102 patients undergoing operative repair of distal radius fractures. Radiographs and clinical notes were reviewed. Results At the initial postoperative visit, 11 patients had more than normal postoperative pain, 0 had deformity, 0 had crepitus with gentle motion, and 0 had instability at the fracture site on examination. These 11 patients were considered to have positive clinical assessments, but none had radiographic changes on x-rays taken that day. Three patients had negative clinical assessments but had radiographic changes noted at the initial postoperative visit. There were no additional radiographic changes between the series taken at the initial postoperative visit and series taken at later postoperative visits. Conclusions These data suggest that for purposes of detecting radiographic changes, radiography at the initial visit is helpful, whereas radiography at subsequent visits may not be. Radiography at subsequent visits may be useful to monitor bony healing, which we did not investigate. Type of study/level of evidence Diagnostic IV.

STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients. SUMMARY OF BACKGROUND DATA Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined. MATERIALS AND METHODS Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions. RESULTS One hundred forty-one patients (male-81; female-60; average age: 77.8±6.5 y; anterior approach-48; posterior approach-93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of "any adverse event" after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21-36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49-152.62; P=0.005) than patients who had a posterior operation. CONCLUSIONS An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.

Background Hepatitis C virus (HCV) is associated with poorer outcomes in total joint arthroplasty (TJA). Recently, oral direct-acting antivirals (DAAs) have become available for HCV curative treatment. The goal of this study is to determine if HCV may be a modifiable risk factor in TJA by comparing postoperative complications among patients with and without preoperative treatment for HCV. Methods US Department of Veterans Affairs dataset of all consecutive primary TJAs performed between 2014 and 2018, when DAAs were available, was retrospectively reviewed. HCV-infected patients were identified using International Classification of Diseases, Ninth and Tenth Revision codes and laboratory values. HCV-infected patients treated prior to TJA with DAA were included in the “treated” group. HCV-infected patients untreated preoperatively were assigned to the “untreated” group. Medical and surgical complications up to 1 year postoperatively were identified using International Classification of Diseases, Ninth and Tenth Revision inpatient and outpatient codes. Results In total, 42,268 patients underwent TJA at Veterans Affairs Hospitals between 2014 and 2018. About 6.0% (n = 2557) of TJA patients had HCV, 17.3% of whom received HCV treatment preoperatively. When evaluating inpatient and outpatient codes, implant infection rates were statistically lower at 90 days and 1 year postoperatively among HCV-treated patients than among those untreated. Odds ratios (ORs) favor lower infection rates in HCV-treated patients (90-day OR: 3.30, P = .045; 1-year OR: 2.16, P = .07). Conclusion Preoperative HCV treatment was associated with lower periprosthetic infection rates among US veterans undergoing TJA. Further investigation is necessary for definitive conclusions.

Background Administrative claims in total joint arthroplasty are used for observational studies and payment adjustments under the Comprehensive Care for Joint Replacement (CJR) legislation. Claims data have not been validated against prospective surgical outcome registries for primary total hip (THA) or knee arthroplasty (TKA). We hypothesized that significant differences in reported comorbidity and adverse event measures exist between administrative claims and prospective registry data relevant to payment adjudication under the CJR reimbursement model. Methods Comorbidities and outcomes in primary TKA and THA in the United Healthcare and Medicare Standard Analytical File 5% Sample insurance claims datasets (PearlDiver Technologies, Inc) were compared to age-matched cohorts from the National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes data from 2007 to 2011 using comparable International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes at 30, 90, and 360 days from index arthroplasty. Pearson's chi-square test was used for statistical analyses. Results The total study population included 93,953 primary THA and 176,944 TKA patients. Primary TKA and THA patients in insurance claims cohorts had significantly fewer reported comorbidities, higher rates of surgical site infection, pulmonary embolism, wound dehiscence, thromboembolic events, and neurologic deficits, and lower reported rates of revision surgery than ACS-NSQIP cohorts within 30 days of primary TKA and THA. Cumulative incidence of adverse events increased significantly from 30 to 360 days after primary arthroplasty. Conclusion We report significant discordance in the prevalence of patient comorbidities and incidence of adverse events in primary THA and TKA between ACS-NSQIP and the administrative claims data of Medicare and United Healthcare. These disparities have implications for observational outcome studies as well as payment adjudication under the CJR reimbursement model in total joint arthroplasty.

Imaging contributes substantially to the rising cost of health care.1 Among surgical specialists, orthopaedic surgeons order a particularly high volume of imaging. Radiographic series are regularly taken during the initial evaluation of a patient, during preoperative planning, while the operation is under way, immediately after the operation, and at intervals throughout postoperative follow-up. In addition to the financial burden, imaging is associated with patient and staff time and exposure to radiation. Several studies have recently been conducted based on a common premise: All routine postoperative radiography after orthopaedic procedures should have clinical utility that can be clearly demonstrated. Such studies have investigated immediate postoperative radiography (in the post-anesthesia care unit [PACU])2 3 and postoperative follow-up radiography (in the outpatient clinic).4 5 6 Such studies have been conducted in spine,2 6 total joint arthroplasty,3 4 and orthopaedic trauma.5 These studies have all drawn similar conclusions: They find little support for routine postoperative radiography, and they recommend that postoperative radiography be minimized and/or used only for patients with signs or symptoms of concern for an abnormal postoperative course. In the study regarding follow-up imaging, Ghattas et al studied follow-up imaging in the postoperative management of fractures. 5 They examined the radiographs of 200 consecutive patients taken at the initial postoperative visit after operative management of an array of fractures throughout the body. Fifteen (7.5%) of 200 fractures in 171 patients had a clinical indication for a radiograph because of an abnormal physical examination finding or history of additional trauma. Three (1.5%) of these fractures had a deviation from standard postoperative care; this deviation was a change in postoperative care on the basis of the patient history and physical examination rather than radiographs. The authors found that for only one patient was a change visible between the PACU radiograph and the postoperative follow-up radiograph; yet, even for this patient, there was no resulting change in clinical management. The authors concluded that routine postoperative imaging at the initial visit after operative management of fractures has low clinical utility and could be discontinued. Similarly, Chaudhry et al studied post-splinting radiographs in minimally displaced fractures and found that post-splinting radiographs of minimally displaced or nondisplaced fractures that do not undergo manipulation before/during immobilization do not provide helpful information but do lead to increased health care costs, radiation exposure, and emergency room waits.7 They concluded that routine performance of post-splinting radiography in these cases should be discouraged. Despite the significance of routine postoperative radiography after hand and upper-extremity procedures in terms of cost, time, and radiation exposure, and despite the controversy regarding the utility of routine radiography raised by studies such as those of Ghattas et al and Chaudhry et al, no authors have characterized current imaging practices, compared those practices with the available evidence (e.g., Ghattas et al), or worked toward establishing a standard of care. This study identifies current postoperative imaging practices among a sample of United States hand and upper-extremity surgeons with respect to two common procedures in hand and upper-extremity surgery: operative repair of distal radius fractures and operative repair of scaphoid fractures. First, we characterize imaging practices in the PACU. Second, we characterize imaging practices during outpatient postoperative follow-up. Third, we characterize the willingness of respondents to decrease their volume of postoperative imaging to save costs.

Chronic scaphoid fracture nonunion continues to present a significant challenge to the treating orthopedic surgeon. Internal fixation with threaded compression screws leads to high union rates, and is currently the gold standard, but there are certainly circumstances where a scaphoid screw does not provide the stability necessary for nonunion repair. Results using a volar buttress plate have been promising, but have not been described in conjunction with the use of vascularized bone graft. Vascularized bone grafts have been shown to be highly effective in achieving rapid and reproducible rates of union. We describe a novel combination of a vascularized volar distal radius wedge autograft pedicled on the volar carpal artery and volar buttress plating for salvage treatment of chronic scaphoid nonunion.

Background Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). Methods Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). Results Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months ( P Conclusion The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.