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Purpose: The acromioclavicular ligament complex (ACLC) is the primary stabilizer against horizontal translation with the superior ACLC providing the main contribution. The purpose of this study was to evaluate the specific regional contributions in the superior half of ACLC, where the surgeon can easily access and repair or reconstruct, for posterior translational and rotational stability.Methods: The superior half of ACLC was divided into three regions; Region A (0°-60°): an anterior 1/3 region of the superior half of ACLC, Region B (60°-120°): a superior 1/3 region of the superior half of ACLC, and Region C (120°-180°): a posterior 1/3 region of the superior half of ACLC. Fifteen fresh-frozen cadaveric shoulders were used. Biomechanical testing was performed to evaluate the resistance force against passive posterior translation (10 mm) and the resistance torque against passive posterior rotation (20°) during the following the four conditions. (1) Stability was tested on all specimens in their intact condition (n = 15). (2) The ACLC was dissected and stability was tested (n = 15). (3) Specimens were randomly divided into three groups by regions of suturing. Stability was tested after suturing Region A, Region B, or Region C (n = 5 per group). (4) Stability was tested after suturing additional regions: Region A + B (0°-120°), Region B + C (60°-180°), or Region A + C (0°-60°, 120°-180°, n = 5 per group).Results: The translational force increased after suturing Region A when compared with dissected ACLC (P = 0.025). The force after suturing Region A + B was significantly higher compared to the dissected ACLC (P < 0.001). The rotational torque increased after suturing Region A or Region B compared with dissected ACLC (P = 0.020, P = 0.045, respectively). The torque after suturing the Region A + C was significantly higher compared to the dissected ACLC (P < 0.001).Conclusion: The combined Region A + B contributed more to posterior translational stability than Region B + C or Region A + C. In contrast, combined Region A + C contributed more to posterior rotational stability than Region A + B or Region B + C. Based on these findings, surgical techniques restoring the entire superior ACLC are recommended to address both posterior translational and rotational stability of the AC joint. [ABSTRACT FROM AUTHOR]

Purpose: Glenoid retroversion is a known independent risk factor for recurrent posterior instability. The purpose was to investigate progressive angles of glenoid retroversion and their influence on humeral head centration and posterior translation with intact, detached, and repaired posterior labrum in a cadaveric human shoulder model.Methods: A total of 10 fresh-frozen human cadaveric shoulders were investigated for this study. After CT- canning, the glenoids were aligned parallel to the floor, with the capsule intact, and the humerus was fixed in 60° of abduction and neutral rotation. Version of the glenoid was created after wedge resection from posterior and fixed with an external fixator throughout the testing. Specimens underwent three conditions: intact, detached, and repaired posterior labrum, while version of the glenoid was set from + 5° anteversion to - 25° retroversion by 5° increments. Within the biomechanical setup, the glenohumeral joint was axially loaded (22 N) to center the joint. At 0° of glenoid version and intact labrum, the initial position was used as baseline and served as point zero of centerization. After cyclic preloading, posterior translation force (20 N) was then applied by a material testing machine, while start and endpoints of the scapula placed on an X-Y table were measured.Results: The decentralization of the humeral head at glenoid version angles of 5°, 10°, 15°, and 20° of retroversion and 5° of anteversion was significantly different (P < 0.001). Every increment of 5° of retroversion led to an additional decentralization of the humeral head overall by (average ± SD) 2.0 mm ± 0.3 in the intact and 2.0 mm ± 0.7 in the detached labrum condition. The repaired showed significantly lower posterior translation compared to the intact condition at 10° (P = 0.012) and 15° (P < 0.01) of retroversion. In addition, CT measured parameters (depth, diameter, and native version) of the glenoid showed no correlation with angle of dislocation of each specimen.Conclusion: Bony alignment in terms of glenoid retroversion angle plays an important role in joint centration and posterior translation, especially in retroversion angles greater than 10°. Isolated posterior labrum repair has a significant effect on posterior translation in glenoid retroversion angles of 5° and 10°. Bony correction of glenoid version may be considered to address posterior shoulder instability with retroversion > 15°. [ABSTRACT FROM AUTHOR]

Background: Low aspiration volumes have been recommended to allow for higher concentrations of progenitor cells during bone marrow harvesting. However, these guidelines then require multiple aspiration attempts in order to maximize cellular yield. The purpose of this study was to investigate the effect of a single, high-volume aspiration with four consecutive aliquots on the number of nucleated cells (NCs) and colony-forming units (CFUs) in concentrated bone marrow aspirate (cBMA) taken from the proximal humerus.Methods: cBMA was taken from the proximal humerus of patients undergoing arthroscopic rotator cuff surgery. Four 12-mL double syringes were used consecutively from a single trocar to obtain four 10 cc aliquots. Each then underwent centrifugation to create a fractionated layer rich in nucleated cells. Following cellular separation, NCs were counted and CFUs were evaluated after incubation of 7-10 days. Cellular comparisons between each aliquot were performed along with their interaction with patient age and sex.Results: Twenty-nine patients (55.9 ± 4.6 years) were included in this study. The number of NCs and CFUs showed significant differences between the four aliquots of aspirate, with the first 10 cc aliquot providing the highest amount (p < 0.001, respectively). No significant differences were found between the sum of the three sequential aliquots compared to the initial 10 cc sample. There were no significant differences between male and female patients (p > 0.05). Increasing age resulted in no significant decrease in the number of NCs and CFUs across the four consecutive aliquots (p > 0.05).Conclusion: In conclusion, while the initial aliquot provided the greatest number of nucleated cells and cultured CFUs, the addition of each sequential volume aspirate yielded similar amounts in total. This demonstrates the potential effectiveness of obtaining of higher volume aspirates from the proximal humerus during rotator cuff repair. [ABSTRACT FROM AUTHOR]

Purpose: To compare the potency of mesenchymal stem cells between the cells derived from the subacromial bursa to concentrated bone marrow aspirate (cBMA) taken from patients undergoing rotator cuff (RC) repair.Methods: Subacromial bursa and cBMA were harvested arthroscopically from 13 patients (age 57.4 ± 5.2 years, mean ± standard deviation) undergoing arthroscopic primary RC repair. Bone marrow was aspirated from the proximal humerus and concentrated using an automated system (Angel System; Arthrex). Subacromial bursa was collected from 2 sites (over the RC tendon and muscle) and digested with collagenase to isolate a single cellular fraction. Proliferation, number of colony-forming units, differentiation potential, and gene expression were compared among the cells derived from each specimen.Results: The cells derived from subacromial bursa showed significantly higher proliferation compared with the cells derived from cBMA after 5, 7, and 10 days (P = .018). Regarding colony-forming units, the subacromial bursa had significantly more colonies than cBMA (P = .002). Subacromial bursal cells over the RC tendon produced significantly more colonies than cells over both the RC muscle and cBMA (P = .033 and P = .028, respectively). Moreover, when compared with cBMA, cells derived from subacromial bursa showed significantly higher differentiation ability and higher gene expression indicative of chondrogenesis, osteogenesis, and adipogenesis.Conclusion: The subacromial bursa is an easily accessible tissue that can be obtained during RC repair, with significant pluripotent stem cell potency for tendon healing. Compared with cBMA taken from the proximal humerus, bursal cells showed significantly increased differentiation ability and gene expression over time.Clinical Relevance: Failed RC repairs have been partly attributed to a poor healing environment. Biologic augmentation of the repair site may help increase healing potential and incorporation of the cuff at the tendon-bone interface. [ABSTRACT FROM AUTHOR]

Purpose: Posterior tibial slope (PTS) represents an important risk factor for anterior cruciate ligament (ACL) graft failure, as seen in clinical studies. An anterior closing wedge osteotomy for slope reduction was performed to investigate the effect on ACL-graft forces and femoro-tibial kinematics in an ACL-deficient and ACL-reconstructed knee in a biomechanical setup.Methods: Ten cadaveric knees with a relatively high native slope (mean ± SD): (slope 10° ± 1.4°, age 48.2 years ± 5.8) were selected based on prior CT measurements. A 10° anterior closing-wedge osteotomy was fixed with an external fixator in the ACL-deficient and ACL-reconstructed knee (quadruple Semi-T/Gracilis-allograft). Each condition was randomly tested with both the native tibial slope and the post-osteotomy reduced slope. Axial loads (200 N, 400 N), anterior tibial draw (134 N), and combined loads were applied to the tibia while mounted on a free moving and rotating X-Y table. Throughout testing, 3D motion tracking captured anterior tibial translation (ATT) and internal tibial rotation (ITR). Change of forces on the reconstructed ACL-graft (via an attached load-cell) were recorded, as well.Results: ATT was significantly decreased after slope reduction in the ACL-deficient knee by 4.3 mm ± 3.6 (p < 0.001) at 200 N and 6.2 mm ± 4.3 (p < 0.001) at 400N of axial load. An increase of ITR of 2.3° ±2.8 (p < 0.001) at 200 N and by 4.0° ±4.1 (p < 0.001) at 400 N was observed after the osteotomy. In the ACL-reconstructed knee, ACL-graft forces decreased after slope reduction osteotomy by a mean of 14.7 N ± 9.8 (p < 0.001) at 200 N and 33.8 N ± 16.3 (p < 0.001) at 400N axial load, which equaled a relative decrease by a mean of 17.0% (SD ± 9.8%), and 33.1% (SD ± 18.1%), respectively. ATT and ITR were not significantly changed in the ACL-reconstructed knee. Testing of a tibial anterior drawing force in the ACL-deficient knee led to a significantly increased ATT by 2.7 mm ± 3.6 (p < 0.001) after the osteotomy. The ACL-reconstructed knee did not show a significant change (n.s.) in ATT after the osteotomy. However, ACL-graft forces detected a significant increase by 13.0 N ± 8.3 (p < 0.001) after the osteotomy with a tibial anterior drawer force, whereas the additional axial loading reduced this difference due to the osteotomy (5.3 N ± 12.6 (n.s.)).Conclusions: Slope-reducing osteotomy decreased anterior tibial translation in the ACL-deficient and ACL-reconstructed knee under axial load, while internal rotation of the tibia increased in the ACL-deficient status after osteotomy. Especially in ACL revision surgery, the osteotomy protects the reconstructed ACL with significantly lower forces on the graft under axial load. [ABSTRACT FROM AUTHOR]

Background: Non-insertional Achilles tendinopathy is a common disorder that may be treated with surgical debridement. A flexor hallucis longus (FHL) transfer is recommended if debridement of ≥50% is performed; however, there are no biomechanical data to support this. The purpose of this study was to assess the added biomechanical strength provided by an FHL transfer with incrementally sized non-insertional Achilles tendon defects.Methods: Thirty matched-pair below-the-knee cadaveric specimens (n = 60) (mean age at the time of donor death, 67 years; range, 36 to 74 years) were obtained and randomly divided into 3 groups according to whether the defect was 25%, 50%, or 75% of the tendon width. One specimen of each pair was then randomly selected to undergo FHL transfer using interference screw fixation. All specimens then underwent cyclic loading of 100 N, and elongation of the medial and lateral limbs of the tendon defect was recorded. The constructs were then loaded to failure to measure stiffness, ultimate strength, and peak elongation before failure.Results: The specimens with a 75% defect had significantly less elongation of the medial and lateral tendon-defect limbs when an FHL transfer had been done (p < 0.05). Ultimate load to failure was significantly increased in all groups (by 242 to 270 N depending on the defect size) following FHL transfer. Failures usually occurred through the tendon defect in the 75% and 50% defect groups, whereas all failures occurred at the Achilles tendon insertion when a 25% defect had been created. No significant differences were found in peak elongation with the addition of an FHL transfer. FHL augmentation resulted in significantly greater stiffness in the 25% and 75% defect groups (p < 0.05).Conclusions: This study showed that an FHL transfer significantly increased load to failure of Achilles tendons with a non-insertional defect involving 25%, 50%, and 75% of the tendon width. The mechanism of failure was usually through the defect in the specimens with a 50% or 75% defect, supporting the use of FHL augmentation with debridement of ≥50%.Clinical Relevance: The present study supports the mechanical concept that FHL transfer is indicated when debridement of the Achilles tendon is ≥50%. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA). A retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed. The prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P <.0001) and more likely to have depression (P <.0001), lower educational attainment (P <.0001), smoke tobacco (P =.003), be Hispanic/Latino (P =.001), live alone (P =.001), and have higher rates of nonprimary osteoarthritis (P <.0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P =.049 and.006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P =.913 and.782 for THA and TKA, respectively), emergency room visits (P =.467 and.355 for THA and TKA respectively), or readmissions (P =.118 and.334 for THA and TKA, respectively). Psychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted. [ABSTRACT FROM AUTHOR]

Purpose: To assess the anti-inflammatory effects of platelet-rich plasma (PRP) and amniotic viscous fluid using a human coculture system of cartilage and synovial tissue from osteoarthritic patients.Methods: A coculture system was created using cartilage and synovium from 3 patients undergoing total knee arthroplasty. To induce inflammation, interleukin-1β was added to each coculture. Biologic agents tested included 2 PRP concentrations (PRPL and PRPH) and 2 different samples of amniotic viscous fluid (Amnion and Flograft). Amnion was also tested with PRP to check for any additive effects. Quantitative polymerase chain reaction was used to measure gene expression of factors involved in osteoarthritis, including disintegrin and metalloproteinase with thrombospondin motifs-5 (ADAMTS-5), tissue inhibitor of metalloproteinases 1 (TIMP-1), vascular endothelial growth factor (VEGF), aggrecan, type 1 collagen, and nitric oxide, at 0, 24, 48, and 72 hours. A synthetic nonsteroidal medication, Ketorolac, was used for baseline comparison to the biologic agents.Results: When comparing from time 0, both Amnion and Flograft resulted in significant decreases of ADAMTS-5 and TIMP-1 gene expression in cartilage and synovium for up to 72 hours. Both amniotic preparations increased collagen-1 gene expression in cartilage and decreased VEGF expression in synovium. Amnion was not found to have any effect on nitric oxide concentration at any time point (P > .05), as opposed to both PRP concentrations (P < .05). All biologic agents showed differences in gene expression similar to Ketorolac in ADAMTS-5, TIMP-1, and VEGF expression.Conclusion: This study found that amniotic fluid had anti-inflammatory effects mostly similar to those of both PRPH and PRPL; however, no significant additive effects in reducing inflammatory gene expression were found when combining biologic agents.Clinical Relevance: PRP and amniotic fluid may provide alternative treatment options to delay the progression of the disease without the systemic and intra-articular side effects of corticosteroids. [ABSTRACT FROM AUTHOR]

Background: Although smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA).Methods: A retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed.Results: There were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052).Conclusion: Tobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from its inpatient only (IPO) list as of January 1, 2018. The purpose of this study was to establish a risk-stratifying nomogram to aid in determining the need for inpatient admission among Medicare-aged patients undergoing primary TKA.Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients aged ≥65 years who underwent primary TKA between 2006 and 2015. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and perioperative variables were incorporated in a multivariate logistic regression model to yield a risk stratification nomogram.Results: Sixty-one thousand two hundred eighty-four inpatient and 26,066 outpatient admissions were analyzed. Age >80 years (odds ratio [OR] = 2.27, P < .0001, 95% confidence interval [CI] = 2.13-2.42), simultaneous bilateral TKA (OR = 2.02, P < .0001, 95% CI = 1.77-2.30), dependent functional status (OR = 1.95, P < .0001, 95% CI = 1.62-2.35), metastatic cancer (OR = 1.91, P = .055, 95% CI = 0.99-3.73), and female gender (OR = 1.76, P < .0001, 95% CI = 1.70-1.82) were the greatest determinants of inpatient stay. The resulting predictive model demonstrated acceptable discrimination and excellent calibration.Conclusion: Our model enabled a reliable and straightforward identification of the most suitable candidates for inpatient admission in Medicare aged-patients undergoing primary TKA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram. [ABSTRACT FROM AUTHOR]

Purpose: To assess whether preoperative subpectoral tenderness in patients with rotator cuff tears was associated with arthroscopic findings of tendinopathy of the long head of the biceps, as well as whether they had resolution of their subpectoral tenderness postoperatively after tenodesis or tenotomy.Methods: Patients presenting between 2011 and 2016 undergoing arthroscopic rotator cuff repair were evaluated preoperatively with the subpectoral biceps test (SBT). This test is performed with the arm adducted and internally rotated to allow palpation of the biceps as it courses under the pectoralis major tendon. Preoperative SBT findings determined operative management with either tenodesis or tenotomy during rotator cuff repair. Patients were followed up postoperatively to assess resolution of subpectoral tenderness with a repeated SBT. Preoperative and postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons, and Constant-Murley scores were recorded in all patients.Results: A total of 128 patients were enrolled in the study, with a mean age of 58 years (range, 33-82 years). Patients with a positive preoperative SBT (n = 68) had significantly lower SANE and Constant-Murley scores preoperatively (P < .01) than patients with a negative SBT (n = 60). All patients with a positive preoperative SBT underwent either tenodesis or tenotomy, with 94% of patients (n = 64) having resolution of subpectoral pain and tenderness at final follow-up. Intraoperatively, 93% of patients with a positive SBT showed gross pathologic changes in the tendon (fraying, erythema, tears, or subluxation) compared with only 65% of patients with negative preoperative examination findings (P < .01). American Shoulder and Elbow Surgeons, Constant-Murley, and SANE scores were significantly increased postoperatively in all patients (P = .02).Conclusions: In this group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy, 94% had resolution of their subpectoral tenderness. A positive SBT was associated with gross pathologic changes of the biceps in 93% of patients.Level Of Evidence: Level III, prospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Despite improvements in surgical technique and implant longevity, some patients continue to report dissatisfaction after total joint arthroplasty (TJA). As patient satisfaction is increasingly used as a quality metric, the objective of this study was to gain better understanding of satisfaction with total joint arthroplasty from the patient perspective.Methods: Five hundred fifty-one primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a minimum of 1-year follow-up and were responsive to a satisfaction survey were analyzed. The incidence, predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate and multivariate logistic regression analyses were performed.Results: Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most significant predictor of dissatisfaction (P = .037). The most common reasons for dissatisfaction after THA were persistent pain (N = 14/34, 41%), functional limitation (N = 12/34, 35%), surgical complication and reoperation (N = 4/34, 12%), staff or quality of care issues (N = 2/34, 6%), and slow recovery (N = 2/34, 6%). The most common reasons for dissatisfaction after TKA were persistent pain (N = 19/46, 41%), functional limitation (N = 12/46, 26%), surgical complication and reoperation (N = 8/46, 17%), staff or quality of care issues (N = 5/46, 11%), and unmet expectations (N = 2/46, 4%).Conclusion: While persistent pain and functional limitation are the 2 leading reasons for dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical outcome and should be interpreted with caution. Potential for incomplete pain relief or full functional recovery should be discussed during preoperative counseling. Empathic care is also important and should be encouraged to enhance the overall patient experience. [ABSTRACT FROM AUTHOR]

Patient-reported outcomes (PROs) are gaining an important role in the assessment of quality of care. There are currently limited data on the effect of payer type on PROs in total joint arthroplasty (TJA). This study compared both disease-specific and general health PROs among patients stratified according to their payer type. Our institutional joint registry was queried for patients who underwent primary, elective, and unilateral hip and knee arthroplasty. Patients were divided according to their insurance type at the time of surgery into 3 groups: Medicaid, Medicare, or commercial. The outcomes assessed were the net changes in PROs as well as absolute scores at 6 months and 1 year. Six of the most commonly used PROs were assessed: Short Form-12 physical and mental components, Western Ontario and McMaster Universities Osteoarthritis Index, Single Assessment Numerical Evaluation, University of Californian Los Angeles activity level rating, and Oxford Hip Score. Analysis of variance and covariance were used. We evaluated 756 procedures (273 Medicaid, 270 Medicare, and 213 commercial insurance). Medicaid patients had significantly lower mean baseline scores across all PROs compared to either Medicare or commercial insurance patients. Medicaid patients were also more likely to be smokers, live alone, have lower educational level, African-American, and have nonprimary osteoarthritis as the indication for TJA. At 1-year follow-up, the net mean outcome gains were comparable among the 3 payer types (P >.05), but Medicaid patients continued to score lower while Medicare and commercial insurance patients continued to score higher (P <.01). When adjusting for all baseline differences among Medicaid patients, the negative effects of payer type resolved except for Oxford Hip Score which remained lower in the Medicaid group (P =.006). When using PROs to assess the value of care, the preoperative to postoperative changes are a better indicator of surgical success than comparing absolute values, especially in Medicaid patients. While TJA imparts similar net improvements to patients of all payer types, Medicaid coverage is a predictor of lower absolute outcome scores at any given time as result of increased baseline health burden (eg, depression, tobacco smoking, and poor overall well-being). Arthroplasty surgeons should be aware of these factors when counseling patients and seek optimization when necessary. The findings should be taken into account by stakeholders when constructing value-based payment models. Further research is needed to better understand the barriers leading to higher prevalence of increased health disparities among Medicaid beneficiaries and how to effectively address them. [ABSTRACT FROM AUTHOR]

Background: Postoperative laboratory testing has been used routinely for patients undergoing total hip arthroplasty (THA). However, with modern-day improvements in perioperative care pathways, it is unclear whether this practice remains justified. The purpose of this study was to assess the utility of routine postoperative laboratory tests in primary THA.Methods: The electronic medical records of 351 patients who underwent primary, unilateral THA between 2015 and 2017 were retrospectively reviewed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits or readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values.Results: Seventy-four patients (21%) had abnormal postoperative laboratory results, of which 82.4% were exclusively due to electrolyte (sodium or potassium) abnormalities. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (P < .001 and P = .013 for sodium and potassium, respectively), diabetes (P = .007), and lack of tranexamic acid use (P < .01). The rates of AKI and blood transfusion were 2.0% and 2.3%, respectively. Factors associated with blood transfusion were higher American Society of Anesthesiologists class and intraoperative blood loss ≥250 mL combined with either preoperative anemia or lack of tranexamic acid use. Factors associated with AKI were higher American Society of Anesthesiologists class and diabetes. Laboratory results did not change the standard course of care in 338 of 351 patients (96%). Abnormal laboratory values were not associated with increased length of stay (P = .228) or emergency department visits/readmissions (P = .21).Conclusion: This study provides evidence that routine postoperative laboratory testing is not necessary in modern-day primary, unilateral THA. Instead, the decision to obtain laboratory tests after surgery should be driven by patients' risk factors. [ABSTRACT FROM AUTHOR]

Abstract Background The Centers for Medicare and Medicaid Services has solicited comments regarding the removal of total hip arthroplasty (THA) from its inpatient-only list. The goal of this study is to develop and internally validate a risk stratification nomogram to aid in the identification of optimal inpatient candidates in this patient population. Methods The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all patients >65 years of age who underwent primary THA between 2006 and 2015. Inpatient stay was the primary outcome measure, as defined by stay >2 days in length. The impact of numerous demographic, comorbid, and perioperative variables was assessed through a multivariable logistic regression analysis to construct a predictive nomogram. Results In total, 30,587 inpatient THAs and 17,024 outpatient THAs were analyzed. Heart failure (odds ratio [OR] 2.11, P =.001), simultaneous bilateral THA (OR 2.47, P <.0001), age >80 years (OR 2.91, P <.0001), female gender (OR 1.90, P <.0001), and dependent functional status (OR 1.89, P <.0001) were the most influential determinants of inpatient status. The final prediction algorithm showed good accuracy, excellent calibration, and internal validation (bias-corrected concordance index of 0.69). Conclusion Our model enabled accurate and simple identification of the best candidates for inpatient admission after THA in Medicare-aged patients. Given the increasing feasibility of outpatient THA coupled with the likelihood of THA being removed from the Centers for Medicare and Medicaid Services inpatient-only list, this model provides a framework to guide discussion and decision-making for stakeholders. [ABSTRACT FROM AUTHOR]

Background: Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay.Methods: Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors.Results: One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001).Conclusion: The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this systematic review was to investigate study quality and risk of bias for randomized trials comparing partial meniscectomy with physical therapy in middle-aged patients with degenerative meniscus tears.Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar was performed from 1990 through 2017. The inclusion criteria were at least 1 validated outcome score, and middle-aged patients (40 years and older) with a degenerative meniscus tear. Studies with a sham arm, and acute and concomitant injuries were excluded. Risk of bias was assessed with the Cochrane Risk of Bias Tool. The quality of studies was assessed with the Cochrane GRADE tool and quality assessment tool (Effective Public Health Practice Project). Publication bias was assessed by funnel plot and Egger's test. The I2 statistics was calculated a measure of statistical heterogeneity.Results: Six studies were included, and all were assessed as having a high risk of bias. There was no publication bias (P = .23). All studies were downgraded (low, n = 5; very low, n = 1). The Effective Public Health Practice Project assessed 1 study as strong, 2 as moderate, and 3 as weak. The overall results demonstrated moderate to low quality of the included studies. The I2 statistic was 96.2%, demonstrating substantial heterogeneity between studies.Conclusions: The results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. The studies evaluated here exhibited a high risk of bias, and the weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics do not allow any meaningful conclusions to be drawn. Therefore, the validity of the results and conclusions of prior systematic reviews and meta-analyses must be viewed with extreme caution. The quality of the available published literature is not robust enough at this time to support claims of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition.Level Of Evidence: Level II, systematic review of Level I and II studies. [ABSTRACT FROM AUTHOR]

Background: Proximal opening wedge osteotomy (POWO) is an established procedure for moderate to severe hallux valgus. A common concern of this procedure is that it results in lengthening of the first metatarsal, which could cause increased intra-articular pressure of the first metatarsophalangeal joint (MTP) and may ultimately lead to arthritis because of these altered mechanics. The purpose of this study was to use a cadaveric model to compare intra-articular pressures and articulating contact properties of the MTP joint following either scarf osteotomy or POWO. Methods: Fresh-frozen cadaveric below-knee specimens with pre-existing hallux valgus (n = 12) and specimens without hallux valgus (n = 6, control group) were used. The hallux valgus specimens were stratified into 2 groups (n = 6 each): POWO or scarf osteotomy. The groups were matched based on the degree of deformity. Peak intra-articular pressure, force, and area were measured in all normal, preoperative, and postoperative specimens with a simulated weightbearing model. These measurements were made with a pressure transducer placed within the first MTP joint. Results: Postoperatively POWO group had slightly higher contact forces and pressures compared to the scarf group and lower contact forces and pressures than those of the normal group but were not statistically significant (P > .05). Normal specimens had higher intra-articular force, pressure, and area than postoperative specimens but the difference was not found to be significant. First metatarsal lengthening was found in both the scarf and POWO specimens; however, neither increase was found to be significant (P > .05). Conclusion: The results from this study show that after operative correction, contact properties of the fist MTP joint among normal, POWO, and scarf osteotomy groups revealed no significant differences. First MTP joints in those with hallux valgus had significantly lower contact force and pressure compared to those without hallux valgus. Clinical Relevance: With little long-term outcomes of proximal opening wedge osteotomy, this study will help predict the possibility of future MTP joint arthritis. [ABSTRACT FROM AUTHOR]