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Objective: High-quality data entry in clinical trial databases is crucial to the usefulness, validity, and replicability of research findings, as it influences evidence-based medical practice and future research. Our aim is to assess the quality of self-reported data in trial registries and present practical and systematic methods for identifying and evaluating data quality., Study Design and Setting: We searched ClinicalTrials.Gov (CTG) for interventional total knee arthroplasty (TKA) trials between 2000 and 2015. We extracted required and optional trial information elements and used the CTG's variables' definitions. We performed a literature review on data quality reporting on frameworks, checklists, and overviews of irregularities in healthcare databases. We identified and assessed data quality attributes as follows: consistency, accuracy, completeness, and timeliness., Results: We included 816 interventional TKA trials. Data irregularities varied widely: 0%-100%. Inconsistency ranged from 0% to 36%, and most often nonrandomized labeled allocation was combined with a "single-group" assignment trial design. Inaccuracy ranged from 0% to 100%. Incompleteness ranged from 0% to 61%; 61% of finished TKA trials did not report their outcome. With regard to irregularities in timeliness, 49% of the trials were registered more than 3 months after the start date., Conclusion: We found significant variations in the data quality of registered clinical TKA trials. Trial sponsors should be committed to ensuring that the information they provide is reliable, consistent, up-to-date, transparent, and accurate. CTG's users need to be critical when drawing conclusions based on the registered data. We believe this awareness will increase well-informed decisions about published articles and treatment protocols, including replicating and improving trial designs., Competing Interests: Declaration of competing interest There are no competing interests for all the authors., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Pilot or feasibility trials examine the feasibility, viability and recruitment potential of larger, main trials. Specifically, a pilot trial can be instrumental in identifying methodological issues essential to the development of an effective research protocol. However, numerous studies published as pilot or feasibility studies have demonstrated notable inconsistencies in the nature of information reported, resulting in poor-quality and incomplete reporting. It is unclear whether such low quality or incompleteness of reporting is also prevalent in arthroplasty pilot trials., Methods and Analysis: This protocol outlines a methodological survey examining the completeness of reporting among hip and knee arthroplasty pilot trials in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 extension to pilot trials. Secondary objectives include: (1) determining the prevalence of 'spin' practices, defined as: (a) placing a focus on statistical significance rather than feasibility, (b) presenting results that show the trial to be non-feasible as feasible or (c) emphasising the effectiveness or potential intervention benefits rather than feasibility; (2) determining factors associated with incomplete reporting, and 'spin'. A search of PubMed will be conducted for pilot trials in hip or knee arthroplasty published between 01 January 2017 and 31 December 2023. Following screening, appropriate data will be extracted from eligible publications and reported as descriptive statistics, encompassing elements of the CONSORT checklist associated with completeness of reporting. Logistic regression analysis and Poisson regression will be used to analyse factors associated with completeness of reporting and spin., Ethics and Dissemination: This methodological review does not require formal ethical approval, as it will solely involve the use of published and publicly reported literature. The results of this study will be disseminated through submission to peer-reviewed journals and academic conference presentations. Study details will be sent to McMaster University's media coordinators to be shared through the institution's research-focused platforms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Total knee arthroplasty (TKA) is an end-stage treatment for knee osteoarthritis that relieves pain and loss of mobility, but patient satisfaction and revision rates require improvement. One cause for TKA revision is joint instability, which may be due to improper ligament balancing. A better understanding of the relationship between prosthesis design, alignment, and ligament engagement is necessary to improve component designs and surgical techniques to achieve better outcomes. We investigated the biomechanical effects of ligament model complexity and ligament wrapping during laxity tests using a virtual joint motion simulator. There was little difference in kinematics due to ligament complexity or ligament wrapping.

As the prevalence of total hip and total knee arthroplasty procedures increase over the next decades, hospitals seek opportunities to improve quality outcomes while simultaneously limiting costs and mitigating risks of complications. The Joint Commission's Advanced Total Hip and Total Knee Replacement (THKR) certification is one of the highest quality standard certification programs in the nation and is the only one that collaborates with the American Academy of Orthopedic Surgeons. To obtain THKR certification, several requirements based on evidence-based clinical practice guidelines must be met. The process is described from initial identification of stakeholders to ongoing efforts to retain certification. Joint Commission THKR certification was awarded after rigorous review and on-site visit. Compliance with advanced care standards from the time of orthopedic consultation through postsurgical follow-up was reviewed. Joint Commission THKR certification provides supporting evidence of the institutions journey in processes toward delivering high quality clinical care. A multidisciplinary team with ongoing collaboration is necessary to obtain and retain certification., Competing Interests: There were no real or potential conflicts of interest regarding this paper., (Copyright © 2024 by National Association of Orthopaedic Nurses.)

Background: Quality rating systems exist to grade the value of care provided by hospitals, but the extent to which these rating systems correlate with patient outcomes is unclear. The association of quality rating systems and hospital characteristics with excess readmission penalties for total hip arthroplasty (THA) and total knee arthroplasty (TKA) was studied., Methods: The fiscal year 2022 Inpatient Prospective Payment System final rule was used to identify 2,286 hospitals subject to the Hospital Readmissions Reduction Program. Overall, 6 hospital quality rating systems and 5 hospital characteristics were obtained. These factors were analyzed to determine the effect on hospital penalties for THA and TKA excess readmissions., Results: Hospitals that achieved a higher Medicare Overall Hospital Quality Star Rating demonstrated a significantly lower likelihood of receiving THA and TKA readmission penalties (Cramer's V = 0.236 and R p  = -0.233; P < .001 for both). Hospitals ranked among the US News & World Report's top 50 best hospitals for orthopaedics were significantly less likely to be penalized (V = 0.042; P = .043). The remaining 4 quality rating systems were not associated with readmission penalties. Penalization was more likely for hospitals with fewer THA and TKA discharges (R p  = -0.142; P < .001), medium-sized institutions (100 to 499 beds; V = 0.075; P = .002), teaching hospitals (V = 0.049; P = .019), and safety net hospitals (V = 0.043; P = .039). Penalization was less likely for West and Midwest hospitals (V = 0.112; P < .001)., Conclusions: A higher Overall Hospital Quality Star Rating and recognition among the US News & World Report's top 50 orthopaedic hospitals were associated with a reduced likelihood of THA and TKA readmission penalties. The other 4 widely accepted quality rating systems did not correlate with readmission penalties. Teaching and safety net hospitals may be biased toward higher readmission rates., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Since the meniscus is an important stabilizing structure of the knee joint and has a significant role in load-bearing and shock absorption, so the complete structural and functional reconstructions of the teared menisci should be done not only after partial meniscectomy but also post total meniscectomy. So far, animal experiments and good clinical practice have showed that TMAT after total meniscectomy has partially solved the problem of structural and functional reconstructions after total meniscectomy. However, partial meniscectomy will also lead to accelerated knee degeneration, and its proportion is much higher than that of patients with total meniscectomy. Herein, the feasibility of PMAT after partial meniscectomy was investigated for the first time by using the 40% posterior horn meniscectomy model of the medial meniscus in Beagle dogs, and also for the first time, TMAT group and the total meniscectomy group were used as control groups. Compared with the TMAT, the transcriptomics evaluation, scanning electron microscope observation, histological regeneration and structure, biomechanical property, inflammation environment, and the knee function post PMAT were more similar to that of normal meniscus was first reported. This study provides a PMAT scheme with clinical translational value for the complete structural and functional reconstruction of the patients with partial meniscectomy and fills the gap in the field of teared meniscus therapy on the basis of quite well clinical applications of the meniscus repair and the TMAT., (© 2022 The Authors. Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

Objective: The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally., Methods: A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated., Results: There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%)., Conclusions: Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar., (Copyright © 2021 Osteoarthritis Research Society International. All rights reserved.)

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care., Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures., Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020., Exposures: Implementation of the CJR model in 2016., Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends., Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups., Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Unicompartmental knee arthroplasty (UKA) represents 10% of knee arthroplasties. Advantages are better functional results, quicker recovery, shorter hospitalization time, and lower blood loss, among others. However, revision rates are larger than total knee arthroplasty. Among the most important factors that explain this are the implant position and alignment, and the correct surgical indication. Greater accuracy in the implant placement may improve clinical results and increase the rate of implant survival. The objective of this study is to evaluate the precision of the Navio robot-assisted system in the position and alignment of medial UKA compared with the conventional technique. This is an experimental pilot study. Twenty-six cadaveric models were randomized into 2 groups: Robot-Assisted surgery (R) and Conventional Surgery (C). Radiological study was performed pre- and post-surgery, evaluating the medial distal femoral angle (MDFA), medial proximal tibial angle (MPTA), tibial slope, tibiofemoral angle (TFA), sagittal femoral angle (SFA), and size of the femoral and tibial components. The main result measurement was the change in postoperative angulation. The results of this study are MDFA median of 1.07° (0.19-4.5) for group R and 0.12° (0.03-10.4) with a significant difference in variances; a Welch t -test of p  = 0.013; and an MPTA of 1.28° (0.05-5.87) for R and 1.3°(0.08-14.1) for C with significantly different variances ( p  = 0.0064). Size of the femoral component has a difference of p  < 0.05 between groups. No differences for dispersion of TFA nor for the size of the tibial component were observed. In conclusion, using robot-assisted UKA allows for greater accuracy in the positioning of the implants and in the prediction of the size of the femoral component., Competing Interests: M.I. reports nonfinancial support and others from Smith and Nephew, during the conduct of the study, and permision to use Navio robotic system. R.N. reports nonfinancial support and other from Smith and Nephew, during the conduct of the study; personal fees from Smith and Nephew, personal fees from Zimmer Biomet, outside the submitted work. J.D. reports nonfinancial support and other from Smith and Nephew, during the conduct of the study; personal fees from Smith and Nephew, outside the submitted work. N.O.R. reports nonfinancial support and other from Smith and Nephew, during the conduct of the study; personal fees from Smith and Nephew, outside the submitted work. R.D. reports nonfinancial support and other from Smith and Nephew, during the conduct of the study., (Thieme. All rights reserved.)

Computer-assisted orthopedic surgery improves mechanical alignment and the accuracy of surgical cuts in the context of total knee arthroplasty (TKA). A simplified, navigation-enhanced instrumentation system was assessed to determine whether the same effects could be achieved with a less intrusive system. Two cohorts of surgeons (experienced and trainees) performed a series of TKA cuts using models with and without navigation-enhanced instrumentation. The accuracy of each system was determined via the rate of outliers, measured as any cut that deviated from the planned cut by more than 2° or 2 mm. The effect of experience level was limited, with only the outlier rate for tibial varus or valgus measurement showing a significant difference between user groups with conventional instrumentation (P=.004). The use of navigation-enhanced instrumentation significantly reduced the total outlier rate compared with conventional instrumentation from 35% to 4% for experienced users (P<.001) and from 34% to 10% for trainees (P<.001). These results suggest that navigation-enhanced instrumentation is a viable alternative to conventional instrumentation to reduce outlier rates and improve cut accuracy. This trial also showed that additional experience may not correlate with improved surgical accuracy. Outliers may not reflect individual surgical ability as much as limitations of the instrumentation or other unidentified factors. [Orthopedics. 2021;44(1):54-57.]., (Copyright 2020, SLACK Incorporated.)

When sizing the femoral component or determining its placement in total knee arthroplasty (TKA), if the anterior-posterior diameter of the femoral condyle is between component sizes, the selected size will differ depending on whether anterior referencing (AR) or posterior referencing (PR) is used. As a result, the amount of resected bone will also vary. In the present prospective study, we compared the two referencing methods to determine which is more suitable for individual patients. We recruited 58 patients (92 joints) who received TKA using the standard technique with intermediate-size components. AR was used in 26 joints, and PR in 23 joints. Seventeen of the patients underwent same-day bilateral TKA in which components of different sizes were used for the left and right joints. AR resulted in significantly smaller anterior and posterior offsets than PR. Preoperative clinical evaluation revealed no significant differences among cases in which intermediate-size components were indicated, or those in which components of different sizes were indicated. When an intermediate-sized component was indicated using the AR method, moving the sizer forward resulted in a larger posterior gap, but this technique was nevertheless considered acceptable. AR is likely to be more suitable than PR as it achieves more physiological anterior clearance.

Background: Given the low early revision rate after total hip arthroplasty (THA) and total knee arthroplasty (TKA), hospital performance is typically compared using 3 years of data. The purpose of this study was to assess how much earlier worsening hospital performance in 1-year revision rates after THA and TKA can be detected., Methods: All 86,468 THA and 73,077 TKA procedures performed from 2014 to 2016 and recorded in the Dutch Arthroplasty Register were included. Negative outlier hospitals were identified by significantly higher O/E (observed divided by expected) 1-year revision rates in a funnel plot. Monthly Shewhart p-charts (with 2 and 3-sigma control limits) and cumulative sum (CUSUM) charts (with 3.5 and 5 control limits) were constructed to detect a doubling of revisions (odds ratio of 2), generating a signal when the control limit was reached. The median number of months until generation of a first signal for negative outliers and the number of false signals for non-negative outliers were calculated. Sensitivity, specificity, and accuracy were calculated for all charts and control limit settings using outlier status in the funnel plot as the gold standard., Results: The funnel plot showed that 13 of 97 hospitals had significantly higher O/E 1-year revision rates and were negative outliers for THA and 7 of 98 hospitals had significantly higher O/E 1-year revision rates and were negative outliers for TKA. The Shewhart p-chart with the 3-sigma control limit generated 68 signals (34 false-positive) for THA and 85 signals (63 false-positive) for TKA. The sensitivity for THA and TKA was 92% and 100%, respectively; the specificity was 69% and 51%, respectively; and the accuracy was 72% and 54%, respectively. The CUSUM chart with a 5 control limit generated 18 signals (1 false-positive) for THA and 7 (1 false-positive) for TKA. The sensitivity was 85% and 71% for THA and TKA, respectively; the specificity was 99% for both; and the accuracy was 97% for both. The Shewhart p-chart with a 3-sigma control limit generated the first signal for negative outliers after a median of 10 months (interquartile range [IQR] = 2 to 18) for THA and 13 months (IQR = 5 to 18) for TKA. The CUSUM chart with a 5 control limit generated the first signal after a median of 18 months (IQR = 7 to 22) for THA and 21 months (IQR = 9 to 25) for TKA., Conclusions: Monthly monitoring using CUSUM charts with a 5 control limit enables earlier detection of worsening 1-year revision rates with accuracy so that initiatives to improve care can start earlier.

Background: Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA)., Methods: We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up., Results: Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark., Conclusions: The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.

There is a noticeable increase in the unnecessary ordering of Magnetic Resonance Imaging (MRI) of the knee in older patients. This quality improvement study assessed the frequency of unnecessary pre-consultation knee MRIs and investigated the effect on the outcome of the patients' consultation with the orthopedic surgeon. 650 medical charts of patients aged 55 years or older referred to an orthopedic clinic with knee complaints were reviewed. Patients arriving with a pre-consultation MRI were identified, and the usefulness of the MRI was evaluated using the appropriateness criteria developed to support this study. Of the 650 patient charts reviewed, 225 patients presented with a pre-consultation MRI, 76% of which were not useful for the orthopedic surgeon. The ordered knee MRI scans were considered not useful because they were requested for confirmed meniscal tear for patients ≥55 years, suspected degenerative disorder and ligament/tendon injury, or for patients with severe osteoarthritis without locking or extension. These MRI scans were done despite the absence of signs of effusion, tenderness, soft tissue swelling, decreased range of motion, or difficulty of weight-bearing, a lack of persistent knee joint pain at the time of assessment, or with no x-ray before ordering MRI. Half of the patients with a pre-consult MRI did not present with plain radiographs of their knee, however, 35% of those still required an x-ray to be ordered at the time of the surgical consult. A logistic regression analysis on post-consult disposition found that patients with pre-consult MRI were less likely to be considered for total knee arthroplasty (TKA) (OR 0.424, CI 0.258-0.698, p = 0.001). Patients assessed by an advanced practice physiotherapist prior to referral for surgical consult were 4.47 more likely to have TKA (CI 2.844-7.039, p< 0.000). Most of the pre-consult knee MRIs were deemed as unnecessary for the orthopedic surgeon's clinical decision-making. This study highlights the potential benefits of following a comprehensive model of care within the referral process to reduce the unnecessary high orders of pre-consult MRI scans., Competing Interests: The authors have declared that no competing interests exist. The afflition does not alter the authros’ adherence to all PLOS ONE policies on sharing data and marterial.

Background: Many practices require tissues from hip and knee arthroplasty procedures to be sent for pathologic examination. These examinations rarely provide information beyond the clinical or radiologic diagnosis and rarely alter clinical management. We aimed to determine the rate at which histologic diagnoses based on gross assessment alone or gross plus microscopic assessment correspond with reported clinical diagnoses in patients undergoing total joint arthroplasties and whether the histologic diagnoses alter patient management., Methods: We retrospectively reviewed arthroplasty cases performed at a high-volume teaching hospital in Manitoba, Canada. The clinical diagnosis was compared with the final pathology report based on gross examination, with or without histologic assessment. The results of the comparison were classified into 3 categories: concordant (same diagnosis), discrepant (different diagnoses without alterations in management) and discordant (different diagnoses resulting in management change). The overall provincial cost for pathologic examination was determined by multiplying the total examination cost by the estimated number of arthroplasty cases., Results: There were 773 patients in our study sample. The concordant rate was 98.3% (95% confidence interval [CI] 97.1%-99.1%), the discrepant rate was 1.7% (95% CI 0.9%-2.9%) and the discordant rate was 0.0% (95% CI 0%-0.5%) for 773 cases. The pathology diagnosis did not alter patient management in any case. A total of 91.5% of specimens did not require full histologic review and received gross descriptions only. The discrepancy rate was higher in cases that included microscopic examination than in those that received only gross descriptions (15.2% v. 0.4%, p < 0.001). The overall provincial cost for pathologic examination was estimated at Can$304 556., Conclusion: Submitting routine tissue from arthroplasty procedures to pathology does not affect patient management and therefore provides no value for the health care resources expended in doing so.

Background: Given the inclusion of orthopaedic quality measures in the Centers for Medicare & Medicaid Services national hospital payment programs, the present study sought to assess whether the public reporting of total hip arthroplasty (THA) and total knee arthroplasty (TKA) risk-standardized readmission rates (RSRRs) and complication rates (RSCRs) was temporally associated with a decrease in the rates of these outcomes among Medicare beneficiaries., Methods: Annual trends in national observed and hospital-level RSRRs and RSCRs were evaluated for patients who underwent hospital-based inpatient hip and/or knee replacement procedures from fiscal year 2010 to fiscal year 2016. Hospital-level rates were calculated with use of the same measures and methodology that were utilized in public reporting. Annual trends in the distribution of hospital-level outcomes were then examined with use of density plots., Results: Complication and readmission rates and variation declined steadily from fiscal year 2010 to fiscal year 2016. Reductions of 33% and 25% were noted in hospital-level RSCRs and RSRRs, respectively. The interquartile range decreased by 18% (relative reduction) for RSCRs and by 34% (relative reduction) for RSRRs. The frequency of risk variables in the complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding., Conclusions: This study showed that hospital-level complication and readmission rates following THA and TKA and the variation in hospital-level performance declined during a period coinciding with the start of public reporting and financial incentives associated with measurement. The consistently decreasing trend in rates of and variation in outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for THA and TKA patients in the 2016 fiscal year compared with the 2010 fiscal year. The interactions between public reporting, payment, and hospital coding practices are complex and require further study., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Despite the growing frequency of revision total knee arthroplasty (rTKA), there is limited information regarding patient-reported outcome measures (PROMs) after that procedure. Therefore, the purpose of this study was to determine (1) PROM improvements in pain, function, quality of life (QOL), and global health and (2) predictors of PROMs for patients undergoing aseptic rTKA as determined using a multilevel model with patients nested within surgeons., Methods: A prospective cohort of 246 patients who underwent aseptic rTKA from January 2016 to December 2017 and had baseline and 1-year postoperative PROMs were analyzed. The most common surgical indications were aseptic loosening (n = 109), instability (n = 73), and implant failure (n = 64). The PROMs included in this study were the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain, -Physical Function Short Form (PS), and -Quality of Life (QOL) as well as the Veterans Rand-12 (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS). Multivariable linear regression models with patients nested within surgeons were constructed for predicting change in PROMs from baseline to 1 year., Results: The mean 1-year postoperative improvements in the KOOS-Pain and PS PROMs were 30.3 and 19.15 points, respectively, for the overall rTKA series. Improvement in the KOOS-Pain was associated with older age, baseline arthrofibrosis, lower baseline pain, and non-Medicare/Medicaid insurance and worsening of the scores was associated with multiple prior surgical procedures and instability. Improvement in the KOOS-PS was associated with baseline arthrofibrosis and female sex and worsening was associated with limited baseline function, an instability diagnosis, multiple prior surgical procedures, and increased hospital length of stay (LOS). Overall, the mean KOOS-QOL improved by 29.7 points. Although the mean VR-12 PCS improved, 54.9% of the patients saw no clinical improvement. Additionally, only 31.3% of the patients reported improvements in the VR-12 MCS. A multilevel mixed-effects model with patients/operations nested within surgeons demonstrated that the differences in the surgeons' results were minimal and explained only ∼1.86%, ∼1.12%, and ∼1.65% of the KOOS-Pain, KOOS-PS, and KOOS-QOL variance that was not explained by other predictors, respectively., Conclusions: Overall, patients undergoing aseptic rTKA had improvements in pain, function, and QOL PROMs at 1 year. Although overall QOL improved, other global-health PROMs remained unchanged. The associations highlighted in this study can help guide the preoperative clinical decision-making process by setting expectations before aseptic rTKA., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Importance: Whether laminar airflow (LAF) in the operating room is effective for decreasing periprosthetic joint infection (PJI) after total joint arthroplasty remains a clinically important yet controversial issue., Objective: To investigate the association between operating room LAF ventilation systems and the risk of PJI in patients undergoing total joint arthroplasty., Design, Setting, and Participants: A retrospective cohort study was conducted of 6972 consecutive patients undergoing primary total knee arthroplasty or total hip arthroplasty at 2 surgical facilities within a single institution from January 1, 2013, to September 15, 2017, with a minimum of 1 year of follow-up. All procedures were performed by 5 board-certified arthroplasty surgeons. Statistical analysis was performed from January 1, 2014, to September 15, 2018., Exposure: Patients underwent total joint arthroplasty in operating rooms equipped with either LAF or turbulent airflow., Main Outcomes and Measures: Patient characteristics were extracted from clinical records. Periprosthetic joint infection was defined according to Musculoskeletal Infection Society criteria within 1 year of the index arthroplasty. A multivariable logistic regression model was performed to explore the potential association between LAF and risk of PJI at 1 year, and then a sensitivity analysis using propensity score matching was performed to further validate the findings., Results: A total of 6972 patients (2797 who underwent total knee arthroplasty and 4175 who underwent total hip arthroplasty; 3690 women [52.9%]; mean [SD] age, 63.9 [10.7] years) were included. The incidence of PJI within 1 year for patients from the facility without LAF was similar to that of patients from the facility with LAF (0.4% [12 of 3027] vs 0.5% [21 of 3945]). In the multivariable logistic regression analysis, after all confounding factors were taken into account, the use of LAF was not associated with a reduction of the risk of PJI (adjusted odds ratio, 0.94; 95% CI, 0.40-2.19; P = .89). After propensity score matching, there was no significant difference in the incidence of PJI within 1 year for patients who underwent total joint arthroplasty at these 2 sites., Conclusions and Relevance: This study suggests that the use of LAF in the operating room was not associated with a reduced incidence of PJI after primary total joint arthroplasty. With an appropriate perioperative protocol for infection prevention, LAF does not seem to play a protective role in PJI prevention.

Primary osteoarthritis (OA) hinders an aging global population as one of the leading causes of years-lost-to-disability (YLD). OA in most patients is considered to be an overuse injury that results in degenerative inflammation of the joints with the associated formation of bony outgrowths. Due to the escalating nature of this chronic pain disease, treatment management for OA can initially begin with a more conservative approach. It can eventually lead to more invasive surgical procedures. At present, the standard of care remains initial conservative management with lifestyle changes, including weight loss with concurrent anti-inflammatory regimens. Injections are frequently used for the escalation of care, but a significant number of patients ultimately resort to total knee arthroplasty. This review will focus specifically on knee OA, providing a brief overview of risk factors and early management and in-depth exploration of the invasive interventions that can offer symptomatic relief and return of function., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2020. Published by Elsevier Ltd.)

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Objective: To evaluate the effect of the surgeon's handedness on the distribution of prosthesis during primary total knee arthroplasty (TKA)., Methods: A retrospective analysis was performed on 86 patients (100 knees) with primary TKA completed by the same right-handed surgeon between December 2016 and December 2018, including 72 cases of single knee and 14 of bilateral knees. The patients were divided into dominant group (right side) and non-dominant group (left side) according to the operating position of the surgeon and each group had 50 knees. There was no significant difference in gender, age, body mass index, disease duration, clinical diagnosis, preoperative Hospital for Special Surgery (HSS) score, and other general data between the two groups ( P >0.05). The operation time and complications were recorded in both groups. The function of knee was evaluated by HSS score. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured by using X-ray film of full-length lower extremity before TKA and at 2 weeks after TKA that were used to evaluate the coronal position of the prosthesis. Posterior distal femoral angle (PDFA) and posterior proximal tibial angle (PPTA) were measured by using lateral X-ray films at 3 months after operation that were used to evaluate the sagittal position of the prosthesis., Results: There was no significant difference in operation time between the two groups ( t =-1.128, P =0.262). One case of posterior tibial artery thrombosis occurred in the dominant group, and 1 case of poor healing of the incision occurred in each of the dominant group and the non-dominant group. Patients in both groups were followed up 12-34 months with an average of 22.0 months. The HSS scores at last follow-up were 87.2±4.3 in the dominant group and 86.8±5.0 in the non-dominant group. There was no significant difference between the two groups ( t =0.471, P =0.639). No complications such as periprosthetic infection, prosthetic loosening, or periprosthetic fracture occurred during follow-up. There was no significant difference in the HKA, mLDFA, and mMPTA between the two groups before and after operation ( P >0.05). The differences in the incidence of sagittal femoral prosthesis malposition and PDFA between the two groups were significant ( P <0.05); however, there was no significant difference in the PPTA, the rate of femoral prosthesis distributed in the neutral position, the incidence of over-flexed femoral prosthesis, and the incidence of anterior femoral notch ( P >0.05)., Conclusion: The surgeon's handedness is one of the factors affecting the placement of the sagittal femoral prosthesis in primary TKA. The incidence of sagittal femoral prosthesis malposition could increase when the surgeon performs on the non-dominant side.

Background: Implant malpositioning, low surgical caseload, and improper patient selection have been identified as essential factors, which could negatively affect the longevity of unicompartmental knee arthroplasty (UKA). The aim of the current study was to evaluate the impact of the surgeon's caseload on patient selection, component positioning, as well as component survivorship and functional outcomes following a PSI-UKA., Methods: A total of 125 patient-specific instrumented (PSI) UKA were included. One hundred and two cases were treated by a high-volume surgeon (usage 40%) and 23 cases by a low-volume surgeon (< 10 cases/year, usage 34%). Preoperative UIS, as well as the postoperative clinical and radiologic outcome, were assessed retrospectively., Results: Irrespective of the surgeon's UKA caseload, PSI allowed good accuracy in component positioning (p > 0.05). The high-volume surgeon had a more strict indication for UKA with 89% showing a UIS > 25 (considered a good indication) compared to 70% for the low-volume surgeon (p = 0.016). The low-volume surgeon achieved worse results regarding functional outcome (p < 0.05) and a tendency toward an increased risk for UKA failure (p = 0.11) compared to the high-volume surgeon., Conclusion: Due to potential selection errors, mostly connected to a low UKA-caseload, low-volume UKA surgeons might achieve worse outcomes. Very strict indications for UKA might be recommended in low-volume surgeons to achieve excellent clinical outcomes following a UKA.

Introduction: The most commonly used tool for implant positioning are conventional instruments (CI) followed by computer-assisted surgery (CAS). A number of studies have investigated the cutting error of the tibial component when CAS is used, but most of them were focused on the cutting angles. The accuracy of CAS to determine the depth of the cut has not received much attention, even though implications are similar or worse, than with an angle mismatch., Materials and Methods: This was an ethics board approved, prospective study of 23 consecutive varus TKAs by a single surgeon. Implant positioning was performed using CAS; however, the depth of the tibial cut was determined with both CAS and CI. Targeted alignment was the mechanical axis and 3° of posterior slope. The planned and the achieved cut, as determined by CAS needed to match. The achieved cut was then measured using a caliper and compared to the depth of the cut as per CAS. Medial and lateral cuts were analyzed separately. Analysis of variance and Bland-Altman plots were used for the comparison., Results: Mean medial navigated cut was 6.3 (± 2.2) mm, mean measured medial cut was 6.6 (± 2.3) mm. Mean lateral navigated cut was 8.9 (± 1.8) mm, mean measured lateral cut was 8.8 (± 1.5) mm. There was a statistical significance for both the medial (p < 0.001) and the lateral (p = 0.004) navigated and measured cuts., Conclusions: The results of this study suggest that the tibial cut depth, measured by the navigation, does not match the actual bony cuts performed, even if a perfect cut was achieved in both sagittal and coronal plane. Surgeons should be aware of the measurement error in the navigation system and potentially add an additional step for verifying the achieved depth of the cut.

Background: Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices., Objectives and Methods: We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery)., Results: A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy., Conclusions: The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs., (Copyright © 2020 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Periprosthetic joint infections (PJIs) are a major source of morbidity and mortality for patients undergoing total joint arthroplasty (TJA). Staphylococcus aureus (S. aureus) colonization is an independent, modifiable risk factor for periprosthetic joint infections. Post-operative infections are reported to be ten times greater in S. aureus carriers than in non-carriers in developed countries though recorded data is lacking for the developing world. This study aims to determine the prevalence of S. aureus colonization in patients awaiting TJA in South Africa., Methods: We prospectively assessed 119 patients awaiting total knee arthroplasty and total hip arthroplasty between May and October 2016. We screened three separate anatomical sites on each patient for S. aureus. Patients with positive cultures were treated with intranasal mupirocin ointment and chlorhexidine body wash. Univariate and comparative statistical analyses to determine risk factors for colonization was conducted using t tests, Fisher's exact tests, and chi-square analyses., Results: The overall prevalence of methicillin-sensitive S. aureus colonization was 31.9% (n = 38). There were no patients colonized with methicillin-resistant S. aureus. Nasal swabs returned a yield of 81.6% (n = 31), with groin swabs and axillary swabs at 39.5% (n = 15) and 28.9% (n = 11), respectively. Eradication was successful in 94.74% (n = 36) after 5 days treatment. All patients (100%) were decolonized after counseling and repeat eradication treatment. The overall complication rate was 7.6% (n = 9). The 30-day readmission rate in the S. aureus-colonized group was 7.9% (n = 3) as opposed to 7.4% (n = 6) in the non-colonized cohort. There were no 60- and 90-day readmissions and no cases were revised at a mean follow-up of 2.26 years., Conclusions: The rate of S. aureus colonization in patients undergoing elective TJA in a developing country was 31.9% and is equivalent to reported rates in developed countries. Eradication treatment with combined intranasal mupirocin ointment and chlorhexidine body wash is a successful treatment modality. A larger cohort of patients is recommended to determine risk factors and post-operative septic sequelae in this population group.

Background: Variation in 1-year revision rates between Dutch hospitals after primary total hip and knee arthroplasty (THA and TKA) may direct quality-improvement initiatives if this variation accurately reflects true hospital differences. The aim of the present study was to assess the extent of variation, both overall and for specific indications, as well as the statistical reliability of ranking hospitals., Methods: All primary THAs and TKAs that were performed between January 2014 and December 2016 were included. Observed/expected (O/E) ratios regarding 1-year revision rates were depicted in a funnel plot with 95% control limits to identify outliers based on 1 or 3 years of data, both overall and by specific indication for revision. The expected number was calculated on the basis of patient mix with use of logistic regression models. The statistical reliability of ranking hospitals (rankability) on these outcomes indicates the percentage of total variation that is explained by "true" hospital differences rather than chance. Rankability was evaluated using fixed and random effects models, for overall revisions and specific indications for revision, including 1 versus 3 years of data., Results: The present study included 86,468 THAs and 73,077 TKAs from 97 and 98 hospitals, respectively. Thirteen hospitals performing THAs were identified as negative outliers (median O/E ratio, 1.9; interquartile range [IQR], 1.5-2.5), with 5 hospitals as outliers in multiple years. Eight negative outliers were identified for periprosthetic joint infection; 4, for dislocation; and 2, for prosthesis loosening. Seven hospitals performing TKAs were identified as negative outliers (median O/E ratio, 2.3; IQR, 2.2-2.8), with 2 hospitals as outliers in multiple years. Two negative outlier hospitals were identified for periprosthetic joint infection and 1 was identified for technical failures. The rankability for overall revisions was 62% (moderate) for THA and 46% (low) for TKA., Conclusions: There was large between-hospital variation in 1-year revision rates after primary THA and TKA. For most outlier hospitals, a specific indication for revision could be identified as contributing to worse performance, particularly for THA; these findings are starting points for quality-improvement initiatives.

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.6 percent differential decrease in average LEJR episode spending with no differential changes in quality, driven by early participants. Patient selection accounted for 27 percent of episode savings. Our findings have important policy implications in view of BPCI Advanced and its two participation waves.

Importance: In 2016, the Centers for Medicare & Medicaid Services introduced mandatory bundled payments for knee and hip replacement surgical procedures among traditional Medicare (TM) patients in randomly selected areas. The association of bundled payments with outcomes among patients enrolled in Medicare Advantage (MA) is not known., Objective: To determine the association of bundled payments for joint replacement surgical procedures with the use of postacute care (PAC) services among MA patients., Design, Setting, and Participants: This cohort study used difference-in-differences analysis to evaluate changes in PAC use among patients enrolled in Medicare who underwent joint replacement operations before and after the introduction of bundled payments (ie, from January 1, 2013, to September 30, 2017). A total of 75 metropolitan statistical areas were randomized to participate in the bundled payment program, with 121 areas serving as controls. Data were analyzed between September 15, 2018, and October 1, 2019., Exposure: Bundled payments for hip and knee joint replacement operations, in which hospitals received a single payment to cover all costs associated with a joint replacement and associated care for the 90 days after surgery., Main Outcomes and Measures: The primary outcomes were discharge to any institutional PAC setting and days spent in institutional PAC within 90 days after surgery. Secondary outcomes included discharge and days spent in specific PAC settings (ie, home health, skilled nursing facility, inpatient rehabilitation)., Results: Of 1 536 387 individuals who underwent hip and knee join replacement surgery, 493 977 (32.2%) were enrolled in MA (mean [SD] age, 73.3 [8.4] years; 386 699 [63.5%] women; 55 078 [6.4%] black) and 1 042 410 (67.8%) were enrolled in TM (mean [SD] age, 73.3 [8.7] years, 829 014 [65.2%] women; 82 890 [9.4%] black). Among MA patients, bundled payments were associated with a reduction of 1.5 (95% CI, 1.0-2.0) percentage points in discharge to an institutional PAC setting (P < .001) and an estimated reduction of 0.3 (95% CI, 0.2-0.5) days spent in an institutional PAC setting (P < .001), a 5.6% relative reduction. Among TM patients, bundled payments were associated with a reduction of 2.6 (95% CI, 2.2-2.9) percentage points in institutional PAC discharge (P < .001) and a reduction of 0.8 (95% CI, 0.7-0.9) days spent in an institutional PAC setting (P < .001), a 2.5% relative reduction. These changes were larger in hospitals with greater proportions of TM patients. In hospitals with low concentrations of MA patients, time spent in institutional PAC settings decreased by 0.9 days among TM patients and 0.8 days among MA patients; in hospitals with high MA concentrations, time spent in institutional PAC settings decreased by 0.6 days for TM patients and 0.2 days for MA patients., Conclusions and Relevance: In this study, the first 18 months of the Centers for Medicare & Medicaid Services bundled payment program for joint replacement surgery were associated with reductions in the use of institutional PAC among MA patients. Past evaluations of bundled payments that focused on TM patients may not have measured the full consequences of this alternative payment model.

The NHS routinely evaluates the quality of life of patients receiving hip or knee replacement surgery using patient-reported outcome measures (PROMs), but some hospital completion rates are only 30%, restricting data usefulness. Statistics limit insights into how and why data are missing, so qualitative methods were used to explore this issue. Observation periods preceded semistructured interviews with 34 preoperative patients attending an orthopedic outpatient clinic. Interview themes covered: completion time/timing, orientation, setting, measures, and practicalities. Triangulated against observations, pragmatic barriers, and facilitators were considered. Refined themes included completion conditions, patient support, and national delivery. Simple improvements (e.g., quiet zone) could improve completion rates and reducing missing data. Reorganizing preoperative leaflets and their systematic distribution via standardized procedures could reassure patients, enhancing PROMs acceptance, while reducing inquiries and subsequent staff burden. Findings have implications for interpreting national statistics. They indicate that further debate about mandating preoperative PROMs is due.

Objective: Primary hip and knee arthroplasties are some of the most frequent surgical procedures in the Spanish Healthcare System. This study was carried out with the aim of identifying the current clinical practices held in the territory for such processes, as well as future trends., Material and Methods: In May 2017 a set of 40 questions regarding the practices, indicators, coordination, concerns and tendencies were sent to 289 Heads of Orthopaedic Services from all over Spain., Results: Responses were received from 141 hospitals. The mean length of stay varied from 2,6 to 12,6days. Mobilization is initiated from the first post-operative hours in 4% of hospitals, until 48h after surgery in 16% of hospitals. There is no unique standard for the use of drains, urinary catheter or fasting time. In addition, different surgical approaches, implant types, analgesia and blood management protocols can coexist within the same hospital. In 87% of cases, there are no formal channel paths for interdisciplinary coordination. Fast-track surgery has been incorporated into the practice of 36% of hospitals, while 66% of hospitals consider that by applying it they could achieve an earlier patient recovery. In 56% of those surveyed, surgeon concerns are focused on infection management and its prevention, which is expected to have a high impact in the future of arthroplasties, together with pain management., Conclusion: The study shows a high variability in practices among centers in processes, clinical protocols and interdisciplinary coordination, which have an effect on results and process indicators., (Copyright © 2019. Publicado por Elsevier España, S.L.U.)

Background: Days alive and out of hospital (DAH) has been proposed as a pragmatic outcome measure of surgical quality. However, there is a lack of procedure specific data or data within an optimised fast-track protocol. Furthermore, information about influence of follow-up duration and types of complications on DAH is limited., Methods: Observational multicentre cohort study of patients undergoing fast-track total hip (THA) and knee arthroplasty (TKA). Prospective information on comorbidity and complete 90 days follow-up was undertaken through the Danish National Patient Register and chart review., Results: For 16 137 procedures, of which 18.6% were high-risk (≥2 preoperative risk factors), the median length of stay was 2 days (inter-quartile range [IQR], 2-3), and 30- and 90-day readmission rates were 5.7% and 8.1%, respectively. Median DAH 30 and DAH 90 days were 27 (26-28) and 87 (85-88) vs 28 (27-28) and 88 (87-89) (P<0.001) in high-vs low-risk patients, respectively. The fraction with DAH ≤25 at 30 days and DAH ≤85 at 90 days was increased in high-vs low-risk patients: 23.3% vs 6.8% (odds ratio [OR]=4.16; 95% confidence interval [CI], 3.73-4.65) and 26.0% vs 8.6% (OR=3.75; 95% CI, 3.38-4.16). There were relatively fewer 'surgical' complications in high- vs low-risk patients with DAH 30 ≤25 (14.6% vs 25.8%) (OR=0.49; 95% CI, 0.37-0.65) and DAH 90 ≤85 (16.9% vs 31.89%) (OR=0.43; 95% CI, 0.34-0.56). About 2% of patients had readmissions, but DAH was >25 and >85 at 30 and 90 days after operation, respectively., Conclusion: Median DAH in fast-track THA/TKA patients is 28 at 30 days and 88 at 90 days after surgery. DAH in high-risk patients was only slightly reduced compared with low-risk patients, but they have relatively more 'medical' complications., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Aims: A retrospective study was conducted to measure short-term in vivo linear and volumetric wear of polyethylene (PE) inserts in 101 total knee arthroplasty (TKA) patients using model-based radiostereometric analysis (MBRSA)., Patients and Methods: Nonweightbearing supine RSA exams were performed postoperatively and at six, 12, and 24 months. Weightbearing standing RSA exams were performed on select patients at 12 and 24 months. Wear was measured both linearly (joint space) and volumetrically (digital model overlap) at each available follow-up. Precision of both methods was assessed by comparing double RSA exams. Patient age, sex, body mass index, and Oxford Knee Scores were analyzed for any association with PE wear., Results: Linear wear occurred at 0.015 mm/year (supine) and 0.220 mm/year (standing). Volumetric wear occurred at 10.3 mm 3 /year (supine) and 39.3 mm 3 /year (standing). Wear occurred primarily on the medial side of the joint. Weightbearing imaging greatly improved the reliability of measurement. Clinical precision of volumetric wear was 34 mm 3 . No significant associations were found between patient demographics or function scores and measured wear., Conclusion: In vivo volumetric wear of TKAs can be assessed at short-term follow-up using MBRSA. Cite this article: Bone Joint J 2019;101-B:1348-1355.

Venous thromboembolism (VTE) is a leading cause of mortality during the perioperative period, with individuals who have undergone hip and knee arthroplasty at the highest risk for VTE. The American College of Chest Physicians recommends 35 days of postoperative thromboprophylaxis and the use of intermittent pneumatic compression (IPC) therapy for mechanical compression after major orthopedic surgery. However, little research has described adherence to these recommendations during recovery at home. The purpose of this cross-sectional descriptive study was to describe thromboprophylaxis prescription, use, and education among patients discharged home after major orthopedic surgery. We surveyed patients within 2 years of major orthopedic surgery. A total of 388 subjects completed the survey. More than three-quarters of respondents reported a thromboprophylaxis duration <35 days. Most (93.8%) respondents were prescribed a pharmacologic agent, while 55.9% were prescribed mechanical compression therapy. Of the respondents who were prescribed mechanical compression therapy, 13.4% were prescribed IPC. Adherence to mechanical compression therapy was moderate, with 63% of respondents wearing mechanical compression therapy ≥75% of the time. The results of this study suggest a need for increased duration of thromboprophylaxis and increased use of IPC in the outpatient setting. Additional research describing prescribers' perceptions of thromboprophylaxis is also needed.

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties., Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported., Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95)., Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Aims: Knee osteonecrosis in advanced stages may lead to joint degeneration. Total knee arthroplasty (TKA) for osteonecrosis has traditionally been associated with suboptimal results. We analyzed outcomes of contemporary TKAs for osteonecrosis, with particular emphasis on: survivorship free from aseptic loosening, any revision, and any reoperation plus the clinical outcomes, complications, and radiological results., Patients and Methods: In total, 156 patients undergoing 167 primary TKAs performed for osteonecrosis between 2004 and 2014 at a single institution were reviewed. The mean age at index TKA was 61 years (14 to 93) and the mean body mass index (BMI) was 30 kg/m 2 (18 to 51) The mean follow-up was six years (2 to 12). A total of 110 TKAs (66%) were performed for primary osteonecrosis and 57 TKAs (34%) for secondary osteonecrosis. Overall, 15 TKAs (9%) had tibial stems, while 12 TKAs (7%) had femoral stems. Posterior-stabilized designs were used in 147 TKAs (88%) of TKAs. Bivariate Cox regression analysis was conducted to identify risk factors for revision and reoperation., Results: Survivorship free from aseptic loosening, any revision, and any reoperation at ten years was 97% (95% confidence interval (CI) 93 to 100), 93% (95% CI 85 to 100), and 82% (95% CI 69 to 93), respectively. No factors, including age, sex, BMI, primary versus secondary osteonecrosis, stem utilization, and constraint, were identified as risk factors for reoperation. Four TKAs (2%) underwent revision, most commonly for tibial aseptic loosening (n = 2). Excluding revisions and reoperations, there was a total of 11 complications (7%), with the most common being a manipulation under anaesthesia (six TKAs, 4%). Mean Knee Society Scores (Knee component) significantly improved from 57 (32 to 87) preoperatively to 91 (49 to 100) postoperatively (p < 0.001). No unrevised TKAs had complete radiolucent lines or radiological evidence of loosening., Conclusion: Contemporary cemented TKAs with selective stem utilization for osteonecrosis resulted in durable survivorship, a low complication rate, and reliable improvement in clinical outcomes. Cite this article: Bone Joint J 2019;101-B:1356-1361.

Background: The main purpose of health service systems is to improve patients' quality of life (QoL) and to ensure equitable access to health services. However, in reality, nearly half of knee osteoarthritis (OA) patients present to the health system do not have access to health services, and their QoL remains poor. These circumstances raise important questions about what (if any) factors can improve health care accessibility and QoL for knee OA patients., Methods: A multicenter, cross-sectional survey was performed with 618 knee OA patients who received care at 16 hospitals in Thailand. Structural equation modeling (SEM) was conducted to investigate the association of health service factors and patient factors with access to health services and QoL., Results: The QoL of knee OA patients was very poor (mean score = 33.8). Only 2.1% of the knee OA patients found it easy to obtain medical care when needed. Approximately 39.4% of them were able to access appropriate interventions before being referred for knee replacement. More than 85% of orthopedic health services had implemented chronic disease management (CDM) policy into practice. However, the implementation was basic, with an average score of 5.9. SEM showed that QoL was determined by both health system factors (β = .10, p = .01) and patient factors (β = .29, p = .00 for self-management and β = -.49, p = .00 for disease factors). Access to health services was determined by self-management (β = .10, p = .01), but it was not significantly associated with QoL (β = .00, p = 1.0)., Conclusions: This study provides compelling information about self-management, access to health services and QoL from the individual and health service system perspectives. Furthermore, it identifies a need to develop health services that are better attuned to the patient's background, such as socioeconomic status, disease severity, and self-management skills.

Background: Implant malalignment may predispose patients to prosthetic failure following total knee arthroplasty (TKA). A more thorough understanding of the surgeon-specific factors that contribute to implant malalignment following TKA may uncover actionable strategies for improving implant survival. The purpose of this study was to determine the impact of surgeon volume and training status on malalignment., Methods: In this retrospective multicenter study, we performed a radiographic analysis of 1,570 primary TKAs performed at 4 private academic and state-funded centers in the U.S. and U.K. Surgeons were categorized as high-volume (≥50 TKAs/year) or low-volume (<50 TKAs/year), and as a trainee (fellow/resident under the supervision of an attending surgeon) or a non-trainee (attending surgeon). On the basis of these designations, 3 groups were defined: high-volume non-trainee, low-volume non-trainee, and trainee. The postoperative medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured. Outlier measurements were defined as follows: DFA, outside of 5° ± 3° of valgus; PTA, >±3° deviation from the neutral axis; and PSA, <0° or >7° of flexion for cruciate-retaining or <0° or >5° of flexion for posterior-stabilized TKAs. "Far outliers" were defined as measurements falling >± 2° outside of these ranges. The proportions of outliers were compared between the groups using univariate and multivariate analyses., Results: When comparing the high and low-volume non-trainee groups using univariate analysis, the proportions of knees with outlier measurements for the PTA (5.3% versus 17.4%) and PSA (17.4% versus 28.3%) and the proportion of total outliers (11.8% versus 20.7%) were significantly lower in the high-volume group (all p < 0.001). The proportions of DFA (1.9% versus 6.5%), PTA (1.8% versus 5.7%), PSA (5.5% versus 12.6%), and total far outliers (3.1% versus 8.3%) were also significantly lower in the high-volume non-trainee group (all p < 0.001). Compared with the trainee group, the high-volume non-trainee group had significantly lower proportions of DFA (12.6% versus 21.6%), PTA (5.3% versus 12.0%), PSA (17.4% versus 33.3%), and total outliers (11.8% versus 22.3%) (all p < 0.001) as well as DFA (1.9% versus 3.9%; p = 0.027), PSA (5.5% versus 12.6%; p < 0.001), and total far outliers (3.1% versus 6.4%; p = 0.004). No significant differences were identified when comparing the low-volume non-trainee group and the trainee group, with the exception of PTA outliers (17.4% versus 12.0%; p = 0.041) and PTA far outliers (5.7% versus 2.6%; p = 0.033). Findings from multivariate analysis accounting for the effects of patient age, body mass index, and individual surgeon demonstrated similar results., Conclusions: Low surgical volume and trainee status were risk factors for outlier and far-outlier malalignment in primary TKA, even when accounting for differences in individual surgeon and patient characteristics. Trainee surgeons performed similarly, and certainly not inferiorly, to low-volume non-trainee surgeons. Even among high-volume non-trainees, the best-performing cohort in our study, the proportion of TKA alignment outliers was still high., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Fast-track and outpatient arthroplasty methodologies combine evidence-based clinical features with organizational optimization resulting in a streamlined pathway from admission to discharge and beyond. This qualitative study explored perceived problems of healthcare professionals during fast-track hip and knee arthroplasty., Methods: Semi-structured interviews were conducted with four surgeons, two anesthesiologists, ten nurses, and four physiotherapists. An inductive content analysis was used to analyze the data. NVivo qualitative data analysis software was used., Results: Analysis of the data revealed eight main categories of problems: patient selection, referrals, meeting the Health Care Guarantee, patient flow, homecare, patient counseling, transparency of the journey, and receiving feedback. In addition, problems related to information flows and communication, responsibilities between different stakeholders, and existing information systems were identified., Conclusions: The study revealed that healthcare professionals perceived several problems during the fast-track journey that reduce its effectiveness and make it more difficult to meet the Health Care Guarantee. Problems could be alleviated by changing internal and external organizational practices, as well as by developing new information and communication technologies that would provide up-to-date communication channels for healthcare professionals and patients. In addition, new collaboration mechanisms should be developed in order to solve the problems that occur across different organizations.

Purpose: The Osteoarthritis Research Society International has identified a core set of performance-based tests of physical function for use in people with knee osteoarthritis (OA). The core set consists of the 30-second chair stand test (30-s CST), 4 × 10 m fast-paced walk test (40 m FPWT) and a stair climb test. The aim of this study was to evaluate the reliability, validity and responsiveness of these performance-based measures to assess the ability to measure physical function in knee OA patients., Methods: A prospective cohort study of 85 knee OA patients indicated for total knee arthroplasty (TKA) was performed. Construct validity and responsiveness were assessed by testing of predefined hypotheses. A subgroup (n = 30) underwent test-retest measurements for reliability analysis. The Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form, pain during activity score and knee extensor strength were used as comparator instruments. Measurements were obtained at baseline and 12 months after TKA., Results: Appropriate test-retest reliability was found for all three tests. Intraclass correlation coefficient (ICC) for the 30-s CST was 0.90 (95% CI 0.68; 0.96), 40 m FPWT 0.93 (0.85; 0.96) and for the 10-step stair climb test (10-step SCT) 0.94 (0.89; 0.97). Adequate construct validity could not be confirmed for the three tests. For the 30-s CST, 42% of the predefined hypotheses were confirmed; for the 40 m FPWT, 27% and for the 10-step SCT 36% were confirmed. The 40 m FPWT was found to be responsive with 75% of predefined hypothesis confirmed, whereas the responsiveness for the other tests could not be confirmed. For the 30 s CST and 10-step SCT, only 50% of hypotheses were confirmed., Conclusions: The three performance-based tests had good reliability, but poor construct validity and responsiveness in the assessment of function for the domains sit-to-stand movement, walking short distances and stair negotiation. The findings of the present study do not justify their use for clinical practice., Level of Evidence: Level 1. Diagnostic study.

Background: Residents' and fellows' participation in orthopedic surgery is a potential source of anxiety and concern for patients. The purpose of this study was to determine patients' attitudes toward trainee involvement in orthopedic surgery, surgeons as educators, and disclosure of trainee involvement., Methods: Three hundred two consecutive patients with preoperative and postoperative appointments at three arthroplasty practices in academic medical centers were surveyed with an anonymous, self-administered questionnaire. The questionnaire was developed in consultation with an expert in survey design., Results: Two hundred thirty-four patients completed the questionnaire (response rate 77.5%). Respondents were 60.5% female, 79.6% white, 66.5% privately insured, and 82.8% had at least some college education. About 65.9% of the respondents felt that surgeons who teach are better surgeons. Nearly all felt residents and fellows should perform surgeries as part of their education (94.1% and 95.3%, respectively). However, 39.7% of the respondents were not satisfactory with a second-year resident assisting in their own surgery. Patients dissatisfied with their most recent orthopedic surgery were more likely to respond that they did not want residents helping with their surgery. Respondents agreed that resident or fellow involvement in surgery should be disclosed (92.2% and 90.1%, respectively)., Conclusions: Insured and educated patients in the United States overwhelmingly desire disclosure of trainee involvement in their surgery. To address the need for orthopedic training in the context of a patient population that is not fully comfortable with trainee involvement in their own surgery, an open discussion between patients and surgeons regarding trainees' roles may be the best course of action., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Revision total knee arthroplasty (rTKA) is a demanding procedure, with a high complication and failure rate and a high rate of bone losses and poor bone quality. Different classifications for bone losses have been proposed, but they do not consider bone quality, which may affect implant fixation. The aim of this study is to describe the outcomes of a consecutive series of rTKA. Furthermore, a modified bone loss classification will be proposed based also on bone quality. Finally, the association between radiolucent line (RLL) development and different risk factors will be evaluated., Methods: All the patients who underwent rTKA between 2008 and 2016 in the same institution were included. rTKAs were performed by the same surgeon according to the three-step technique. Bone losses were classified according to the proposed classification, including bone quality evaluation. The Knee Scoring System (KSS), the Hospital for Special Surgery Knee Score (HSS), and the SF-12 were used for the clinical evaluation. Radiological evaluation was performed according to the Knee Society Roentgenographic Evaluation System. Different possible risk factors (i.e., gender, age, amount of bone losses) associated to RLL development were identified, and this association was evaluated using logistic regression., Results: Fifty-one patients (53 knees) were included (60.8% female, average age 71.5 years). The average follow-up was 56.6 months (range 24-182). The most frequent cause of failure was aseptic loosening (41.5%). 18.9% of the cases demonstrated poor bone quality. Bone losses were treated according to the proposed algorithm. In all the cases, there was a significant improvement in all the scores (P < 0.05). The average post-operative range of motion was 110.5° (SD 10.7). At the radiological evaluation, all the implants resulted well aligned, with 15.1% of non-progressive RLL. There were 2 failures, with a cumulative survivorship of 92.1% at the last follow-up (SD 5.3%). At the logistic regression, none of the evaluated variables resulted associated to RLL development., Conclusion: rTKA is a demanding procedure, and adequate treatment of bone losses is mandatory to achieve good results. However, also bone quality should be taken into consideration when approaching bone losses, and the proposed classification may need surgeons after an adequate validation., Level of Evidence: Level IV.

Aims: There has been a recent resurgence in interest in combined partial knee arthroplasty (PKA) as an alternative to total knee arthroplasty (TKA). The varied terminology used to describe these procedures leads to confusion and ambiguity in communication between surgeons, allied health professionals, and patients. A standardized classification system is required for patient safety, accurate clinical record-keeping, clear communication, correct coding for appropriate remuneration, and joint registry data collection., Materials and Methods: An advanced PubMed search was conducted, using medical subject headings (MeSH) to identify terms and abbreviations used to describe knee arthroplasty procedures. The search related to TKA, unicompartmental (UKA), patellofemoral (PFA), and combined PKA procedures. Surveys were conducted of orthopaedic surgeons, trainees, and biomechanical engineers, who were asked which of the descriptive terms and abbreviations identified from the literature search they found most intuitive and appropriate to describe each procedure. The results were used to determine a popular consensus., Results: Survey participants preferred "bi-unicondylar arthroplasty" (Bi-UKA) to describe ipsilateral medial and lateral unicompartmental arthroplasty; "medial bi-compartmental arthroplasty" (BCA-M) to describe ipsilateral medial unicompartmental arthroplasty with patellofemoral arthroplasty; "lateral bi-compartmental arthroplasty" (BCA-L) to describe ipsilateral lateral unicompartmental arthroplasty with patellofemoral arthroplasty; and tri-compartmental arthroplasty (TCA) to describe ipsilateral patellofemoral and medial and lateral unicompartmental arthroplasties. "Combined partial knee arthroplasty" (CPKA) was the favoured umbrella term., Conclusion: We recommend bi-unicondylar arthroplasty (Bi-UKA), medial bicompartmental arthroplasty (BCA-M), lateral bicompartmental arthroplasty (BCA-L), and tricompartmental arthroplasty (TCA) as the preferred terms to classify CPKA procedures. Cite this article: Bone Joint J 2019;101-B:922-928.

Background: The accelerometer-based navigation (ABN) system is an emerging navigation system for total knee arthroplasty (TKA). This study aimed to determine whether the ABN system could improve the accuracy of mechanical alignment, component positioning, and short-term clinical outcomes for TKA when compared to conventional instruments (CON)., Methods: A total of 204 patients were selected and divided into two groups (CON: 135, ABN: 69) after applying the inclusion and exclusion criteria. Then, 1:1 propensity score matching was performed for age, gender, body mass index, hip-knee-ankle angle (HKA), Knee Society Score (KSS), Western Ontario and McMaster Universities (WOMAC) score, and follow-up times. A total of 82 consecutive patients (82 knees) underwent total knee arthroplasty using ABN (n = 41) or CON (n = 41) were enrolled in this study. The postoperative HKA, frontal femoral component (FFC) angle, frontal tibial component (FTC) angle, lateral femoral flexion (LFF) angle, and lateral tibial component (LTC) angle were compared between the two groups to evaluate mechanical alignment and component positioning. Additional clinical parameters, including haemoglobin reduction, the KSS, and the WOMAC score, were assessed at the final follow-up (the mean follow-up period was 20.9 months in the CON group and 21.2 months in the ABN group)., Results: The ABN group had a significantly improved mean absolute deviation of HKA (P = 0.033), FFC (P = 0.004), FTC (P = 0.017), LFF (P = 0.023), and LTC (P = 0.031) compared to those of the CON group. The numbers of FFCs and LTCs within 3° were significantly different (P = 0.021, P = 0.023, respectively) between the two groups. However, no differences in the numbers of FTCs within 3° (P = 0.166) and LFF within 3° (P = 0.556) were found. The ABN group had a significantly higher KS function score (P = 0.032), and the pain and stiffness scores were significantly different (P = 0.034, P = 0.020, respectively) between the two groups. Moreover, the ABN system could reduce hidden blood loss postoperatively. However, no difference was found in the KS knee score and the total WOMAC score between the two groups., Conclusion: This study demonstrates that ABN system improved TKA mechanical alignment and component positioning and decreased the hidden blood loss postoperatively compared to conventional instruments. However, no significant differences were found in short-term clinical outcomes between ABN and conventional instruments at the final follow-up. However, whether this system contributes to revision rates and long-term clinical outcomes requires further study.

Elements of a successful comprehensive joint replacement program include preoperative education, joint class or camps, office support, and follow-up staff and systems. To meet the demand for consistent and safe outpatient joint replacement discharges, these elements must be optimized and, in many cases, enhanced beyond standard procedures. The office and staff protocols that support the outpatient joint replacement patient before and after surgery are as important as the surgery itself. There are unique consequences, or "ripple effects", of speeding patient recovery after joint replacement surgery and proceeding to early discharges. By understanding these differences and by being proactive, rather than reactive, the enhanced protocols can provide a safe and successful outpatient experience., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Total knee replacement patients have shown reductions in knee flexion range of motion, knee extensor moments, and gait speed during stair ascent and stair descent. However, it is unknown how patients dissatisfied with their total knee replacement differ from those who are satisfied during more difficult activities such as stair negotiation. Therefore, the purpose of this study was to compare knee biomechanics of patients who are dissatisfied with their joint replacement to those who are satisfied and healthy participants during stair negotiation., Methods: Nine dissatisfied, fifteen satisfied patients and fifteen healthy participants participated, completing stair ascent and descent trials on an instrumented staircase. A 2 × 3 ANOVA was used to analyze biomechanical differences between groups and limbs during both activities., Findings: The dissatisfied group showed reduced 2nd peak vertical GRF (P ≤ 0.0040) and loading-response knee extension moments (P ≤ 0.0041) in their operated limb compared to their non-operated limb and to satisfied and healthy groups during stair ascent. First peak vertical GRF (P < 0.0088) and both loading-response (P < 0.0117) and push-off abduction moments (P < 0.0028) showed reduced values in operated limbs compared to non-operated limbs for all groups. During stair descent, the dissatisfied group showed reduced loading-response and push-off knee extension moments (P ≤ 0.006) in their operated limb compared to their non-operated limb and the healthy group. The loading-response knee extension (P < 0.0379) and abduction moments (P ≤ 0.0048) were also reduced in the dissatisfied group compared to the satisfied group., Interpretation: Patients who were dissatisfied showed asymmetrical loading of the knees in conjunction, which may have contributed to their dissatisfaction., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA., Methods: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables., Results: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient)., Conclusion: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention., (Copyright © 2019 Elsevier Inc. All rights reserved.)