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Background: The Articular Surface Replacement™ (ASR™) metal-on-metal hip arthroplasty system (DePuy Orthopaedics, Inc, Warsaw, IN, USA) reportedly has a higher than anticipated early failure rate leading to a voluntary recall. This prompted us to evaluate all ASR™ components implanted at our center.Questions/purposes: In all ASR™ components, we reported (1) revision rate, (2) blood metal ion levels, and (3) intraoperative findings for revisions related to adverse reaction to metal debris (ARMD).Methods: We retrospectively reviewed all 172 patients (190 hips) who underwent THA (149 hips) or hip resurfacing (41 hips) with the ASR™ system. We determined failure rates. We obtained blood metal ion concentrations from 93 patients at last followup. We evaluated MRI studies and intraoperative histopathology. Minimum followup was 12 months (mean, 40 months; range, 12-74 months).Results: At latest followup, we had revised 24 of 190 hips (13%): in 18 patients with THA and five patients with resurfacing. Mean time to revision was 45 months (range, 12-75 months). Mean blood concentrations were 13 μg/L (range, 0-150 μg/L) for cobalt and 6 μg/L (range, 0-87 μg/L) for chromium. Mean prerevision blood metal ion levels were higher in the revised group (cobalt: 48 μg/L; chromium: 18 μg/L) than in the nonrevised group (cobalt: 5 μg/L; chromium: 2 μg/L). ARMD was present in 14 of the 24 hips revised in this study.Conclusions: Surgeons must have a low threshold for concern for ARMD in patients with ASR™ systems. Blood metal ion levels and MRI can be used to evaluate patients with underperforming implants. Intraoperative histopathologic analysis and joint fluid cytology can help diagnose ARMD at the time of revision.Level Of Evidence: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The best method for managing large bone defects during revision knee arthroplasty is unknown. Metaphyseal fixation using porous tantalum cones has been proposed for severe bone loss. Whether this approach achieves osseointegration with low complication rates is unclear.Questions/purposes: We therefore asked: (1) What is the risk of infection in revision knee arthroplasty with large bone defects reconstructed with porous tantalum cones? (2) What is the rate of osseointegration with these cones? (3) What is the rate of loosening and reoperation? (4) Is knee function restored?Methods: We retrospectively reviewed 27 patients who had 33 tantalum cones (nine femoral, 24 tibial) implanted during 27 revision knee arthroplasties. There were 14 women and 13 men with a mean age of 64.6 years. Preoperative diagnosis was reimplantation for infection in 13 knees, aseptic loosening in 10, and wear-osteolysis in four. Patients were evaluated clinically and radiographically using the score systems of the Knee Society and followed for a minimum of 2 years (mean, 3.3 years; range, 2-5.7 years).Results: One knee with two cones was removed for infection. All but one cone showed osseointegration. One knee was revised for femoral cone and component loosening. There was one reoperation for femoral shaft fracture and one for superficial dehiscence. The mean Knee Society pain score improved from 40 points preoperatively to 79 points postoperatively. The mean function score improved from 19 points to 47 points.Conclusions: Our observations suggest metaphyseal fixation with tantalum cones can be achieved. Longer-term followup is required to determine whether the fixation is durable. [ABSTRACT FROM AUTHOR]

Changes in progenitor cell biology remain at the forefront of many theories of biologic aging, but there are limited studies evaluating this in humans. Aging has been associated with a progressive depletion of circulating progenitor cells, but age-related bone marrow-resident progenitor cell depletion has not been systematically determined in humans. Patients undergoing total hip replacement were consented, and bone marrow and peripheral progenitor cells were enumerated based on aldehyde dehydrogenase activity and CD34 and CD133 expression. Circulating progenitors demonstrated an age-dependent decline. In contrast, marrow-resident progenitor cell content demonstrated no age association with any progenitor cell subtype. In humans, aging is associated with depletion of circulating, but not marrow-resident, progenitors. This finding has impact on the mechanism(s) responsible for age-related changes in circulating stem cells and important implications for the use of autologous marrow for the treatment of age-related diseases. [ABSTRACT FROM AUTHOR]

Background: Bone ingrowth into a cementless prosthesis can be achieved by both porous and hydroxyapatite coatings. The purpose of this study was to compare the performance of a hydroxyapatite-coated proximal sleeve and a porous bead-coated sleeve in patients managed with a modular revision hip system.Methods: Between August 1992 and December 1996, fifty-three consecutive femoral revisions performed with an S-ROM stem in fifty-two patients were prospectively randomized at the time of surgery to either a hydroxyapatite-coated or a porous-coated sleeve. All patients were evaluated clinically and radiographically at three months, six months, and yearly for a minimum of two years (average, four years; range, two to 7.5 years). Femoral defects were classified according to the criteria of Paprosky et al. Six patients died and four patients were lost to follow-up, leaving forty-two patients (forty-three hips) as the final study group.Results: For the entire group, two femoral stems, one of which had been implanted in a hip with a Paprosky type-II femoral defect and the other in a hip with a Paprosky type-IIIB femoral defect, required a repeat revision, one for pain and the other for aseptic loosening. Radiographic evidence of bone ingrowth was observed in 96% (twenty-six) of the twenty-seven femora with type-I or II defects and in 81% (thirteen) of the sixteen femora with type-III defects. Femoral component survival, with use of revision as the end point, was 95% at four years for the entire group. The Harris hip scores were not significantly different when stratified by implant type, but were significantly different when stratified by bone loss (p < 0.05). In the femora with type-I or II defects, no difference was detected between those treated with a hydroxyapatite-coated implant and those that received a porous-coated implant with respect to bone ingrowth. However, in femora with type-III defects, the likelihood of the development of bone ingrowth was 2.6 (95% confidence interval, 1.3 to 5.17) times greater in hips that received a hydroxyapatite-coated implant (all eight developed ingrowth) than in hips that had a porous-coated implant (five of eight developed ingrowth) (p = 0.05).Conclusions: Bone fixation was achieved more often with hydroxyapatite-coated sleeves in femora with Paprosky type-III defects, but no significant difference was noted in outcomes between the two implant types when used in bone with type-I or type-II femoral defects. Overall, the S-ROM modular hip stem performed better in femora with type-I or II bone defects than in femora with type-III defects.Level Of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The clinical impact of the surgical approach in total hip arthroplasty (THA) has been widely reviewed. This study evaluated the total encounter and 90-day costs of THA for 2 surgical approaches (posterior [P] and direct anterior [DA]) in 1 tertiary health system., Methods: This is a retrospective review of 2,101 THAs (1,092 P and 1,009 DA) by 4 surgeons (2 with the highest volume of DA and P, respectively) from 2017 to 2022 at 1 academic center. Demographics, comorbidities, operative time, length of hospital stay, 90-day hospital returns, and complications were compared. The total encounter cost and 90-day postoperative cost were itemized. Multivariable regression analyses evaluated associations with increased cost at each time point., Results: The DA cohort had a higher median encounter cost ($8,348.66 versus 7,332.42, P < .01), resulting from higher intraoperative (P < .01) and radiology (P < .01) expenses. Regression analyses demonstrated the DA was independently associated with increased encounter costs (odds ratio 1.1; 95% confidence interval 1.1 to 1.1; P < .01). There was a higher incidence of 90-day emergency department visits in the DA cohort (16 versus 12%, P = .02), with a trend toward increased readmissions. There was no difference in 90-day reoperations. Median 90-day cost was higher in the DA cohort ($126.99 versus 0.00, P < .01), and regression analyses demonstrated the DA had an association with increased 90-day cost (odds ratio 2.2; 95% confidence interval 1.5 to 3.0; P < .01)., Conclusions: Despite a younger patient population, the DA was independently associated with increased encounter and 90-day costs in a single academic hospital system. This study may underestimate the cost difference, as capital costs such as specialized tables were not analyzed., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This retrospective study investigated the impact of continuing vs discontinuing home oral hypoglycemic medications for patients with diabetes undergoing total hip arthroplasty., Materials and Methods: Patients who were not exclusively receiving home oral hypoglycemic regimens were excluded. Additionally, patients whose diabetes was not managed inpatient postoperatively were excluded. Included patients were retrospectively evaluated for early postoperative glycemic control, renal function, and metabolic abnormalities. Patients were then compared based on whether their home oral hypoglycemic regimen was continued vs discontinued in favor of initiating insulin while inpatient and analyzed using multivariable regression analysis., Results: A total of 532 patients undergoing total hip arthroplasty met inclusion criteria, with 78.6% continuing their home oral hypoglycemic regimen. Those who continued showed significantly lower median maximum inpatient blood glucose (178.5 mg/dL vs 249.5 mg/dL; P <.001) and median average inpatient blood glucose (138.4 mg/dL vs 178.6 mg/dL; P <.001). Linear regression analysis, adjusting for various potential confounding factors, revealed a positive correlation between discontinuation of home hypoglycemic medications and higher maximum in-patient blood glucose (β=70.15 [95% CI, 59.27-81.03]; P <.001). Patients in the continuation group had lower proportions of acute kidney injury (18.7% vs 41.2%; P <.001) and metabolic acidosis (4.3% vs 17.5%; P <.001), along with a shorter length of stay (1.0 vs 2.0 days; P <.001)., Conclusion: These findings suggest that continuing a home oral hypoglycemic regimen for patients with diabetes after total hip arthroplasty is associated with superior glycemic control without exacerbating renal abnormalities or increasing metabolic complications. [ Orthopedics . 2024;47(5):276-282.].

Background: Increasing deformity of the lower extremities, as measured by the hip-knee-ankle angle (HKAA), is associated with poor patient outcomes after total hip and knee arthroplasty (THA, TKA). Automated calculation of HKAA is imperative to reduce the burden on orthopaedic surgeons. We proposed a detection-based deep learning (DL) model to calculate HKAA in THA and TKA patients and assessed the agreement between DL-derived HKAAs and manual measurement., Methods: We retrospectively identified 1,379 long-leg radiographs (LLRs) from patients scheduled for THA or TKA within an academic medical center. There were 1,221 LLRs used to develop the model (randomly split into 70% training, 20% validation, and 10% held-out test sets); 158 LLRs were considered "difficult," as the femoral head was difficult to distinguish from surrounding tissue. There were 2 raters who annotated the HKAA of both lower extremities, and inter-rater reliability was calculated to compare the DL-derived HKAAs with manual measurement within the test set., Results: The DL model achieved a mean average precision of 0.985 on the test set. The average HKAA of the operative leg was 173.05 ± 4.54°; the nonoperative leg was 175.55 ± 3.56°. The inter-rater reliability between manual and DL-derived HKAA measurements on the operative leg and nonoperative leg indicated excellent reliability (intraclass correlation (2,k) = 0.987 [0.96, 0.99], intraclass correlation (2, k) = 0.987 [0.98, 0.99, respectively]). The standard error of measurement for the DL-derived HKAA for the operative and nonoperative legs was 0.515° and 0.403°, respectively., Conclusions: A detection-based DL algorithm can calculate the HKAA in LLRs and is comparable to that calculated by manual measurement. The algorithm can detect the bilateral femoral head, knee, and ankle joints with high precision, even in patients where the femoral head is difficult to visualize., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients., Methods: This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed., Results: Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients., Conclusions: Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Renal transplant (RT) patients are at increased risk for complications after total knee arthroplasty (TKA); however, it is unknown if the time from RT to TKA influences such risks. This study evaluated RT patients undergoing primary TKA at various time intervals after transplant. We hypothesized that increased time between RT and TKA would decrease the risk of complications after TKA., Methods: There were 499 RT patients in a national database undergoing subsequent primary TKA from 2010 to 2020. Patients were stratified by intervals of less than 1 year, between 1 and 2 years, and more than 2 years from RT to TKA. Medical complications up to 90 days, readmissions, and 2-year revisions were compared via univariable and multivariable analyses., Results: Patients who underwent TKA less than 1 year after RT were associated with higher 90-day medical complications when compared to those who underwent TKA 1 to 2 years after RT (odds ratio [OR] 0.4, confidence interval [CI] 0.2 to 0.8, P = .01) and more than 2 years (OR 0.3, CI 0.2 to 0.7, P < .01) after RT. Acute kidney injury and blood transfusion were the most common complications. The TKAs performed 2 years after RT were less likely to have 90-day readmissions when compared to TKAs performed less than 1 year after RT (OR 0.4, CI: 0.2 to 0.9, P < .01). However, time from RT to TKA did not increase the risk of revision at 2 years (P > .30)., Conclusions: Patients undergoing TKA within 1 year of RT have an increased risk of 90-day postoperative medical complications and readmissions, but the time interval from RT does not appear to affect revision risk. These findings suggest waiting 1 year after RT before proceeding with TKA may be advantageous., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities., Methods: Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations., Results: A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications., Conclusions: Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis., Level Iii Evidence: Retrospective Cohort Study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes., Methods: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov., Results: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points., Conclusions: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted., Level of Evidence: Level 1, RCT., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Valgus knee deformity is observed in nearly 10% of patients undergoing total knee arthroplasty (TKA). The degree of polyethylene constraint required to balance a valgus knee remains controversial, and historically, posterior-stabilized (PS) designs have been favored. This study evaluated the survivorship of TKA done in valgus knees based on implant design and specifically compared posterior-stabilized (PS) and ultracongruent (UC) liners., Methods: A total of 549 primary TKAs performed on valgus knees by fellowship-trained arthroplasty surgeons from 2013 to 2019 were reviewed. Demographics, comorbidities, degrees of preoperative deformity, implants used, and all-cause revisions until final follow-up were recorded. Cox regression analyses evaluated survival to all-cause revision in each cohort. The mean follow-up was 4.9 years (range, 2 to 9)., Results: There were 403 UC liners compared to 146 PS liners. There was no difference in patient age (68 versus 67 years; P = .30), body mass index (30.9 versus 30.4; P = .36), or degree of deformity (8.6 versus 8.8 degrees; P = .75) between the cohorts. At final follow-up, there were 5 revisions in the PS cohort (3.4%) versus 11 revisions in the UC cohort (2.7%) (P = .90). The most common reason for revision in both cohorts was periprosthetic joint infection (4 PS; 8 UC). Multivariable regression analyses controlling for age, body mass index, Elixhauser comorbidity score, sex, and degree of deformity demonstrated UC polyethylene liners were not associated with revision (hazard ratio 0.76; 95% confidence interval [CI] 0.26 to 2.21; P = .62). There was no difference in eight-year survivorship to all-cause revision, including aseptic and septic failure., Conclusions: Alternative polyethylene liners from the historically utilized PS liners for TKA for valgus deformity did not reduce survivorship. With modern polyethylene designs, UC inserts can be utilized for this deformity without increasing the risk of failure., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting., Methods: A single tertiary academic center's institutional database was reviewed for patients who underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least 1 year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures, emergency department visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria., Results: Patients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (P < 0.001), Elixhauser comorbidity index (P < 0.001), proportion of patients who had an American Society of Anesthesiologists classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0.422) scores as well as similar rates of achieving minimum clinically important difference for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of emergency department visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years CONCLUSIONS: Although ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Tobacco use is a well-documented modifiable risk factor for perioperative complications., Aim: To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty (TJA) procedure., Methods: A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery. Eligible patients were contacted via phone survey to understand their tobacco use pattern, and patient reported outcomes. A total of 37 TJA patients participated., Results: Our cohort was on average 61-years-old, 60% ( n = 22) women, with an average body mass index of 30 kg/m 2 . The average follow-up time was 2.9 ± 1.9 years. A total of 73.0% ( n = 27) of patients endorsed complete abstinence from tobacco use prior to surgery. Various cessation methods were used perioperatively including prescription therapy (13.5%), over the counter nicotine replacement (18.9%), cessation programs (5.4%). At final follow up, 43.2% ( n = 16) of prior tobacco smokers reported complete abstinence. Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System (PROMIS)-10 mental health scores (49 vs 58; P = 0.01), and hip dysfunction and osteoarthritis outcome score for joint replacement (HOOS. JR) scores (63 vs 82; P = 0.02). No patients in this cohort had a prosthetic joint infection or required revision surgery., Conclusion: We report a tobacco cessation rate of 43.2% in patients undergoing elective TJA nearly 3 years postoperatively. Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS. JR scores. The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes., Competing Interests: Conflict-of-interest statement: The authors report no conflicts of interest related to this study., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: For total hip arthroplasty (THA), a new technology in the evolution of computer-assisted surgery has emerged in the form of augmented reality (AR). We sought to determine the impact of AR on resident and fellow education after implementation at an academic teaching center., Materials and Methods: The senior author's intraoperative technique allows for the orthopedic trainee to use AR to correct the acetabular component's position after an attempt is made with standard instrumentation. One year after the implementation of this AR method, both resident and fellow trainees were issued an anonymous survey regarding their experience and descriptive statistics were calculated for the results., Results: Sixteen trainees responded to the survey. One hundred percent felt the use of AR improved their understanding of acetabular component placement and improved their intraoperative experience. Sixty-nine percent reported feeling there was a small increase in operative time but 25% reported no increase in operative time when using AR. Seventy-five percent of trainees felt that patients benefited from the technology and would be in favor of AR if they were having a THA. The majority of those surveyed reported a desire to use AR in their practice if it is available., Conclusion: Computer-assisted surgery has demonstrated variable impacts on orthopedic education. After the implementation of AR at an academic teaching center, all trainees reported it improved their intraoperative experience and their understanding of acetabular component placement. Further studies are needed to determine if AR is able to improve a trainee's component placement. [ Orthopedics . 2024;47(4):e157-e160.].

Background: The decision to treat shoulder osteoarthritis (OA) definitively with shoulder arthroplasty (SA) is multifactorial, considering objective findings, subjective information, and patient goals. The first goal of this study was to determine if Patient Reported Outcome Measurement Information System (PROMIS) measures correlated with patients with shoulder OA who underwent SA within 1 year. The second goal of this study was to determine if score cut-offs in PROMIS domains could further discriminate which shoulder OA patients underwent SA within 1 year., Methods: This retrospective case-control study examined patients with a diagnosis of shoulder OA who consulted an orthopedic provider from November 1, 2020 to May 23, 2022, and recorded PROMIS measures in the domains of Physical Function, Depression, and/or Pain Interference. A surgical group was defined as patients who underwent SA within 1 year of the most recent PROMIS measures and the nonsurgical patients were defined as the control group. Mean PROMIS scores were compared between the surgical and control groups. Separate logistic regression models controlling for age, race, ethnicity, and comorbidity count were performed for each PROMIS domain as a 1) continuous variable, and then as 2) binary variable defined by PROMIS score cut-off points to determine which scores correlated with undergoing SA to further characterize the potential clinical utility of PROMIS score cut-offs in relating to undergoing SA., Results: The surgical group of 478 patients was older (68.2 vs. 63.8 years), more often of White race (82.6% vs. 70.9%), and less often of Hispanic Ethnicity (1.5% vs. 2.9%) than the control group of 3343 patients. Using optimal cut-offs in PROMIS scores, Pain Interference ≥63 (odds ratio [OR] = 2.97 (2.41-3.64), P < .001), Physical Function ≤39 (OR = 1.81 (95% confidence interval, 1.48-2.22), P < .001), and depression ≥49 (OR = 1.82 (95% confidence interval, 1.50-2.22), P < .001) were all found to correlate with undergoing SA within 1 year in multivariable logistic regressions., Conclusion: The results of this study demonstrate that cut-off scores for PROMIS measures differentiated patients undergoing SA within 1 year. These cut-off scores may have clinical utility in aiding in decision-making regarding surgical candidates for SA. Further research is needed to validate these cut-off scores and determine how they relate to patient outcomes after SA., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the management and outcomes of aseptic revision total knee arthroplasty (arTKA) with unsuspected positive cultures (UPCs) compared to those with sterile cultures., Methods: The institutional database at a single tertiary center was retrospectively reviewed for arTKA from January 2013 to October 2023. Patients who met Musculoskeletal Infection Society criteria for periprosthetic joint infection (PJI) based on available preoperative infectious workup, received antibiotic spacers, or did not have at least 1 year of follow-up were excluded. Patients were stratified based on intraoperative cultures into 4 cohorts: sterile cultures, 1 UPC, ≥ 2 UPCs with different organisms, and ≥ 2 UPCs with the same organism. Univariable analyses were used to compare these groups. Kaplan-Meier survivorship analysis assessed infection-free survival at 5 years, and Cox proportional hazards regressions were used to evaluate factors that influence infection-free survival. A total of 691 arTKAs at a mean follow-up of 4.2 years were included in the study. Of these, 49 (7.1%) had 1 UPC with a new organism, 10 (1.4%) had ≥2 UPCs of the same organism, and 2 (0.2%) had ≥2 UPCs with different organisms., Results: Postoperative antibiotics were prescribed to 114 (16.5%) patients-13 (26.5%) with 1 UPC, 6 (60.0%) with ≥2 UPCs of the same organism, and 0 (0.0%) of patients who had ≥2 UPCs of different organisms. There were no differences in infection-free survival at 5 years between patients who had sterile cultures and 1 UPC (96 versus 89%; P = .39) nor between sterile cultures and ≥2 UPCs of different organisms (96 versus 100%; P < .72). However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years compared to patients who had sterile cultures (58 versus 96%; P < .001). Cox proportional hazards regression suggested that when adjusting for covariates, an American Society of Anesthesiologists classification of ≥3 (hazard ratio [HR] = 3.1; P = .007), ≥2 UPCs of the same organism (HR = 11.0; P < .001), 1 UPC (HR = 4.2; P = .018), and arTKA with hinge constructs (HR = 4.1; P = .008) were associated with increased risk of rerevision for PJI., Conclusions: Patients who had 1 UPC or ≥2 UPCs with different organisms had similar infection-free survival at 5 years as patients who had sterile cultures. However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years. Overall, 1 UPC or ≥2 UPCs of the same organism at the time of arTKA may suggest the patient is at higher risk of rerevision for PJI. More studies are needed to determine what interventions can be implemented to mitigate this risk., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Case: A 32-year-old woman with a history of hip fusion presented with significant lower back, hip, and knee pain as well as severely limited hip mobility and function. Single-stage fusion takedown and conversion to total hip arthroplasty (THA) was performed using augmented reality navigation. At 1 year, the patient was pain free with improved function. This study is the first to report the technique and outcomes of surgical fusion conversion to THA, using mixed reality navigation., Conclusion: Mixed reality navigation in complex conversion THA can be useful for identifying the patient's true acetabulum and for patient-specific acetabular component placement to maximize outcomes., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C371)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Aims: This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection., Methods: A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery., Results: The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively., Conclusion: Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low., Competing Interests: None declared., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days., Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days., Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection (P < 0.01), hospital readmission (P < 0.01), and revision surgery (P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days., Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: With pressures to decrease the financial burden of total hip arthroplasty (THA), it is imperative to understand the cost drivers of this procedure. This study evaluated operative and total encounter costs for two surgical approaches to THA-posterior (P) and direct anterior (DA)., Materials and Methods: A total of 233 THAs (134 P and 99 DA) performed by two fellowship-trained arthroplasty surgeons from 2017 to 2022 were reviewed. Demographics, comorbidities, mobility status, operative time, length of stay, implants used, discharge location, and complications until final follow-up were recorded. Total encounter cost was collected and itemized. Multivariable regression analyses evaluated predictors of cost., Results: There were differences in age (67 years for DA and 63 years for P; P =.03), body mass index (28.0 kg/m 2 for DA and 33.8 kg/m 2 for P; P <.01), Elixhauser Comorbidity Index score (4.6 for DA and 5.6 for P; P =.04), and operative time (2.1 hours for DA and 1.9 hours for P; P <.01) between the two cohorts. The DA cohort trended toward shorter length of stay, with the highest percentage of patients discharged home (86.9%; P =.02). The P cohort had the lowest encounter ($9601 for DA and $9100 for P; P =.20) and intraoperative (including implant used) ($7268 for DA and $6792 for P; P <.01) costs. The DA cohort had a significantly higher cost of radiology during the encounter ($244; P <.01). Regression analysis demonstrated that length of stay and DA approach were both predictors of increased encounter cost., Conclusion: The DA cohort had improved measures of health; however, this approach was associated with a higher operative cost and was predictive of increased encounter cost despite a shorter length of stay. [ Orthopedics . 2024;47(3):e151-e156.].

Introduction: On January 1, 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list, expanding outpatient TKA (oTKA) to include patients with insurance coverage through their programs. These regulatory changes reinforced the need for preoperative optimization to ensure a safe and timely discharge after surgery. This study compared modifiable preoperative optimization metrics in patients who underwent oTKA pre-IPO and post-IPO removal. The authors hypothesized that patients post-IPO removal would demonstrate improvement in the selected categories., Methods: Outpatient TKA in a national database was identified and stratified by surgical year (2015 to 2017 versus 2018 to 2020). Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, hematocrit, sodium, smoking, and body mass index. The percentage of patients who did not meet thresholds pre-IPO and post-IPO removal were compared., Results: In total, 2,074 patients underwent oTKA from 2015 to 2017 compared with 46,480 from 2018 to 2020. Patients undergoing oTKA after IPO removal were significantly older (67.0 versus 64.4 years; P < 0.01). A lower percentage of patients in the post-IPO cohort fell outside the threshold for all modifiable risk factors. Results were significant for preoperative sodium (10.7% versus 8.8%; P < 0.01), body mass index (12.4% versus 11.0% P = 0.05), and smoking history (9.9% versus 6.6%; P < 0.01)., Conclusion: Outpatient TKA has increased considerably post-IPO removal. As this regulatory change has allowed older patients with increased comorbidities to undergo oTKA, the need for appropriate preoperative optimization has increased. The current data set demonstrates that surgeons have improved preoperative optimization efforts for select modifiable risk factors., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities., Methods: This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses., Results: Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0)., Conclusion: AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study., (© 2023. W. Montague Cobb-NMA Health Institute.)

Background: With the increasing incidence of total joint arthroplasty (TJA), there is a desire to reduce peri-operative complications and resource utilization. As degenerative conditions progress in multiple joints, many patients undergo multiple procedures., Aim: To determine if both physicians and patients learn from the patient's initial arthroplasty, resulting in improved outcomes following the second procedure., Methods: The institutional database was retrospectively queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients with only unilateral THA or TKA, and patients undergoing same-day bilateral TJA, were excluded. Patient demographics, comorbidities, and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery. Outcome metrics evaluated included operative time, length of stay (LOS), disposition, 90-d readmissions and emergency department (ED) visits., Results: A total of 642 patients, including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA, were analyzed. There was no significant difference in demographics or comorbidities between the first and second procedure, which were separated by a mean of 285 d. For THA and TKA, LOS was significantly less for the second surgery, with 66% of patients having a shorter hospitalization ( P < 0.001). THA patients had significantly decreased operative time only when the same sized implant was utilized ( P = 0.025). The vast majority (93.3%) of patients were discharged to the same type of location following their second surgery. However, when a change in disposition was present from the first surgery, patients were significantly more likely to be discharged to home after the second procedure ( P = 0.033). There was no difference between procedures for post-operative readmissions ( P = 0.438) or ED visits ( P = 0.915)., Conclusion: After gaining valuable experience recovering from the initial surgery, a patient's perioperative outcomes are improved for their second TJA. This may be the result of increased confidence and decreased anxiety, and it supports the theory that enhanced patient education pre-operatively may improve outcomes. For the surgical team, the second procedure of a staged THA is more efficient, although this finding did not hold for TKA., Competing Interests: Conflict-of-interest statement: Colin Penrose and Christine Jiang Wu report no conflicts. Sean Patrick Ryan reports research support from Zimmer Biomet and Smith & Nephew, outside the submitted work. Michael Paul Bolognesi reports royalties from Total Joint Orthopaedics and Zimmer Biomet, stock options from Amedica, research support from Depuy Synthes, Exactech, PCORI, and financial support from Smith & Nephew, DJO, and Acelity, and research support from KCI, outside of this work. Thorsten Markus Seyler reports paid consultant work from Total Joint Orthopedics, Smith & Nephew, Heraeus Medical, and Peptilogics, research support from Zimmer Biomet, Royalties from Pattern Health, publishing royalties from Lippincott Williams & Wilkins, and IP royalties from Restor3d, outside the submitted work. Samuel Secord Wellman reports research support from Zimmer Biomet and DePuy Synthes, stock options from Joint Development, LLC, research support from Medacta, Smith & Nephew, Stryker, and royalties from Joint Orthopedics, outside the submitted work., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Weight loss is commonly recommended before total knee arthroplasty (TKA) despite inconsistent evidence for better outcomes. This study sought to examine the impacts of preoperative weight loss on patient-reported and adverse outcomes among TKA patients supervised by a medical weight management clinic., Methods: This study retrospectively analyzed patients who underwent medical weight management supervision within 18 months before TKA comparing patients who did and did not have clinically relevant weight loss. Preoperative body mass indices, demographics, Patient-Reported Outcomes Measurement Information System physical function and pain interference scores, pain intensity scores, and adverse outcomes were extracted. Multivariable linear regressions were performed to determine if preoperative weight loss correlated with patient-reported outcomes after controlling for confounders., Results: There were 90 patients, 75.6% women, who had a mean age of 65 years (range, 42-82) and were analyzed. There were 51 (56.7%) patients who underwent clinically relevant weight loss with a mean weight loss of 10.4% and experienced no difference in adverse outcomes. Preoperative weight loss predicted significantly improved 3-month postoperative physical function (β = 15.2 [13.0-17.3], P < .001), but not pain interference (β = -18.9 [-57.1-19.4], P = .215) or pain intensity (β = -1.8 [-4.9-1.2], P = .222) scores., Conclusion: We found that medically supervised preoperative weight loss predicted improvement in physical function 3 months after TKA. This weight loss caused no major adverse effects. Further research is needed to understand the causal relationships between preoperative weight loss, medical supervision, and outcome after TKA and to elucidate potential longer-term benefits in a larger sample., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Outpatient total hip arthroplasty (THA) is a safe option for select patients. The purpose of this study was to analyze a national database and understand risk factors that lead to unplanned early readmission and reoperation after outpatient THA. The National Surgical Quality Improvement Program database was used to collect outpatient THAs performed from 2013 to 2020. The outpatient setting was defined as a reported hospital length of stay of 23 hours or less. Data variables collected included patient demographics, medical comorbidities, American Society of Anesthesiologists classification, functional status, preoperative laboratory values, National Surgical Quality Improvement Program morbidity probability, and 30-day readmissions and reoperations. A total of 15,055 patients underwent outpatient THA. Mean age was 62.6 years, and 52.1% of patients were men. Mean body mass index was 29.3 kg/m 2 . The overall rate of readmission was 1.8%, and the reoperation rate was 1.0%. Patients with a 30-day readmission were older ( P <.01), with a higher incidence of hypertension ( P <.01), steroid use ( P <.01), and bleeding disorders ( P =.01). Patients with a 30-day reoperation had higher body mass index ( P <.01), hypertension ( P <.01), and steroid use ( P <.01). Regression analysis demonstrated that independent risk factors for readmission were age ( P <.01) and steroid use ( P <.01). Risk factors for 30-day reoperation were hypertension ( P <.01) and steroid use ( P <.01). There is a higher risk of early readmission after outpatient THA for older patients with hypertension, bleeding disorders, and steroid use. Patients with hypertension and steroid use have a higher risk for reoperation after outpatient THA. Modifiable risk factors should be addressed preoperatively, with proper patient selection for outpatient THA. [ Orthopedics . 2024;47(1):e38-e44.].

Background: High body mass index (BMI) is associated with adverse outcomes after total knee arthroplasty (TKA). Thus, many patients are advised to lose weight before TKA. This study examined how weight loss before TKA is associated with adverse outcomes depending on patients' initial BMI., Methods: This was a retrospective study of 2,110 primary TKAs at a single academic center. Data on preoperative BMIs, demographics, comorbidities, and incidences of revision or prosthetic joint infection (PJI) were obtained. Multivariable logistic regressions segmented by patients' initial (1-year preoperative) BMI classifications were performed to determine if a > 5% BMI decrease from 1 year or 6 months preoperatively predicted PJI and revision controlling for patient age, race, sex, and Elixhauser comorbidity index., Results: Preoperative weight loss did not predict adverse outcomes for patients who had Obesity Class II or III. 6-month weight loss had greater odds of adverse outcomes than 1-year weight loss and most significantly predicted the occurrence of 1-year PJI (adjusted odds ratio: 6.55, P < .001) for patients who had Obesity Class 1 or lower., Conclusion: This study does not show a statistically significant effect to patients who had Obesity Class II and III losing weight preoperatively with respect to PJI or revision. For patients who have Obesity Class I or lower pursuing TKA, future research should consider potential risks associated with weight loss. Further study is needed to determine if weight loss can be implemented as a safe and effective risk reduction strategy for specific BMI classes of TKA patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40-49 years), middle (50-79 years), and elderly (80-89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays ( p < 0.001) but longer operative times ( p < 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia ( p < 0.001), acute renal failure ( p < 0.001), stroke ( p < 0.001), cardiac arrest ( p < 0.001), and transfusions ( p < 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% ( p < 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.

As the population ages and patients maintain higher levels of activity, the incidence of major and minor orthopaedic procedures continues to rise. At the same time, health policies are incentivizing efforts to improve the quality and value of musculoskeletal health services. As such, orthopaedic surgeons play a key role in directing the optimization of patients before surgery by assessing patient risk factors to inform risk/benefit discussions during shared decision-making and designing optimization programs to address modifiable risks. These efforts can lead to improved health outcomes, reduced costs, and preference-congruent treatment decisions. In this review, we (1) summarize the evidence on factors known to affect outcomes after common orthopaedic procedures, (2) identify which factors are considered modifiable and amenable to preoperative intervention, and (3) provide guidance for preoperative optimization., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Physical function and pain outcomes vary after arthroplasty. We investigated differences in postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to identify preoperative factors that predict postoperative PROMIS scores., Methods: Patients who underwent TKA and THA from 2014-2020 were eligible. Preoperative variables including demographics, comorbidities, and pain scores were obtained from the medical record. Patients completed surveys measuring postoperative PF and PI. Descriptive statistics and separate linear regression models for each anatomical location were performed to examine factors predicting postoperative PROMIS PF and PI scores., Results: Surveys were completed by 2411 patients (19.5% response rate). Unadjusted mean PF postoperative scores were 47.2 for TKA and 48.8 for THA. Preoperative predictors of lower PF included female sex; body mass index and comorbidities for TKA and THA; and age, tobacco use, and non-White race for THA. Mean PI scores were 47.9 for THA and 49.0 for TKA. Preoperative predictors of increased PI included non-White race and increased body mass index for TKA and THA; higher preoperative pain for TKA; and female sex and increased comorbidity for THA., Conclusions: Postoperative PROMIS scores were similar for TKA and THA, with THA having slightly higher PF and lower PI scores. Regression models using preoperative variables showed similar performance for TKA compared with THA. These findings suggest areas for future development of clinical decision support tools., (© 2023 The Authors.)

Perioperative efficiency has become increasingly important with cost constraints and expanding indications for total hip arthroplasty (THA). We chose to analyze body mass index (BMI) and American Society of Anesthesiologists (ASA) score, in predicting perioperative efficiency. We retrospectively reviewed the institutional database for primary THAs from July 2015 to January 2018. Patient demographics and perioperative times lines were collected. A multivariable model was utilized to evaluate BMI (< 30, ≥ 30) and ASA (< 3, ≥ 3) for all outcomes. A total of 2,934 patients were included with mean age 62.0 (12.2) years, and 1,599 (54.5%) were female. A BMI ≥ 30 was associated with prolonged operative time (p < 0.001) while an ASA ≥ 3 was predictive of post-anesthesia care unit time (p < 0.001), physical therapy hours (p < 0.001), and length of stay (p < 0.001). Both BMI (p = 0.004) and ASA (p < 0.001) were associated with skilled nursing/rehabilitation dispositions. While BMI predicts prolonged operative time, ASA predicts perioperative delays for anesthesia, nursing, and physical therapy. (Journal of Surgical Orthopaedic Advances 32(3):169-172, 2023).

Background: Recently, some payers have limited access to total knee arthroplasty (TKA) to patients who have Kellgren-Lawrence (KL) grade 4 osteoarthritis only. This study compared the outcomes of patients who have KL grade 3 and 4 osteoarthritis after TKA to determine if this new policy is justified., Methods: This was a secondary analysis of a series originally established to collect outcomes for a single, cemented implant design. A total of 152 patients underwent primary, unilateral TKA at two centers from 2014 to 2016. Only patients who had KL grade 3 (n = 69) or 4 (n = 83) osteoarthritis were included. There was no difference in age, sex, American Society of Anesthesiologists score, or preoperative Knee Society Score (KSS) between the groups. Patients who had KL grade 4 disease had a higher body mass index. KSS and Forgotten Joint Score (FJS) were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Generalized linear models were used to compare outcomes., Results: Controlling for demographics, improvements in KSS were comparable between the groups at all time points. There was no difference in KSS, FJS, and the proportion that achieved the patient acceptable symptom state for FJS at 2 years., Conclusion: Patients who had KL grade 3 and 4 osteoarthritis experienced similar improvement at all time points up to 2 years after primary TKA. There is no justification for payers to deny access to surgical treatment for patients who have KL grade 3 osteoarthritis and have otherwise failed nonoperative treatment., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort., Methods: A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses., Results: The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P = .0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P = .0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P = .03]., Conclusion: For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange., Level of Evidence: Level III, therapeutic study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: On January 1, 2020, the Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the Inpatient-Only (IPO) list. This study evaluated patient demographics and comorbidities, preoperative optimization efforts, and 30-day outcomes of patients undergoing outpatient THA before and after IPO removal. The authors hypothesized that patients undergoing THA post-IPO removal would have improved optimization of modifiable risk factors and equivalent 30-day outcomes., Methods: There were 17,063 outpatient THAs in a national database stratified by surgery performed before (2015 to 2019: 5,239 patients) and after IPO (2020: 11,824 patients) removal. Demographics, comorbidities, and 30-day outcomes were compared with univariable and multivariable analyses. Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, creatinine, hematocrit, smoking history, and body mass index. The percentage of patients who fell outside the thresholds in each cohort were compared., Results: Patients undergoing outpatient THA post-IPO removal were significantly older; mean age 65 years (range, 18 to 92) versus 62 (range, 18 to 90) years (P < .01), with a higher percentage of American Society of Anesthesiologists scores 3 and 4 (P < .01). There was no difference in 30-day readmissions (P = .57) or reoperations (P = 1.00). A significantly lower percentage of patients fell outside the established threshold for albumin (P < .01) post-IPO removal, and trended towards lower percentages for hematocrit and smoking status., Conclusion: The removal of THA from the IPO list expanded patient selection for outpatient arthroplasty. Preoperative optimization is critical to minimize postoperative complications, and the current study demonstrates that 30-day outcomes have not worsened post-IPO removal., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In patients, who have coexisting lumbar spine and degenerative hip disease, there remains uncertainty regarding whether hip or spine surgery should be performed first. We hypothesized that undergoing total hip arthroplasty (THA) would protect against subsequent lumbar spine surgery (LSS) in patients who have 'hip-spine syndrome.', Methods: A retrospective cohort study was performed from 2013 to 2021 on patients who had radiographically-confirmed hip osteoarthritis and degenerative lumbar spine pathology, evaluated separately in spine and arthroplasty clinics prior to surgical intervention. Included patients ultimately underwent THA and/or LSS. The primary outcome was survivorship free of LSS or THA after the other was initially performed., Results: Of 256 patients, 206 (80.5%) underwent THA first. Only 14 of 206 (6.8%) who underwent THA required subsequent LSS, while 31 of 50 (62%) who underwent LSS required subsequent THA, (P < .001). At 5 years, there was 93.9% survivorship-free of LSS in the THA first group, compared to 44.7% survivorship-free of subsequent THA in the LSS group. Multivariate analyses showed that patients who had THA first had lower odds of undergoing subsequent surgery (odds ratio [OR]: 0.61, CI: 0.52-0.70, P < .001) compared to those who underwent LSS first. Additionally, those who have higher initial Kellgren-Lawrence grade hip osteoarthritis had lower odds (OR: 0.94, CI: 0.89-0.99, P = .04), and those who have progressive neurologic deficits (OR: 2.64, CI: 1.89-3.7, P < .001) and neurogenic claudication (OR: 1.15, CI: 1.06-1.24, P = .001) had increased odds of undergoing subsequent LSS., Conclusion: Patients with 'hip-spine syndrome' may receive more initial benefit from undergoing THA, potentially reducing the subsequent need for LSS. The exceptions were those patients who had lower-severity hip osteoarthritis and symptoms of major spinal stenosis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Flexion instability is a common cause for revision after total knee arthroplasty (TKA); however, little objective criteria exist to determine excessive laxity in flexion. This study sought to determine the reliability of stress radiographs for flexion laxity using manual stress as well as a commercially available flexion stress device, with the hypothesis that a commercially available force device would provide increased translation compared to manual stress, and radiographic measurements would be reproducible., Methods: Ten patients who previously underwent TKA with non-hinged components were prospectively and consecutively enrolled at a single center to undergo stress radiographs. Three lateral radiographs with the knee at 90° of flexion were obtained for each patient: rest, commercial stress device at 150N, and manual stress. Calibrated radiographs were evaluated by two raters, and inter-rater and intra-rater reliability were determined using intraclass correlation coefficients (ICC)., Results: Ten patients (seven female) with mean age 72 (range 55-82) years and average duration from surgery 36 (range 12-96) months were evaluated. The commercial stress device provided significantly less anterior translation than manual stress (- 0.3 mm vs. 3.9 mm; p < 0.01). Two patients reported pain with use of the stress device. Inter-observer reliability of measurements was good for commercial stress (ICC = 0.86) and excellent for manual stress (ICC = 0.94). Eighty-five percent of measurements were within 1 mm between observers. Intra-observer reliability of measurements was good to excellent for both the stress device and manual stress., Conclusions: Lateral stress radiographs may assist in the objective evaluation of flexion instability. A commercially available product provided less translation than manual stress; however, measurements were reliable and reproducible between observers. Further research is required to correlate translation with stress radiographs to patient outcomes following revision arthroplasty., (© 2023. The Author(s).)

Background: High impact chronic pain (HICP) is not typically measured following orthopedic surgeries, but has a substantial negative impact on postoperative quality of life. This analysis determined which Patient-Reported Outcome Measurement Information System (PROMIS) measures accurately estimate HICP status following total joint arthroplasty (TJA)., Methods: This was a secondary analysis of a hip and knee TJA cohort. HICP status was determined by two items from the Graded Chronic Pain Scale-Revised. The cohort (n = 2,400) consisted of 47.5% hip (n = 1,142) and 52.5% knee TJA (n = 1,258). For total hip arthroplasty (THA), 53.7% were women (n = 615), 48.6% were 65 years or older (n = 557), 72.5% completed the survey more than 24 months after first surgery (n = 831), and 9.9% had HICP (n = 114). For total knee arthroplasty (TKA), 54.3% were women (n = 687), 59.3% were 65 years or older (n = 750), 72.3% survey completed the survey more than 24 months after first surgery (n = 915), and 11.5% had HICP (n = 145). Included PROMIS measures were pain interference, physical function, anxiety, and sleep disturbance. First, discriminant function analysis determined PROMIS measure contribution to HICP status. Then, area under the curve (AUC) calculated the accuracy of PROMIS measures to estimate HICP status. Influences of sociodemographic and surgical characteristics on AUC were explored in sensitivity analyses., Results: Results for TKA and THA were similar so they are presented collectively for the sake of brevity. Mean differences were identified for all PROMIS measures for those with HICP (All P values < 0.01). Pain interference (β = 0.934) and sleep disturbance (β = 0.154) were independently correlated with HICP status in discriminant function analyses. The AUC (95% CIs) for HICP were as follows: pain interference (.952-.973), physical function (.921-.949), sleep (.780-.838), and anxiety (.687-.757). Sensitivity analyses revealed little change in AUC and HICP cutoff scores for PROMIS pain interference and physical function., Conclusion: Two PROMIS measures commonly administered as standard of care for orthopedics, pain interference, and physical function, can be used to estimate HICP status for THA and TKA, thereby refining assessment of TJA outcomes., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: As value-based reimbursement models mature, understanding the potential trade-off between inpatient lengths of stay and complications or need for costly postacute care becomes more pressing. Understanding and predicting a patient's expected baseline length of stay may help providers understand how best to decide optimal discharge timing for high-risk total joint arthroplasty (TJA) patients., Methods: A retrospective review was conducted of 37,406 primary total hip (17,134, 46%) and knee (20,272, 54%) arthroplasties performed at two high-volume, geographically diverse, tertiary health systems during the study period. Patients were stratified by 3 binary outcomes for extended inpatient length of stay: 72 + hours (29%), 4 + days (11%), or 5 + days (5%). The predictive ability of over 50 sociodemographic/comorbidity variables was tested. Multivariable logistic regression models were created using institution #1 (derivation), with accuracy tested using the cohort from institution #2 (validation)., Results: During the study period, patients underwent an extended length of stay with a decreasing frequency over time, with privately insured patients having a significantly shorter length of stay relative to those with Medicare (1.9 versus 2.3 days, P < .0001). Extended stay patients also had significantly higher 90-day readmission rates (P < .0001), even when excluding those discharged to postacute care (P < .01). Multivariable logistic regression models created from the training cohort demonstrated excellent accuracy (area under the curve (AUC): 0.755, 0.783, 0.810) and performed well under external validation (AUC: 0.719, 0.743, 0.763). Many important variables were common to all 3 models, including age, sex, American Society of Anesthesiologists (ASA) score, body mass index, marital status, bilateral case, insurance type, and 13 comorbidities., Discussion: An online, freely available, preoperative clinical decision tool accurately predicts risk of extended inpatient length of stay after TJA. Many risk factors are potentially modifiable, and these validated tools may help guide clinicians in preoperative patient counseling, medical optimization, and understanding optimal discharge timing., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Perioperative advancements have made outpatient primary total hip arthroplasty (THA) a viable option for patients. This study evaluated the feasibility of expedited discharge after revision THA and compared 30-day outcomes to patients who had prolonged inpatient hospitalizations. The authors hypothesized that expedited discharge would not result in inferior 30-day outcomes., Methods: Aseptic revision THAs in a national database were reviewed from 2013 to 2020. THAs were stratified by hospital length of stay (LOS) more or less than 24 hours. Demographics, comorbidities, preoperative laboratory values, American Society of Anesthesiology (ASA) scores, operative times, components revised, 30-day readmissions, and reoperations were compared. Multivariable analyses evaluated predictors of discharge prior to 24 hours, 30-day readmissions, and reoperations. Of 17,044 aseptic revision THAs, 211 were discharged within 24 hours., Results: Accelerated discharge patients were younger, mean age 63 years (range, 20-92) versus 66 years (range, 18-94) (P < .01) had lower body mass index, mean 28.7 (range, 18.3-46.4) versus 29.9 (range, 17.3-52.5) (P = .01), and ASA scores (ASA, 1-2; 40.4-57.8%) (P < .01). Components revised had no association with LOS (P = .39); however, operative times were shorter and mean 100 minutes (range, 35-369) versus 139 minutes (range, 24-962) (P < .01) in accelerated discharge patients. Accelerated discharge patients had lower readmission rates (P < .01) but no difference in reoperation rates (P = .06)., Conclusion: Discharge less than 24 hours after revision THA is a feasible option for the correct patient and further efforts to decrease LOS should be evaluated., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Well-powered studies evaluating the effects of Paget's disease on patient outcomes following primary total knee arthroplasty (TKA) are limited. The objective of this study was to determine whether Paget's disease patients undergoing primary TKA have higher rates of complications. A query of an administrative database was performed identifying Paget's disease patients undergoing primary TKA as the study cohort. Patients who did not have Paget's disease served as a matching cohort. Study group patients were matched in a 1:5 ratio by age, sex, and comorbidities. The query yielded 34,284 patients in the study ( n  = 5,714) and matched ( n  = 28,570) cohorts. Outcomes analyzed included length of stay (LOS), costs of care, 90-day medical and surgical complications, and 2-year implant-related complications. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of complications. Paget's disease patients undergoing primary TKA were found to have significantly longer in-hospital LOS (4 vs. 3 days, p  < 0.0001). Study group patients incurred significantly higher 90-day episode-of-care costs ($15,124.55 vs. $14,610.01, p  < 0.0001). Additionally, Paget's disease patients were found to have higher incidences and odds of medical/surgical (25.93 vs. 13.58%; OR: 1.64, p  < 0.0001) and implant-related complications (8.97 vs. 5.02%; OR: 1.71, p  < 0.0001). Specifically, Paget's disease patients were more likely to have periprosthetic fractures, mechanical loosening, and revision TKAs ( p  < 0.0001). This study demonstrated that Paget's disease was associated with longer in-hospital LOS, increased costs, and higher rates of complications. The study can be utilized by physicians to adequately educate patients with Paget's disease concerning potential complications following their primary TKA., Competing Interests: T.M.S. reports other from AAHKS social media, other from TJO, Smith & Nephew, Hereaus, Next Science, other from Zimmer Biomet, KCl, Reflexion Health, other from Depuy, Stryker, Exactech, outside the submitted work. M.P.B. reports other from TJO, Zimmer Biomet, other from Amedica, other from Depuy, Synthes, Exactech, PCORI, Stryker, Smith & Nephew, DJO, EOA, AAHKS, AAOS, JOA, JSOA, Arthroplasty Today, outside the submitted work. M.A.M. reports other from Microport, Stryker, other from Merz, Medical Compression Systems, DJ Orthopaedics, J&J, OrthoSensor, Pacira, Sage products, TissueGene, U.S. Medical Innovations, DJ Orthopaedics, NIH, Ongoing Care Solutions, other from JOA, JKS, Surgical Techniques International, American Journal of Orthopedics, Orthopedics, other from AAOS, outside the submitted work. M.W.R. reports other from Stryker, Smith & Nephew, Zimmer, other from AAOS, AAHKS, outside the submitted work. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

Aims: In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations., Methods: Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation., Results: Of 21,610 aseptic revision TKAs evaluated, 530 were discharged within 24 hours. Short-stay patients were younger (63.1 years (49 to 78) vs 65.1 years (18 to 94)), with lower BMI (32.3 kg/m 2 (17 to 47) vs 33.6 kg/m 2 (19 to 54) and lower ASA grades. Diabetes, chronic obstructive pulmonary disease, hypertension, and cancer were all associated with a hospital stay over 24 hours. Single component revisions (56.8% (n = 301) vs 32.4% (n = 6,823)), and shorter mean operating time (89.7 minutes (25 to 275) vs 130.2 minutes (30 to 517)) were associated with accelerated discharge. Accelerated discharge was not associated with 30-day readmission and reoperation., Conclusion: Accelerated discharge after revision TKA did not increase short-term complications, readmissions, or reoperations. Further efforts to decrease hospital stays in this setting should be evaluated.Cite this article: Bone Joint J  2022;104-B(12):1323-1328.

Purpose: Survival after solid organ transplant (SOT) is improving, and demand for total joint arthroplasty (TJA) among SOT recipients is rising. Outcomes including revision, periprosthetic joint infection, and survivorship based on SOT type are variable. We sought to compare peri-operative complications, implant survivorship, and mortality for patients undergoing TJA following SOT., Methods: A retrospective review of the institutional database for primary TJA among SOT recipients from 2000 to 2020 was performed. Revisions, conversion TJA, and patients with multiple organ transplants were excluded. Patients were stratified by transplant organ. Transfusions, 90-day readmissions and emergency department (ED) visits, revisions, and mortality were compared using descriptive statistics and Cox proportional hazard ratios., Results: A total of 119 total hip arthroplasties (THA) and 63 total knee arthroplasties (TKA) in SOT recipients were studied. Most common SOT was renal (39%), then lung (27%), liver (24%), and heart (10%). TKA postoperative transfusion rates varied by organ (p = 0.037; [heart 0%, liver 9.5%, renal 24.0%, lung 50.0%]). Implant survivorship was 95.6% at one year (95% CI 90.3-98.1) and 92.1% at four years (83.9-96.3). Mortality was 2.9% at one year (95% CI 1.1-7.4) and 23.2% at four years (95% CI 16.1-32.3). After adjusting for procedure, duration from transplant to TJA, age, and Elixhauser Index, lung recipients had higher mortality versus heart (RR 4.39 [95% CI 1.64-15.38]; p = 0.002), kidney (7.98 [3.04-24.61]; p < 0.001), and liver (7.98 [3.04-24.61; p < 0.001) patients., Conclusion: TJA after SOT yields acceptable peri-operative outcomes and implant survivorship, but mortality risk is substantial, especially among lung transplant recipients., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA., Methods: We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center., Results: The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7-95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3-89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24-4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95-1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation., Conclusions: PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.

Background: There are few large studies evaluating total knee arthroplasty (TKA) in young patients. Therefore, we sought to evaluate patients aged 45 years or younger undergoing a primary TKA., Methods: This was a retrospective, single-institution study, from 2003 to 2018, evaluating primary TKA in patients aged 45 years or younger. We identified 162 TKAs with a minimum follow-up duration of 2 years. Common surgical indications were degenerative joint disease (50%), post-traumatic arthritis (21%), and inflammatory arthritis (20%). Forty-nine knees had a prior significant knee surgery. We evaluated survivorship free of revision for any reason and aseptic revision. In addition, we characterized complication rates and risk factors for failure., Results: The mean age was 39 years, 70% were female, and the mean clinical follow-up duration was 7 years. At 8 years, survivorship free of revision for any reason was 82%, and survivorship free of aseptic revision was 87%. Fifty-five knees experienced at least 1 complication, with an overall complication rate of 34%. There were 6 (4%) periprosthetic joint infections (PJIs), and 24 (15%) knees of patients underwent manipulation under anesthesia with or without arthroscopic lysis of adhesions. There were no specific risk factors for revisions identified. Age less than 40 years was associated with PJI ( P  = .031), and marital status at the time of TKA was associated with arthrofibrosis requiring an intervention ( P  = .045)., Conclusions: TKAs in patients aged 45 years or younger are associated with acceptable survivorship at a mean follow-up duration of 7 years. Patients should be counseled about the elevated risk of complications, specifically PJI and arthrofibrosis., (© 2022 The Authors.)

Individual or pooled commercial claims data sources such as the IBM MarketScan and PearlDiver provide information from health-care encounters by individuals enrolled in participating health insurance plans. These data sources contain deidentified data on demographic characteristics, enrollment start and end dates, inpatient and outpatient procedures and medical diagnoses with associated service dates and settings, and dispensed medications. Although there are concerns that long-term follow-up is limited because of interruptions in the continuity of coverage and reliance on billing data may overrecord or underrecord diagnoses and confounders, these data sources are nevertheless valuable for orthopaedic studies focusing on short-term complications, costs, and utilization., Competing Interests: Disclosure: This work was funded by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (P30AR76312) and the American Joint Replacement Research-Collaborative (AJRR-C) https://ajrrc.org/. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H197)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) domains for sleep disturbance, anxiety, and dyspnea have been under-reported for total joint arthroplasty (TJA). The aims of this study were to report postoperative differences for these domains based on TJA location and chronic pain state. We also investigated whether these domains were associated with physical function and pain interference outcomes., Methods: This was a retrospective, observational study of patients who underwent hip, knee, or shoulder TJA (primary and revision surgeries) at a single academic tertiary referral center. A subset of these patients completed an email-based survey for chronic pain grade (Chronic Pain Grade Scale-Revised) and sleep disturbance, anxiety, dyspnea, physical function, and pain interference (PROMIS short forms). Pre-operative and operative data were extracted from the electronic health record. Data analysis investigated PROMIS domains for differences in TJA location and chronic pain grade. Hierarchical linear regression determined associations of these domains with physical function and pain interference., Results: A total of 2638 individuals provided informed consent and completed the email survey. In the ANOVA models for sleep disturbance, anxiety, and dyspnea, there was no location by chronic pain grade interaction (p > 0.05) and no difference based on TJA location (p > 0.05). There were differences for chronic pain grade (p < 0.01). The poorest postoperative outcome score for each domain was associated with high impact chronic pain. Furthermore, sleep disturbance and dyspnea had the strongest associations with physical function and pain interference (p < 0.01)., Conclusions: Sleep disturbance, anxiety, and dyspnea did not vary based on TJA location, but were associated with postoperative chronic pain grade. Sleep disturbance and dyspnea were strongly associated with commonly reported outcomes of physical function and pain interference. These findings provide guidance for those interested in expanding TJA outcome assessment to include sleep disturbance, anxiety, and/or dyspnea., (© 2022. The Author(s).)