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Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.

BackgroundSeveral nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care.ObjectivesTo analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty.MethodsWe identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged

Ultra-high-molecular-weight polyethylene (UHMWPE) components for orthopedic implants have historically been integrated into metal backings by direct-compression molding (DCM). However, metal backings are costly, stiffer than cortical bone, and may be associated with medical imaging distortion and metal release. Hybrid-manufactured DCM UHMWPE overmolded additively manufactured polyetheretherketone (PEEK) structural components could offer an alternative solution, but are yet to be explored. In this study, five different porous topologies (grid, triangular, honeycomb, octahedral, and gyroid) and three surface feature sizes (low, medium, and high) were implemented into the top surface of digital cylindrical specimens prior to being 3D printed in PEEK and then overmolded with UHMWPE. Separation forces were recorded as 1.97–3.86 kN, therefore matching and bettering the historical industry values (2–3 kN) recorded for DCM UHMWPE metal components. Infill topology affected failure mechanism (Type 1 or 2) and obtained separation forces, with shapes having greater sidewall numbers (honeycomb-60%) and interconnectivity (gyroid-30%) through their builds, tolerating higher transmitted forces. Surface feature size also had an impact on applied load, whereby those with low infill-%s generally recorded lower levels of performance vs. medium and high infill strategies. These preliminary findings suggest that hybrid-manufactured structural composites could replace metal backings and produce orthopedic implants with high-performing polymer–polymer interfaces. [ABSTRACT FROM AUTHOR]

This paper measures syndemic substance use disorder, violence, and mental health and compares the syndemic among HIV-infected heterosexual men, heterosexual women, and men who have sex with men (MSM). Data were from a sample of high needs substance-using, HIV-infected people in South Florida between 2010 and 2012 (n = 481). We used confirmatory factor analysis to measure a syndemic latent variable and applied measurement invariance models to identify group differences in the data structure of syndemic co-morbidities among heterosexual men, heterosexual women, and MSM. We found that variables used to measure the syndemic fit each sub-group, supporting that substance use disorder, violence, and mental health coincide in HIV-infected individuals. Heterosexual men and MSM demonstrated similar syndemic latent variable factor loadings, but significantly different item intercepts, indicating that heterosexual men had larger mean values on substance use disorder, anxiety, and depression than MSM. Heterosexual men and heterosexual women demonstrated significantly different syndemic variable factor loadings, indicating that anxiety and depression contribute more (and substance use contributes less) to the syndemic in heterosexual men compared to heterosexual women. MSM and heterosexual women demonstrated similar syndemic latent variable factor loadings and intercepts, but had significantly different factor residual variances indicating more variance in violent victimization and depression for MSM and more variance in stress for heterosexual women than what is captured by the observed syndemic indicators. Furthermore, heterosexual women had a larger syndemic factor mean than MSM, indicating that the syndemic burden is greater among heterosexual women than MSM. Our findings support that measurement invariance can elucidate differences in the syndemic to tailor interventions to sub-group needs.

BackgroundThe most common bearing surface used among primary THAs worldwide is a metal or ceramic femoral head that articulates against a highly crosslinked ultrahigh-molecular-weight polyethylene (HXLPE) acetabular liner. Despite their widespread use, relatively little is known about the comparative effectiveness of ceramic versus metal femoral heads with respect to risk of revision and dislocation as well as the role of head size in this relationship.Questions/purposesThe purpose of this study was to evaluate the risk of (1) all-cause revision in metal versus ceramic femoral heads when used with an HXLPE liner, including an evaluation of the effect of head size; and (2) dislocation in metal versus ceramic femoral heads when used with an HXLPE liner as well as an assessment of the effect of head size.MethodsData were collected as part of the Kaiser Permanente Total Joint Replacement Registry between 2001 and 2013. Patients in this study were on average overweight (body mass index = 29 kg/m2), 67 years old, mostly female (57%), and had osteoarthritis (93%) as the primary indication for surgery. The material of the femoral head (metal, ceramic) was crossed with head size (< 32, 32, 36, > 36 mm), yielding eight device groupings. Only uncemented devices were evaluated. The primary outcome was all-cause revision (n = 28,772) and the secondary outcome was dislocation within 1 year (n = 19,623). Propensity scores were used to adjust for potential confounding at the implant/patient level using between-within semiparametric survival models that control for surgeon and hospital confounding and adjust estimates for the within-cluster correlation among observations on the response.ResultsFor all-cause revision, there was no difference between ceramic versus metal (reference) heads in combination with an HXLPE liner (hazard ratio [HR] = 0.82 [0.65-1.04], p = 0.099). Smaller metal head sizes of < 32 mm were associated with increased risk of revision relative to 36 mm (HR = 1.66 [1.20-2.31], p = 0.002, adjusted p = 0.025). For dislocation, ceramic heads increased risk relative to metal at < 32 mm only (HR = 4.39 [1.72-11.19], p = 0.002, adjusted p = 0.020). Head sizes < 32 mm were associated with increased risk of dislocation relative to 36 mm for metal (HR = 2.99 [1.40-6.39], p = 0.005, adjusted p = 0.047) and ceramic heads (HR = 15.69 [6.07-40.55], p < 0.001, adjusted p < 0.001).ConclusionsThe results did not provide evidence for use of one femoral head material over another when used with HXLPE liners for the outcome of revision, but for dislocation, metal performed better than ceramic with < 32-mm heads. Overall, the findings suggest increased risk of revision/dislocation with head sizes < 32 mm.Level of evidenceLevel III, therapeutic study.

Recent research shows that co-use of stimulants and opioids appears to be increasing and injection of opioids and stimulants carries a risk for HIV transmission. This study examined stimulant injection and sexual HIV risk behaviors among individuals who reported nonmedical use of gabapentin and opioids (n = 62). Comparisons of people who injected stimulants to those who did not were conducted using chi-square and t-tests. Compared to those who did not, people who injected stimulants, were less likely to be African American/Black (p < 0.05) and more likely to report sex with another person who injects drugs (p < 0.01), recent injections of prescription and/or illicit opioids (p <.000), and hepatitis C infection (p < 0.01). Condomless intercourse during group sex was more prevalent among stimulant injectors, significant at the trend level (p < 0.1). Given the documented association between the use of opioids and nonmedical use of gabapentin and the growing trend of opioid-stimulant co-use, future research must examine whether nonmedical use of gabapentin is an indicator of substance use disorder severity and/or a risk factor for injection drug use. Education and intervention opportunities that address group sex and other sexual risk behaviors are warranted. [ABSTRACT FROM AUTHOR]

IntroductionAdvances in surgical technique, implant design, and clinical care pathways have resulted in higher expectations for improved clinical outcomes after primary THA; however, despite these advances, it is unclear whether the risk of revision THA actually has decreased with time. Understanding trends in short- and mid-term risks of revision will be helpful in directing clinical, research, and policy efforts to improve THA outcomes.Question/purposesWe therefore asked (1) whether there have been changes in overall short- and mid-term risks of revision THA among patients in the Medicare population who underwent primary THA between 1998 and 2010; and (2) whether there are different demographic factors associated with short- and mid- term risks of revision THA.MethodsUsing the Medicare 5% national sample database, patients who underwent primary THA between 1998 and 2010 followed by subsequent revision through 2011 were identified by ICD-9-CM procedure codes 81.51 and 81.53/80.05/00.70-00.73, respectively. This dataset included a random sample of Medicare beneficiaries based on their social security number. Only patients with minimum 1-year followup after primary THA were included in our analysis. A total of 64,260 patients who underwent primary THA were identified from the 1998 to 2010 Medicare 5% dataset. Eighty-eight percent of the patients had 1-year followup providing a final study cohort of 56,700 patients. The risk of revision was evaluated at 1, 3, 5, and 7 years. Multivariate Cox regression was used to evaluate temporal trends in revision risk using two methods to account for time effects with periods 1998 to 2002, 2003 to 2007, and 2008 to 2010 for the index year of primary THA, and individual year of index of primary THA as independent variables. The analysis adjusted for patient age, sex, race, census region, Charlson score, and socioeconomic status.ResultsThe 7-year crude risk of revision THA declined from 7.10% in 1998 to 2002 to 6.09% in 2008 to 2010, representing a 14.4% overall reduction in adjusted risk of revision (p = 0.0058; 95% CI, 4.4%-23%). Similarly, the 5-year crude risk of revision THA declined from 5.96% in 1998 to 2002 to 5.11% in 2008 to 2010, representing a 14.2% overall reduction in adjusted risk of revision (p = 0.0069; 95% CI, 4.1%-23%). However, the adjusted risk of revision THA at 3 years was not different from 1998 to 2002 (4.70%) and 2008 to 2010 (4.03%; p = 0.1176). Similarly, the adjusted risk of revision at 1 year did not differ from 1998 to 2002 (2.83%) and 2008 to 2010 (2.42%; p = 0.3386). Patients with more comorbidities had a greater adjusted risk of revision (p < 0.001) at all times: 94% (95% CI, 58%-138%) and 56% (95% CI, 33%-84%) at 1 year and 7 years, respectively, for Charlson score of 5+ vs 0).ConclusionsAlthough the mid-term (5 and 7 years) risk of revision THA has decreased during the past 14 years among Medicare beneficiaries who underwent primary THA, the short-term risk has not. These findings suggest that greater clinical, research, and policy emphasis is needed to identify potentially avoidable causes of early failure after primary THA in patients in the Medicare population, and multistakeholder solutions are needed to optimize short-term outcomes.Level of evidenceLevel III, therapeutic study.