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Background: Hospital networks centralize primary total joint arthroplasty (TJA) within their existing systems to develop specialized service lines with higher surgical volumes to reduce adverse events. It is not known what role hospital network centralization has had on primary TJA outcomes., Purpose: We sought to determine whether the degree of hospital network centralization for primary TJA is associated with (1) 90-day postoperative complication rates, (2) 90-day hospital readmission rates, or (3) 1-year revision rates., Methods: We conducted a retrospective database study of Medicare Part A beneficiaries who underwent inpatient primary TJA for osteoarthritis in 2016 and 2017 ( n = 523,142 patients); individual hospital-level characteristics and hospital networks were also identified ( n = 360 unique networks, n = 3339 hospitals). Patients having surgery at a hospital that was not a member of a health care network were excluded ( n = 163,998 patients) because we wanted to examine only the role of network structures on outcomes; this resulted in a cohort of 359,144 patients. Hospital network centralization, which was defined as the percentage of total network cases performed at the highest volume hospital and categorized into quartiles (eg, lowest 25% of networks by concentration, 26%-50% of networks by concentration, etc). Primary outcomes included postoperative 90-day complications, 90-day readmissions, and 1-year revisions. Multivariable logistic and linear regressions evaluated associations of hospital network centralization with outcomes and controlled for relevant patient-level and hospital-level covariates, including hospital network volumes., Results: Odds of 90-day complications were lower in the most centralized hospital networks than in least centralized networks (odds ratio [OR] = 0.85; 95% confidence interval [CI]: 0.75, 0.95). Degree of centralization was not associated with readmissions or 1-year revision rates. Non-modifiable patient and individual hospital characteristics appeared to have a greater association with complications, readmissions, and early revision rates than hospital network centralization or volume., Conclusion: This retrospective database study found that increased centralization of primary TJA within a hospital network was associated with lower 90-day complication rates but not with 90-day readmission or 1-year revision rates. This suggests that structural changes within hospital networks may be beneficial to reduce early complications in this patient population. In addition, our findings suggest that risk adjustment in assessing non-modifiable patient and hospital risk factors may be important when assessing TJA outcomes., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Benjamin F. Ricciardi, MD, reports relationships with National Institutes of Health, Johnson and Johnson, AAOS, and AAHKS. Thomas G. Myers, MD, reports relationships with AAOS and AAHKS. Caroline P. Thirukumaran, MBBS, MHA, PhD, reports relationships with National Institutes of Health and Academy Health. The other authors declared no potential conflicts of interest., (© The Author(s) 2024.)

Aims: The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up., Methods: This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes., Results: Complications within 90 days of surgery were increased in the sleeve gastrectomy group relative to the obese control group after controlling for underlying preoperative demographic characteristics (odds ratio (OR) 4.00 (95% CI 1.14 to 13.9); p = 0.030). Postoperative revisions were similar in the sleeve gastrectomy group relative to the obese control group after controlling for underlying preoperative demographic characteristics (OR 17.8 (95% CI 0.64 to 494.3); p = 0.090). Patient-Reported Outcomes Measurement Information System (PROMIS) depression decreased by a greater amount from pre- to postoperative in the obese controls relative to the sleeve gastrectomy group (OR 4.04 (95% CI 0.06 to 8.02); p = 0.047). PROMIS pain interference and physical function change from pre- to postoperative was not associated with sleeve gastrectomy status., Conclusion: We found a higher rate of complications at 90 days in patients who underwent sleeve gastrectomy prior to primary hip or knee arthroplasty relative to a matched, obese control population. Prosthetic revision rates were similar between the two groups, while improvements in PROMIS depression scores were larger in the obese cohort. This study suggests that sleeve gastrectomy to achieve preoperative weight loss prior to arthroplasty surgery may not mitigate early complication risks in obese patient populations., Competing Interests: C. P. Thirukumaran reports a grant from the National Institutes of Health, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Brown University, Boston University, the National Institutes of Health, Oxford University Press, and Veterans Affairs, all of which are unrelated to this study. C. P. Thirukumaran also reports a leadership or fiduciary role in the Orthopaedic Research Society, and editorial roles in Anesthesia and Analgesia and Current Osteoporosis Reports. B. Ricciardi reports funding from the National Institutes of Health and Johnson & Johnson, and honoraria unrelated to this study from Mass General Brigham. B. Ricciardi is also an editorial board member on Clinical Orthopaedics and Related Research, HSS Journal, The Knee, and Arthroplasty Today, and is a committee member of the American Academy of Orthopaedic Surgery and AAHKS., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

➤: Orthopaedic education should produce surgeons who are competent to function independently and can obtain and maintain board certification., ➤: Contemporary orthopaedic training programs exist within a fixed 5-year time frame, which may not be a perfect match for each trainee., ➤: Most modern orthopaedic residencies have not yet fully adopted objective, proficiency-based, surgical skill training methods despite nearly 2 decades of evidence supporting the use of this methodology., ➤: Competency-based medical education backed by surgical simulation rooted in proficiency-based progression has the potential to address surgical skill acquisition challenges in orthopaedic surgery., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G773)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)