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Background: The use of online search engines for health information is becoming common practice. We analyzed Google search queries to identify the most frequently asked topics and questions related to lateral epicondylitis ("tennis elbow") and the Web sites provided to address these questions., Methods: Four search terms for lateral epicondylitis were entered into Google Web Search. A list of the most frequently asked questions along with their associated Web sites was extracted and categorized by 2 independent reviewers., Results: A total of 400 questions were extracted with 168 associated Web sites. The most popular question topics were related to indications/management (39.0%), risks/complications (19.5%), and the ability to perform specific activities (18.8%). Frequently asked questions had to do with the duration of symptoms, self-management strategies (eg, brace use and self-massage), and the indications for surgery. The most common Web sites provided to address these questions were social media (27.5%), commercial (24.5%), academic (16.5%), and medical practice (16.3%)., Conclusion: The most frequently asked questions about lateral epicondylitis on Google centered around symptom duration and management, with most information originating from social media and commercial Web sites. Our data can be used to anticipate patient concerns and set expectations regarding the prognosis and management of lateral epicondylitis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion., Methods: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions., Results: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%)., Conclusions: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Socioeconomic factors have been associated with an increased need for manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). The purpose of this study was to compare the rate of MUA and range of motion (ROM) following primary TKA in English and non-English-speaking patients. The authors conducted a retrospective cohort study of all primary TKAs performed at their institution between 2010 and 2017. A total of 1,099 English-speaking and 163 non-English-speaking patients were included. There was no significant difference in rate of MUA (3.5 vs. 4.9%, p = 0.392) or postoperative ROM (102.2 vs. 100°, p = 0.142) between English and non-English-speaking patients. Younger age (p = 0.001) and female sex (p = 0.005), but not patient language, were associated with need for MUA. Patient language does not appear to impact the rate of MUA or ROM following TKA. (Journal of Surgical Orthopaedic Advances 33(3):158-161, 2024).

Background: Prosthetic joint infection (PJI) carries major morbidity and mortality as well as a complicated and lengthy treatment course. In patients who have high degrees of socioeconomic disadvantage, this may be a particularly devastating complication. Our study sought to evaluate the impact of socioeconomic deprivation on outcomes following treatment for PJI of the knee., Methods: We conducted a retrospective review of revision total knee arthroplasty (TKA) procedures performed for the treatment of initial PJI between 2008 and 2020 at a single tertiary care center in the United States. The Area Deprivation Index (ADI) was used to quantify socioeconomic deprivation. The primary outcome measure was presence of a functional knee joint at the time of most recent follow-up defined as TKA components or an articulating spacer. A total of 96 patients were included for analysis. The median follow-up duration was 26.5 months., Results: There was no significant difference in the rate of treatment failure (P = .63). However, the proportion of patients who had a functional knee arthroplasty (in contrast to having undergone arthrodesis, amputation, or retention of a static spacer) declined significantly with increasing ADI index (81.8% for the least disadvantaged group, 58.7% for the middle group, 42.9% for the most disadvantaged group, P = .021)., Conclusions: Patients who have a higher socioeconomic disadvantage as measured by ADI are less likely to maintain a functional knee arthroplasty following treatment for TKA PJI. These findings support continued efforts to improve access to care and optimize treatment plans for patients who have socioeconomic disadvantage., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Studies have linked socioeconomic factors including lower income and minority race with worse functional outcomes following total knee arthroplasty (TKA). Arthrofibrosis is a common complication following TKA, and manipulation under anesthesia (MUA) is an effective treatment option for arthrofibrosis. This study aimed to determine if neighborhood-level socioeconomic disadvantage predicts need for MUA and postoperative range of motion (ROM) among patients undergoing primary elective TKA., Methods: We performed a retrospective cohort study of primary TKAs performed at a single institution over a three-year duration. Area Deprivation Index (ADI) was used to determine each patient's level of socioeconomic disadvantage based on their home address. Patients were allocated into three groups based on ADI: least socioeconomic disadvantage (ADI 1-3), middle socioeconomic disadvantage (ADI 4-6), and most socioeconomic disadvantage (ADI 7-10). Demographic factors and comorbid conditions were recorded. Bivariate analysis was used to evaluate the relationship between degree of socioeconomic disadvantage and need for MUA and postoperative ROM., Results: In total, 600 patients were included and 26.7 % were categorized as most disadvantaged. In comparison to the middle and least disadvantaged groups, these patients were more likely to be Women (71.2 vs. 67.9 and 58.6 %; p  = 0.027), younger (60.7 vs. 62.9 and 66.3 years; p  < 0.001) and have higher BMI (34.9 vs. 33 and 31.7; p  < 0.001) (most disadvantaged vs. middle and least). Analysis revealed no difference in rate of MUA (6.3 vs. 2.5 vs. 4 %; p  = 0.179) or postoperative ROM (98 vs. 98 vs. 100°; p  = 0.753) between the three groups (most, middle, and least disadvantaged, respectively)., Conclusion: Neighborhood socioeconomic disadvantage does not predict rate of MUA or postoperative ROM following TKA. Patients residing in neighborhoods with higher ADI who underwent TKA were more likely to be younger, Women, and have higher BMI, consistent with previous literature. Our results support efforts to improve access to orthopaedic care, including TKA, to patients of all socioeconomic levels., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Background: The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) note "strong" evidence that early and delayed mobilization protocols after small to medium arthroscopic rotator cuff repairs achieve similar rotator cuff healing rates. Purpose : We utilized the reverse fragility index (RFI) to assess the fragility of randomized controlled trials (RCTs) reporting no statistically significant difference in tendon re-tear rates after rotator cuff repair in those undergoing early versus delayed rehabilitation. Methods : Randomized controlled trials used in the most recent AAOS CPGs on the timing of postoperative mobilization after arthroscopic rotator cuff repairs were analyzed. Only RCTs with a reported P value ≥ .05 were included. The RFI at a threshold of P < .05 was calculated for each study. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. Results : In 6 clinical trials with a total of 542 patients, the number of tendon re-tear events was 48. The median RFI at the P < .05 threshold was 4 (range: 3.25-4.75), and the median RFQ was .05 (range: 0.03-0.08). The median loss to follow-up was 6 patients. Of the 6 studies investigated, 3 reported a loss to follow-up greater than their respective RFI. Conclusion : The equivalence in rotator cuff repair healing rates associated with early and delayed mobilization protocols rests on fragile studies, as their statistical non-significance can be reversed by changing the outcome status of only a handful of patients. Consideration should be given to the routine reporting of RFI in clinical practice guidelines including RCTs with statistically non-significant results., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Patrick J. Denard, MD, reports relationships with Arthrex, Inc., Orthopedics Today, Pacira, Wolters Kluwer Health. Mariano E. Menendez, MD, reports relationships with Arthrex, Inc. The other authors declare no potential conflicts of interest., (© The Author(s) 2023.)

Background: Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant., Purpose: The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation., Study Design: Systematic review; Level of evidence, 1., Methods: A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant., Results: Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI., Conclusion: The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.A.M. has received support for education from Kairos Surgical. R.N.P. has received hospitality payments from Stryker Corp. M.E.M. has received consulting fees from Arthrex and hospitality payments from Encore Medical, Medical Device Business Services, and Smith & Nephew. M.J.S. has received support for education from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: To compare complication rates, reoperation rates, and subjective outcomes after arthroscopic and open irrigation and debridement for treatment of native knee septic arthritis., Methods: Following The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the Embase, Cochrane, and PubMed databases was performed. Comparative studies reporting clinical outcomes after arthroscopic versus open treatment for septic arthritis of the native knee in human adults were included. Excluded were case series with <10 patients, inclusion of patients <18 years old, studies on non-native joints, abstract-only publications, and studies without stratification of the involved joint. Two reviewers in duplicate independently performed search and data extraction. The quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies instrument. The mean score among the included studies was 18.2 (range 16-23)., Results: Eleven studies were included, comprising 2,343 knees treated arthroscopically, and 1,595 treated with arthrotomy. Studies reported no differences in erythrocyte sedimentation rate, C-reactive protein, peripheral white blood cells, or symptom chronicity between groups. Nine studies (81.8%) attempted to control for potentially confounding variables in their analyses, and 4 studies (36.4%) reported significant differences in patient characteristics. Reoperation rates ranged from 0% to 50% for arthroscopy and 6% to 71% for arthrotomy. Complication rates ranged from 0% to 39.4% arthroscopically and 0% to 49% for arthrotomy. Superior patient-reported outcomes were achieved after arthroscopy in 2 studies that analyzed subjective outcomes., Conclusions: Arthroscopic management of native knee septic arthritis is a safe and effective alternative to open treatment and is associated with comparable complication rates, reoperation rates, hospitalization lengths, readmission rates, and superior patient-reported outcomes compared with open irrigation and debridement., Level of Evidence: Level IV, systematic review of Level I, III, and IV studies., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Functional somatic syndromes (FSSs), defined as chronic physical symptoms with no identifiable organic cause, may impact results after hip and knee arthroplasty. The purpose of this study was to perform a systematic review assessing the relationship between FSSs and clinical outcomes after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA)., Methods: The PubMed and Web of Science databases were queried from January 1955 through December 2021 for studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches, and chronic low back pain) on outcomes after primary THA/TKA/UKA. Outcomes of interest included patient-reported outcome measures (PROMs), postoperative opioid use, complications, revisions, and costs of care., Results: There were twenty-eight studies, including 768,909 patients, of which 378,384 had an FSS. Five studies reported preoperative PROMs prior to THA/TKA, all of which showed worse PROMs among patients with at least 1 FSS diagnosis. Thirteen studies reported postoperative PROMs after THA/TKA, all of which demonstrated worse PROMs among patients with at least 1 FSS diagnosis. Patients with FSS diagnoses were more likely to continue using opioids at 3, 6, and 12 months following TKA, THA, and UKA. Medical and surgical complications, as well as revision rates, were higher among patients with FSSs., Conclusion: Patients with FSSs have inferior PROMs and are at increased risk for prolonged postoperative opioid use, medical and surgical complications, and revision after hip and knee arthroplasty. Improved understanding of the factors influencing the success of hip and knee arthroplasty is critical. Future studies should address the biopsychosocial determinants of health that can impact outcomes after total joint arthroplasty., (© 2024. The Author(s).)

Background: High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure., Purpose: To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs., Study Design: Systematic review; Level of evidence, 4., Methods: The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded., Results: A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%)., Conclusion: Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.E.M. has received consulting fees from Arthrex and hospitality payments from Encore Medical, Medical Device Business Services, and Smith & Nephew. S.P.R. has received consulting fees from Globus Medical and Medical Device Business Services, speaking fees from Synthes GmbH, and royalties from Globus Medical. J.D. has received grants from Arthrex and Acumed; support for education from Arthrex, Smith & Nephew, and Synthes; and consulting fees from DJO. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Introduction: Product guarantees are known to the manufacturing industry, however warranties have been rare in Orthopaedic surgery. Over the last 10 years, select manufacturers of implants have instituted warranties of varying scope, length, and reimbursement. This phenomenon prompted us to investigate the landscape of warranties in Orthopaedics and compare that to other medical industries to better inform their impact on patient care., Methods: We conducted a systematic review of patient access material of over 120 Orthopaedic manufacturers including that of the Top 25 grossing companies of 2022 to identify the prevalence and scope of these warranties., Results: We identified eight companies that offer a warranty on implants. The expiration time for the implant warranties ranged from one year to lifetime. The scope of the warranties ranged from coverage of a one-time component replacement to outcome-based guarantees that cover any complications and revisions that may result from the surgery., Discussion: While the use of warranties remains uncommon in orthopaedics, their utility is expanding and evolving. Contemporary warranties appear to have a focus on enhancing product-marketability and improving quality-control., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers., Methods: Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed., Results: Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) ( P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort., Conclusions: Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate the robustness of sports medicine and arthroscopy related randomized controlled trials (RCTs) reporting nonsignificant results by calculating the reverse fragility index (RFI) and reverse fragility quotient (RFQ)., Methods: All sports medicine and arthroscopic-related RCTs from January 1, 2010, through August 3, 2021, were identified. Randomized-controlled trials comparing dichotomous variables with a reported P value ≥ .05 were included. Study characteristics, such as publication year and sample size, as well as loss to follow-up and number of outcome events were recorded. The RFI at a threshold of P < .05 and respective RFQ were calculated for each study. Coefficients of determination were calculated to determine the relationships between RFI and the number of outcome events, sample size, and number of patients lost to follow-up. The number of RCTs in which the loss to follow-up was greater than the RFI was determined., Results: Fifty-four studies and 4,638 patients were included in this analysis. The mean sample size and loss to follow-up were 85.9 patients and 12.5 patients, respectively. The mean RFI was 3.7, signifying that a change of 3.7 events in one arm was needed to flip the results of the study from non-significant to significant (P < .05). Of the 54 studies investigated, 33 (61%) had a loss to follow-up greater than their calculated RFI. The mean RFQ was 0.05. A significant correlation between RFI with sample size (R 2  = 0.10, P = .02) and the total number of observed events (R 2  = 0.13, P < .01) was found. No significant correlation existed between RFI and loss to follow-up in the lesser arm (R 2  = 0.01, P = .41)., Conclusions: The RFI and RFQ are statistical tools that allow the fragility of studies reporting nonsignificant results to be appraised. Using this methodology, we found that the majority of sports medicine and arthroscopy-related RCTs reporting nonsignificant results are fragile., Clinical Relevance: RFI and RFQ serve as tools that can be used to assess the validity of RCT results and provide additional context for appropriate conclusions., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs., Methods: A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded., Results: Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI., Conclusion: The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected., Level of Evidence: Level I., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery., Methods: A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs., Results: The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs., Conclusions: Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline., Level of Evidence: Level III, systematic review of Level II-III studies., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA)., Methods: PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics., Results: All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively., Conclusion: Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit., (Copyright © 2022. Published by Elsevier Inc.)

Background: Despite the most recent American Academy of Orthopaedic Surgeons clinical practice guideline making a "strong" recommendation against the use of intraoperative navigation in total knee arthroplasty (TKA), its use is increasing. We utilized the concept of the reverse fragility index (RFI) to assess the strength of neutrality of the randomized controlled trials (RCTs) comparing the long-term survivorship of computer-navigated and conventional TKA., Methods: A systematic review was performed including all RCTs through August 3, 2021, comparing the long-term outcomes of computer-navigated and conventional TKA. Randomized trials with mean follow-up of >8 years and survivorship with revision as the end point were included. The RFI quantifies the strength of a study's neutrality by calculating the minimum number of events necessary to flip the result from nonsignificant to significant. The RFI at a threshold of p < 0.05 was calculated for each study reporting nonsignificant results. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size., Results: Ten clinical trials with 2,518 patients and 38 all-cause revisions were analyzed. All 10 studies reported nonsignificant results. The median RFI at the p < 0.05 threshold was 4, meaning that a median of 4 events would be needed to change the results from nonsignificant to significant. The median RFQ was 0.029, indicating that the nonsignificance of the results was contingent on only 2.9 events per 100 participants. The median loss to follow-up was 27 patients. In all studies, the number of patients lost to follow-up was greater than the RFI., Conclusions: The equipoise in long-term survivorship between computer-navigated and conventional TKA rests on fragile studies, as their statistical nonsignificance could be reversed by changing the outcome status of only a handful of patients--a number that was always smaller than the number lost to follow-up. Routine reporting of the RFI in trials with nonsignificant findings may provide readers with a measure of confidence in the neutrality of the results., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., 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/H302)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty., Methods: In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage., Results: For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74)., Conclusion: We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage., Level of Evidence: Level III., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Conventional triggered electromyography (EMG) in percutaneous pedicle screw (PPS) systems may be unreliable due to the interaction between the insertion apparatus and patient's soft tissue. Our aim was 1) to describe a modified technique of triggered EMG monitoring using insulated Kirschner wire (K-wires), 2) to compare EMG potentials with conventional techniques, and 3) to demonstrate the relationship between patient body mass index (BMI) and triggered EMG potentials., Methods: This was a prospective cross-sectional study of 50 patients undergoing minimally invasive PPS placement. Triggered EMG measurements using K-wires before and after insulation were compared. The difference between EMG measurements before and after insulation was correlated with patient BMI., Results: A total of 50 patients, 22 females and 28 males, underwent triggered EMG testing using K-wires prior to final PPS placement in the thoracic and lumbosacral spine for a total of 472 triggered EMG measurements. When compared to standard triggered EMG monitoring, insulated triggered EMG monitoring demonstrated an average 55.4% decrease in EMG values (P < 0.001). Increasing BMI correlated to increasing % decrease in EMG values (r-coefficient, 0.376; P < 0.01)., Conclusions: We describe a cost-effective, efficient, and reliable technique for triggered EMG during PPS placement which may help ensure accurate screw placement and minimize potentially devastating complications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The use of alternative antibiotics to cefazolin has been associated with increased risk of infection after shoulder arthroplasty. Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin and may reduce the occurrence of infection after shoulder arthroplasty, but the financial viability of this practice is unclear. We used break-even modeling to determine the economic viability of routine preoperative allergy testing for infection prevention in total shoulder arthroplasty patients reporting penicillin and cephalosporin allergies., Methods: Allergy testing cost ($248.24), infection rates after shoulder arthroplasty following use of noncefazolin antibiotics (3.09%), and infection-related care costs ($55,243) were derived from the literature. A break-even equation using these variables was developed to determine the absolute risk reduction (ARR) in the infection rate that would economically justify the routine implementation of preoperative allergy testing. The number needed to treat was calculated from the ARR., Results: Preoperative allergy testing is considered economically justified if it prevents at least 1 infection out of 223 shoulder arthroplasties (ARR = 0.45%). These protocols remained economically viable at varying allergy testing costs, initial infection rates, and infection-related care costs., Conclusions: Routine preoperative penicillin allergy testing is an economically justified infection prevention strategy among patients reporting penicillin and cephalosporin allergies in the setting of elective shoulder arthroplasty. Widespread implementation of this practice may considerably reduce the economic and societal burden associated with prosthetic infections., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty., Methods: A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed., Results: In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA., Conclusion: Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty., Methods: We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores., Results: Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77)., Conclusions: Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Concerted efforts to optimize outcomes and data transparency in shoulder arthroplasty have led to the creation of the American Academy of Orthopaedic Surgeons (AAOS) Shoulder and Elbow Registry, the first nationwide registry of its kind. We used online crowdsourcing to explore the general public's perceptions and beliefs toward the disclosure of quality and price data in shoulder arthroplasty., Methods: A total of 498 participants recruited using Amazon Mechanical Turk (MTurk) completed a survey regarding beliefs about public disclosure of quality and price data in shoulder arthroplasty. The MTurk is an online marketplace for crowdsourcing tasks (e.g., answering surveys) to a pool of over 500,000 registered workers in exchange for financial compensation. Requesters post human-intelligence tasks, and workers can respond to those that they are interested in completing. This web-based platform is an efficient survey tool for medical research, with comparable national representativeness to traditional convenience samples., Results: The majority (95%) of respondents believed surgeons and hospitals should share their data with national registries such as the AAOS Shoulder and Elbow Registry. Most believed that patients considering shoulder arthroplasty should have public access to surgeons' outcomes and complication rates (96%), years of experience (95%), and case volume (92%). Most respondents desired price transparency in implant costs (95%), surgeon reimbursement (80%), and hospital reimbursement (84%). In decreasing order of importance, the top three factors guiding surgeon choice were: (1) surgeon included in the insurer's network, (2) annual case volume, and (3) publicly available outcomes., Conclusion: Increased quality and price transparency in shoulder arthroplasty may empower patients to make better-informed decisions about their care and ultimately enhance value. Given the strong public desire for data transparency and the notion that public disclosure of data is intrinsically associated with performance improvement, surgeons and hospitals should strongly consider submitting their data to national registries such as the AAOS Shoulder and Elbow Registry., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Menendez et al.)

Background: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients., Methods: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT)., Results: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates., Conclusion: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses., Competing Interests: J.J.K. reports personal fees from Cowen Healthcare, personal fees from McKinsey & Company, personal fees from Wells Fargo, other from Conformis, other from NuVasive, outside the submitted work. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

Background: The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF)., Methods: The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded., Results: Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%)., Conclusion: Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources., Purpose: The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges., Methods: The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome., Results: Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery., Conclusion: In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes., Methods: Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact., Results: Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn., Conclusion: Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed., Questions/purposes: We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?, Methods: The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112])., Results: The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19])., Conclusion: There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty., Clinical Relevance: Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: Muscle atrophy (MA) and fatty infiltration (FI) are degenerative processes of the rotator cuff musculature that have incompletely understood relationships with the development of eccentric glenoid wear in the setting of primary glenohumeral osteoarthritis (GHOA)., Methods: All patients with GHOA and an intact rotator cuff who underwent both magnetic resonance imaging and computed tomography scans of the affected shoulder prior to total shoulder arthroplasty between 2015 and 2020 were identified from a prospectively maintained registry. Rotator cuff MA was measured quantitatively on sequential sagittal magnetic resonance images, whereas FI was assessed on sagittal magnetic resonance imaging slices using the Goutallier classification. Preoperative computed tomography scans were reconstructed using automated 3-dimensional software to determine glenoid retroversion, glenoid inclination, and humeral head subluxation. Glenoid deformity was classified according to the Walch classification. Univariate and multivariable regression analyses were performed to characterize associations between age, sex, muscle area, FI, and glenoid morphology., Results: Among the 127 included patients, significant associations were found between male sex and larger overall rotator cuff musculature (P < .01), increased ratio of the posterior rotator cuff (PRC) to the subscapularis area (P = .01), and glenoid retroversion (19° vs. 14°, P < .01). Larger supraspinatus and PRC muscle size was correlated with increased retroversion (r = 0.23 [P = .006] for supraspinatus and r = 0.25 [P = .004] for PRC) and humeral head subluxation (r = 0.25 [P = .004] for supraspinatus and r = 0.28 [P = .001] for PRC). The ratio of PRC muscle size to anterior rotator cuff muscle size was not associated with evidence of eccentric glenoid wear (P > .05). After we controlled for confounding factors, increasing glenoid retroversion was associated with high-grade infraspinatus FI (β, 6.8; 95% confidence interval, 2.9-10.7; P < .01) whereas larger PRC musculature was predictive of a Walch type B (vs. type A) glenoid (odds ratio, 1.3; 95% confidence interval, 1.0-1.5; P = .04)., Conclusion: Patients with eccentric glenoid wear in the setting of primary GHOA and an intact rotator cuff appear to have both larger PRC musculature and higher rates of infraspinatus FI. Although the temporal and causal relationships of these associations remain ambiguous, MA and FI should be considered 2 discrete processes in the natural history of GHOA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs., Methods: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores., Results: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001)., Conclusions: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore public opinion, understanding, and preferences regarding the use of stem cell therapies for the treatment of joint and tendon pathologies using online crowdsourcing., Methods: A 30-question survey was completed by 931 members of the public using Amazon Mechanical Turk, a validated crowdsourcing method. Outcomes included perceptions and preferences regarding the use of stem cells therapies for the nonsurgical treatment of orthopaedic conditions. Sociodemographic factors and a validated assessment of health literacy were collected. Inclusion criteria were adult participants 18 years or older, residence within the United States, and a valid Social Security number. Multivariable logistic regression modeling was used to determine population characteristics associated with the belief that stem cells represent the most effective treatment for long-standing joint or tendon disorders., Results: Most respondents reported that stem cell therapies have convincing evidence to support their use for orthopaedic conditions (84.5%) and are approved and regulated by the Food and Drug Administration (65%). About three-quarters of respondents reported that stem cells can stop the progression of and alleviate pain from arthritis or damaged tendons, and over half (53.5%) reported that stem cells can cure arthritis. Factors with the greatest influence on respondents' decision to receive stem cell therapies are research supporting their safety and effectiveness and doctor recommendation. However, 63.3% of respondents stated that they would consider stem cells if their doctor recommended it, regardless of evidence supporting their effectiveness, and over half would seek another doctor if their orthopaedic surgeon did not offer this treatment option., Conclusions: The public's limited understanding regarding the current evidence associated with stem cell therapies for osteoarthritis and tendinous pathologies may contribute to unrealistic expectations and misinformed decisions. This study highlights the importance of patient education and expectation setting, as well as evidence transparency, as stem cell therapies become increasingly accessible., Level of Evidence: Level IV, case series., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery., Methods: A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted., Results: A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively., Conclusion: Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making., (© 2021 The Author(s).)

Purpose: This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs., Methods: Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR., Results: Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin., Conclusions: Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction., Level of Evidence: IV, economic analysis., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, P =.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [ Orthopedics . 2021;44(5):e668-e674.].

Background: We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic., Methods: A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology., Results: Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively)., Conclusion: The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: Despite the commonplace use of tranexamic acid in total joint arthroplasty, much of the current data regarding its cost-effectiveness examines savings directly related to its hemostatic properties, without considering its protective effect against periprosthetic joint infections. Using break-even economic modeling, we calculated the cost-effectiveness of routine tranexamic acid administration for infection prevention in total joint arthroplasty., Materials and Methods: The cost of intraoperative intravenous tranexamic acid, the cost of revision arthroplasty for periprosthetic joint infections, and the baseline rates of periprosthetic joint infections in patients who did not receive intraoperative tranexamic acid were obtained from the literature and institutional purchasing records. Break-even economic modeling incorporating these variables was performed to determine the absolute risk reduction in infection rate to make routine intraoperative tranexamic acid use economically justified. The number needed to treat was calculated from the absolute risk reduction., Results: Routine use of intraoperative tranexamic acid is economically justified if it prevents at least 1 infection out of 3125 total joint arthroplasties (absolute risk reduction = 0.032%). Cost-effectiveness was maintained with varying costs of tranexamic acid, infection rates, and periprosthetic joint infection costs., Conclusion: The routine use of intraoperative tranexamic acid is a highly cost-effective practice for infection prevention in primary and revision total joint arthroplasty. The use of tranexamic acid is warranted across a wide range of costs of tranexamic acid, initial infection rates, and costs of periprosthetic joint infection treatment., Competing Interests: Dr. Kavolus declares stock or stock options with Conformis, Histogenics, Neogenomics, Nuvasive, and Vericel. No other author has anything to declare., (© 2021 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Background: Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH)., Methods: A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness., Results: Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs., Conclusion: Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Case: We describe 2 cases of gross trunnion failure (GTF) in males with Centers for Disease Control and Prevention Class 3 obesity 10 years after metal-on-polyethylene total hip arthroplasty (THA) with a titanium-alloy femoral stem and Type 1 taper. One patient received a large diameter cobalt-chromium femoral head, whereas the other received a smaller diameter head, both with high-offset femoral stems., Conclusion: This is the first report of GTF involving the Echo Bi-Metric femoral stem after metal-on-polyethylene THA, and surgeons should consider the potential complication of GTF when using this specific femoral stem with metal heads in obese male patients., 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/B537)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery., Methods: A 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology., Results: Most respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery., Conclusion: The public's unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We studied variation in perioperative opioid use after total joint arthroplasty with respect to patient and procedure characteristics in order to inform initiatives to optimize pain relief., Methods: We recorded perioperative opioid consumption for a cohort of total joint arthroplasty patients to identify factors underlying variation in perioperative opioid use., Results: Younger patient age, tobacco use, greater symptoms of depression, private insurance, and knee arthroplasty were associated with increased opioid consumption., Conclusions: Awareness of the patient characteristics associated with increased perioperative opioid use can help inform implementation of targeted strategies for safe, optimal pain relief and satisfaction., Competing Interests: •CSS certifies that he had nothing of value related to this study.•MEM certifies that he had nothing of value related to this study.•NRP certifies that he had nothing of value related to this study.•AAF certifies that he had nothing of value related to this study.•YMK certifies that he had nothing of value related to this study.•HB certifies that he had nothing of value related to this study.•DR certified that he had nothing of value related to this study.•HR certifies that he had nothing of value related to this study., (© 2021 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Background: Prosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA)., Methods: Baseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness., Results: The use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200., Conclusion: The use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Many U.S. health systems are grappling with how to safely resume elective surgery amid the COVID-19 pandemic. We used online crowdsourcing to explore public perceptions and concerns toward resuming elective surgery during the pandemic, and to determine factors associated with the preferred timing of surgery after health systems reopen., Methods: A 21-question survey was completed by 722 members of the public using Amazon Mechanical Turk. Multivariable logistic regression analysis was performed to determine factors associated with the timing of preferred surgery after health systems reopen., Results: Most (61%) participants were concerned with contracting COVID-19 during the surgical process, primarily during check-in and in waiting room areas, as well as through excessive interactions with staff. Overall, 57% would choose to have their surgery at a hospital over an outpatient surgery center. About 1 in 4 (27%) would feel comfortable undergoing elective surgery in the first month of health systems reopening. After multivariable adjustment, native English speaking (OR, 2.6; 95% CI, 1.04-6.4; P = .042), male sex (OR, 1.9; 95% CI, 1.3-2.7; P < .001), and Veterans Affairs insurance (OR, 4.5; 95% CI, 1.1-18.7; P = .036) were independent predictors of preferring earlier surgery., Conclusion: Women and non-native English speakers may be more hesitant to undergo elective surgery amid the COVID-19 pandemic. Despite concerns of contagion, more than half of the public favors a hospital setting over an outpatient surgery center for their elective surgery. Concerted efforts to minimize patient congestion and unnecessary face-to-face interactions may prove most effective in reducing public anxiety and concerns over the safety of resuming elective care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine whether surgical repair of distal biceps tendon ruptures in professional football players would lead to a decrease in postinjury performance when compared to preinjury performance and control-matched peers. We also sought to define return to sport, postinjury career length, and games played per season in National Football League players following surgical repair of distal biceps tendon ruptures., Methods: Data for National Football League players who underwent surgical repair of distal biceps tendon ruptures during a 20-year time period were collected. A total of 25 cases in 22 players were included in the analysis. Matched controls based on player position, age, experience, and performance statistics were identified. Performance scores for cases and controls were calculated using a standardized scoring system specific to player position., Results: Of the 25 cases, 21 (84%) were able to return to sport in the National Football League. The overall 1-year survival rate of return to play in players undergoing surgical repair of distal biceps tendon ruptures was 76% and overall 2-year survival was 56%. Players who underwent surgical repair of distal biceps tendon ruptures had significantly shorter postinjury career lengths and played fewer games per season postinjury than matched controls. There was no significant difference by position in postinjury performance scores when compared to matched controls., Conclusion: National Football League players undergoing surgical repair of distal biceps tendon ruptures have a high rate of return to sport, though many retire within the next few seasons following surgery. Players who do return to competition can be expected to perform at a level comparable to their peers., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies., Methods: The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR., Results: Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment., Conclusion: Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States., Methods: Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups., Results: The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P trend  = .97) with an increase in total hip arthroplasty (THA) revision (P trend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P trend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both)., Conclusion: The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Newer strategies to decolonize the shoulder of Cutibacterium acnes may hold promise in minimizing the occurrence of infections after shoulder arthroplasty, but little is known about their cost-effectiveness. Break-even models can determine the economic viability of interventions in settings with low outcome event rates that would realistically preclude a randomized clinical trial. We used such modeling to determine the economic viability of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty., Methods: Skin decolonization protocol costs ($11.76 for benzoyl peroxide; $0.96 for hydrogen peroxide), baseline infection rates for shoulder arthroplasty (0.70%), and infection-related care costs ($50,230) were derived from institutional records and the literature. A break-even equation incorporating these variables was developed to determine the absolute risk reduction (ARR) in the infection rate to make prophylactic use economically justified. The number needed to treat was calculated from the ARR., Results: Topical benzoyl peroxide is considered economically justified if it prevents at least 1 infection out of 4348 shoulder arthroplasties (ARR = 0.023%). Hydrogen peroxide is economically justified if it prevents at least 1 infection out of 50,000 cases (ARR = 0.002%). These protocols remained economically viable at varying unit costs, initial infection rates, and infection-related care costs., Conclusions: The use of topical benzoyl peroxide and skin preparations with hydrogen peroxide are highly economically justified practices for infection prevention in shoulder arthroplasty. Efforts to determine drawbacks of routine skin decolonization strategies are warranted as they may change the value analysis., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature. LEVEL OF EVIDENCE:: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.