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Background: As the demand for total knee arthroplasty (TKA) escalates, 90-day readmissions have emerged as a pressing clinical and economic concern for the current value-based health care system. Consequently, health care providers have focused on estimating the risk levels of readmitted patients; however, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following TKA., Methods: A prospective cohort of primary unilateral TKAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 10,521 patients). Unplanned readmissions were reviewed individually to determine their primary cause, either medical or orthopaedic-related. Orthopaedic-related readmissions were specific complications affecting the joint, prosthesis, or surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently., Results: Overall, the rate of 90-day readmissions was 6.7% (n = 704). Over 82% of these readmissions were due to medical-related causes (n = 580), with the remaining 18% being orthopaedic-related (n = 124) readmissions. The area under the curve for the 90-day readmission model was 0.68 (95% confidence interval: 0.67 to 0.70). Sex, smoking, length of stay, and discharge disposition were associated with orthopaedic readmission, while age, sex, race, the Charlson Comorbidity Index, insurance, surgery day, opioid overdose risk score, length of stay, and discharge disposition were associated with medical-related 90-day readmissions., Conclusions: Medical-related readmissions after TKA are more prevalent than orthopaedic-related readmissions. Through successfully constructing and validating multiple 90-day readmission predictive models, we highlight the distinct risk profiles for medical and orthopaedic-related readmissions. This emphasizes the necessity for nuanced, patient-specific risk stratification and preventive measures., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Patellar tendon rupture (PTR) is a rare and severe postoperative complication of total knee arthroplasty (TKA). Even rarer is the intraoperative occurrence of PTR during TKA. PTR is a major complication as it can lead to chronic disability, functional limitations, and postoperative morbidity. Therefore, surgical repair of the intraoperative PTR is typically pursued through one of the following three methods: (i) primary repair with direct suturing; (ii) direct suturing with cerclage augmentation, and (iii) direct suturing with either autograft or synthetic graft augmentation. In the case of an incomplete tear, direct repair with suture anchors for distal tears, and end-to-end repair with/without synthetic graft augmentation for mid-substance and proximal tears, is recommended. In the case of complete tears, if adequate tissue is present, direct repair with extensor mechanism reconstruction should be performed, regardless of the location of the tear. Furthermore, for complete tears with defective tissue, extensor mechanism reconstruction should be performed using mesh or allograft augmentation, regardless of the location of the tear. This review aims to provide a comprehensive and thorough overview of the prevention, diagnosis, management, and outcomes of intraoperative extensor mechanism injuries during TKA., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: This study aimed to define an intra-articular surgeon-administered technique that may be comparable to ultrasound (US)-guided adductor canal block (ACB)., Methods: Five cadaver lower limbs were examined. An anesthesiologist administered a US-guided ACB using 20 mL of dilute indocyanine dye. An orthopedic surgeon performed a medial parapatellar arthrotomy and introduced an 18-gauge needle 1-2 cm proximal to the palpated adductor tubercle angled posteromedially. Needle position and dye spread were fluoroscopically documented., Results: This technique consistently reached the infrapatellar branch of the saphenous nerve, nerve to the vastus medialis muscle, and posterior capsule, with minimal proximal dye spread., Conclusions: This technique may be an efficient complement to ACB or surgeon infiltration or an alternative to US-guided ACB when it is not available., (© 2025 The Authors.)

Abstract: The Centers for Medicare & Medicaid Services (CMS) recently introduced mandatory reporting of patient-reported outcomes (PROs) following primary, elective total joint arthroplasty (TJA) procedures. This article explores the implications and implementation challenges of this policy shift in the field of orthopaedic surgery. With a review of the existing literature, we analyze the potential benefits and limitations of PROs, discuss the role of CMS in health-care quality improvement initiatives, explain the predicted difficulties in the successful implementation of this new mandate, and provide recommendations for the successful integration of the reporting of PROs in clinical practice., 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/I377)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic surgeries in the United States, yet little information exists regarding its utilization in different settlement types. This study aimed to determine the number of TKA-performing surgeons by settlement type and assess trends in the volume of TKAs in urban, micropolitan, small town, and rural settings., Methods: Using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners database, the number of orthopaedic surgeons performing primary and revision TKAs from 2013 to 2020 was determined. The zip code where TKA was performed was used to identify the rural-urban commuting area codes (RUCA) and classify locations into one of four settlement types: urban/metropolitan, micropolitan (large town), small town, or rural. Correlations in surgeon number and TKA volume by settlement type were evaluated by Mann-Kendall tests., Results: Between the years of 2013 and 2020, TKAs were billed by up to 7,192 orthopaedic surgeons. The proportions of TKAs occurring in settlement types were the following: urban/metropolitan, 85.2%; micropolitan, 11.5%; small town, 2.6%; rural, 0.6%. Areas without RUCA data had 32.9 TKAs per surgeon per year, the highest overall median surgeries per year over the 8-year period. The median number of TKAs per surgeon per year was 28, 25.4, 21.4, and 20.7 for urban/metropolitan, micropolitan, small towns, and rural areas, respectively., Conclusion: A considerable difference exists in both the number of surgeons and the proportion of TKAs conducted across various settlement types. Twenty percent of population in the United States lives in rural areas; however, only 0.6% of billed TKAs occurred in these areas over the study period, indicating a gap in orthopaedic care access. It is imperative to understand TKA surgeon distribution and focus on strategies aimed at attracting and retaining proficient surgeons to address the healthcare needs of these underserved regions., (Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)

Background: Total hip arthroplasty (THA) practices are evolving under the influence of the current value-based healthcare system and bundled payment models. This study aimed to (1) evaluate national trends in discharge disposition and postoperative outcomes after THA, (2) compare discharge cohorts on episode-of-care parameters, and (3) determine predictors of nonhome discharge from 2011 to 2021., Methods: The National Surgical Quality Improvement Program database was queried for THA data from 2011 to 2021. A total of 328,380 patients undergoing THA were identified between 2011 and 2021. Of these patients, 276,710 were discharged home and 51,670 were discharged to nonhome locations. Trends of annual discharge disposition, healthcare utilization parameters, and proxies for postoperative complications were reported. A multivariable logistic regression analysis was conducted to identify potential risk factors for nonhome discharge., Results: The percentage of patients who were discharged to home increased from 70.20% in 2011 to 92.42% in 2021. In those discharged to home, 30-day readmission rates, 30-day major complication rates, length of stay, any wound complications, and need for transfusion all decreased within the past decade. The percentage of patients who were discharged to nonhome locations decreased from 29.80% in 2011 to 7.58% in 2021. In this group, major complication rates within 30 days, length of stay, and need for mechanical ventilation increased from 2011 to 2021. Greater age, female sex, body mass index of <18.5, race, smoking, higher comorbidity burden, and functional status were associated with greater odds ratios of nonhome discharge., Conclusion: Home discharge after THA has increased substantially over the past decade, with more than 90% of patients now being discharged home. However, a small subset of higher-risk patients still requires nonhome discharge and experience worse outcomes. Focused efforts based on known discharge risk factors may allow implementing perioperative optimization strategies to further improve outcomes in this population., (Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)

Objectives: Proteolytic cartilage extracellular matrix breakdown is a major mechanism of articular cartilage loss in osteoarthritis (OA) pathogenesis. We sought to determine the overlap of proteolytic peptides in matched knee OA cartilage and synovial fluid on a proteome-wide scale to increase the prospective biomarker repertoire and to attribute proteolytic cleavages to specific secreted proteases., Design: Matched human knee OA cartilage and synovial fluid (n = 5) were analyzed by N-terminomics using Terminal Amine Isotopic Labeling of Substrates (TAILS), comprising labeling and enrichment of protein N-termini, high-resolution mass spectrometry and positional peptide mapping. Donor non-OA articular cartilage was digested with CMA1, MMP13 or ADAMTS5, and TAILS was used to identify cleavage sites, which were matched against cartilage and synovial fluid degradomes., Results: Of over 20,000 cleaved peptides in the combined OA cartilage and synovial fluid degradomes, 677 peptides, originating from 153 proteins, were present in all cartilage and synovial fluid samples. CMA1, MMP13 and ADAMTS5 digestion of cartilage identified numerous cleavage sites for each protease and distinct cleavage site preferences. Peptides resulting from the activities of these proteases were detected in OA cartilage and synovial fluid., Conclusions: Proteolytic fragments from both cartilage and circulating proteins are detectable by synovial fluid degradomics. CMA1, MMP13 and ADAMTS5 activity profiles in cartilage are distinct from each other and the previously determined HtrA1 profile. This work expands the proteolytic biomarker space for OA investigation, suggests that multiple, diverse proteases contribute to cartilage destruction, and demonstrates that their specific contributions can each be defined by multiple biomarkers., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success., Methods: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices., Results: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care., Conclusions: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Hospital readmissions after primary total knee arthroplasty (TKA) significantly drive health care expenditure and resource utilization. Recent studies have suggested differences between medical and orthopaedic readmissions after TKA and their episodes of care (EOCs) but lack patient-level data reporting. This study aimed to compare EOCs for medical and orthopaedic-related readmissions regarding initial readmission wards, services consulted, intensive care unit (ICU) admissions, blood transfusions, surgical interventions, length of stay, and discharge disposition.All patients enrolled in a prospective data collection system at a tertiary medical center undergoing elective, unilateral, primary TKA from 2016 to 2020 and readmitted within 90 days of discharge were included. Readmissions were categorized as related to medical or orthopaedic causes. Patients' electronic medical records were reviewed to collect demographic and clinical information about EOC associated with the readmission hospital course.In total, 82.4% (580/704) of 90-day readmissions after elective, primary TKA were related to medical causes, with the remaining 17.6% (124/704) of readmissions due to orthopaedic causes. Medical readmissions most often pertained to gastrointestinal complaints, while wound complications accounted for most orthopaedic readmissions. Most readmissions (63.1%, 444/704) occurred within the first 30 days after TKA. Patients with medical and orthopaedic readmissions had differences in EOC, such that more medical readmissions required ICU care (10.6 vs. 1.6%, p  < 0.001), and more patients with orthopaedic readmissions needed a surgical intervention (65.4 vs. 6.7%, p  < 0.001).By understanding differences in EOC for medical and orthopaedic readmissions after TKA, targeted initiatives can be developed to deliver more efficient, cost-effective orthopaedic surgical care, as the orthopaedic surgical community continues to provide value-based care., Competing Interests: None declared., (Thieme. All rights reserved.)

This study characterized the dissolution properties of two commercially available bone substitutes: (1) A calcium sulfate (CaS)/brushite/β-tricalcium phosphate (TCP) graft containing 75% CaS and 25% calcium phosphate; and (2) a CaS/hydroxyapatite (HA) bone graft substitute composed of 60% CaS and 40% HA. Graft material was cast into pellets (4.8 mm outer diameter × 3.2 mm). Each pellet was placed into a fritted thimble and weighed before being placed into 200 mL of deionized water. The pellets were removed from the water on days 1, 2, 3, 4, 6, 8, 14, 18, or until no longer visible. The mass and volume of each pellet were calculated at each timepoint to determine the rate of dissolution. Analysis of variance was performed on all data. Statistical significance was defined as p  < 0.05. The CaS/HA pellets were completely dissolved after day 8, while the CaS/brushite/β-TCP pellets remained until day 18. The CaS/brushite/β-TCP pellets had significantly more mass and volume at days 1, 2, 3, 4, 6, and 8 timepoints. The CaS/brushite/β-TCP pellets lost 46% less mass and 53% less volume over the first 4 days as compared to CaS/HA pellets. The CaS/brushite/β-TCP pellets had a rough, porous texture, while the CaS/HA pellets had a smooth outer surface. Overall the CaS/brushite/β-TCP pellets dissolved approximately twice as slowly as the CaS/HA pellets in vitro. As these in vitro findings might have in vivo implications, further clinical data are required to further confirm and establish the optimal synthetic bone substitute strategy or antibiotic delivery carrier., Competing Interests: N.S.P. is a paid consultant for Stryker Corporation. M.S. and J.F. are paid employees of Stryker Corporation., (Thieme. All rights reserved.)

Introduction: The average body mass index (BMI) in the United States has tripled over the last five decades despite concerted population-based efforts for weight management. Elevated BMI and, in particular, obesity are risk factors for osteoarthritis. This trend has led to increased demands for total knee (TKA) and total hip arthroplasty (THA), necessitating an in-depth understanding of how elevated BMI impacts TKA and THA., Areas Covered: This paper reviews the literature investigating the effects of elevated BMI, primarily obesity, on TKA and THA, focusing on preoperative, intraoperative, and postoperative considerations. It describes the associated risks, economic implications, and ethical considerations of patients with high BMIs undergoing TKA or THA. To ensure all relevant literature was included, Ovid Medline and Google Scholar databases were searched for the following terms, 'body mass index,' 'obesity,' 'knee,' 'hip,' and 'arthroplasty' for articles published from January 2019 through July 2024., Expert Opinion: Despite the challenges of high BMI in TKA and THA, a deeper understanding of obesity as a chronic illness, coupled with advances in surgical techniques, can improve patient outcomes. A multidisciplinary approach and further research will optimize the care of patients with elevated BMIs undergoing total joint arthroplasty (TJA).

Background: Unicompartmental knee arthroplasty (UKA) procedures have become much more common in the United States in recent years, with >40,000 UKAs performed annually 1 . However, it is estimated that 10% to 40% of UKAs fail and thus require conversion to total knee arthroplasty (TKA) 2-5 . In the field of total joint arthroplasty, robotic-assisted surgeries have demonstrated advantages such as better accuracy and precision of implant positioning and improved restoration of a neutral mechanical axis 6-9 . These advantages may be useful in UKA to TKA conversion surgeries, as the use of robotic assistance may result in improved bone preservation., Description: Robotic-assisted TKA is performed with the patient in the supine position, under spinal anesthesia, and with use of a tourniquet. A limited incision is made approximately 1 cm medial to a standard midline incision, through the previous UKA incision. A medial parapatellar arthrotomy and partial synovectomy are performed. Array pins are placed in a standard fashion: intra-incisional in the femoral diaphysis and extra-incisional in the distal tibial diaphysis. Femoral and tibial bone registration is performed, along with functional knee balancing to adjust implant positioning. The robotic arm-assisted system is then utilized to achieve the planned bone resections. After completing all bone cuts, trial components are inserted. Trial reduction is then performed, and knee extension, stability, and range of motion are assessed. The final implant is cemented into place. We utilize a cruciate-retaining TKA implant. No augments are required., Alternatives: An alternative treatment option is manual UKA to TKA conversion., Rationale: Robotic-assisted conversion of UKA to TKA is especially useful for patients requiring bone preservation. For example, 1 case series found that the use of robotic-assisted conversion of UKA to TKA resulted in a decreased use of augments and a smaller average polyethylene insert thickness compared with manual conversion. Furthermore, mechanical bone loss may occur secondary to implant loosening. Thus, in patients with aseptic loosening, robotic-assisted conversion of UKA to TKA may be useful 10 ., Expected Outcomes: Results of robotic-assisted conversion of UKA to TKA have thus far been excellent. In a study of 4 patients undergoing robotic-assisted conversion of UKA to TKA, all patients experienced uneventful recoveries without any need for subsequent re-revision 10 . In a case report of a robotic-assisted conversion of UKA to TKA, the patient was pain-free at both 6 months and 1 year postoperatively, with a range of motion of 0° to 120° at 6 months and 0° to 130° at 1 year, and excellent component alignment on radiographs at 1 year 11 . In another case report, the patient had full range of motion and a normal, painless gait at 1 year postoperatively 12 . When comparing manual versus robotic-assisted conversion, 1 study found no difference in postoperative range of motion or complications among the 28 patients assessed 13 ., Important Tips: Ensure accurate soft-tissue balancing prior to implant removal and osseous resection.Augments can easily be cut by executing the initial cut, then moving the resection depth either 5 or 10 mm deeper. The cut is then performed only in the compartment that needs an augment. Augment cutting is usually performed in a stepwise fashion to avoid excessive resection in the other compartments in order to preserve native bone.Having revision implants with increased constraint and metaphyseal fixation available is important during these cases because, as in any revision surgery, unexpected events can lead to the need for other implant choices., Acronyms and Abbreviations: UKA = unicompartmental knee arthroplastyRA = robotic-assistedTKA = total knee arthroplastyROM = range of motionCT = computed tomographyPCL = posterior cruciate ligamentDVT = deep venous thrombosisVTE = venous thromboembolism., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A481)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Core decompression was developed as a joint-preserving procedure for patients with early-stage osteonecrosis of the femoral head. Previous studies indicated a high success rate that outperforms nonoperative management of pre-collapse hips. The traditional single-tunnel core decompression technique uses a cannulated drill bit inserted into the lateral cortex of the proximal femur. Multiple small drilling was introduced to decrease the risk of fracture through a less invasive technique. Adjunctive therapeutics such as tantalum rods, bone-grafting, orthobiologic (e,g, bone marrow aspirate concentrate, mesenchymal stem cells, platelet-rich plasma, and human umbilical cord mesenchymal stem cell extracts) as well as electric stimulation have all been studied. No consensus regarding the ideal treatment has been reached. This review analyzes the advantages and disadvantages of current core decompression techniques to provide orthopaedic surgeons with direction in managing patients with avascular necrosis of the femoral head., Competing Interests: Declarations. Competing interests: All other authors have no disclosures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: There is conflicting data in the literature regarding the clinical utility of wearable devices. This study examined the association between patient reported outcome measures (PROMs) and step and stair flight counts obtained from wearable devices in postoperative total hip arthroplasty (THA) patients., Methods: Data was collected from a multicenter prospective longitudinal cohort study from October 2018 to February 2022. A smartphone-based platform with smartwatch was utilized for collection of daily step and stair flight counts. Subjects (N = 1644) completed the Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and numerical rating scale (NRS) pain scores preoperatively and at 1 and 3 months postoperatively. Patients who reported living in a multi-level home (N = 931) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between step and stair flight counts with NRS pain and HOOS JR scores., Results: Step counts demonstrated a weak negative correlation to NRS pain scores at preoperative (r = - 0.15, p < 0.0001), 1-month (r = - 0.15, p < 0.0001), and 3-months follow-up (r = - 0.06, p = 0.05). Step counts demonstrated a weak positive correlation with HOOS JR scores at preoperative (r = 0.16, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.13, p < 0.0001). Stair flight counts demonstrated a weak negative correlation with NRS pain preoperatively (r = - 0.19, p < 0.0001) and at 1-month (r = - 0.11, p = 0.003). Stair flight counts positively correlated with HOOS JR scores at preoperative (r = 0.24, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.09, p = 0.02)., Conclusion: The utilization of wearable technology can enhance the evaluation of patient outcomes after THA, primarily due to the observed correlation between data collected from wearables and PROMs. Our study highlights the importance of the use of objective data, in addition to subjective patient reported data, when analyzing postoperative patient progress, which propels forward the field of postoperative THA patient care., Competing Interests: Declarations. Conflict of interests: Mr. Nickelas Huffman, Dr. Ignacio Pasqualini, Dr Shujaa T. Khan, and Ms. Alison Klika do not have any conflicts of interest to disclose. Ethical approval: The study was approved by the WCG Institutional Review Board and registered in ClinicalTrials.gov prior to enrollment activities (NCT03737149); all subjects provided written informed consent., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Patients with immune-mediated inflammatory diseases (IMIDs) like rheumatoid arthritis (RA) are at higher risk for severe COVID-19 and long-term complications in bone health. Emerging clinical evidence demonstrated that SARS-CoV-2 infection reduces bone turnover and promotes bone loss, but the mechanism underlying worsened bone health remains elusive. This study sought to identify specific immune mediators that exacerbated preexisting IMIDs after SARS-CoV-2 exposure. Plasma samples from 4 groups were analyzed: healthy, IMID only, COVID-19 only, and COVID-19 + IMID. Using high-throughput multiplexed proteomics, we profiled 1,500 protein biomarkers and identified 148 unique biomarkers in COVID-19 patients with IMIDs, including elevated inflammatory cytokines (e.g., IL-17F) and bone resorption markers. Long-term circulating SARS-CoV-2 ORF8, a virulence factor for COVID-19, was detected in the COVID + IMID group. RA was one of the most common IMIDs in our study. ORF8 treatment of RA-derived human osteoblasts (RA-hOBs) increased levels of inflammatory (TNF, IL6, CCL2) and bone resorption (RANKL/osteoprotegerin ratio) markers compared with healthy controls. Supernatants from ORF8-treated RA-hOBs drove the differentiation of macrophages into osteoclast-like cells. These findings suggest that SARS-CoV-2 exposure can exacerbate IMIDs through ORF8-driven inflammation and osteoclastogenesis, highlighting potential therapeutic targets for managing COVID-19-induced bone pathologies.

Introduction: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics., Methods: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted., Results: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance ( P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons., Conclusion: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon., Study Description: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Introduction: As the number of primary total hip arthroplasty (THA) procedures continues to increase, so too does the demand for revision surgery, with a 43-70% rise in revision THA anticipated by 2030. Femoral stem extraction in revision THA is particularly challenging and may lead to complications like femoral bone loss or fractures. However, increasing catalogue of femoral stems available for primary and revision THA has led technological advances in extraction devices to potentially overcome these limitations. This review aims to discuss the identification of femoral implants and the various femoral stem extraction devices currently available., Methods: A scoping review of current literature was conducted to explore currently available femoral extraction devices. The devices not available in literature but used in clinical practice have also been included. This review focused on the technical components, advantages, and limitations of different femoral extraction tools, including osteotomes, reciprocating saws, high-speed burrs, trephines, and extraction systems like the Watson Extraction System, Exodus Revision Hip System, Shukla Hip Universal Stem Extraction System, and DePuy Synthes Extractors., Results: Identifying femoral implants is a critical step in preoperative planning to allow for appropriate equipment to be available during revision surgery. The present review highlights that no single extraction device is universally applicable. Tools like flexible osteotomes, burrs, and trephines offer versatility but may risk bone damage. Advanced systems like the Watson Extraction System and Shukla Hip Universal Stem Extraction System provide more precise extraction, reducing the likelihood of cortical perforations and decreasing operative time., Conclusions: Efficient femoral stem extraction in rTHA is essential for managing complications and preserving bone stock. While traditional tools remain valuable, the development of specialized extraction systems offers improved precision and efficiency. Preoperative planning, including accurate implant identification, and the selection of appropriate extraction devices are crucial for successful outcomes in revision hip arthroplasty., Competing Interests: Declarations. Competing interests: Authors 1, 2, 3 and 4 have no competing interests to declare. Author 5 has the following disclosures not related to the present study. American Association of Hip and Knee Surgeons: Board or committee member. ISCT: Board or committee member. Journal of Hip Surgery: Editorial or governing board. Journal of Knee Surgery: Editorial or governing board. Orthopaedic Research Society: Board or committee member. Osteal Therapeutics: Research support. Pacira: Paid consultant. Peptilogics: Research support., RegenLab: Research support. Signature Orthopaedics: Research support. Stryker: Paid consultant. Zimmer: Research support. Author 6 has the following disclosures not related to the present study. Brasseler: Paid presenter or speaker. RomTech: Stock or stock Options., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Patients who undergo a second THA at least 1 year after the first one may experience different recovery courses after each THA. It is unknown what the clinically relevant improvements and healthcare utilization are after each THA in patients undergoing contralateral THA > 1 year apart., Questions/purposes: (1) Do patient-reported outcome measures (PROMs) differ at baseline and 1 year after THA for the first and second hip arthroplasty? (2) Does the likelihood of achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds differ for the first and second hip arthroplasty? (3) Does utilization of healthcare within 90 days of THA, using discharge disposition, length of stay (LOS), and 90-day readmission risk as proxies, differ between the first and second hip arthroplasty?, Methods: Between January 2016 and December 2021, a total of 14,023 primary THAs for hip osteoarthritis were performed at a large tertiary academic center, and data from each were longitudinally maintained in an institutional database. In this retrospective study, we excluded nonelective (n = 265), simultaneous bilateral (n = 89), staged bilateral < 1 year apart (n = 1856), unilateral THAs (n = 7541), and those who were lost prior to the minimum study follow-up of 1 year or had incomplete data sets (n =3618), leaving 654 contralateral THAs > 1 year apart (327 patients) for analysis here. The median (range) patient age was 64 years (26 to 88) at the time of the first THA and 66 years (27 to 88) at the second THA. The mean (IQR) time from first THA to second THA was 696 days (488 to 1008). In all, 62% (204 of 327) of patients were women, and 89% (286 of 321) were White. The median (range) BMI was 29 kg/m2 (first THA 16 to 60, second THA 18 to 56) at both THAs. PROMs were obtained preoperatively and at 1 year after each of the THAs and included Hip Disability and Osteoarthritis Outcome Score pain (HOOS-pain), physical function (HOOS-PS), and joint replacement (HOOS-JR) scores, as well as the Veterans Rand 12-Item Health Survey mental component summary score. Each was scored from 0 to 100, with higher scores representing better patient perceived outcomes. A distribution-based method was used to calculate the MCID thresholds (HOOS-pain 8.35, HOOS-PS 9.47, and HOOS-JR 7.76), while an anchor-based method was utilized for the PASS thresholds (HOOS-pain 80.6, HOOS-PS 83.6, and HOOS-JR 83.6). Healthcare utilization outcomes included discharge disposition, LOS, and 90-day readmission rates., Results: Patients had slightly lower baseline PROM scores in all HOOS subdomains before the first THA compared with the second THA (median HOOS-pain 38 versus 42, p < 0.001; HOOS-PS 54 versus 58, p < 0.001; HOOS-JR 43 versus 47, p < 0.001). The difference between baseline and 1-year postoperative scores was slightly larger in all HOOS subdomains after the first THA (median HOOS-pain difference 52 versus 50, p < 0.001; HOOS-PS difference 38 versus 31, p < 0.001; HOOS-JR difference 42 versus 39, p < 0.001). There was no difference in the percentage of patients achieving the MCID in HOOS-pain (97% versus 97%; p = 0.93), HOOS-PS (92% versus 88%; p = 0.17), and HOOS-JR (96% versus 94%; p = 0.18) between the first and second THAs. Although there was also no difference in the percentage of patients achieving PASS thresholds in HOOS-pain (81% versus 77%; p = 0.11), HOOS-PS (82% versus 79%; p = 0.055), and HOOS-JR (71% versus 71%; p = 0.39) between the first and second THAs, considerably fewer patients were reaching the PASS threshold in both THAs. After the second THA, slightly more patients were discharged home (95% versus 91%; p = 0.03) and had a very slightly shorter LOS (1.28 versus 1.35 days; p < 0.001). There was no difference in 90-day readmission rates between the first and second THA (4% versus 5%; p = 0.84)., Conclusion: In patients undergoing contralateral THA > 1 year apart, baseline PROMs were slightly worse before the first THA, and improvements were slightly greater compared with the second THA, although these differences were likely not clinically significant. Clinically meaningful improvements, based on MCID and PASS thresholds, were similar at 1 year for both THAs, yet 20% to 25% of patients reported inadequate pain relief after both surgeries. Healthcare utilization was also comparable between both procedures. Surgeons can use these findings to counsel patients on the likely similar outcomes following both their THAs. Future studies should explore factors contributing to inadequate pain relief and identify strategies to improve patient outcomes after both THAs.Level of Evidence Level III, therapeutic study., 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 © 2024 by the Association of Bone and Joint Surgeons.)

Periprosthetic joint infection (PJI) is a multifactorial disease, and the risk of contracting infection is determined by the complex interplays between environmental and host-related factors. While research has shown that certain individuals may have a genetic predisposition for PJI, the existing literature is scarce, and the heterogeneity in the assessed genes limits its clinical applicability. Our review on genetic susceptibility for PJI has the following two objectives: (1) Explore the potential risk of developing PJI based on specific genetic polymorphisms or allelic variations; and (2) Characterize the regulatory cascades involved in the risk of developing PJI. This review focused on clinical studies investigating the association between genetic mutations or variations with the development of PJI. The genes investigated in these studies included toll-like receptors and humoral pattern recognition molecules, cytokines, chemokines, mannose-binding lectin (MBL), bone metabolism molecules, and human leukocyte antigen. Among these genes, polymorphisms in IL-1, MBL, vitamin D receptors, HLA-C, and HLA-DQ might have a relevant impact on the development of PJI. The literature surrounding this topic is limited, but emerging transcriptomic and genome-wide association studies hold promise for identifying at-risk genes. This advancement could pave the way for incorporating genetic testing into preoperative risk stratification, enhancing personalized patient care.

Background: After clinical introduction in 2005, sequentially annealed, highly cross-linked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices of SA HXLPE and conventional gamma inert-sterilized (Gamma Inert) ultra-high-molecular-weight polyethylene tibial inserts implanted for >5 years., Methods: There were 74 total knee arthroplasty tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for >5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semiquantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials 2102. Differences between cohorts were assessed with Mann-Whitney U-tests., Results: Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = .022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = .002) and anterior-posterior faces (P = .023). No difference was observed at the backside surface (P = .060)., Conclusions: Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Periprosthetic joint infection is a complication of total joint arthroplasty with treatment costs over $1.6 billion dollars per year in the US with high failure rates. Therefore, generation of coatings that can prevent infection is paramount. Diamond-like carbon (DLC) is an ideal coating for implants as they are wear-resistant, corrosion-resistant, inert, and have a low friction coefficient. The purpose of this study was to test the efficacy of DLC surface treatment in prevention of biofilm on titanium discs infected with Staphylococcus aureus in vitro., Methods: Titanium alloy discs (n = 4 non-coated and n = 4 DLC-coated) were infected with 5 × 10 5 colony-forming units (CFU) of S. aureus for 2 weeks then analysed via crystal violet and scanning electron microscopy (SEM)., Results: Crystal violet analysis yielded differences in the appearance of biofilm on implant surface where DLC-coated had a clumpier appearance but no difference in biofilm quantification. Interestingly, this clumpy appearance did lead to differences in SEM biofilm coverage where significantly less biofilm coverage was found on DLC-coated discs (81.78% vs. 54.17%, p < 0.003)., Conclusion: DLC-coated titanium alloy implants may have preventative properties in S. aureus infection. Observing differences in biofilm coverage does warrant additional testing including CFU titration and biofilm kinetics with eventual use in an animal model of periprosthetic joint infection., (© 2024. The Author(s).)

Background: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider., Methods: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio., Results: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187)., Conclusions: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Despite high total knee arthroplasty (TKA) survivorship after 10 years (92%-99%), a gap persists where patient satisfaction lags clinical success. Additionally, while cobalt chrome molybdenum (CoCrMo) use decreases in primary total hip arthroplasty, the alloy continues to be widely used in TKA femoral components. In vivo, CoCrMo degradation may be associated with adverse local tissue reactions (ALTR) and compared with the hip, the damage mechanisms that may release metal in the knee and the potential biological effects remain poorly understood. In this study, we characterized the damage on 50 retrieved CoCrMo femoral knee implants paired with 19 titanium alloy and 31 CoCrMo tibial baseplates. We asked (1) what damage modes can release CoCrMo debris in vivo from femoral components and (2) how frequently does the damage occur? First, we developed a semiquantitative scoring system for abrasive wear. Then, we characterized damage modes on CoCrMo femoral implants using digital optical microscopy (DOM), scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS). We found that wear, electrocautery damage, and Ti-6Al-4V material transfer were ubiquitous. Of the 50 CoCrMo femoral implants we investigated, we documented wear on 100% (n = 50/50), electrocautery damage on 98% (n = 49/50), and Ti-6Al-4V material transfer to the posterior condyles on 95% (n = 18/19). Our results suggest that these damage modes may be more prevalent than previously thought and may act as metal release mechanisms in vivo., (© 2024 The Author(s). Journal of Biomedical Materials Research Part B: Applied Biomaterials published by Wiley Periodicals LLC.)

Background: Community deprivation has been linked to poor health outcomes following primary total knee arthroplasty (pTKA), but few studies have explored revision TKA (rTKA). The present study analyzed implications of neighborhood deprivation on rTKA outcomes by characterizing relationships between Area Deprivation Index (ADI) and (1) non-home discharge disposition (DD), (2) hospital length of stay (LOS), (3) 90-day emergency department (ED) visits, (4) 90-day hospital readmissions, and (5) the effect of race on these healthcare outcomes., Methods: A total of 1,434 patients who underwent rTKA between January 2016 and June 2022 were analyzed. Associations between the ADI and postoperative healthcare resource utilization outcomes were evaluated using multivariate logistic regression. Mediation effect was estimated using a nonparametric bootstrap resampling method., Results: Greater ADI was associated with non-home DD (p < 0.001), LOS ≥ 3 days (p < 0.001), 90-day ED visits (p = 0.015), and 90-day hospital readmission (p = 0.002). Although there was no significant difference in ADI between septic and aseptic patients, septic patients undergoing rTKA were more likely to experience non-home discharge (p < 0.001), prolonged LOS (p < 0.001), and 90-day hospital readmission (p = 0.001). The effect of race on non-home DD was found to be mediated via ADI (p = 0.038). Similarly, results showed the effect of race on prolonged LOS was mediated via ADI (p = 0.01)., Conclusion: A higher ADI was associated with non-home discharge, prolonged LOS, 90-day ED visits, and 90-day hospital readmissions. The impacts of patient race on both non-home discharge and prolonged LOS were mediated by ADI. This index allows clinicians to better understand and address disparities in rTKA outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: A greater area deprivation index (ADI), a tool that gauges socioeconomic disadvantage at the neighborhood level, is associated with worse health care outcomes following primary total hip arthroplasty. However, its association with revision total hip arthroplasty (rTHA) is unknown. This study aimed to determine the association between ADI and rates of postoperative health care resource utilization following rTHA., Methods: A total of 996 patients who underwent rTHA between 2016 and 2022 were enrolled in a prospective study. The primary outcomes assessed were nonhome discharge disposition (DD), length of stay (LOS) ≥ three days, 90-day emergency department (ED) visits, and 90-day hospital readmissions. The ADI was calculated using the patient's home address at the time of surgery, with greater ADI indicating greater socioeconomic disadvantage. We evaluated the mediation effect of patient race on ADI and postoperative health care utilization using a multivariable logistic regression model., Results: A higher median ADI was revealed for patients who experienced nonhome discharge (P = 0.001), extended LOS (P < 0.001), and ED readmission within 90 days of surgery (P = 0.045). When comparing septic versus aseptic rTHA patients, there were significant differences in health care resource utilization but no difference in ADI between the two groups. For aseptic rTHA, ADI significantly mediated the effect of race on both nonhome DD and LOS ≥ 3 (41 and 46% mediation, respectively). In septic rTHA, ADI mediated 31.1% of the effect of race on nonhome DD, but showed minimal mediation effect on LOS. The mediation effect of ADI on ED admission and hospital readmission was minimal for both groups., Conclusions: Higher ADI scores are associated with increased health care utilization after rTHA, including longer hospital stays and more nonhome discharges. The ADI significantly mediates the effect of race on these outcomes, particularly in aseptic rTHA cases, suggesting that neighborhood socioeconomic factors play a crucial role in previously observed racial disparities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The rate of unplanned hospital readmissions following total hip arthroplasty (THA) varies from 3 to 10%, representing a major economic burden. However, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to: (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate; and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following THA., Methods: A prospective cohort of primary unilateral THAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 8,893 patients) using a validated institutional data collection system. Orthopaedic-related readmissions were specific complications affecting the prosthesis, joint, and surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently., Results: Overall, the rate of 90-day readmissions was 5.6%. Medical readmissions (4.2%) were found to be more prevalent than orthopaedic-related readmissions (1.4%). The area under the curve for the 90-day readmission model was 0.71 (95% confidence interval: 0.69 to 0.74). Factors significantly associated with medical-related readmissions were advanced age, Black race, education, Charlson Comorbidity Index, surgical approach, opioid overdose risk score, and nonhome discharge. In contrast, risk factors linked to orthopaedic-related readmissions encompassed body mass index, patient-reported outcome measure phenotype, nonosteoarthritis indication, opioid overdose risk, and nonhome discharge., Conclusions: Of the overall 90-day readmissions following primary THA, 75% were due to medical-related complications. Our successful predictive model for complication-specific 90-day readmissions highlights how different risk factors may disproportionately influence medical versus orthopaedic-related readmissions, suggesting that patient-specific, tailored preventive measures could reduce postoperative readmissions in the current value-based health care setting., (Published by Elsevier Inc.)

Background: Total joint arthroplasty (TJA) is well-recognized for improving quality of life and functional outcomes of patients with osteoarthritis; however, TJA's impact on body weight remains unclear. Recent trends have demonstrated a shift among TJA patients, such that patients who have higher body mass indices (BMIs) are undergoing this common surgery. Given this trend, it is critical to characterize the impact TJA has on body weight or BMI. This meta-analysis aimed to quantitatively assess whether patients lose, gain, or maintain body weight or BMI after TJA., Methods: This study followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases were queried from inception through July 2022. The included studies: (1) reported on weight or BMI after elective, primary total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (2) weight or BMI change was deemed to be associated with THA or TKA. The excluded studies: (1) included weight or BMI interventions; and (2) reported on unicompartmental, partial, or revision arthroplasty or joint arthroscopy. Meta-analyses for weight change, BMI change, and proportion of patients achieving clinically significant change were performed using random-effects models. Factors associated with clinically significant change were systematically reported. A total of 60,837 patients from 39 studies were included., Results: No significant differences existed between preoperative and postoperative weights (P = 1.0; P = 0.28) or BMIs (P = 1.0; P = 1.0) after THA or TKA, respectively. Overall, 66% of THA patients (P < 0.01) and 65% of TKA patients (P < 0.01) did not experience clinically significant weight change., Conclusions: Among a TJA cohort, two-thirds of the patients maintained their preoperative body weight or BMI after surgery. With these results, orthopaedic surgeons can better manage patient expectations of TJA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The impact of socioeconomic status on achievement of clinically relevant patient-reported outcome measure (PROM) improvements and satisfaction after total hip arthroplasty (THA) is unknown. Area Deprivation Index (ADI) is a metric that can be used as a proxy for a patient's neighborhood socioeconomic status. This study aimed to assess the association between ADI and failure to achieve: (1) clinically relevant improvements in PROMs; and (2) self-reported satisfaction at 1 year following THA., Methods: A prospective cohort of 7,506 patients who underwent primary unilateral THA from January 2016 to July 2021 was included. The ADI was stratified into quintiles based on their distribution in our sample. Multivariable logistic regression models were created to investigate the effect of ADI on 1-year PROMs. The included PROMs were the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain, Physical Function Shortform (PS), and Joint Replacement (JR). Clinically relevant improvements were assessed through minimal clinically important difference and patient acceptable symptom state threshold achievement., Results: There was no significant association between ADI and failure to achieve minimal clinically important difference for HOOS pain (P = 0.42), PS (P = 0.91), or JR (P = 0.20). However, higher ADI scores were independently associated with increased odds of failing to achieve patient acceptable symptom state for HOOS Pain (P = 0.002), PS (P = 0.003), and JR (P = 0.017). The ADI was not associated with failure to achieve patient satisfaction at 1 year (P = 0.93)., Conclusions: Greater neighborhood socioeconomic disadvantage was associated with decreased odds of achieving clinically relevant improvement in patient-perceived symptomatic state, but not associated with patients' perception of their overall pain and function 1 year after THA. Targeted interventions to address access and care pathways for low socioeconomic status patients may present an opportunity to improve patient-perceived outcomes following THA., Level of Evidence: Level III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Osteoporosis (OP) has been linked to complications after total hip arthroplasty (THA), but its impact on health care utilization and patient-reported outcomes remains unclear. This study aimed to evaluate the association between: 1) pre-THA OP and health care utilization as well as patient-reported pain and function outcome measures; and 2) dual energy X-ray absorptiometry (DEXA) scan-based T-scores and the aforementioned outcomes., Methods: A retrospective analysis of prospectively collected data of primary THA (2015 to 2018) was performed (n = 5,321) from a validated academic institutional database of a large North American tertiary health care system; of which 4,074 (76.6%) completed 1-year follow-up. Outcomes included prolonged length of stay [LOS] > three days, discharge disposition, 90-day readmission, and 1-year reoperation, as well as Hip Disability and Osteoarthritis Outcome Score (HOOS]) Pain, HOOS-function (PS), and minimal clinically important difference thresholds (MCID), and satisfaction., Results: The prevalence of OP pre-THA was 56.9%, of which 39.8% were not prescribed OP medications and 15.3% had a DEXA scan. Compared to those who did not have OP, those who had OP were independently associated with higher odds of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation (P < 0.005). Furthermore, they had significantly higher odds of failing to achieve MCID (odds ratio: 1.41 (95% confidence interval: 1.06 to 1.89)) for HOOS-PS and satisfaction (odds ratio: 1.5 (95% confidence interval: 1.16 to 1.93)) at one year. Higher T-scores were associated with lower odds of prolonged LOS, nonhome discharge, failure to achieve MCID in HOOS-Pain, and HOOS-PS., Conclusions: Over half of patients had OP; however, only 15.3% of patients had a DEXA scan before THA. Patients who had OP were at higher risk of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation in addition to poor pain/function improvement and dissatisfaction one year after THA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Osteonecrosis of the femoral head (ONFH) is a chronic progressive debilitating disease that often affects young and active patients. It results from vascular interruption to the femoral head and can be caused by trauma, chronic corticosteroid use, chronic alcoholism, and coagulopathies. Treatment includes core decompression, a surgical procedure that may help delay or forestall disease progression if performed at the early stages of the disease. Technological advances have made the procedure more efficient and effective. There are several core decompression systems available in the market, giving healthcare providers options for core decompression technique: (1) The PerFuse™ Percutaneous Decompression System (Zimmer Biomet, Warsaw, Indiana) offers the advantage of utilizing autologous stem cell progenitor augmentation which has been shown to provide clinical benefits to patients; (2) The Advanced Core Decompression System (Stryker, Kalamazoo, Michigan) utilizes synthetic regenerative bone grafts, and these calcium-based synthetic grafts are well-accepted as the adjuvant modality for small defects; and (3) The Avascular Necrosis/Osteonecrosis Core Decompression Expandable Reamer System (Arthrex Inc., Naples, Florida) offers the unique ability for endoscopic-assisted core decompression, which may provide increased ability to treat early-stage ONFH by identifying necrotic lesions not visible radiographically. The preferred management of ONFH remains a topic of controversy and is reliant on the disease stage. Future randomized clinical trials comparing various core decompressions systems, with or without the use of bone marrow aspirates and arthro-endoscopy, may provide insight into the true clinical benefits of each method.

» Nuclear imaging techniques, including bone scintigraphy, labeled leukocyte scintigraphy, positron emission tomography (PET), and single-photon emission computed tomography (SPECT) combined with computed tomography (CT), have wide applications in orthopaedics for evaluating trauma, painful total joint arthroplasty, musculoskeletal infection, and orthopaedic oncology.» Three-phase bone scintigraphy is a first-line, highly sensitive nuclear medicine study for evaluating orthopaedic pathology when initial studies are inconclusive. However, its specificity is limited, and findings may be falsely positive for up to 2 years after total joint arthroplasty because of physiologic bone remodeling.» Labeled leukocyte scintigraphy or gallium scintigraphy can improve diagnostic accuracy in patients with a positive bone scan and suspected musculoskeletal or periprosthetic joint infection.» 18-Fluorodeoxyglucose PET/CT demonstrates high sensitivity and specificity for diagnosing bone neoplasms, infections, and metabolic disorders. Emerging PET/magnetic resonance imaging technology offers reduced radiation exposure and greater soft-tissue detail but presents technical and cost challenges.» SPECT/CT provides valuable functional and anatomic detail for characterizing the extent and location of bone pathology, serving as an important adjunct to other imaging modalities.» Ultimately, the choice of nuclear imaging modality should consider the specific clinical context, diagnostic accuracy, impact on management, and cost-effectiveness on a case-by-case basis., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B155)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

At the top of the evidence-based pyramid, systematic reviews stand out as the most powerful, synthesizing findings from numerous primary studies. Specifically, a quantitative systematic review, known as a meta-analysis, combines results from various studies to address a specific research question. This review serves as a guide on how to: (1) design; (2) perform; and (3) publish an orthopedic arthroplasty systematic review. In Part III, we focus on how to design and perform a meta-analysis. We delineate the advantages and disadvantages of meta-analyses compared to systematic reviews, acknowledging their potential challenges due to time constraints and the complexities posed by study heterogeneity and data availability. Despite these obstacles, a well-executed meta-analysis contributes precision and heightened statistical power, standing at the apex of the evidence-based pyramid. The design of a meta-analysis closely mirrors that of a systematic review, but necessitates the inclusion of effect sizes, variability measures, sample sizes, outcome measures, and overall study characteristics. Effective data presentation involves the use of forest plots, along with analyses for heterogeneities and subgroups. Widely-used software tools are common in this domain, and there is a growing trend toward incorporating artificial intelligence software. Ultimately, the intention is for these papers to act as foundational resources for individuals interested in conducting systematic reviews and meta-analyses in the context of orthopaedic arthroplasty, where applicable., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Printed porous titanium metaphyseal cones have become a mainstay for managing bone loss in revision total knee arthroplasty (rTKA). A short or long stem is routinely used when implanting a cone to augment fixation and offload stresses. This retrospective analysis compared the short-term survivorships and functional outcomes for use of a short or long stem with a metaphyseal cone.A total of 179 cases using metaphyseal cones and stems with median follow-up of 1.95 years (interquartile range, 1.00-2.14) were compared based on stem type. There were 55 cases with long stem(s) and 124 cases with short stem(s). Cases with both long and short stems were excluded. Demographics, Kaplan-Meier survivorships, and preoperative and 1-year postoperative patient-reported outcome measures (PROMs; 2011 Knee Society Score [KSS] objective knee score, function, and satisfaction scores; EuroQol five-dimension scale; and Short Form Survey Physical Component Summary and Mental Component Summary scores) were compared using t -tests with a significance level of α = 0.05. There were no significant differences in body mass index (mean ± standard deviation) or sex (men [%]) between the short and long stem cohorts (32.3 ± 5.3, 36.3% and 31.5 ± 5.5, 38.2%, respectively; p  > 0.05). Patients who had short stems were younger (65.9 ± 8.8 vs. 69.0 ± 9.4, p  = 0.0323).Revision-free survivorship for the femoral or tibial component was 100% for long stems and 98.2% for short stems at 1 and 2 years, respectively (log-rank p  = 0.6330). The two revisions in the short group were for infection, thus the survivorship for aseptic loosening was 100% at 2 years for both cohorts. There were no significant differences in preoperative or postoperative PROMs.This study demonstrated that highly porous printed metaphyseal cones provided rTKA with excellent early survivorship and similar PROMs whether a short or long stem was used. Additional studies will be needed to discern longer term differences., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care., Methods: A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant., Results: High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI., Conclusions: Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs)., Methods: This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities., Results: There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 μg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 μg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control., Conclusions: The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The first generation of titanium nitride (TiN) coatings for orthopaedic implants was clinically introduced in the 1990s because of their promising biocompatibility, wear resistance, and corrosion resistance. This study evaluated the in vivo performance of early TiN-coated knee and hip implants, focusing on the bearing surfaces and mechanisms of in vivo damage., Methods: There were 13 TiN-coated implants (5 knee and 8 hip) retrieved from 8 patients as part of a multi-institutional implant retrieval program. The average implantation time was 4.25 years for knees and 17.5 years for hips. Implant revisions occurred for various reasons, including polyethylene wear, loosening, pain, infection, and instability. Components were examined using a semiquantitative scoring method, and surface roughness measurements were performed using white-light interferometry. Surface morphology, chemistry, and particle characterization were also assessed by scanning electron microscopy., Results: For hips, mild corrosion was found on femoral head tapers, along with severe scratching on certain femoral heads. Knee implants exhibited low burnishing and scratching for both mechanisms. Roughness measurements (S a ) were 37.3 nm (interquartile range = 22.0 to 62.4) for hips and 85.3 nm (interquartile range = 66.3 to 110) for knees. The observed scratch depth in both hip and knee implants due to third-body particles ranged from 0.3 to 1.3 μm. The coating coverage remained intact in the majority of the implants, with 2 cases of small, localized cohesive chipping and substrate exposure., Conclusions: The results of this study confirm the potential in vivo durability of early TiN coatings and will be useful in benchmarking wear tests for modern TiN-coated orthopaedic implants., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: In the current shift toward value-based healthcare, patient-reported outcome measures (PROMs) have become essential to assess the effectiveness of medical interventions. However, elucidation of the optimal timeframe for PROMs evaluation remains crucial. This study aimed to (1) determine the proportion of patients who experienced clinically meaningful improvements in PROMs scores at each follow-up visit after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and (2) calculate and apply the clinical relevance ratio (CRR) for these long-term PROM collections postoperatively., Methods: A total of 12 independent studies reporting THA (n = 8 studies) and TKA (n = 4 studies) postoperative PROM data with up to 10 years of follow-up in Europe or the United States were aggregated. A distribution-based minimal clinically important difference threshold and CRR were used to determine which patients had clinically meaningful improvements in PROMs at 1, 5, and 10 years., Results: The proportion of patients who had clinically meaningful improvements in PROM scores stabilized after 1 year following both THA and TKA. Overall, the CRR decreased over time for all PROMs, with the CRR beginning to decrease at 1-year follow-up, bringing into question the robustness and clinical relevance of long-term PROMs data., Conclusions: The present study challenges the utility of requiring PROMs with a minimum follow-up of 2 years for THA and TKA. Research efforts should be focused on registries evaluating implant survivorship at longer-term follow-up, while PROMs should be better assessed up to 1-year follow-up. Reconsidering the long-term PROMs assessment would lead to more efficient and cost-effective research in orthopedic outcomes, without compromising data quality., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Abstract: The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting., 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/H923 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects ( N  = 1,844 TKA patients and N  = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment ( N  = 896 TKA patients and N  = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p  < 0.0001) and 1-month follow-up (r = -0.14, p  < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p  < 0.0001) and 1-month follow-up (r = -0.11, p  = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p  < 0.0001) and 1-month postoperative (r = 0.17, p  < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p  = 0.0002) and at 1-month postoperatively (r = 0.10, p  = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it., Questions/purposes: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms?, Methods: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs., Results: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29])., Conclusion: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA., Level of Evidence: Level III, therapeutic study., 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 © 2024 by the Association of Bone and Joint Surgeons.)

Background: Chronic periprosthetic joint infection (PJI) is a major complication of total joint arthroplasty. The underlying pathogenesis often involves the formation of bacterial biofilm that protects the pathogen from both host immune responses and antibiotics. The gold standard treatment requires implant removal, a procedure that carries associated morbidity and mortality risks. Strategies to preserve the implant while treating PJI are desperately needed. Our group has developed an anti-biofilm treatment, PhotothermAA gel, which has shown complete eradication of 2-week-old mature biofilm in vitro. In this study, we tested the anti-biofilm efficacy and safety of PhotothermAA in vivo when combined with debridement, antibiotics and implant retention (DAIR) in a rabbit model of knee PJI., Methods: New Zealand white rabbits (n = 21) underwent knee joint arthrotomy, titanium tibial implant insertion, and inoculation with Xen36 (bioluminescent Staphylococcus aureus) after capsule closure. At 2 weeks, rabbits underwent sham surgery (n = 6), DAIR (n = 6), or PhotothermAA with DAIR (n = 9) and were sacrificed 2 weeks later to measure implant biofilm burden, soft-tissue infection, and tissue necrosis., Results: The combination of anti-biofilm PhotothermAA with DAIR significantly decreased implant biofilm coverage via scanning electron microscopy compared to DAIR alone (1.8 versus 81.0%; P < .0001). Periprosthetic soft-tissue cultures were significantly decreased in the PhotothermAA with DAIR treatment group (log reduction: Sham 1.6, DAIR 2.0, combination 5.6; P < .0001). Treatment-associated necrosis was absent via gross histology of tissue adjacent to the treatment area (P = .715)., Conclusions: The addition of an anti-biofilm solution like PhotothermAA as a supplement to current treatments that allow implant retention may prove useful in PJI treatment., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: With the removal of total hip arthroplasty (THA) from the inpatient-only (IPO) lists, the orthopedic landscape across the United States has changed rapidly. Thus, this study aimed to: 1) characterize the change in THA volume for outpatient and inpatient surgeries; 2) elucidate demographical differences before and after removal from the IPO list; and 3) analyze 30-day complications, readmissions, and reoperations., Methods: The National Surgical Quality Improvement Program database was queried for primary THAs between January 2010 and December 2021. The primary outcome was the annual volume of outpatient and inpatient THAs. Secondary outcomes involved 30-day complications, readmissions, and reoperations. The variables between cohorts were analyzed using goodness-of-fit Chi-square tests with summary statistics., Results: Of the 332,423 THAs between 2010 and 2021, 88% were inpatient THAs (n = 292,974) and 12% were outpatient THAs (n = 39,449). From 2019 to 2021, the volume of inpatient THA decreased by 55% (42,779 to 19,075), while outpatient THA increased by 751% (2,518 to 21,424). Patients who had a THA after 2019 were older (P < .001), more commonly women (P < .001), white (P < .001), and more likely American Society of Anesthesiologists Class III (P < .001). The outpatient cohort had fewer 30-day complications, readmissions, and reoperations. The length of stay for both cohorts decreased until 2019, before increasing in 2020 and 2021 for inpatient THAs, while home discharge and operative time increased for both., Conclusions: The volume of outpatient THA increased almost eightfold after its removal from the IPO lists in 2020. Despite expanding eligibility with older patients and more comorbidities, 30-day complications, readmissions, and reoperations remain low. These findings support the safe transition to outpatient THA with appropriate patient selection and optimization., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Artificial intelligence in the field of orthopaedics has been a topic of increasing interest and opportunity in recent years. Its applications are widespread both for physicians and patients, including use in clinical decision-making, in the operating room, and in research. In this study, we aimed to assess the quality of ChatGPT answers when asked questions related to total knee arthroplasty., Methods: ChatGPT prompts were created by turning 15 of the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines into questions. An online survey was created, which included screenshots of each prompt and answers to the 15 questions. Surgeons were asked to grade ChatGPT answers from 1 to 5 based on their characteristics: (1) relevance, (2) accuracy, (3) clarity, (4) completeness, (5) evidence-based, and (6) consistency. There were 11 Adult Joint Reconstruction fellowship-trained surgeons who completed the survey. Questions were subclassified based on the subject of the prompt: (1) risk factors, (2) implant/intraoperative, and (3) pain/functional outcomes. The average and standard deviation for all answers, as well as for each subgroup, were calculated. Inter-rater reliability (IRR) was also calculated., Results: All answer characteristics were graded as being above average (ie, a score > 3). Relevance demonstrated the highest scores (4.43 ± 0.77) by surgeons surveyed, and consistency demonstrated the lowest scores (3.54 ± 1.10). ChatGPT prompts in the Risk Factors group demonstrated the best responses, while those in the Pain/Functional Outcome group demonstrated the lowest. The overall IRR was found to be 0.33 (poor reliability), with the highest IRR for relevance (0.43) and the lowest for evidence-based (0.28)., Conclusions: ChatGPT can answer questions regarding well-established clinical guidelines in total knee arthroplasty with above-average accuracy but demonstrates variable reliability. This investigation is the first step in understanding large language model artificial intelligence like ChatGPT and how well they perform in the field of arthroplasty., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Birmingham Hip Resurfacing (BHR) has emerged as a compelling and innovative alternative to total hip arthroplasty (THA), especially among young, active patients. However, the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds have not yet been determined for patients undergoing BHR. Therefore, the current study aimed to (1) determine the MCID and PASS thresholds for both the Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS physical function shortform (PS), for patients who underwent BHR; and (2) identify factors influencing the achievement of MCID and PASS for HOOS-Pain and HOOS-PS., Methods: Prospectively collected data from patients undergoing BHR was analyzed. Patients with osteoarthritis and completed preoperative and 1-year postoperative PROMs were included. Distribution-based and anchored-based approaches were used to estimate MCID and PASS, respectively. The optimal cut-off point for PASS thresholds was calculated using the Youden index., Results: MCID for HOOS-Pain and PS were calculated to be 9.2 and 9.3, respectively. The PASS threshold for HOOS-Pain and PS were ≥ 77.7 and ≥ 87.3, respectively. The current study identified several factors affecting postoperative achievement of thresholds. Baseline Mental Component Summary (MCS) scores were a predictor for achieving MCID for postoperative HOOS-Pain, achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Furthermore, baseline HOOS-Pain was a significant predictor for achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS., Conclusions: MCID and PASS thresholds were established for HOOS-Pain and PS domains following BHR with most patients achieving these clinically meaningful benchmarks. Additionally, several factors affecting achievement of MCID and PASS were identified, including modifiable risk factors that may allow clinicians to implement optimization strategies and further improve outcomes., (© 2024. The Author(s).)

Periprosthetic joint infection (PJI) presents a critical challenge in orthopedic care, contributing to significant patient morbidity and healthcare costs. This burden is expected to increase secondary to growing demand for total joint arthroplasty (TJA). Despite the profound significance of PJI, there is currently no universally accepted "gold standard" diagnostic criteria using serum biomarker thresholds; latest criteria fail to differentiate acute infections from chronic or consider time since initial surgery. Furthermore, contemporary PJI treatment, which conventionally requires 2-stage revision surgery in conjunction with rigorous antibiotic treatment, can be particularly taxing on patients. Fortunately, recent years have seen marked evolution in both PJI diagnosis and treatment methods. Contemporary research supports time-dependent serum biomarker thresholds with greater sensitivity and specificity than previously reported, as well as alternative surgical options which may be more suitable for certain patients. The following narrative review aims to describe the significance and pathogenesis of PJI before characterizing current challenges, novel innovations, and the future landscape of PJI diagnosis and management. Here, we spotlight the emerging utility of novel biomarkers and metagenomic next-generation sequencing for diagnosis, advancements in patient-centered surgical outcome prediction tools for PJI risk assessment and prevention, and evolving surgical techniques including 1-stage and a "hybrid" 1.5-stage revision surgeries. Additionally, we explore cutting-edge therapeutic modalities including peptide and bacteriophage-based treatments, intraoperative anti-biofilm gel, the VT-X7 antibiotic pump, and promising immune-based interventions. Ultimately, these advancements hold the potential to revolutionize PJI management, offering hope for improved outcomes and reduced burdens on healthcare systems., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Matthew E. Deren reports a relationship with RomTech that includes: equity or stocks. Nicolas S. Piuzzi reports a relationship with American Association of Hip and Knee Surgeons that includes: board membership. Nicolas S. Piuzzi reports a relationship with ISCT that includes: board membership. Nicolas S. Piuzzi reports a relationship with Journal of Hip Surgery that includes: board membership. Nicolas S. Piuzzi reports a relationship with Journal of Knee Surgery that includes: board membership. Nicolas S. Piuzzi reports a relationship with Orthopaedic Research Society that includes: board membership. Nicolas S. Piuzzi reports a relationship with Osteal Therapeutics that includes: non-financial support. Nicolas S. Piuzzi reports a relationship with Peptilogics that includes: non-financial support. Nicolas S. Piuzzi reports a relationship with RegenLab that includes: non-financial support. Nicolas S. Piuzzi reports a relationship with Signature Orthopaedics that includes: non-financial support. Nicolas S. Piuzzi reports a relationship with Stryker that includes: consulting or advisory. Nicolas S. Piuzzi reports a relationship with Zimmer that includes: non-financial support. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024.)

Revision total hip arthroplasty (THA) presents a formidable challenge when addressing extensive acetabular defects, particularly in severe cases classified under Paprosky types 3A and 3B and American Academy of Orthopaedic Surgeons types 3 and 4. Traditional methods often fall short, prompting the potential use of custom triflange acetabular components or patient-specific acetabular implants (PSAIs). These implants are specifically designed to conform to an individual's anatomy, aiming to enhance defect reconstruction and pelvic stabilization. This case series describes the utilization of advanced 3-dimensional printing and rapid prototyping technologies to construct customized acetabular components, which can be instrumental in enabling precise preoperative planning and surgical execution for these difficult acetabular cases and potentially leading to improved surgical outcomes.

Abstract: The Centers for Medicare & Medicaid Services (CMS) has finalized a landmark national policy to standardize and expand the collection and reporting of patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This policy will be rolled out through phased implementation, beginning with voluntary reporting starting in 2023 and transitioning to mandatory reporting starting in 2025, which will be tied to hospital payment determinations in fiscal year 2028. The overarching goal of this policy is to gather meaningful pre- and postoperative PROM data directly from patients to enhance clinical care, shared decision-making, and quality measurement for these common elective procedures. This national initiative underscores the value of incorporating patient perspectives and priorities into assessments of surgical care quality. For orthopaedic surgeons and hospitals, participating in the initial voluntary reporting period provides an opportunity to integrate PROM collection into clinical workflows and to leverage these data to improve patient care. The achievement of robust PROM response rates and a strong performance on the underlying THA/TKA Patient-Reported Outcome-Based Performance Measure may have increasing relevance as payment models shift toward value-based care. The aim of the present forum was to provide an in-depth review of this new CMS policy and key details regarding required PROM instruments, data-collection time frames, and other specifications that surgical teams should understand as they prepare for implementation. The goal was to equip orthopaedic surgeons with actionable information as they embark on this new era of national PROM collection and reporting., 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/H876 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Femoral stemmed total knee arthroplasty (FS TKA) may be used in patients deemed higher risk for periprosthetic fracture (PPF) to reduce PPF risk. However, the cost effectiveness of FS TKA has not been defined. Using a risk modeling analysis, we investigate the cost effectiveness of FS in primary TKA compared with the implant cost of revision to distal femoral replacement (DFR) following PPF. A model of risk categories was created representing patients at increasing fracture risk, ranging from 2.5 to 30%. The number needed to treat (NNT) was calculated for each risk category, which was multiplied by the increased cost of FS TKA and compared with the cost of DFR. The 50th percentile implant pricing data for primary TKA, FS TKA, and DFR were identified and used for the analysis. FS TKA resulted in an increased cost of $2,717.83, compared with the increased implant cost of DFR of $27,222.29. At 50% relative risk reduction with FS TKA, the NNT for risk categories of 2.5, 10, 20, and 30% were 80, 20, 10, and 6.67, respectively. At 20% risk, FS TKA times NNT equaled $27,178.30. A 10% absolute risk reduction in fracture risk obtained with FS TKA is needed to achieve cost neutrality with DFR. FS TKA is not cost effective for low fracture risk patients but may be cost effective for patients with fracture risk more than 20%. Further study is needed to better define the quantifiable risk reduction achieved in using FS TKA and identify high-risk PPF patients., Competing Interests: None declared., (Thieme. All rights reserved.)