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Background: Jehovah’s Witness patients refuse blood transfusion because of their religious beliefs making total hip arthroplasty (THA) challenging. This study aims to determine the safety of THA in Jehovah’s Witness patients using standard perioperative protocols as well as evaluate the effectiveness of tranexamic acid (TXA) in controlling blood loss. Methods: Databases from two tertiary academic centers were queried from 2003 to 2021 to identify THA patients. Demographics, pre- and postoperative hemoglobin (hgb) and hematocrit (hct) lab values, use of TXA intraoperatively, 90-day postoperative hospital utilization, and need for subsequent revision were extracted. Patients who identified as Jehovah’s Witness were then compared to a 3:1 propensity score matched cohort of non-Jehovah’s Witness patients. Linear regression analysis assessed the effect of intraoperative TXA on change in hgb from pre- to post-THA and logistic regression was used to assess risk of reaching hgb levels < 8.0 g/dL. Results: A total of 207 non-Jehovah’s Witness patients and 69 Jehovah’s Witness patients who underwent THA were analyzed. Both groups were found to have similar preoperative hgb and hct as well as postoperative hgb, hct, and hgb shift. Of the Jehovah’s Witness patients 3 (6.4%) patients reached a hgb < 8.0 g/dL. Additionally, a higher proportion of Jehovah’s Witness patients receive intraoperative TXA (55 [79.7%]) compared to non-Jehovah’s Witness patients (127 [61.4%]) (p = 0.01; SMD = 0.41). Logistic regression analysis found that Jehovah’s Witness did not have greater odds of reaching a hgb < 8.0 g/dL (OR = 1.03 [0.95, 1.10]; p = 0.49) and that patient who received intraoperative TXA had decreased odds of reaching a hgb < 8.0 (OR = 0.87 [0.80, 0.95]; p = 0.001). Multivariate linear regression found that intraoperative TXA was also associated with a smaller decrease in hgb from pre- to post-THA (β = 0.69 [0.16, 1.22]; p = 0.01). Overall, Jehovah’s Witness patients had excellent revision-free (97% [93%, 100%]) and infection-free (99% [96%, 100%]) survival at 7 years. Conclusion: Although Jehovah’s Witness patients refuse transfusion, THA can be performed safely in these patients with excellent implant survivorship by optimizing preoperative hgb levels and utilizing intraoperative TXA. Level of evidence: Level III Evidence. [ABSTRACT FROM AUTHOR]

Purpose: Studies demonstrate similar long-term Total Knee Arthroplasty (TKA) outcomes in patients with significant versus minimal preoperative coronal plane deformity. Limited short-term outcomes data, which determine costs of care, exist. Methods: We retrospectively explored the impact of preoperative coronal plane deformity on operative time, length of stay (LOS), and discharge to skilled nursing facility (SNF) in TKA. A total of 3,964 patients undergoing unilateral primary TKA at our institution from 2014 to 2019 were included (1,158 > 10˚ deformity: mean age 67.2 years, 47% male; 2,806 < 10˚ deformity: mean age 67 years, 37.4% male). The degree of coronal plane deformity (mechanical axis deviation on preoperative radiographs) was recorded. Patients with no knee radiographs ≤ 3 years preoperatively were excluded. Statistical analysis included Chi-Square tests, Student’s t-tests, Mann-Whitney U tests, and uni- and multivariable linear and logistic regression analyses. Results: The > 10˚ deformity cohort had a longer time from procedure start to finish (113.56 vs. 110.68 min; p = 0.020), greater deviation from surgeon mean operative time (+ 6.19 vs. + 0.69 min; p < 0.001), and higher proportion of cases requiring > 15 (26.8% vs. 22%;p = 0.001) and > 30 (12.3% vs. 7.8%;p < 0.001) additional minutes over their scheduled times. LOS was similar between cohorts (median 2 days, IQR 1–3). The deformity cohort more likely discharged to SNF (19.9% vs. 15.8%;p = 0.002). For every 1˚ increase in coronal plane deformity, operative time increased by 0.566 min (p = 0.000). The odds of SNF discharge increased with increasing coronal plane deformity (OR 1.029 [1.009,1.050]; p = 0.004). Conclusion: Greater preoperative coronal deformity is associated with increased operative time and odds of discharge to SNF in TKA. [ABSTRACT FROM AUTHOR]

Background: There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient-reported outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs. Methods: This was a single-institution, retrospective study of 1093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into control (BMI = 18.5-29.9; n = 615), obesity class I (BMI = 30.0-34.9; n = 285), and obesity class II (BMI > 35.0; n = 193) groups. Patient information, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1). Results: Compared to control and class I, class II patients had the lowest mean age (P =.001), highest mean ASA score (P <.001), and greatest proportion of female sex (P <.001) and Black/African American race (P =.005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (P >.05). Preoperatively, class II had lower (worse) mean scores for Foot and Ankle Outcome Score pain and ADL subscales than controls (post hoc pairwise P <.001 for both). At final follow-up, both class II and class I had lower (worse) mean Short Musculoskeletal Function Assessment (post hoc pairwise P <.001 and P =.030, respectively) and 36-Item Short Form Health Survey scores (post hoc pairwise P <.001 and P =.005, respectively) than controls. Conclusion: At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single-institution study to date examining the effect of obesity on outcomes after primary TAA. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Three-dimensional (3D) printing technology has advanced greatly over the past decade and is being used extensively throughout the field of medicine. Several orthopaedic surgery specialties have demonstrated that 3D printing technology can improve patient care and physician education. Foot and ankle pathology can be complex as the 3D anatomy can be challenging to appreciate. Deformity can occur in several planes simultaneously and bone defects either from previous surgery or trauma can further complicate surgical correction. Three-dimensional printing technology provides an avenue to tackle the challenges associated with complex foot and ankle pathology. A basic understanding of how these implants are designed and made is important for surgeons as this technology is becoming more widespread and the clinical applications continue to grow within foot and ankle surgery.Levels of Evidence: Level V. [ABSTRACT FROM AUTHOR]

Background: Jehovah's Witness patients refuse blood transfusion because of their religious beliefs making total hip arthroplasty (THA) challenging. This study aims to determine the safety of THA in Jehovah's Witness patients using standard perioperative protocols as well as evaluate the effectiveness of tranexamic acid (TXA) in controlling blood loss., Methods: Databases from two tertiary academic centers were queried from 2003 to 2021 to identify THA patients. Demographics, pre- and postoperative hemoglobin (hgb) and hematocrit (hct) lab values, use of TXA intraoperatively, 90-day postoperative hospital utilization, and need for subsequent revision were extracted. Patients who identified as Jehovah's Witness were then compared to a 3:1 propensity score matched cohort of non-Jehovah's Witness patients. Linear regression analysis assessed the effect of intraoperative TXA on change in hgb from pre- to post-THA and logistic regression was used to assess risk of reaching hgb levels < 8.0 g/dL., Results: A total of 207 non-Jehovah's Witness patients and 69 Jehovah's Witness patients who underwent THA were analyzed. Both groups were found to have similar preoperative hgb and hct as well as postoperative hgb, hct, and hgb shift. Of the Jehovah's Witness patients 3 (6.4%) patients reached a hgb < 8.0 g/dL. Additionally, a higher proportion of Jehovah's Witness patients receive intraoperative TXA (55 [79.7%]) compared to non-Jehovah's Witness patients (127 [61.4%]) (p = 0.01; SMD = 0.41). Logistic regression analysis found that Jehovah's Witness did not have greater odds of reaching a hgb < 8.0 g/dL (OR = 1.03 [0.95, 1.10]; p = 0.49) and that patient who received intraoperative TXA had decreased odds of reaching a hgb < 8.0 (OR = 0.87 [0.80, 0.95]; p = 0.001). Multivariate linear regression found that intraoperative TXA was also associated with a smaller decrease in hgb from pre- to post-THA (β = 0.69 [0.16, 1.22]; p = 0.01). Overall, Jehovah's Witness patients had excellent revision-free (97% [93%, 100%]) and infection-free (99% [96%, 100%]) survival at 7 years., Conclusion: Although Jehovah's Witness patients refuse transfusion, THA can be performed safely in these patients with excellent implant survivorship by optimizing preoperative hgb levels and utilizing intraoperative TXA., Level of Evidence: Level III Evidence., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Studies demonstrate similar long-term Total Knee Arthroplasty (TKA) outcomes in patients with significant versus minimal preoperative coronal plane deformity. Limited short-term outcomes data, which determine costs of care, exist., Methods: We retrospectively explored the impact of preoperative coronal plane deformity on operative time, length of stay (LOS), and discharge to skilled nursing facility (SNF) in TKA. A total of 3,964 patients undergoing unilateral primary TKA at our institution from 2014 to 2019 were included (1,158 > 10˚ deformity: mean age 67.2 years, 47% male; 2,806 < 10˚ deformity: mean age 67 years, 37.4% male). The degree of coronal plane deformity (mechanical axis deviation on preoperative radiographs) was recorded. Patients with no knee radiographs ≤ 3 years preoperatively were excluded. Statistical analysis included Chi-Square tests, Student's t-tests, Mann-Whitney U tests, and uni- and multivariable linear and logistic regression analyses., Results: The > 10˚ deformity cohort had a longer time from procedure start to finish (113.56 vs. 110.68 min; p = 0.020), greater deviation from surgeon mean operative time (+ 6.19 vs. + 0.69 min; p < 0.001), and higher proportion of cases requiring > 15 (26.8% vs. 22%;p = 0.001) and > 30 (12.3% vs. 7.8%;p < 0.001) additional minutes over their scheduled times. LOS was similar between cohorts (median 2 days, IQR 1-3). The deformity cohort more likely discharged to SNF (19.9% vs. 15.8%;p = 0.002). For every 1˚ increase in coronal plane deformity, operative time increased by 0.566 min (p = 0.000). The odds of SNF discharge increased with increasing coronal plane deformity (OR 1.029 [1.009,1.050]; p = 0.004)., Conclusion: Greater preoperative coronal deformity is associated with increased operative time and odds of discharge to SNF in TKA., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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

Outpatient shoulder arthroplasty presents potential clinical benefits but also risk without perioperative optimization. Length of stay depends largely on surgeon preferences, and a large single-surgeon cohort may provide insight into optimal strategies and costs for outpatient shoulder arthroplasty. A single-surgeon cohort of 472 anatomic and reverse shoulder arthroplasties performed between 2017 and 2020 was retrospectively reviewed. Cases were stratified by those who did or did not undergo same-day discharge. The 90-day readmission, discharge to post-acute care, cost, and 45 patient/case factors were examined. Two hundred fifty (53%) underwent same-day discharge, with the proportion of outpatient cases increasing over time to nearly 80%, with no significant difference in 90-day readmissions. Revision cases often underwent same-day discharge, whereas fractures were typically admitted. The cost was significantly higher for inpatients, with implants accounting for 52%. Surgeons may safely transition a substantial proportion of shoulder arthroplasties to same-day discharge with some reassurance regarding cost savings and 90-day readmissions. (Journal of Surgical Orthopaedic Advances 32(4):263-269, 2023).

Background: Two-stage revision arthroplasty is the gold standard for treating chronic prosthetic joint infection (PJI), but there has been limited analysis of the costs incurred beyond the index procedure and how additional complications and/or surgeries impact the cost of care., Methods: The electronic health record was queried for patients who underwent a total hip arthroplasty complicated by PJI and then underwent removal of the prosthesis with implantation of an antibiotic-impregnated articulating cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department (ED) visits, and postoperative complications were recorded. Data on total costs were collected with an internal accounting database. The average follow-up duration was 3.35 years., Results: Univariate analyses showed statistically significant differences between outcome groups (reimplantation, reimplantation requiring later revision, retained spacer, and Girdlestone resection arthroplasty) in total overall costs, ED visit costs, and postoperative costs at 1 and 2 years after the initial spacer placement. The median total cost at 2 years for each group was $38,865 ($29,144-49,471) (reimplantation), $79,223 ($53,442-100,152) (reimplantation with revision), $54,096 ($20,872-73,903) (retained spacer), $62,134 ($52,135-101,546) (Girdlestone). Patients who underwent successful reimplantation requiring no further surgery had significantly lower total costs than patients who needed revision surgeries after reimplantation ($38,865 [$29,144-49,471] vs $79,223 [$53,442-100,152], P  = .007). Patients with a Girdlestone resection arthroplasty had higher total costs at 1 year ($59,708 [$41,781-80,916] vs $33,093 [$27,237-40,429], P  = .043) and higher costs attributable to ED visits at 2 years than the reimplantation group ($23,581 [$14,029-41,519] vs $15,307 [$6291-29,119], P  = .009)., Conclusions: A significant variation exists among total costs for the 2-stage treatment of hip PJI when stratified by the final outcome., (© 2022 The Authors.)

Three-dimensional (3D) printing is an exciting form of manufacturing technology that has transformed the way we can treat various medical pathologies. Also known as additive manufacturing, 3D printing fuses materials together in a layer-by-layer fashion to construct a final 3D product. This technology allows flexibility in the design process and enables efficient production of both off-the-shelf and personalized medical products that accommodate patient needs better than traditional manufacturing processes. In the field of orthopaedic surgery, 3D printing implants and instrumentation can be used to address a variety of pathologies that would otherwise be challenging to manage with products made from traditional subtractive manufacturing. Furthermore, 3D bioprinting has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform how we treat patients with debilitating musculoskeletal injuries. Although costs can be high, as technology advances, the economics of 3D printing will improve, especially as the benefits of this technology have clearly been demonstrated in both orthopaedic surgery and medicine as a whole. This review outlines the basics of 3D printing technology and its current applications in orthopaedic surgery and ends with a brief summary of 3D bioprinting and its potential future impact., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)