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Sarcopenia is a progressive loss of skeletal muscle mass and function. It is associated with adverse outcomes after several orthopaedic procedures. However, its role in total joint arthroplasty (TJA) is not fully explored. Therefore, we wanted to conduct a systematic review and meta-analysis to answer the following questions: (1) What is the prevalence of sarcopenia in patients undergoing TJA?; (2) What factors are associated with the prevalence of sarcopenia in patients undergoing TJA?; What is the impact of sarcopenia on medical outcomes following TJA?; and (4) What is the impact of sarcopenia on surgical outcomes following TJA? Electronic databases PubMed, Scopus, Cochrane, and Google Scholar were searched. The data were pooled using the random-effects model and graphically represented by a forest plot. We included a total of 13 studies, evaluating 399,097 patients. The pooled prevalence of sarcopenia was 20.1% (95% confidence interval [CI] 13.6 to 28.8%; P <.00001; I2 = 94.7%) in total knee arthroplasty (TKA) and 5.2% (95% CI 0.1 to 69.7%; P =.128; I2 = 99.6%) in total hip arthroplasty (THA). Meta-regression found no links between age, sex, body mass index, diabetes, obesity, arthroplasty type, and sarcopenia prevalence in TJA. Sarcopenia increased risk of blood transfusion (odds ratio [OR] 4.68 [95% CI 3.51 to 6.25]; P <.00001), pneumonia (OR 1.94 [95% CI 1.14 to 3.30]; P =.01), urinary tract infection (UTI) (OR 1.64 [95% CI 1.31 to 2.05]; P <.001), prosthetic fracture (OR 2.12 [95% CI 1.51 to 2.98]; P <.0001), prosthetic dislocation (OR 1.99 [95% CI 1.62 to 2.44]; P <.00001), and mechanical loosening (OR 1.78 [95% CI 1.43 to 2.22]; P <.00001) in TKA. Sarcopenic patients were at an increased risk of UTI (OR 1.79 [95% CI 1.32 to 2.43]; P =.0002) and prosthetic loosening (OR 1.97 [95% CI 1.10 to 3.53]; P =.02) post-THA. Baseline sarcopenia was prevalent in patients undergoing TJA. It was associated with an increased risk of UTI and prosthetic loosening following TKA and THA. Increased risk of blood transfusion, pneumonia, prosthetic fractures, and mechanical loosening following TKA. [ABSTRACT FROM AUTHOR]

Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection. PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection). All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients. Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA. Level III, Therapeutic Study. [ABSTRACT FROM AUTHOR]

Abstract Objective By reviewing the literature analyzing vancomycin powder for preventive surgery, the effect of this method on reducing the infection rate after TJA was systematically evaluated to provide a basis for future clinical work. Methods Using PubMed, Medline, Elsevier, and CNKI, with the following mesh words: “vancomycin”, “local / intraoperative / topical / intrawound”, “TJA”, “TKA”, “THA”, “total joint arthroplasty”, “total knee arthroplasty”, “total hip arthroplasty”, “infection”, and “SSI”, to search for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of postoperative infection, we compared the overall infection rate in the literature by using RevMan 5.3 meta-analysis software and analyzed the impact of vancomycin on the infection rate of different parts and types of TJA according to different subgroups. Results A total of 22 qualified studies were selected; twenty-five studies compared the effect of prophylactic use of vancomycin powder on infection rates after TJA. There were 23,363 cases in total, including 9545 cases in the vancomycin group and 13,818 cases in the control group. The results of the meta-analysis showed that the possibility of postoperative infection after prophylactic use of vancomycin powder was significantly lower than that without vancomycin risk ratio: 0.38 [0.23,0.59], P

Background: Acute kidney injury (AKI) is associated with increased complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine the risk factors for AKI after THA and TKA and evaluate if preoperative use of antihypertensive drugs is a risk factor for AKI. Methods: A retrospective review of 7406 primary TKAs and THAs (4532 hips and 2874 knees) from 2013 to 2019 was performed. The following preoperative variables were obtained from medical records: medications, chemistry 7 panel, Elixhauser comorbidities, and demographic factors. AKI was defined as an increase in serum creatinine by 26.4 μmol·L−1. Multivariate analysis was performed to identify the risk factors. Results: The overall incidence of postoperative AKI was 6.2% (n = 459). Risk factors for postoperative AKI were found to be: chronic kidney disease (odds ratio [OR] = 7.09; 95% confidence interval [CI]: 4.8-9.4), diabetes (OR: 5.03; 95% CI: 2.8-6.06), ≥3 antihypertensive drugs (OR: 4.2; 95% CI: 2.1-6.2), preoperative use of an angiotensin receptor blockers or angiotensin-converting enzyme inhibitors (OR: 3.8; 95% CI: 2.2-5.9), perioperative vancomycin (OR: 2.7; 95% CI: 1.8-4.6), and body mass index >40 kg/m2 (OR: 1.9; 95% CI: 1.3-3.06). Conclusions: We have identified several modifiable risk factors for AKI that can be optimized prior to an elective THA or TKA. The use of certain antihypertensive agents namely angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and multidrug antihypertensive regimens were found to significantly increase the risk of AKI. Therefore, perioperative management of patients undergoing joint replacement should include medical comanagement with a focus on careful management of antihypertensives.

The request for total knee arthroplasties (TKA) is increasingly being raised and imposes an enormous burden on the healthcare system. Most subjects represent symptomatic concomitant low back pain (LBP) at baseline, interfering with functional outcomes with little or no improvement in mental health following TKA. Orthopedics should notify the patients suffering from concomitant LBP about the like hood of unfavorable recovery. The authors describe the functional outcomes and satisfaction following TKA in patients suffering from concomitant LBP.

Objective: By reviewing the literature analyzing vancomycin powder for preventive surgery, the effect of this method on reducing the infection rate after TJA was systematically evaluated to provide a basis for future clinical work. Methods: Using PubMed, Medline, Elsevier, and CNKI, with the following mesh words: "vancomycin", "local / intraoperative / topical / intrawound", "TJA", "TKA", "THA", "total joint arthroplasty", "total knee arthroplasty", "total hip arthroplasty", "infection", and "SSI", to search for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of postoperative infection, we compared the overall infection rate in the literature by using RevMan 5.3 meta-analysis software and analyzed the impact of vancomycin on the infection rate of different parts and types of TJA according to different subgroups. Results: A total of 22 qualified studies were selected; twenty-five studies compared the effect of prophylactic use of vancomycin powder on infection rates after TJA. There were 23,363 cases in total, including 9545 cases in the vancomycin group and 13,818 cases in the control group. The results of the meta-analysis showed that the possibility of postoperative infection after prophylactic use of vancomycin powder was significantly lower than that without vancomycin risk ratio: 0.38 [0.23,0.59], P < 0.01). However, a meta-analysis of randomized controlled trials (RCTs) showed no significant effect of vancomycin on postoperative infection (P = 0.52). Conclusion: Based on the retrospective studies, local prophylactic use of vancomycin powder in TJA can significantly reduce the incidence of postoperative infection. High-quality RCTs should be carried out to further evaluate these results. [ABSTRACT FROM AUTHOR]

It remains unclear whether a history of recent COVID-19 infection affects the outcomes and risks of complications of total joint arthroplasty (TJA). The purpose of this study was to compare the outcomes of TJA in patients who have and have not had a recent COVID-19 infection. A large national database was queried for patients undergoing total hip and total knee arthroplasty. Patients who had a diagnosis of COVID-19 within 90-days preoperatively were matched to patients who did not have a history of COVID-19 based on age, sex, Charlson Comorbidity Index, and procedure. A total of 31,453 patients undergoing TJA were identified, of which 616 (2.0%) had a preoperative diagnosis of COVID-19. Of these, 281 COVID-19 positive patients were matched with 281 patients who did not have COVID-19. The 90-day complications were compared between patients who did and did not have a diagnosis of COVID-19 at 1, 2, and 3 months preoperatively. Multivariate analyses were used to further control for potential confounders. Multivariate analysis of the matched cohorts showed that COVID-19 infection within 1 month prior to TJA was associated with an increased rate of postoperative deep vein thrombosis (odds ratio [OR]: 6.50, 95% confidence interval: 1.48-28.45, P =.010) and venous thromboembolic events (odds ratio: 8.32, confidence interval: 2.12-34.84, P =.002). COVID-19 infection within 2 and 3 months prior to TJA did not significantly affect outcomes. COVID-19 infection within 1 month prior to TJA significantly increases the risk of postoperative thromboembolic events; however, complication rates returned to baseline after that time point. Surgeons should consider delaying elective total hip arthroplasty and total knee arthroplasty until 1 month after a COVID-19 infection. [ABSTRACT FROM AUTHOR]

Background: Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage. Methods: Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review. Results: It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty. Conclusions: The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening. [ABSTRACT FROM AUTHOR]

Abstract Background Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is a serious complication for patients. Some joint surgeons have tried to use vancomycin powder (VP) in total knee and total hip arthroplasty to prevent postoperative PJI, but its effect is still not clear. At present, there is no meta-analysis that specifically analyses the effect of different doses of vancomycin powder on the incidence of PJI. Methods We carried out a search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and identified the studies we needed. Review Manager (RevMan) 5.3 software was employed for statistical analysis. Results The analysis of primary TKA (PTKA) showed that using 1 g (RR 0.38, 95% CI 0.22–0.67 [P = 0.0008]) and 2 g (RR 0.48, 95% CI 0.31–0.74 [P = 0.0008]) of vancomycin powder in primary TKA (PTKA) could all significantly prevent PJI. The analysis of primary THA (PTHA) showed that using 1 g (RR 0.37, 95% CI 0.17–0.80 [P = 0.01]) of vancomycin powder effectively decreased the incidence of PJI, while using 2 g (RR 1.02, 95% CI 0.53–1.97 [P = 0.94]) of vancomycin powder had no significant effect on preventing PJI. Because the data were abnormal, we believed the conclusion that using 2 g of vancomycin powder in primary THA had no effect on preventing PJI was doubtful. Using vancomycin powder in revision TKA (RTKA) significantly reduced the PJI rate (RR 0.33, 95% CI 0.14–0.77 [P = 0.01]), similar to revision THA (RTHA) (RR 0.37, 95% CI 0.14–0.96 [P = 0.04]). Conclusions In primary TKA, both 1 g and 2 g of vancomycin powder can effectively prevent PJI. In primary THA, using 1 g of vancomycin powder is a better choice, while the effect of using 2 g of vancomycin powder is not clear, and a more prospective randomized controlled trial should be done to verify it. In revision TKA and revision THA, vancomycin powder is a good choice to prevent PJI.

Background: Obese and African American populations suffer from higher incidence of hip and knee osteoarthritis, yet African Americans are less likely to undergo total hip and knee arthroplasty (TJA). Patient interest in TJA is a necessary first step for surgery. Medical device company direct-to-consumer advertising for TJA represents 1 potential factor driving disparities in utilization. Here we analyze demographics of models represented in medical device company direct-to-consumer TJA advertisements to understand whether advertisement content correlates with the population in need. Methods: We analyzed medical device company pamphlets, websites, and banner and video advertisements of the top 4 medical device companies in US arthroplasty sales, collected via ad-specific search engine and direct correspondence. Variables include model race, sex, age, and weight. Pearson likelihood ratio tests were used to compare categorical variables. Results: Of the 116 advertisements collected, the model featured in the advertisement was white in 69.8%. The proportion of white models differed across medical device companies (company C, 75%) (P < .001) and advertisement type (video, 81.8%) (P < .001). Only 2.6% of advertisements featured obese models. Neither company C nor D, nor pamphlet or website advertisements used obese models. Conclusions: Direct-to-consumer advertising from the top 4 orthopedic US medical device companies does not represent the population in need: While TJA remains underutilized by African American/Hispanic patients, models were overwhelmingly white. While obese patients are known to need TJA, patients in the advertisements were overwhelmingly not obese. We advocate for medical device companies to refocus their advertising strategies to target diverse patients in need of TJA. Level of evidence: III (retrospective cohort study).

Background: In 2020, the coronavirus disease 2019 (COVID-19) pandemic caused the cessation of nonemergent total joint arthroplasty (TJA, referring to total hip and total knee arthroplasty) operations between mid-March and April 2020. The purpose of this study is to analyze the effects and potential disparities in access to care due to the COVID-19 restrictions. Methods: A database was used to examine the demographics of patients undergoing TJA from May to December 2019 (pre-COVID-19) and from May to December 2020 (post-COVID-19 restrictions). Categorical covariates were summarized by reporting counts and percentages and compared using Fisher exact tests. Continuous covariates were summarized by reporting means and standard deviations. Two-sample t-tests were used for continuous covariates. The equality of TJA counts by year was tested using a test of proportions. Results: There were more TJA procedures performed during the post-COVID-19 period in 2020 than in the pre-COVID-19 period (1151 vs 882, P < .001). There was an increase in the relative percentage of THAs vs TKAs performed in 2020 vs 2019 (26.9% vs 18.8%, P < .001) and an increase in patients with Medicaid with a decrease in private insurance (P = .043). The average length of stay was shorter in 2020 with a greater percentage of TJAs performed outpatient (P < .001). There were no differences in patient sex, race, body mass index, smoking status, or age between the 2 periods. Conclusions: A relative increase in THA procedures, an increase in patients with Medicaid and decrease in private insurance, and a a decreased length of stay were seen after COVID-19 restrictions. These trends may reflect pandemic-related changes in insurance status as well as the growing shift to same-day discharge.

Background: Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is a serious complication for patients. Some joint surgeons have tried to use vancomycin powder (VP) in total knee and total hip arthroplasty to prevent postoperative PJI, but its effect is still not clear. At present, there is no meta-analysis that specifically analyses the effect of different doses of vancomycin powder on the incidence of PJI. Methods: We carried out a search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and identified the studies we needed. Review Manager (RevMan) 5.3 software was employed for statistical analysis. Results: The analysis of primary TKA (PTKA) showed that using 1 g (RR 0.38, 95% CI 0.22–0.67 [P = 0.0008]) and 2 g (RR 0.48, 95% CI 0.31–0.74 [P = 0.0008]) of vancomycin powder in primary TKA (PTKA) could all significantly prevent PJI. The analysis of primary THA (PTHA) showed that using 1 g (RR 0.37, 95% CI 0.17–0.80 [P = 0.01]) of vancomycin powder effectively decreased the incidence of PJI, while using 2 g (RR 1.02, 95% CI 0.53–1.97 [P = 0.94]) of vancomycin powder had no significant effect on preventing PJI. Because the data were abnormal, we believed the conclusion that using 2 g of vancomycin powder in primary THA had no effect on preventing PJI was doubtful. Using vancomycin powder in revision TKA (RTKA) significantly reduced the PJI rate (RR 0.33, 95% CI 0.14–0.77 [P = 0.01]), similar to revision THA (RTHA) (RR 0.37, 95% CI 0.14–0.96 [P = 0.04]). Conclusions: In primary TKA, both 1 g and 2 g of vancomycin powder can effectively prevent PJI. In primary THA, using 1 g of vancomycin powder is a better choice, while the effect of using 2 g of vancomycin powder is not clear, and a more prospective randomized controlled trial should be done to verify it. In revision TKA and revision THA, vancomycin powder is a good choice to prevent PJI. [ABSTRACT FROM AUTHOR]

Background: Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance.Methods: We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD > 0.1 indicates significance) and a multivariate linear regression.Results: The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD > 0.1). Age was a determinant of attendance for telehealth (SD > 0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD > 0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P < .05) and telehealth (P < .0001) were predictors of failed class attendance.Conclusion: This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth. [ABSTRACT FROM AUTHOR]

Background: Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA.Methods: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes.Results: A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m2), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05).Conclusion: Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately.Level Of Evidence: Level 3: Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]

Background: Morbidly obese (body mass index [BMI] >40 kg/m2) patients undergoing total joint arthroplasty (TJA) are at high risk for postoperative venous thromboembolism (VTE); however, there is debate surrounding the optimal pharmacologic agent for prevention of VTE after TJA in this patient subset. Current guidelines recommend against direct-acting oral anticoagulants (DOACs) in patients of BMI >40 kg/m2 due to low quality evidence justifying their use. We evaluated whether patients of BMI >40 kg/m2 undergoing primary unilateral TJA would have increased risk of postoperative VTE if prescribed DOACs compared to non-DOAC agents such as aspirin.Methods: This retrospective study analyzed 897 patients of BMI >40 kg/m2 undergoing primary unilateral TJA. Demographic and comorbidity-related variables were collected. The association between postoperative VTE and prophylactic pharmacologic agent prescribed was evaluated by multivariate logistic regression.Results: After controlling for comorbidities, we found that the sole use of DOACs, specifically apixaban, for VTE prophylaxis was associated with an increased risk of developing VTE compared to prophylaxis with aspirin alone in patients of BMI >40 kg/m2 (odds ratio 2.962, P = .016). Regardless of VTE prophylactic agent, patients with BMI >40 kg/m2 undergoing TKA had at least 4.5-fold increased odds of developing VTE compared to patients undergoing THA (OR 4.830, P = .019).Conclusion: In our retrospective study of a large sample size of patients with BMI >40 kg/m2, we found that the use of DOACs, specifically apixaban, for VTE prophylaxis following TJA was associated with increased odds of a VTE complication compared to the use of aspirin alone. [ABSTRACT FROM AUTHOR]

Abstract Background There is increasing literature on the usefulness of patient-reported outcome measures (PROMs), but far fewer studies to determine their use by orthopedic surgeons and the barriers they face in applying PROMs in their daily clinical activity. Methods Cross-sectional study using a questionnaire that was distributed in both soft and hard copy formats to a sample of 262 orthopedic surgeons. Participants included orthopedic surgeons who are employed by the Ministry of Health (MOH) in Riyadh and the Eastern Province, Saudi Arabia. The questionnaire was distributed through on-site visitations to orthopedic departments in MOH hospitals as well as through online correspondence by email, WhatsApp, and social media. Results The study sample included 262 orthopedic surgeons (13.7% females and 86.3% males). Surgeons aged < 34, 35–44, and 45–54 years old represented 28.66%, 38.9%, and 20.2% of the study sample, respectively. The majority of the included surgeons did not use PROMs (69.1%), and some (17.2%) used it for research purposes. Only 5% used it regularly in daily clinical work. Conclusion The clinical use of PROMs among orthopedic surgeons was negligible, even though an overwhelming majority were interested in using PROMs. The reasons provided included a lack of knowledge on how to use PROMs and the perception that it is too time-consuming to add to regular clinical routine. There should be more efforts towards training surgeons on how to use PROMs, whereas increasing compatibility with existing software tools used by MOH hospitals may help offset time-related reservations.

Operative time has been shown to be a significant risk factor for short-term complications following total shoulder arthroplasty (TSA). Identifying TSA cases that require increased operative time may potentially lead to improved outcomes, yet there is a lack of previous research on specific risk factors associated with prolonged TSA operative time. The purpose of this study was to determine independent predictors for prolonged operative time following TSA. Adult patients undergoing primary TSA from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients with sepsis, disseminated cancer, infection, or who underwent emergency surgery were excluded from our dataset. Prolonged operative time was defined as ≥ 150 minutes, or one standard deviation above the mean operative time of 109 minutes. Clinical characteristics assessed included age, sex, race, BMI, American Society of Anesthesiologists class, surgical setting (inpatient vs. outpatient), anesthesia type, preoperative albumin, and hematocrit. Comorbidities assessed included diabetes, smoking, dyspnea, functional status, chronic obstructive pulmonary disease, ascites, congestive heart failure, hypertension, renal failure, dialysis, steroid use, weight loss, bleeding disorder, and preoperative transfusion. Risk factors were assessed using bivariate and multivariate analysis. Of 16,568 total patients undergoing TSA, 14.8% (2,453) had prolonged operative time. On bivariate analysis, younger age, male sex, nonwhite race, increased BMI, outpatient procedure, smoking status, dyspnea, steroid use, and bleeding disorder were significantly associated with prolonged operative time (all, P <.05). After controlling for confounding variables on multivariate analysis, increased BMI (OR 1.023; P =.045) and male gender (OR 1.647; P <.001) were found to be independent predictors of prolonged TSA operative time. Notably, age was not found to be an independent predictor of prolonged operative time (P >.05). Increased BMI and male gender were found to be predictive of prolonged TSA operative time. Since increased operative time has been shown to be associated with increased short-term postoperative complications, surgeons and perioperative teams should be aware of the potential for prolonged operative time in patients with these risk factors who undergo TSA. Level III; Retrospective Case-control Comparative Study [ABSTRACT FROM AUTHOR]

Aims and Objectives: Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA) and is associated with significant morbidity, mortality, and cost. This pilot study primarily aimed to investigate if preoperative dental screenings would impact the rate of PJI following TJA when compared to historical controls. Secondarily, this study aimed to evaluate the prevalence of dental pathology in patients undergoing TJA., Methods: Charts from 103 consecutive patients undergoing primary or revision total hip arthroplasty (THA, rTHA) or total knee arthroplasty (TKA, rTKA) by a single surgeon at a single academic institution over a two-year period were reviewed and selected for inclusion. All patients were referred to a dentist for preoperative clearance using a standardized form. The rate of dental pathology before surgery, details of the dental intervention required, and any dental work performed within six months postoperatively were evaluated. The demographic and comorbidity composition of our patient population was also collected. Finally, rates of PJI following each type of TJA were obtained for demographic- and comorbidity-matched historical controls from similar study designs to examine the potential impact of preoperative dental intervention., Results: Of the 103 patients, 31 (30.1%) were found to have preoperative dental pathology. Twenty-eight of these 31 patients (90.3%) required dental intervention prior to surgery. Based on demographic- and comorbidity-matched historical data, we expected two (95% CI (0, 6)) PJI cases for the THA group, 0 (95% CI (0, 2)) PJI cases for the TKA group, two (95% CI (0, 5)) PJI cases for the rTHA group, and two (95% CI (0, 5)) PJI cases for the rTKA group. However, in our study, there were no PJIs after any TJA up to the latest follow-up, which was unlikely for THA, rTHA, and rTKA groups given the calculated Poisson probabilities (9.39%, 15.11%, and 11.26%, respectively). Finding 0 cases was likely for the TKA group given the calculated Poisson probability of 72.61%., Conclusions: This pilot study demonstrated that preoperative dental screening, which aims to decrease the chance of PJI due to bacteremia, may have an impact on the rate of PJI following THA, rTKA, and rTHA but not TKA based on Poisson probabilities calculated from demographic- and comorbidity-matched historical controls that lacked preoperative dental screening. For THA, rTKA, and rTHA, the Poisson probabilities of observing 0 cases of PJI postoperatively, as was the case in our study, were unlikely, suggesting that some variable in our cohort was decreasing the PJI rate for these groups. However, in the case of TKA, the Poisson probability of observing 0 cases was likely and matched the results of our study, suggesting that no variable in our cohort was affecting the PJI rate for this group. We cannot draw direct conclusions from this retrospective observational study, but the preliminary findings prompt further investigation through an appropriately controlled, blinded, multi-centered, and powered prospective randomized controlled trial., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jimenez et al.)

Background: Malnutrition is a devastating condition which disproportionally affects the elderly population. Malnutrition furthers the pre-existing elevated risk for osteoarthritis in this population, thus exacerbating joint damage in patients and furthering the need for total joint arthroplasty (TJA). A marker for malnutrition is a low body mass index (BMI). The purpose of this study is to investigate whether low BMI status increased the risk for 2-year mortality or reoperation, 90-day readmission, or extended length of stay (LOS) following TJA.Methods: A retrospective study was performed using the Partners Arthroplasty Registry which contains data from 2016 to 2019. The registry was queried for primary total hip and primary total knee arthroplasty (TKA) patients that had a minimum of 2-years follow-up data. Demographic, surgical, and clinical outcome variables were obtained from these patients. The association between underweight BMI and objective outcomes of reoperation, 90-day readmission, mortality, and LOS was evaluated by univariate analysis followed by multiple logistic and linear regression analyses.Results: The final cohort used for analysis consisted of 4802 TJA cases. After accounting for potential confounders, underweight BMI was found to be independently associated with increased risk of mortality within 2 years following TJA (odds ratio 8.77) (95% confidence interval 2.14-32.0) and increased LOS of 0.44 days (95% confidence interval 0.02-0.86).Conclusion: Our findings demonstrate that TJA patients with an underweight BMI experience an 8 times increased risk of 2-year mortality and an increased LOS of 0.44 days. Orthopedic surgeons should consider nutritional consultation and medical optimization in these high-risk patients prior to surgery. [ABSTRACT FROM AUTHOR]

Background: There is increasing literature on the usefulness of patient-reported outcome measures (PROMs), but far fewer studies to determine their use by orthopedic surgeons and the barriers they face in applying PROMs in their daily clinical activity. Methods: Cross-sectional study using a questionnaire that was distributed in both soft and hard copy formats to a sample of 262 orthopedic surgeons. Participants included orthopedic surgeons who are employed by the Ministry of Health (MOH) in Riyadh and the Eastern Province, Saudi Arabia. The questionnaire was distributed through on-site visitations to orthopedic departments in MOH hospitals as well as through online correspondence by email, WhatsApp, and social media. Results: The study sample included 262 orthopedic surgeons (13.7% females and 86.3% males). Surgeons aged < 34, 35–44, and 45–54 years old represented 28.66%, 38.9%, and 20.2% of the study sample, respectively. The majority of the included surgeons did not use PROMs (69.1%), and some (17.2%) used it for research purposes. Only 5% used it regularly in daily clinical work. Conclusion: The clinical use of PROMs among orthopedic surgeons was negligible, even though an overwhelming majority were interested in using PROMs. The reasons provided included a lack of knowledge on how to use PROMs and the perception that it is too time-consuming to add to regular clinical routine. There should be more efforts towards training surgeons on how to use PROMs, whereas increasing compatibility with existing software tools used by MOH hospitals may help offset time-related reservations. [ABSTRACT FROM AUTHOR]

James E Feng, David Novikov, Afshin A Anoushiravani, Ran Schwarzkopf Division of Adult Reconstructive Surgery, NYU Langone Orthopedics, NYU Langone Health, New York, NY, USA Abstract: Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice. Keywords: perioperative optimization, clinical care pathways, adult reconstruction total joint replacement, perioperative orthopaedic surgical home, POSH

The purposes of this pilot study are to utilize digital remote monitoring to (a) evaluate the usability and satisfaction of a wireless blood pressure (BP) and heart rate (HR) monitor and (b) determine whether these data can enable safe mobilization at home after same-day discharge (SDD) joint replacement. A population of 23 SDD patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) were given a cellular BP/HR monitor, with real-time data capture. Patients took three readings after surgery, observing for specific blood pressure decreases, HR increases, or hypotensive symptoms. If any criteria applied, patients followed a hydration protocol and delayed ambulation. Home coaching was also provided to each patient. Patient experience was surveyed, and responses were assessed using descriptive statistics. Of 18 patients discharged (78%), 17 returned surveys, of which 100% reported successful device operation. The mean “ease of use” rating was 8.9/10; satisfaction with home coaching was 9.7/10; and belief that the protocol improved patient safety was 8.4/10. A total of 27.8% (n = 5) had hypotensive readings and appropriately delayed ambulation. Our pilot findings support the feasibility of and confirm the satisfaction with remote monitoring after SDD arthroplasty. All patients with symptoms of hypotension were successfully remotely managed using a standardized hydration protocol prior to safe mobilization.

Heterotopic ossification (HO) is the presence of normal bone in soft tissue where bone should not exist. After direct musculoskeletal trauma of the surrounding soft tissue, HO is hypothesized to develop from a dysfunction of normal lamellar bone formation and remodeling that appears in nonskeletal areas of the body. Acquired HO related to total joint arthroplasty (TJA) of the hip and knee forms outside the joint capsule and can be a challenging condition when it impairs the essential healing process after elective surgery. Although HO is rare after elective TJA and thus clinically immaterial, when clinically relevant HO develops, patients may experience the following: 1) limited ambulation, 2) restricted range of motion, and 3) severe pain and discomfort that may lead to loss of function. Ultimately, patients with clinically relevant HO after elective TJA may require additional treatment, including medication, radiation therapy, manipulation under anesthesia, surgical excision of the HO, and possibly revision TJA. Awareness of HO and an understanding of the associated risk factors along with the various management options will enable health care practitioners and their patients to optimize their surgical outcomes. [ABSTRACT FROM AUTHOR]

This primer presents a synopsis of pain management strategies associated with total joint arthroplasty. Patients considering total joint arthroplasty often experience moderate to severe pain, which places them at risk of opioid abuse or addiction. Currently, the best practice strategies involve the development of individualized multimodal perioperative approaches to pain management. These practices include prescribing opioids at their lowest dose and for the shortest duration necessary to control symptoms, with close monitoring of common adverse effects. Implementing these practices is essential to battling the ongoing opioid crisis in the US. [ABSTRACT FROM AUTHOR]

Despite the adaptation of checklists for specific surgeries being developed, there remains a lack of an available standard for an orthopaedic-specific checklist. Benefits of implementing checklists include cost-effectiveness as well as the ability to significantly reduce both mortality and complication rates in a variety of healthcare settings. The aim of this review is to analyze the evidence surrounding the effectiveness of checklists as well as recommend for the development of a standard checklist for specific orthopaedic surgeries such as total joint arthroplasty (TJA). [ABSTRACT FROM AUTHOR]

Patients who are discharged home following primary hip and knee arthroplasty have lower associated costs and better outcomes than patients who are discharged to skilled nursing facilities (SNFs). However, patients who live alone are more likely to be discharged to an SNF. We studied the factors that determine the discharge destination for patients who live alone after total joint arthroplasty (TJA) at an urban tertiary care academic hospital between April 2016 and April 2017. We identified 127 patients who lived alone: 79 (62.2%) were sent home, and 48 (37.8%) were sent to an SNF after surgery. Patients who went home versus to an SNF differed in age, employment status, exercise/active status, patient expectation of discharge to an SNF, ASA score, and the length of stay. After controlling for expectations of discharge to an SNF (OR: 28.98), patients who were younger (OR: 0.03) and employed (OR: 6.91) were more likely to be discharged home. In conclusion, the expectation of discharge location was the strongest predictor of discharge to an SNF even after controlling for age and employment. Future research should include a multi-hospital approach to strengthen the validity of our findings and investigate additional factors that impact discharge destination.

The pathology of early aseptic implant failure has been linked in basic science, case, and group studies to metal implant debris–induced delayed-type hypersensitivity (DTH) responses (or metal allergy). However, a precondition of metal DTH does not always result in implant failure. The methods of diagnosing metal DTH responses measure cell-mediated adaptive immunity, where conditioned lymphocytes respond to specific stimuli. Metal-sensitivity testing is a direct test of an individual’s immune response to metal challenge, which has been in use for over the past half century to measure delayed-type responses to drugs (such as antibiotics) where the results indicate levels of immune reactivity. Currently approved methods for human diagnostic testing for metal DTH include both skin testing (patch testing) and in vitro blood testing using lymphocyte transformation testing (LTT). LTT testing may be better suited for diagnosing implant-related sensitivity, given the ability of dermal exposure to metals to induce DTH responses. Metal sensitivity among the general population has been well established with a rate of 10%-15%, where hypersensitivity to nickel is the most common. However, it remains unknown about the exact percentage of these presensitized people that will go on to develop pathogenic metal-sensitivity responses to their implant. Recent studies show that when exposure to metal implant debris is minimized, the chances of metal DTH reactivity are also minimized. Further, past basic science studies, case studies, and cohort studies indicate the clinical utility of metal-sensitivity testing in specific patient populations. Continuing clinical outcome studies are needed to relate positive patch and metal-LTT test results with other clinical determinants to more definitively predict and prevent pathologic reactivity to implants. [ABSTRACT FROM AUTHOR]

The tuck jump assessment (TJA) is a plyometric jumping assessment with 10 flaw criteria against which technique is assessed over a 10-second interval. The TJA has been reported as a tool for identifying neuromuscular deficits that increase risk for anterior cruciate ligament injury, but group specific data on female TJA scores are limited. No cut point has been developed for groups with different activity levels or participation in athletics. This study investigated the association between TJA score and athletic participation in college-aged females. One hundred twenty-one females (53 collegiate athletes and 68 college students) completed the TJA. TJA score was the sum of flaws for the 10 criteria observed, and the number of jumps was recorded. Poisson regression was used to assess the association between TJA score and number of jumps. The association between each of the 10 flaws between groups was assessed with the chi-square test. No significant association was found between groups for TJA score (mean ± SD: 4.66 ± 1.07 athletes; 5.45 ± 1.05 college cohort; p = 0.06; β = 0.82). Athletes jumped significantly more times (1 2.23 ± 1.04 athletes; 9.35 ± 1.4 college cohort). Athletes had a lower proportion of 2 flaws: "thighs do not reach parallel" and "pause between jumps." Lower statistical power may limit interpretation of the remaining flaws. The lack of control of the number of jumps may impact TJA score. To improve the TJA usefulness on the field and clinic, the protocol may need to standardize the number of jumps. [ABSTRACT FROM AUTHOR]

Background: The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty.Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed.Results: Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups.Conclusion: MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases. [ABSTRACT FROM AUTHOR]

There is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA. We searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders. The risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P =.002, I2 = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P <.00001, I2 = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P =.02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P =.50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P <.00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P <.0001). Mental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients. [ABSTRACT FROM AUTHOR]

Background: We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W.Methods: This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or "no significant change" after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve.Results: The MCID-W for TJA was -1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013).Conclusion: We described the MCID-W value (-1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA. [ABSTRACT FROM AUTHOR]

The purposes of this pilot study are to utilize digital remote monitoring to (a) evaluate the usability and satisfaction of a wireless blood pressure (BP) and heart rate (HR) monitor and (b) determine whether these data can enable safe mobilization at home after same-day discharge (SDD) joint replacement. A population of 23 SDD patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) were given a cellular BP/HR monitor, with real-time data capture. Patients took three readings after surgery, observing for specific blood pressure decreases, HR increases, or hypotensive symptoms. If any criteria applied, patients followed a hydration protocol and delayed ambulation. Home coaching was also provided to each patient. Patient experience was surveyed, and responses were assessed using descriptive statistics. Of 18 patients discharged (78%), 17 returned surveys, of which 100% reported successful device operation. The mean "ease of use" rating was 8.9/10; satisfaction with home coaching was 9.7/10; and belief that the protocol improved patient safety was 8.4/10. A total of 27.8% (n = 5) had hypotensive readings and appropriately delayed ambulation. Our pilot findings support the feasibility of and confirm the satisfaction with remote monitoring after SDD arthroplasty. All patients with symptoms of hypotension were successfully remotely managed using a standardized hydration protocol prior to safe mobilization. [ABSTRACT FROM AUTHOR]

Despite the adaptation of checklists for specific surgeries being developed, there remains a lack of an available standard for an orthopaedic-specific checklist. Benefits of implementing checklists include cost-effectiveness as well as the ability to significantly reduce both mortality and complication rates in a variety of healthcare settings. The aim of this review is to analyze the evidence surrounding the effectiveness of checklists as well as recommend for the development of a standard checklist for specific orthopaedic surgeries such as total joint arthroplasty (TJA).

The US health care system has been fragmented for more than 40 years; this model created a need for modification. Sociopoliticomedical system-related factors led to the Affordable Care Act (ACA) and a restructuring of health care provision/delivery. The ACA increases access to high-quality "affordable care" under cost-effective measures. This article provides a comprehensive review of health reform and the motivating factors that drive policy to empower arthroplasty providers to effectively advocate for the field of orthopedics as a whole, and the patients served., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services' Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Louis Pasteur once said that: "Fortune favours the prepared mind." As one of the great scientists who contributed to the fight against infection, he emphasised the importance of being prepared at all times to recognise infection and deal with it. Despite the many scientific discoveries and technological advances, such as the advent of antibiotics and the use of sterile techniques, infection continues to be a problem that haunts orthopaedic surgeons and inflicts suffering on patients. The medical community has implemented many practices with the intention of preventing infection and treating it effectively when it occurs. Although high-level evidence may support some of these practices, many are based on little to no scientific foundation. Thus, around the world, there is great variation in practices for the prevention and management of periprosthetic joint infection. This paper summaries the instigation, conduct and findings of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.