Faculty Bibliography

BACKGROUND/UNASSIGNED:The primary aim of this study is to evaluate differences in inpatient charges between primary (pTEA) and revision (rTEA) total elbow arthroplasty among Medicare and Medicaid patients. Our secondary aim is to assess whether these charges vary across hospitals with differing total elbow arthroplasty (TEA) procedural volumes. We hypothesize that rTEA would be more expensive than pTEA and that charges would be higher for low-volume hospitals. METHODS/UNASSIGNED:The Statewide Planning and Research Cooperative System database was queried for all Medicare and Medicaid Services patients who underwent a pTEA or rTEA in New York State from 2010 to 2020. Hospitals were classified as high-volume (≥3 surgeries/year), medium-volume (between 2-3 surgeries/year), or low-volume (less than 2 surgeries/year). Facilities performing fewer than 1 surgery per year or with fewer than 4 years of TEA data were excluded. Total inpatient charges were collected and subsequently subdivided into ancillary and accommodation charges. Inpatient charges and readmission data were compared across the 2 procedures and volume groups. RESULTS/UNASSIGNED:> .05 for rTEA). CONCLUSION/UNASSIGNED:rTEA is associated with longer inpatient stay, higher inpatient charges, and greater readmission rates compared to pTEA. Primary TEA in low-volume hospitals is associated with higher total charges compared to medium and high-volume hospitals. These findings provide valuable insights for hospital administrators and public health officials aiming to create effective strategies to manage costs and combat the growing burden of healthcare expenses in the United States.

INTRODUCTION/BACKGROUND:Medicare's Bundled Payments for Care Initiative is a risk-sharing, value-based alternative payment model. As such, Medicare providers are financially responsible for poor outcomes, potentially disincentivizing operating on high-risk individuals, including obese patients and smokers. We sought to describe the change in these modifiable risk factors among Medicare, Medicaid, and commercially insured patients in the 6-year period after implementation of Bundled Payments for Care Initiative. METHODS:We analyzed a consecutive series of 11,790 patients who underwent total hip arthroplasty between January 1, 2013, and August 31, 2019. We categorized patients based on smoking status (current, former, or never) and body mass index (BMI; obese if BMI was >30 kg/m2, morbidly obese if BMI was >40 kg/m2, and superobese if BMI was >50 kg/m2). Correlations between each year's proportion of patients in each smoking category and obesity category were evaluated. RESULTS:We included 11,582 patients with complete demographic and insurance information. There was a statistically significant decrease in the proportion of Medicare patients who were active smokers (7.91% in 2013, 5.99% in 2019, Pearson correlation coefficient = -0.759, P = .048). When looking at patients with BMI >40 kg/m2, commercially insured patients significantly increased (3.64% in 2013, 6.65% in 2019, Pearson correlation coefficient = 0.860, P = .013). Our study also demonstrated a significantly higher rate of active smokers among Medicaid patients compared with other insurance groups (P = .001), which is consistent with the general population. DISCUSSION/CONCLUSIONS:Our results demonstrated that the proportion of Medicare-insured patients who were active smokers decreased significantly over the study period. In addition, the proportion of obese commercially insured patients increased, but the proportion of obese Medicare patients did not. These findings suggest the possibility that surgeons may be disincentivized to operate on both obese patients and those who are actively smoking who are enrolled in risk-sharing, value-based programs. Notably, we found a potential trickle-down effect to Medicare patients with our smoking cessation program. The same was not observed for patients with Medicaid or Commercial insurance or for weight reduction before surgery for any insurance group. A possible explanation is that obesity is not as modifiable as smoking and increased efforts to address obesity in the arthritis population are needed. LEVEL OF EVIDENCE/METHODS:III, retrospective observational analysis.

PURPOSE/OBJECTIVE:The purpose of this study was to assess the 10-year arthroplasty-free survivorship of patients over 50 years of age who underwent knee arthroscopy and to assess whether this survivorship is affected by the diagnoses of knee osteoarthritis (OA) or obesity at the time of arthroscopy. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database from 2010 to 2020 was queried to identify all patients over the age of 50 who underwent knee arthroscopy. Kaplan-Meier survival analysis was used to assess arthroplasty-free survivorship. Cox proportional hazards models were performed to assess the effect of the diagnoses of knee OA and obesity at the time of arthroscopy based on ICD-9 and 10 codes. RESULTS:A total of 300,587 patients aged 50 years or older underwent knee arthroscopy. The arthroplasty-free survivorship rate following knee arthroscopy is 83.0% at 5 years. However, at 10 years, the arthroplasty-free survivorship decreased to 66.6%. Patients without knee OA nor obesity had an arthroplasty-free survivorship of 84.1% at 5 years and 68.5% at 10 years. However, patients with a diagnosis of both knee OA and obesity based on ICD-9 and 10 codes had an arthroplasty-free survivorship of 66.2% at 5 years and 15.4% at 10 years. (HR: 2.38; 95% CI: 2.18, 2.60; p < 0.001) CONCLUSION: At five years there is an 83% rate of arthroplasty-free survivorship. This effect deteriorates at the 10-year mark, and many are eventually destined for knee arthroplasty. Presence of diagnosis codes for both knee OA and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older. LEVEL OF EVIDENCE/METHODS:IV, Prognostic, Case Series.

BACKGROUND:10 years after changing our institution's total hip arthroplasty (THA) preoperative antibiotic prophylactic protocol by adding gram-negative (GN) coverage, this study aimed to assess the impact of adding GN specific coverage (GNSC) prior to THA on periprosthetic joint infection (PJI) rates. METHODS:This was a retrospective case-control study of 14,598 patients who underwent primary, elective THA between July 2012 and January 2022, with minimum 1-year follow-up. All patients were under perioperative antibiotic protocol that included GNSC with either weight-based gentamicin or aztreonam (+GNSC) and were compared to a historical control group of patients for which the antibiotic prophylactic protocol did not include GNSC (-GNSC). PJI and nephrotoxicity rates, as well as the severity of nephrotoxicity according to the RIFLE criteria, were compared between the study populations and 4122 controls. RESULTS: = 0.567), which are the two more severe forms of nephrotoxicity, were comparable between the groups. CONCLUSIONS:The addition of gentamicin or aztreonam prior to THA reduces the incidence of GN-related PJIs. Increased nephrotoxicity rates were limited to the mildest form, usually associated with reversibility and favourable outcomes.

BACKGROUND:Despite advances in surgical techniques and postoperative prophylactic protocols, venous thromboembolism (VTE) events remain an important source of morbidity following total hip arthroplasty (THA). Prior research in cardiology and other surgical fields has suggested that statin medications may have a protective effect against VTE. Our study aimed to: 1) Assess if preoperative statin use was associated with decreased rates of VTE following THA, and 2) conduct a subgroup analysis of statin intensity and VTE events. METHODS:A total of 1,154 patients who had preoperative statin use for at least four weeks before surgery and who underwent primary THA at a large, urban academic center between January 1, 2012, and June 1, 2023, were identified. The 90-day postoperative VTE events, deep vein thrombosis (DVT), pulmonary embolism (PE), emergency department (ED) visits, reoperations, and readmission rates were collected from institutional coding software. Mortality rate in the 90-day postoperative period was also measured. Propensity matching was used to control for demographics and selected comorbidities. RESULTS:Preoperative statin use was associated with significantly lower rates of 90-day VTE events (Statin: 0.43% versus No-Statin: 1.13%, P = 0.047). There were no significant differences in 90-day PE, DVT, ED visit, readmission, or reoperation rates. There were no deaths within 90 days of THA in either group. Subgroup analysis of statin intensity revealed no significant differences in any outcomes measured between high-intensity, medium-intensity, and low-intensity statin groups. CONCLUSION/CONCLUSIONS:Preoperative statin use is associated with significantly lower rates of VTE events in the 90-day postoperative period following THA. Further research into the effect of statins on post-THA VTE is warranted.

BACKGROUND:A frequently stated goal of an artificial knee arthroplasties is to achieve normal kinematics. However, this is not easily defined based on variations in motions previously measured for a range of activities. For activities such as crouching up and down, a fan pattern has been measured, where the lateral femoral contact displaces progressively posteriorly with flexion, and the medial contact remains almost constant. In walking and other activities, femoral-tibial contacts vary considerably in position, and even lateral pivoting has been measured at the start of the motion cycle. Fluoroscopic studies of total knee arthroplasty (TKA) patients have shown that such kinematics are not usually achieved for most TKA designs. In recent years, there has been an increasing interest in non-cruciate retaining knee arthroplasties, where both cruciate ligaments are resected. A challenge with such designs is to define the design criteria, taking account of the extensive kinematic data of normal knees, as well as clinical factors. METHODS:A TKA design was formulated where the main bearing surfaces produced medial stability and lateral mobility, but where the addition of an offset cylindrical bearing surface in the center induced progressive axial rotation and lateral 'rollback' with flexion. At the same time, anterior-posterior (A-P) and rotational laxity were provided, as in the normal knee. The new design was compared experimentally with four types of contemporary non-cruciate total knee arthroplasties. Three-dimensional printed models were fabricated. A test machine was constructed where shear and torque forces were applied at a range of flexion angles, and contact positions were determined. RESULTS:It was found that the design with the intercondylar cylindrical surface satisfied the design criteria more closely compared with the other designs. CONCLUSION/CONCLUSIONS:For non-cruciate designs to produce more normal motion characteristics, some mechanical configuration acting in concert with the lateral and medial condyles is likely to be necessary.

BACKGROUND:Femoral neck fractures pose a notable health challenge globally, with a projected rise in cases due to aging populations. While treatment protocols are established, the effect of surgeon training on treatment decisions, particularly trauma versus arthroplasty fellowship training, remains less clear. METHODS:This study, using data from the Statewide Planning and Research Cooperative System in New York State, examined 26,761 patients meeting inclusion criteria. Among 951 treating surgeons, 20.6% had no subspecialty fellowship training while 4.6% had training in multiple subspecialties, with arthroplasty (232 surgeons, 24.4%), sports (230 surgeons, 24.2%), and trauma (93 surgeons, 9.8%) being the most common. RESULTS:Analysis revealed notable differences in surgical treatments based on subspecialty, with trauma surgeons favoring fixation and arthroplasty surgeons favoring total hip arthroplasty (THA). Even after adjusting for covariates, patients treated by arthroplasty-trained surgeons were more likely to receive THA. In addition, there was consistency between trauma and arthroplasty surgeons in treating lower functional demand patients with hemiarthroplasty. While trauma surgeons performed more fixations and arthroplasty surgeons more THAs, baseline characteristics and perioperative outcomes between fixation and THA patients were similar, indicating comparable baseline health despite treatment differences. Multivariable logistic regression confirmed that treatment by an arthroplasty surgeon markedly increased the odds of receiving THA. CONCLUSION/CONCLUSIONS:This study underscores the complexity added by surgeon subspecialty in femoral neck fracture management and emphasizes the importance of recognizing how surgeon-specific factors influence treatment decisions. Understanding these nuances can inform training optimization and promote collaborative approaches within the orthopaedic community, ultimately contributing to enhanced patient outcomes as femoral neck fracture management evolves.

The efficacy of "Expanded Gram-Negative Antimicrobial Prophylaxis" (EGNAP) in preventing postoperative infections has been previously reported in total hip arthroplasty (THA). However, it remains unclear as to whether these benefits extend to total knee arthroplasty (TKA). This study investigated whether adding EGNAP to our institution's preoperative antibiotic prophylaxis protocol would affect periprosthetic joint infection (PJI) risk in TKA patients. We retrospectively reviewed 10,666 elective, unilateral, primary TKA cases performed at a single-specialty tertiary academic hospital from 2018 to 2022. Before June 2021, all patients received 2 g of cefazolin for 24 h as part of the prophylactic antibiotic protocol. After June 2021, gentamicin or aztreonam (EGNAP) was added to the protocol for all TKA patients. Patients were grouped based on whether they received EGNAP or not (control group) before surgery. The groups were propensity score-matched in a 2:1 ratio. PJI and nephrotoxicity (using RIFLE criteria) risk was compared. After matching, the final study population consisted of 3007 patients in the non-EGNAP group and 1503 patients in the EGNAP group. There was no significant difference between the EGNAP and no EGNAP groups in the overall incidence of PJI (1.9% vs. 2.0%; p = 0.111) or the incidence of Gram-positive PJIs (0.3% vs. 0.8%; p = 0.103). The incidence of Gram-negative PJIs was 0.5% in the EGNAP group and 0.4% in the no EGNAP group, which was also not different between the groups (p = 0.692). There were no differences in nephrotoxicity between groups (p = 0.521). The addition of EGNAP to the antibiotic prophylactic protocol prior to TKA had no effect on overall or Gram-negative PJI risk in TKA patients. The findings of this study suggest that while EGNAP is safe to use and has minimal nephrotoxic effects, its prophylactic benefits do not extend to the primary TKA population. This may be attributed to the generally low rate of Gram-negative infections in TKA patients, where adding EGNAP does not provide a clear advantage in reducing the risk of such infections, unlike its potential benefits in primary THA population. This study investigates the effects of using prophylactic Gram-negative antibiotics prior to TKA and shows that though it is safe to use, Gram-negative bacterial coverage may have no impact on postoperative infection incidence.

INTRODUCTION/BACKGROUND:Robotic-assisted technologies provide the ability to avoid soft tissue release by utilizing more accurate bony cuts during total knee arthroplasty (TKA). However, the ideal limb alignment is not yet established. The aim of this study was to predict postoperative Coronal Plane Alignment of the Knee (CPAK) using corresponding native bony measurements. METHODS:This study analyzed a retrospective cohort of 530 primary robotic-assisted TKAs. Machine learning was utilized to predict appropriate target lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA). Normalization of LDFA and MPTA alignments was performed using the min-max scaler operation on the training set with feature range [-1, 1] and repeated separately for the input and target distributions. A neural network of hidden dimensions (16, 8, 4) was trained via supervised learning to predict planned LDFA and MPTA values from preoperative LDFA and MPTA measurements. RESULTS:The model converged after 104 epochs and batch size 4 with mean squared error ±1.82°. The model's regression agrees with the hypothesized change in preoperative to planned coronal alignment: valgus measurements are translated to neutral/aligned targets while varus alignments are translated to varus alignment of lesser severity. Evaluative statistics demonstrate this method for planning knee morphologies is significantly more accurate than making predictions about the mean (RMSE 1.440; R-squared 0.444; Nash Sutcliffe 0.579). CONCLUSION/CONCLUSIONS:This study's model provides accurate predictions for target knee alignment morphologies. Future work is warranted to evaluate this method's usefulness for planning robotic TKA.

Health equity is the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well being. The combination of the COVID-19 pandemic and increased awareness of social injustice shed critical light on health inequities. DEI efforts in health care directly affect patient outcomes and quality of life. By creating and implementing high-quality DEI programs, our orthopedic surgery practices and organizations can help ameliorate healthcare inequities and deliver inclusive, person-centered, and culturally competent patient care. Substantial variability in definition, data collection, methodology, and goals exist between organizations that measure health equity. DEI metrics and targets will be used to measure quality, but reliance on data acquired through patient questionnaires or through their interaction with technology may exclude the most at-risk populations. The purpose of this review is to outline the various organizations involved in evaluating DEI metrics so that orthopaedic teams can better measure and more effectively report the effect of DEI efforts on patient outcomes.