Faculty Bibliography

INTRODUCTION/BACKGROUND:Patellar resurfacing in primary total knee arthroplasty (TKA) has been debated for decades. This study aimed to evaluate cost-effectiveness and clinical outcomes of patellar resurfacing in modern TKA at a high-volume arthroplasty center. METHODS:A retrospective study was conducted on 4,534 patients who underwent unilateral, elective, primary TKA from 2021 to 2024 at an urban academic institute. Patients were stratified by patellar resurfacing: resurfaced (n=3,753) or not (n=781). Baseline characteristics, operative costs [implants, anesthesia, operating room time], and postoperative outcomes (revision incidence) were collected. The median follow up was 2.0 years (1.0- 4.8). The individual cost of patellar component was adjusted for implant manufacturer and cementation out of total implant cost. Multivariable regression analysis determined added operating room time (ORT) due to patellar resurfacing, controlling for body-mass index, usage of robotics, navigation and cementation. Relative costs of added ORT and the patellar component were compared to total implant and procedure costs of patellar-resurfacing operations. RESULTS:The patellar component accounted for an average of 7.9% of the total implant cost in patellar-resurfacing operations. Patellar-resurfacing operations had longer operative times (112.2 vs. 105.4 minutes, P<0.001), and multivariable regression determined patellar resurfacing is associated with an added 6.3 minutes of total ORT (P<0.001). The patellar component implant cost and the cost of added ORT due to resurfacing accounted for 4.5% of the total procedure cost in resurfaced group. Resurfaced group had an overall 5% higher total operative cost than the non-resurfaced group. No differences existed in length of stay (LOS), discharge disposition, or all-cause and patella-specific revision incidence. CONCLUSION/CONCLUSIONS:We found that patellar resurfacing was associated with longer operative times and greater implant and procedure costs, although there was no effect on LOS, discharge disposition, or all-cause and patella-specific revision incidence. Ultimately, the decision to resurface the patella in primary TKA should be based on patient-specific indications and clinical judgment. However, it is important to consider the additional cost associated with this procedure.

BACKGROUND:Studies on patients have shown that normal anatomic motion is often not achieved with current total knee arthroplasty (TKA) designs. The purpose of this study was to determine whether anatomic motion could be restored using a design where intercondylar guiding surfaces were positioned between the medial and lateral femoral condyles. METHODS:A crouching machine was constructed, which included simulations of the collateral ligaments, the quadriceps mechanism, the hamstrings, and the gastrocnemius. Medial pivot, medially congruent, ultracongruent, and replica intercondylar TKAs were designed and 3-dimensionally printed. The femoral-tibial kinematics were measured by determining lateral and medial contacts, as the knee underwent flexion and extension from 12 to 130°. RESULTS:The replica intercondylar design showed an almost constant position of the medial contact, with a progressive posterior displacement laterally during flexion. In contrast, the other designs showed nearly parallel motion with minimal variation in contact location. CONCLUSIONS:It was concluded that intercondylar guiding surfaces could produce anatomical motion in a TKA where the cruciate ligaments were resected.

BACKGROUND:Patello-femoral arthroplasty (PFA) is a mainstay treatment of isolated patello-femoral osteoarthritis (PFOA). Despite comparable outcomes to total knee arthroplasty (TKA), the reoperation rate following PFA remains poorly characterized in the literature. This study aimed to determine the cumulative incidence and temporal patterns of ipsilateral knee reoperation following primary PFA. METHODS:A retrospective cohort study was conducted using a statewide all-payer claims database. Adults undergoing primary PFA between 2017 and 2024 were identified (N = 3,715). The primary outcome was time to first ipsilateral reoperation, which was categorized into arthroplasty, instability procedures, arthrofibrosis, and infection-related procedures. Cumulative incidence functions (CIF) and Fine-Gray competing-risks regression models were used to evaluate the risk of ipsilateral knee reoperation, reported as sub-distribution hazard ratios (sHR), and risk factors following PFA. RESULTS:The cohort had a median age of 56 years (interquartile range (IQR), 45.0 to 65.0), and 60.2% were women. The median follow-up time was 2.1 years (IQR, 0.4 to 4.5). The cumulative incidence of any reoperation was 15.2% at one year, 18.3% at two years, and 21.8% at five years. At five years, arthroplasty represented the most common reoperation subtype (9.1%), followed by instability procedures (4.3%) and arthroscopy (4.2%). Prior patella dislocation (sHR, 2.45 [95% confidence interval (CI), 1.99 to 3.01]; P < 0.001) and prior ipsilateral knee surgery (sHR, 2.39 [95% CI, 1.59 to 3.59]; P < 0.001) were independently associated with increased reoperation risk across multiple categories. CONCLUSION/CONCLUSIONS:The 21.8% five-year reoperation rate reported in this study exceeds previously reported revision rates, reflecting a substantial surgical burden going beyond conversion to TKA. Prior patella dislocation and prior ipsilateral surgery represent notable risk factors for reoperation. These findings underscore the substantial burden that PFA reoperation imposes on patients, providers, and payers.

BACKGROUND/UNASSIGNED:Despite similar rates of osteoarthritis, minority populations undergo fewer hip and knee arthroplasties and have more complications. More than 90% of US hospitals have certified electronic health records, yet only 40% of patients utilize electronic patient portals (EPPs), with lower rates across some demographics. Adverse quality metrics and lower patient-reported outcome survey completion rates were noted for patients with inactive portals. Activation rates for EPPs can be lower among underrepresented groups, perpetuating existing disparities in access to care. Barriers to EPP activation must be identified to design interventions that improve portal utilization and, therefore, outcomes. We designed this study as there are no published reports analyzing factors which impede EPP utilization by total joint patients. METHODS/UNASSIGNED:In this IRB-exempt qualitative study, sixty-six arthroplasty patients were interviewed using a questionnaire designed to reveal reasons for EPP nonusage. Demographic factors including language, age, sex, insurance type, and zip code were collected from the electronic health records. Dedoose, a qualitative research tool, was used to analyze data and abstract trends from interview notes and transcripts. RESULTS/UNASSIGNED:We found arthroplasty patients' demographics and social drivers of health influenced utilization of EPPs. Older adults struggled with digital literacy or lack of familiarity with technology. Limited internet access was cited as an obstacle to use. Patients with language barriers reported accessibility issues. Patients additionally reported concerns regarding personal information being online and perceptions that portals would not be useful. CONCLUSIONS/UNASSIGNED:EPPs are becoming the preferred method of patient-physician communication. Demographic and social factors impact patient willingness and ability to access EPPs. Certain patients are, therefore, at greater risk of ineffective communication with care teams, delayed follow-up appointments, or challenges with scheduling and managing rehabilitation. This may lead to suboptimal recovery and surgical outcomes. The current study investigated underlying issues impeding EPP usage to inform potential interventions.

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.

PURPOSE:To assess the 10-year arthroplasty-free survivorship of patients older than 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 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 International Classification of Diseases, Ninth Revision and Tenth Revision codes. RESULTS:A total of 300,587 patients aged 50 years or older underwent knee arthroscopy. The arthroplasty-free survivorship rate after knee arthroscopy was 83.0% at 5 years. However, at 10 years, the arthroplasty-free survivorship decreased to 66.6%. Patients without knee OA or 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 as determined by International Classification of Diseases, Ninth Revision and Tenth Revision codes had an arthroplasty-free survivorship of 66.2% at 5 years and 15.4% at 10 years (hazard ratio 2.38; 95% confidence interval 2.18-2.60; P < .001). CONCLUSIONS:At 5 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:Level IV, prognostic case series.

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.

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.

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.

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.