Faculty Bibliography

BACKGROUND:Weight management strategies before total hip arthroplasty (THA) include bariatric surgery and Glucagon-like peptide-1 receptor agonists, including semaglutide. Previous studies have reported higher THA implant failure in patients who had prior bariatric surgery. This study aimed to evaluate semaglutide as a weight management alternative for patients undergoing THA and any effects on perioperative outcomes. METHODS:A retrospective review of primary, elective THAs performed between 2012 and 2024 was conducted at a single, urban, academic center. The study identified 224 patients who had a history of bariatric surgery, 202 patients who had perioperative semaglutide use, and a control group of 2,991 patients who had a body mass index (BMI) > 35. Demographic variables and clinical outcomes were compared between cohorts. RESULTS:The bariatric patients were younger (57 versus 61, P = 0.012) and more often women (65.6 versus 57.4 versus 55.4%, P < 0.001) than semaglutide and control patients. Preoperative hemoglobin A1c was lowest in semaglutide patients (6.2 versus 5.7 versus 5.8%, P < 0.001). The changes in BMI varied across groups one year before and after THA (P < 0.001). The bariatric and semaglutide groups decreased their BMI by 1.4 and 0.8, respectively, and control patients increased by 0.4. Implant survivorship was 95.5% at 10 years. There was no correlation found between any cohort and 90-day emergency department visits, readmissions, and all-time revision. Higher American Society of Anesthesiologists class and Charlson Comorbidity Index ≥ 5 conferred increased complications. CONCLUSIONS:Semaglutide appears to be a safe alternative to bariatric surgery for weight management before THA, with similar implant survival and postoperative complication rates. Further studies are warranted to understand outcomes for THA patients who use semaglutide.

BACKGROUND:The impact of liver cirrhosis on surgical outcomes is well-known. This study aimed to compare postoperative outcomes of total hip arthroplasty (THA) in patients with versus without cirrhosis. METHODS: = 10). RESULTS: = 0.479) between non-cirrhotic and cirrhotic THA patients at 120 months of follow-up. CONCLUSIONS:Cirrhotic patients, particularly those categorized as moderate-to-severe, undergoing THA may have higher risk of having a readmission or revision for PJI. However, overall 90-day readmission and revision risk were similar between non-cirrhotic and cirrhotic patients. Future research with larger sample sizes and databases is needed to further risk stratify, optimize and counsel cirrhosis patients surrounding THA.

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.

Genetics is a burgeoning field within adult reconstructive surgery. Genome-wide sequencing has identified genetic variants found to be associated with not only the development of osteoarthritis but also arthroplasty-related complications, such as aseptic loosening, prosthetic joint infection, arthrofibrosis, and postoperative pain. Examples include newer technology, such as next-generation sequencing, in diagnosing culture-negative prosthetic joint infection. Genetics drives new therapeutic technologies, such as gene therapy, gene-editing, and bacteriophage treatment. Although still rare, a handful of phase 3 clinical trials of gene therapy for osteoarthritis have begun to demonstrate efficacy with low-risk profiles. As the field continues to grow, public and professional buy-in as well as cost present challenges.

INTRODUCTION/BACKGROUND:There is increased awareness of socioeconomic disparities among total hip arthroplasty (THA) patients. Most studies contain small sample sizes and few control for confounding variables. This study aims to evaluate postoperative outcomes and survivorship after THA in patients of different races/ethnicities. METHODS:Patients who underwent a primary THA were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were stratified into 4 groups: White, Black, Hispanic, or Asian. Categorical variables and continuous variables were compared, and revision free survival was calculated using Kaplan Meier survival analysis. Multivariate Cox proportional hazard regression was used to calculate revision hazard ratios. RESULTS: = 0.021). There were no significant differences in the cumulative revision event rate up to 10 years postoperatively. CONCLUSIONS:Non-White patients are significantly more likely to have worse short-term outcomes and complications. However, overall rates of revision at 1 year are similar across these groups, with a slightly lower rate of revision in Black patients after controlling for confounding factors.

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:Obesity and diabetes mellitus (DM) pose challenges for patients undergoing total knee arthroplasty (TKA). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as agents for weight and DM management, but they affect multiple organ systems. Outcomes, trends, and demographics for perioperative GLP-1RA use in patients with TKA are not well understood. METHODS:A retrospective review of 13,751 primary, elective TKAs with at least 90 days of follow-up at an urban academic health system between 2012 and 2023 identified 865 patients who had perioperative GLP-1RA use. A 10:1 propensity score match based on sex, age, smoking status, American Society of Anesthesiologists classification, and body mass index created a control cohort of 8,650 TKAs with no GLP-1RA use. RESULTS:The use of GLP-1RAs varied significantly by race, Medicaid insurance, Charlson Comorbidity Index, and presence of DM. Black and Latino patients and those covered by Medicaid were significantly less likely to receive GLP-1RAs. The GLP-1RA group had significantly shorter length of stay (2.1 versus 2.5 days, P < 0.001) and a higher rate of home discharge (91.7 versus 84.2%, P < 0.001). The GLP-1RA users had significantly higher rates of 90-day emergency department visits (5.9 versus 4.0%, P = 0.008), but no differences in 90-day readmissions (4.3 versus 3.6%, P = 0.168) or 2-year revision (2.3 versus 2.6%, P = 0.362) compared to matched controls. The GLP-1RA patients had significantly lower all-cause revision rates at the last follow-up (2.7 versus 3.9%, P = 0.034), but there was no significant difference in Kaplan-Meier implant survival (P = 0.311). Before TKA, GLP-1RA patients had an average decrease in body mass index of 0.4, compared to an average increase of 1.2 for matched controls. CONCLUSIONS:Our results demonstrate that the use of GLP-1RAs is significantly lower for minority patients and those covered by Medicaid. Patients using GLP-1RAs have noninferior clinical outcomes with the potential for weight loss leading up to TKA. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Recent literature suggests a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, the impact of increased comorbidities on the cost-effectiveness of TKA is underexplored. This study aimed to compare the financial implications and perioperative outcomes of patients with and without a high comorbidity burden (HCB). METHODS:We retrospectively reviewed 10,647 patients who underwent elective, unilateral TKA between 2012 and 2021 at a single academic health center with available financial data. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups. A 1:1 propensity match was performed based on baseline characteristics, resulting in 1,536 matched patients (768 per group). Revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. Ninety-day readmissions and revisions were also analyzed. RESULTS:The HCB patients had significantly higher total (P < 0.001) and direct (P < 0.001) costs, while hospital revenue did not differ between cohorts (P = 0.638). This disparity resulted in a significantly decreased CM for the HCB group (P = 0.009). Additionally, HCB patients had a longer length of stay (P < 0.001) and a higher rate of 90-day readmissions (P = 0.005). CONCLUSIONS:Increased inpatient costs for HCB patients undergoing TKA were not offset by proportional revenue, leading to a decreased CM. Furthermore, higher 90-day readmissions exacerbate the financial burden. These findings highlight potential challenges for hospitals in covering indirect expenses, which could jeopardize accessibility to care for HCB patients. Reimbursement models should be revised to better account for the increased financial burden associated with managing HCB patients. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Social determinants strongly influence overall health, including recovery after total joint arthroplasty (TJA). The modern electronic health record includes a list of individuals identified by patients as their primary contacts. We aimed to assess whether the relationship between patients and their documented primary contacts was associated with outcomes after TJA. METHODS:We retrospectively reviewed primary, elective total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) at a single institution from June 2011 to December 2022, and stratified patients into two groups: family (F) [familial relationships to include spouse, first, or second degree relative] or non-family (NF) [nonfamilial relationships, such as friend or neighbor] based on patient relationship to their primary emergency contact. Baseline characteristics and postoperative outcomes were compared. Binary logistic regression was utilized to assess variables associated with all-cause revision. In total, 17,520 THAs were included as follows: 16,123 (92.0%) in the F group and 1,397 (8.0%) in the NF group. Additionally, 20,397 TKAs were included as follows: 18,819 (92.3%) in the F group and 1,578 (7.7%) in the NF group. RESULTS:For both THA and TKA patients, having a NF primary contact was independently associated with a higher risk of all-cause revision at the latest follow-up (OR [odds ratio]: 1.48 [95% CI (confidence interval): 1.05 to 2.08], P = 0.025) and (OR: 1.62 [95% CI: 1.10 to 2.38], P = 0.014), respectively. In both THA and TKA, the F group had shorter lengths of stay (P < 0.001) and was more likely to be discharged home (P < 0.001) compared to the NF group. CONCLUSIONS:TJA patients who have a familial primary contact demonstrate better postoperative outcomes compared to those who do not have a familial contact. Awareness of social support and additional postoperative support for patients who have NF primary contacts may be warranted following TJA.