Faculty Bibliography

BACKGROUND:Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). METHODS:A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. RESULTS:A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). CONCLUSION/CONCLUSIONS:Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. LEVEL OF EVIDENCE/METHODS:III, Retrospective Observational Analysis.

OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

BACKGROUND:Total hip arthroplasty (THA) is a frequently performed, highly successful orthopedic procedure. Although primary osteoarthritis (PA) is the most common reason for (THA), there are several secondary conditions that lead to degenerative hip disease that are successfully treated with THA. The purpose of this study was to examine the incidence of these secondary causes of arthritis (SA) leading to THA and to compare the relative surgical costs, operating times, and hospital length of stay (LOS) for THA done for PA versus SA. METHODS:Electronic medical records from 836 continuous patients undergoing primary THA over a 2-year period were reviewed at a single high-volume joint arthroplasty center. Data obtained included age, sex, laterality, diagnosis leading to THA, surgical costs based on hospital fees, operating room time, and hospital LOS. Using operative reports, office visit notes, and radiology reports or images, patients were categorized into PA or SA groupings. PA was defined as osteoarthritis of no other known etiology, whereas SA was defined when a known underlying diagnosis led to degenerative joint disease of the hip. SA included hip dysplasia, post-traumatic arthritis (PTA), avascular necrosis (AVN), inflammatory arthropathy, Perthes disease, and slipped capital femoral epiphysis (SCFE). Means and proportions of the variables from both groups were analyzed and compared using t-tests and chi-squared tests where applicable. RESULTS:There were 599 patients in the PA group and 237 patients in the SA group. The SA group was significantly younger than the PA group (54.4 years versus 64.0 years; p = 0.0001). The SA cohort had significantly higher mean surgical costs ($29,662 versus $27,078; p = 0.0005), operating room times (189 minutes versus 179 minutes; p = 0.0042), and LOS (4.2 days versus 3.9 days; p = 0.0312). Within the SA group, the hip dysplasia subgrouping had the lowest cost and operating room time, whereas the PTA subgrouping had the highest cost and operating room time. CONCLUSIONS:More than a quarter of primary THAs are performed due to secondary arthritis, most commonly due to hip dysplasia. Cases of THA due to secondary arthritis are associated with significantly increased hospital costs, operating time, and postoperative length of stay compared to THA's performed for primary osteoarthritis. Patients with post-traumatic hip arthritis may contribute the highest economic burden and present the most complex cases for arthroplasty surgeons.

Distal biceps tendon ruptures are a topic of great interest in the orthopedic literature with differentiation between complete and partial tears being difficult to recognize. Recent cadaveric and radiologic studies have shown that the muscle maintains two distinct tendons and tendinous insertions. In this clinical case report, we describe the rare case of a patient with a congenitally bifid distal biceps tendon who selectively ruptured a single bundle of the tendon and subsequently underwent surgical repair.

AIMS/OBJECTIVE:non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. PATIENTS AND METHODS/METHODS:(13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. RESULTS:There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. CONCLUSION/CONCLUSIONS:2019;101-B(6 Supple B):2-8.

AIMS/OBJECTIVE:A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. PATIENTS AND METHODS/METHODS:-tests where appropriate and proportions were compared using the chi-squared test. RESULTS:A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). CONCLUSION/CONCLUSIONS:2019;101-B:646-651.

Total joint arthroplasty has traditionally been performed as an inpatient procedure to mitigate the risks of perioperative complications, limited mobility, and pain control issues. Reducing readmissions and complications is increasingly important with the push toward outcomes based reimbursement. Nonetheless, there is a definite trend toward not only shortening postoperative length of stay but also toward considering a same day discharge arthroplasty model in appropriately selected patients. In this review, we outline the literature evidence regarding same day discharge in total joint arthroplasty and discuss our own institutional guidelines for appropriate patient selection as well as contraindications.

Accurate placement of components is imperative for successful outcomes after total hip arthroplasty (THA). Although technology-assisted techniques offer the potential for greater accuracy in prosthesis positioning, the need for additional resources prevents their widespread use. The goal of this study was to compare primary THA procedures performed with and without intraoperative fluoroscopic guidance with regard to accuracy of prosthesis placement, operative time, and postoperative complications. The authors reviewed 341 consecutive cases (330 patients) undergoing primary THA at the authors' institution from September 2007 to January 2010. Postoperative anteroposterior radiographs were used to measure acetabular inclination angle, leg length discrepancy, and femoral offset discrepancy. Operative time and postoperative complications related to implant positioning were recorded. Mean acetabular inclination angle, leg length discrepancy, and offset discrepancy for control vs study groups were 43.0° (range, 32.2°-61.4°) vs 43.8° (range, 29.0°-55.1°), 4.75 mm (range, 0-25) vs 4.24 mm (range, 0-27), and 8.47 mm (range, 0-9.7) vs 7.70 mm (range, 0-31), respectively. Complication rates were not significantly different between the control (8.1%) and study (5.3%) groups. Mean operative time was significantly higher in the study group compared with the control group (59.8 vs 52.8 minutes) (P<.0001). The findings showed that intraoperative fluoroscopy may not improve prosthesis accuracy or decrease postoperative complication rates compared with a freehand technique. Because of significantly increased operative time and cost associated with fluoroscopic guidance, the authors discourage the use of this technique in uncomplicated primary THA performed at high-volume arthroplasty institutions.