Faculty Bibliography

BACKGROUND:As worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. METHODS:A retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients' age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients' ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. RESULTS:In the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients' race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. CONCLUSIONS:Over the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. LEVEL OF EVIDENCE/METHODS:IV.

BACKGROUND:Utilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time. METHODS:Of 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance. RESULTS:From 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period. CONCLUSIONS:The results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

INTRODUCTION/BACKGROUND:The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS:An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS:Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION/CONCLUSIONS:Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.

The Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) is a validated patient-reported measure for assessing pain and function following total knee arthroplasty (TKA). This study investigates how patient demographic factors (i.e., age, sex, and race) correlate with KOOS JR response rates. This was a retrospective cohort study of adult, English-speaking patients who underwent primary TKA between 2017 and 2023 at an academic institution. KOOS JR completion status-complete or incomplete-was recorded within 90 days postoperatively. Standard statistical analyses were performed to assess KOOS JR completion against demographic factors. Among 2,883 total patients, 70.2% had complete and 29.8% had incomplete KOOS JR questionnaires. Complete status (all p < 0.01) was associated with patients aged 60 to 79 (71.8%), white race (77.6%), Medicare (81.7%), marriage (76.8%), and the highest income quartile (75.7%). Incomplete status (all p < 0.001) was associated with patients aged 18 to 59 (64.4%), Medicaid (82.4%), and lower income quartiles (41.6% first quartile, 36.8% third quartile). Multiple patient demographic factors may affect KOOS JR completion rates; patients who are older, white, and of higher socioeconomic status are more likely to participate. Addressing underrepresented groups is important to improve the utility and generalizability of the KOOS JR.

BACKGROUND:Postoperative return to recreational activity is a common concern among the increasingly active total knee arthroplasty (TKA) patient population, though there is a paucity of research characterizing sport-specific return and function. This study aimed to assess participation level, postoperative return to activity, sport function, and limitations for recreational athletes undergoing TKA. METHODS:A survey of recreational sports participation among primary, elective TKA patients from a single academic center between June 2011 and January 2022 was conducted. Of the 10,777 surveys administered, responses were received from 1,063 (9.9%) patients, among whom 784 indicated being active in cycling (273 [34.8%]), running (33 [4.2%]), jogging (68 [8.7%]), swimming (228 [29.1%]), tennis (63 [8.0%]), skiing (55 [7.0%]), or high-impact team sports (64 [8.2%]) between two years preoperatively and time of survey administration, and were included for analyses. RESULTS:Cycling (62.3% at two years preoperatively vs. 59.0% at latest follow-up) and swimming (62.7% at two years preoperatively vs. 63.6% at latest follow-up) demonstrated the most favorable participation rate changes, while running (84.0% at two years preoperatively vs. 48.5% at latest follow-up) and skiing (72.7% at two years preoperatively vs. 45.5% at latest follow-up) demonstrated the least favorable participation rate changes. The majority of respondents were "satisfied" or "very satisfied" with their return across all sports, though dissatisfaction was highest among runners and joggers. For cycling, running, jogging, and swimming, respondents most commonly reported no change in speed or distance capacity, though among these cyclists reported the highest rates of improved speed and distance. The majority of returning skiers reported improved balance, form, and ability to put on skis. CONCLUSION/CONCLUSIONS:Return to sport is feasible following TKA with high satisfaction. Swimming and cycling represent manageable postoperative activities with high return-rates, while runners and joggers face increased difficulty returning to equal or better activity levels. Patients should receive individualized, sports-specific counseling regarding their expected postoperative course based on their goals of treatment.

INTRODUCTION/BACKGROUND:Optimizing operating room (OR) scheduling accuracy is important for OR efficiency, meeting patient expectations, and maximizing value for health systems. However, limited data exist on factors influencing the precision of Total Hip Arthroplasty (THA) OR scheduling. This study aims to identify the factors influencing the accuracy of OR scheduling for THA. METHODS:A retrospective review of 6,072 THA (5,579 primary THA and 493 revision THA) performed between January 2020 and May 2023 at an urban, academic institution was conducted. We collected baseline patient characteristics, surgeon years of experience, and compared actual wheels in to wheels out (WIWO) OR time against scheduled OR time. Significant scheduling inaccuracies were defined as actual OR times deviating by at least 15% from scheduled OR times. Logistic regression analyses were employed to assess the impact of patient, surgeon, and intraoperative factors on OR scheduling accuracy. RESULTS:Using adjusted odds ratios, primary THA patients who had a lower BMI and surgeons who had less than 10 years of experience were associated with overestimation of OR time. Whereas, higher BMI, younger age, general anesthesia, non-primary osteoarthritis indications, and afternoon procedure start times were linked to underestimation of OR time. For revision THA, lower BMI and fewer components revised correlated with overestimated OR time. Men, higher BMI, more components revised, septic indication for surgery, and morning procedure start times were associated with underestimation of OR time. CONCLUSION/CONCLUSIONS:This study highlights several critical patient, surgeon, and intraoperative factors influencing OR scheduling accuracy for THA. OR scheduling models should consider these factors to enhance OR efficiency.

BACKGROUND:Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons. METHODS:A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases. RESULTS:The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056). CONCLUSIONS:Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:While increased body mass index (BMI) in patients undergoing total hip arthroplasty (THA) increases surgical complexity, there is a paucity of objective studies assessing the impact of patient BMI on the cardiovascular stress experienced by surgeons during THA. The aim of this study was to assess the impact of patient BMI on surgeon cardiovascular strain during THA. METHODS:We prospectively evaluated three fellowship-trained arthroplasty surgeons performing a total of 115 THAs. A smart-vest worn by the surgeons recorded mean heart rate, stress index (correlate of sympathetic activation), respiratory rate, minute ventilation, and energy expenditure throughout the procedures. Patient demographics as well as perioperative data including surgical approach, surgery duration, number of assistants, and the timing of the surgery during the day were collected. Linear regression was utilized to assess the impact of patient characteristics and perioperative data on cardiorespiratory metrics. RESULTS:Average surgeon heart rate, energy expenditure, and stress index during surgery were 98.50 beats/min, 309.49 cal/h, and 14.10, respectively. Higher patient BMI was significantly associated with increased hourly energy expenditure (P = 0.027), mean heart rate (P = 0.037), and stress index (P = 0.027) independent of surgical approach. Respiratory rate and minute ventilation were not associated with patient BMI. The number of assistants and time of surgery during the day did not impact cardiorespiratory strain on the surgeon. CONCLUSION/CONCLUSIONS:The physiologic burden on surgeons during primary THA significantly increases as patient BMI increases. This study suggests that healthcare systems should consider adjusting reimbursement models to account for increased surgeon workload due to obesity. Further surgeons should adopt strategies in operative planning and case scheduling to handle this added physical strain. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting. METHODS:A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups. RESULTS:The use of barbed sutures decreased closure time by 6 min (30.1 vs. 36.1 min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5 mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up. CONCLUSION/CONCLUSIONS:Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique. LEVEL OF EVIDENCE/METHODS:I.

INTRODUCTION/BACKGROUND:Artificial intelligence (AI) in the field of orthopaedics has been a topic of increasing interest and opportunity in recent years. Its applications are widespread both for physicians and patients, including use in clinical decision-making, in the operating room, and in research. In this study, we aimed to assess the quality of ChatGPT answers when asked questions related to total knee arthroplasty (TKA). METHODS:ChatGPT prompts were created by turning 15 of the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines into questions. An online survey was created, which included screenshots of each prompt and answers to the 15 questions. Surgeons were asked to grade ChatGPT answers from 1 to 5 based on their characteristics: 1) Relevance; 2) Accuracy; 3) Clarity; 4) Completeness; 5) Evidence-based; and 6) Consistency. There were eleven Adult Joint Reconstruction fellowship-trained surgeons who completed the survey. Questions were subclassified based on the subject of the prompt: 1) risk factors, 2) implant/Intraoperative, and 3) pain/functional outcomes. The average and standard deviation for all answers, as well as for each subgroup, were calculated. Inter-rater reliability (IRR) was also calculated. RESULTS:All answer characteristics were graded as being above average (i.e., a score > 3). Relevance demonstrated the highest scores (4.43±0.77) by surgeons surveyed, and consistency demonstrated the lowest scores (3.54±1.10). ChatGPT prompts in the Risk Factors group demonstrated the best responses, while those in the Pain/Functional Outcome group demonstrated the lowest. The overall IRR was found to be 0.33 (poor reliability), with the highest IRR for relevance (0.43) and the lowest for evidence-based (0.28). CONCLUSION/CONCLUSIONS:ChatGPT can answer questions regarding well-established clinical guidelines in TKA with above-average accuracy but demonstrates variable reliability. This investigation is the first step in understanding large language model (LLM) AIs like ChatGPT and how well they perform in the field of arthroplasty.