Faculty Bibliography

PURPOSE/OBJECTIVE:To report surgical outcomes in patients treated with conversion total hip arthroplasty (CTHA) for early failure of cephalomedullary nails (CMNs). METHODS:A retrospective review was conducted of CTHA for treatment of failed CMN within 1 year of initial surgery for intertrochanteric (IT) hip fractures. The cohort was matched 1:5 to patients who underwent elective primary THA (PTHA). Patient demographics, mechanism of CMN failure, surgical outcomes, and complication rates were assessed. RESULTS:22 patients met criteria with a mean time to failure of 145 days. Modes of failure included: lag screw cut-out with superior migration (9, 40.9%), or medialization (8, 36.4%), and aseptic nonunion with implant failure (2, 9.0%) and without implant failure (3, 13.6%). Fourteen of the patients (63.6%) had acetabular-sided damage secondary to lag screw penetration, all in the screw cut-out groups. Patient demographics were similar between cohorts. Compared to PTHA, CTHA patients had increased operative time, blood loss, LOS, and readmission rates. After IMN failure, the operative leg was shorter than the contralateral leg in all cases. CTHA restored leg lengths to <  = 10 mm in 15 (68.1%) of patients, with an average leg length discrepancy after CTHA of 6.7 mm. CTHA patients had increased rates of overall surgical complications and medical complications, specifically anemia (all p < 0.01). Tranexamic acid was used less often in the CTHA group (p < 0.01). Rate of periprosthetic joint infection (PJI), dislocation, and revision were all higher in the CTHA, though did not reach statistical significance. CONCLUSION/CONCLUSIONS:The majority (77.3%) of CMN implant failure for nonunion within 1 year was due to screw cut-out. CTHA is a salvage option for early failed IT hip fracture repair, but expected surgical outcomes are more similar to revision THA than primary THA, with increased risk of readmission, longer surgery and LOS, increased blood loss, and higher complication rates. LEVEL OF EVIDENCE/METHODS:III, Retrospective comparative study.

PURPOSE/OBJECTIVE:The clinical impact of postoperative venous thromboembolism (VTE) following total joint arthroplasty (TJA) remains unclear. In this study, we evaluate the effect of VTE following TJA on postoperative outcomes including discharge disposition, readmission rates, and revision rates. METHODS:We retrospectively reviewed all patients over the age of 18 who underwent primary, elective THA or TKA between 2013 and 2020. Patients were stratified into two cohorts based on whether or not they had a VTE following their procedure. Baseline patient demographics and clinical outcomes such as readmissions and revisions were collected. Propensity score matching was performed to limit significant demographic differences, while independent sample t-tests and Pearson's chi-squared test were used to compare outcomes of interest between the groups. RESULTS:, p = 0.032). All other patient demographics were similar. Compared to the non-VTE cohort, the VTE cohort was less likely to be discharged home (66.1% vs 80.7%; p = 0.021), had a higher rate of 90-day all-cause readmissions (27.5% vs 9.2%, p = 0.001), and a higher two-year revision rate (11.0% vs 0.9%, p = 0.003). CONCLUSION/CONCLUSIONS:Patients with postoperative VTE were less likely to be discharged home and had higher 90-day readmission and two-year revision rates. Therefore, mitigating perioperative risk factors, initiating appropriate long-term anticoagulation, and maintaining close follow-up for patients with postoperative VTE may play significant roles in decreasing hospital costs and the economic burden to the healthcare system. LEVEL OF EVIDENCE III/UNASSIGNED:Retrospective Cohort Study.

PURPOSE/OBJECTIVE:Back pain may both decrease patient satisfaction after TKA and confound outcome assessment in satisfied patients. Our primary objective was to determine whether preoperative back pain is associated with differences in postoperative patient-reported outcome measures (PROMs). METHODS:We retrospectively reviewed 234 primary TKA patients who completed PROMs preoperatively and 12 weeks postoperatively, which included a back pain questionnaire, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the Forgotten Joint Score-12 (FJS-12). Cohorts were defined based on the severity of preoperative back pain (none, mild, moderate and severe) and compared. Demographics were compared using ANOVA and Chi-square analysis. Univariate ANCOVA analysis was utilized to compare PROMs while accounting for significant demographic differences. RESULTS:Both preoperative KOOS JR scores (none: 47.90, mild: 47.61, moderate: 44.61 and severe: 38.70; p = 0.013) and 12-week postoperative KOOS JR scores (none: 61.24, mild: 64.94, moderate: 57.48 and severe: 57.01; p = 0.012) had a statistically significant inverse relationship with regard to the intensity of preoperative back pain. Although FJS-12 scores at the 12-week postoperative period trended lower with increasing levels of preoperative back pain (p = 0.362), it did not reach statistical significance. Patients who reported severe back pain preoperatively achieved the largest delta improvement from baseline compared to those with lesser pain intensity (p = 0.003). Patients who had a 2-grade improvement in their back pain achieved significantly higher KOOS JR scores 12 weeks postoperatively compared to patients with either 1-grade or no improvement (63.53 vs. 55.98; p = 0.042). Both preoperative (47.99 vs. 41.11; p = 0.003) and 12-week postoperative (64.06 vs. 55.73; p < 0.001) KOOS JR scores were statistically higher for those who reported mild or no back pain pre-and postoperatively than those who reported moderate or severe back pain pre-and postoperatively. CONCLUSION/CONCLUSIONS:Knee pain and back pain both exert negative effects on outcome instruments designed to measure pain and function. Although mean improvement from pre- to postoperative KOOS JR scores for patients with severe pre-existing back pain was higher than their counterparts, this statistical difference is likely not clinically significant. This implies that all patients may experience similar benefits from TKA despite the presence or absence of back pain. Attempts to measure TKA outcomes using PROMs should seek to control for lumbago and other sources of body pain. Level of Evidence IIIRetrospective Cohort Study.

INTRODUCTION/BACKGROUND:As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay. MATERIALS AND METHODS/METHODS:We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences. RESULTS:A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts. CONCLUSION/CONCLUSIONS:Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

BACKGROUND:As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA. METHODS:A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress. RESULTS:; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA. CONCLUSION/CONCLUSIONS:THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.

INTRODUCTION/BACKGROUND:The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty. MATERIALS AND METHODS/METHODS:We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences. RESULTS:This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort. CONCLUSION/CONCLUSIONS:Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes. LEVEL OF EVIDENCE/METHODS:III, Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Obesity has been associated with poorer outcomes following total knee arthroplasty (TKA); however, data remain sparse on its impact on patients' joint awareness following surgery. This study aims to investigate the impact of body mass index (BMI) on improvement in outcomes following TKA as assessed by the Forgotten Joint Score-12 (FJS-12). MATERIALS AND METHODS/METHODS:): < 30, 30.0-34.9 (obese class I), 35.0-39.9 (obese class II), and ≥ 40 (obese class III). FJS-12 and KOOS, JR scores were collected at various time points. Demographic differences were assessed with Chi-square and ANOVA tests. Mean scores between BMI groups were compared using univariate ANCOVA, controlling for observed demographic differences. RESULTS:Of the 1075 patients included, there were 457 with a BMI < 30, 331 who were obese class I, 162 obese class II, and 125 obese class III. There were no statistical differences in FJS-12 scores between the BMI groups at 3 months (27.24 vs. 25.33 vs. 23.57 vs. 22.48; p = 0.99), 1 year (45.07 vs. 41.86 vs. 40.51 vs. 36.22; p = 0.92) and 2 years (51.31 vs. 52.86 vs. 46.17 vs. 44.97; p = 0.94). Preoperative KOOS, JR scores significantly differed between the various BMI categories (49.33 vs. 46.63 vs. 44.24 vs. 39.33; p < 0.01); however, 3-month (p = 0.20) and 1-year (p = 0.13) scores were not statistically significant. Mean improvement in FJS-12 scores from 3 months to 2 years was statistically greatest for obese class I patients and lowest for obese class III patients (24.07 vs. 27.53 vs. 22.60 vs. 22.49; p = 0.01). KOOS, JR score improvement from baseline to 1 year was statistically greatest for obese class III patients and lowest for non-obese patients (22.34 vs. 25.49 vs. 23.77 vs. 27.58; p < 0.01). CONCLUSION/CONCLUSIONS:While all groups demonstrated postoperative improvement, those with higher BMI reported lower mean FJS-12 scores but these differences were not found to be significant. Our study showed no significant impact of BMI on postoperative joint awareness, which implies that obese patients, in all obesity classes, experience similar functional improvement following TKA. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

Hinged prostheses have been increasingly utilized in complex and revision total knee arthroplasty (TKA) cases requiring additional mechanical support and global stability. However, there is limited data detailing the outcomes of modern hinge designs in these procedures. The aim of this study is to report a minimum 2-year functional outcomes and survivorship of a novel-guided motion-hinged knee TKA system. A multicenter, retrospective cohort study was conducted on consecutive TKA patients between March 2013 and August 2017 with a novel-guided motion-hinged knee system. Demographics, change in range of motion (ΔROM), quality metrics, and implant survivorship were collected with a minimum of 2-year follow-up. Implant survival was analyzed by using the Kaplan-Meier method. Overall, 147 hinged knee cases (18 complex primaries and 129 revisions) were identified with an average follow-up duration of 3.8 ± 1.2 years. Patients presented with an average of 2.4 ± 1.6 prior knee surgeries, and 51 (34.7%) had a history of knee infections. The ROM improved postoperatively: Δ extension = 2 ± 1 degrees, Δflexion = 7 ± 3 degrees, Δtotal ROM = 9 ± 4 degrees. Kaplan-Meier survivorship analysis for implant revision at 2- and 5-year follow-up showed a survival rate of 100 and 98.5% (95% confidence interval: 94.3-99.6%), respectively, with one patient undergoing two-stage revision for infection and another undergoing femoral revision for aseptic loosening. Survivorship for aseptic all-cause reoperation at 2- and 5-year follow-up was 93.2% (87.7-96.3%) and 88.2% (80.0-93.2%), respectively. Fourteen patients underwent aseptic reoperation (patellar complications: n = 7 [4.8%]; instability: n = 5 [3.4%]; tuberosity fixation: n = 1 [0.7%]; extensor mechanism failure: n = 1 [1.1%]). Survivorship for all-cause reoperation at 2- and 5-year follow-up were 85% (78.2-90.0%) and 77.7% (68.8-84.3%), respectively. Fifteen patients underwent reoperation for infection (DAIR: n = 14 (9.5%); two-stage revision: n = 1 [0.7%]). Despite some reoperations, this guided-motion hinged-knee TKA system demonstrates excellent survivorship for component revision compared to other modern hinged knee implants reported in the literature. Patients also displayed an improvement in knee ROM at their latest follow-up.

The Centers for Medicaid and Medicare Services (CMS) removed primary total knee arthroplasty (TKA) from the inpatient-only list in January 2018. This study aims to compare outcomes in Medicare-aged patients who underwent primary TKA and had an in-hospital stay spanning less than two-midnights to those with a length of stay greater than or equal to two-midnights. We retrospectively reviewed 4,138 patients ages ≥65 who underwent primary TKA from 2016 to 2020. Two cohorts were established based on length of stay (LOS), those with an LOS <2 midnights were labeled outpatient and those with an LOS ≥2 midnights were labeled inpatient as per CMS designation. Demographic, clinical data, knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR), and veterans RAND 12 physical and mental components (VR-12 PCS & MCS) were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Clinical data and KOOS, JR and VR-12 PCS and MCS scores were compared by using multilinear regression analysis, controlling for demographic differences. There were 841 (20%) patients with a LOS < 2 midnights and 3,297 (80%) patients with a LOS ≥ 2 midnights. Patients with a LOS < 2 midnights were significantly younger (71.70 vs. 73.06; p < 0.001), more likely male (42.1 vs. 25.7%; p < 0.001), Caucasian (68.8 vs. 57.7%; p <0.001), have lower BMI (30.80 vs. 31.92; p < 0.001), Charlson Comorbidity Index (CCI; 4.62 vs. 4.96; p < 0.001), and American Society of Anesthesiologists (ASA) class II or higher (p < 0.001). These patients were more likely to be discharged home compared to patients with LOS ≥ 2 midnights (95.8 vs. 73.1%; p < 0.001). Patients who stayed ≥ 2 midnights reported lower patient-reported outcome scores at all time-periods (preoperatively, 3 months and 1 year), but these differences did not exceed the minimum clinically important difference. Mean improvement preoperatively to 1 year postoperatively in KOOS, JR (22.53 vs. 25.89; p < 0.001), and VR-12 PCS (12.16 vs. 11.49; p = 0.002) was statistically higher for patients who stayed < 2 midnights, though these differences were not clinically significant. All-cause ED visits (p = 0.167), 90-day all-cause readmissions (p = 0.069) and revision (p = 0.277) did not statistically differ between the two cohorts. TKA patients classified as outpatient had similar quality metrics and saw similar clinical improvement following TKA with respect to most patient reported outcome measures, although they were demographically different. Outpatient classification is more likely to be assigned to younger males with higher functional scores, lower BMI, CCI, and ASA class compared with inpatients. This Retrospective Cohort Study shows level III evidence.

The study aimed to optimize value-based health care practices in total joint arthroplasty (TJA), and we need to understand how the surgical setting can influence efficiency of care. While this has previously been investigated, the purpose of this study was to clarify if these findings are generalizable to an institution with an orthopaedic specialty hospital. A retrospective review was conducted of 6,913 patients who underwent primary or revision total knee arthroplasty (TKA) at one of four hospitals within a single, urban, and academic health system: a high volume academic (HVA) hospital, a low volume academic (LVA) hospital, a high volume community (HVC) hospital, or a low volume community (LVC) hospital. Patient demographics were collected in an arthroplasty database, as were operating room (OR) times and several specific time points during the surgery. The HVA (orthopaedic specialty) hospital had the shortest total primary TKA OR times and the LVC that had the longest times (156.69 vs. 174.68, p < 0.0001). The HVA hospital had the shortest total revision TKA OR times, and the LVC had the longest times (158.20 vs. 184.95, p < 0.0001). In our health system, the HVA orthoapedic specialty hospital had the shortest overall OR time, even when compared with the HVC hospital. This is in contradistinction to prior findings that HVC institutions had the shortest OR times in a health system that did not have an orthopaedic specialty hospital. This provides evidence that an orthopaedic specialty hospital can be a model for efficient care, even at an academic teaching institution.