Faculty Bibliography

AIMS/OBJECTIVE:Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications. METHODS:(SD 6.5). Outcomes included intraoperative complications, one-year all-cause re-revisions, and subsidence at postoperative time intervals (two weeks, six weeks, six months, nine months, and one year). RESULTS:There were eight intraoperative complications (4.9%), six of which were intraoperative fractures; none occurred during stem insertion. Six hips (3.7%) underwent re-revision within one year; only one procedure involved removal of the prosthesis due to infection. Mean total subsidence at latest follow-up was 1.64 mm (SD 2.47). Overall, 17 of 144 stems (11.8%) on which measurements could be performed had >5 mm of subsidence, and 3/144 (2.1%) had >10 mm of subsidence within one year. A univariate regression analysis found that additional subsidence after three months was minimal. A multivariate regression analysis found that subsidence was not significantly associated with periprosthetic fracture as an indication for surgery, the presence of an extended trochanteric osteotomy (ETO), Paprosky classification of femoral bone loss, stem length, or type of procedure performed (i.e. full revision vs conversion/primary). CONCLUSION/CONCLUSIONS:2020;102-B(2):191-197.

Background/UNASSIGNED:Perioperative opioid use is becoming an increasingly concerning topic in total joint arthroplasty (TJA). The current study aims to add to the paucity of prior studies that have detailed perioperative opioid use patterns and the effects of preoperative chronic opioid use among a cohort of total hip arthroplasty (THA) patients. Methods/UNASSIGNED:A retrospective analysis of 256 consecutive patients who underwent a THA at our institution between February 2016 and June 2016 was performed. Two cohorts were compared: patients deemed 1) preoperative chronic opioid users, and 2) non-chronic users. Variables compared included baseline characteristics, quality metrics, and patients' opioid use histories 3 months prior to surgery and 6 months following surgery. Results/UNASSIGNED:Of the 256 patients, 54 (21.1%) patients were identified as preoperative chronic opioid users. Baseline characteristics including age, gender, BMI, and ASA scores were similar between both cohorts. Discharge disposition, value-based purchasing (VBP) costs, length of stay (LOS), emergency room visits, and postoperative office visits were similar between the two cohorts. Readmission rates (30-day, 90-day, and 6-month) were significantly higher (p < 0.05) in the chronic opioid users cohort. By the 6-month postoperative time period, chronic opioid users were consuming approximately 100-times the morphine equivalents than non-chronic users. Conclusions/UNASSIGNED:The current study demonstrates that a substantial proportion of preoperative chronic opioid users continue to consume large amounts of opioids up to 6-months following THA surgery. Furthermore, preoperative chronic use is significantly associated with poorer quality outcomes, specifically with respect to readmission rates. Level of evidence/UNASSIGNED:Level II, Prognostic Study.

Introduction/UNASSIGNED:The epidemiology of re-revision total hip arthroplasty (THA) is not yet well-understood. We aim to investigate the epidemiology and risk-factors that are associated with re-revision THA. Methods/UNASSIGNED:288 revision THA were analyzed between 1/2012 and 12/2013. Patients who underwent two or greater revision THA were included. Hips with first-revision due to periprosthetic joint infection (PJI) were excluded. Failure was defined as reoperation. Results/UNASSIGNED:51 re-revision patients were available. Mean age was 59.6 (±14.2 years), 32 (67%) females, average BMI of 28.8 (±5.4), and median ASA 2 (23; 55%). The most common re-revision indications were acetabular component loosening (15; 29%), PJI (13; 25%) and instability (9; 18%). The most common indications for first revision in the re-revision population were acetabular component loosening (11; 27%), polyethylene wear (8; 19%) and instability (8; 19%). There was an increased risk of re-revision failure if the re-revision involved exchanging only the head and polyethylene liner (RR = 1.792; p = 0.017), instability was the first-revision indication (RR = 3.000; p < 0.001), and instability was the re-revision indication (RR = 1.867; p = 0.038). If isolated femoral component revision was indicated during the re-revision, there was a decreased risk of failure (RR = 0.268, p = 0.046). 1-year re-revision survival was 54% (23/43). Discussion/UNASSIGNED:Acetabular component loosening, instability, and PJI were the most common indications for re-revision. Revision due to instability is a recurrent problem that leads to re-revision failure. There was a higher infection rate in the re-revision population compared to published revision PJI. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population.

INTRODUCTION/BACKGROUND:An understanding of patient characteristics associated with persistent chronic opioid use after total joint arthroplasty (TJA) will allow surgeons to better manage these patients. Our study aims to identify risk factors among preoperative chronic opioid users who continue to chronically use narcotics after total hip arthroplasty (THA). METHODS:A retrospective analysis was performed on 256 THA recipients using the state's mandated opioid monitoring program to identify preoperative chronic opioid users. Chronic users were stratified into two cohorts based on their use 6 months after surgery: (1) persistent chronic and (2) previous chronic users. Patient demographics and relevant histories were abstracted and comparatively assessed between the cohorts. In addition, an analysis was performed to calculate which preoperative opioid dose was most predictive of chronic use. RESULTS:Within the study population, 54 patients were identified as preoperative chronic opioid users. Of them, 13 (24.1%) were identified as persistent chronic users 6 months following surgery. Specific characteristics associated with a higher likelihood of persistent chronic opioid use included: male gender, ASA score > 2, and Medicare as a payer type. A 33 mg/day morphine-equivalent dose consumption prior to surgery was most predictive for persistent chronic opioid use. CONCLUSION/CONCLUSIONS:Our study demonstrates that patients who are male, have an ASA > 2, and use Medicare are at greater risk of persistent chronic opioid use. Thus, given the poor outcomes associated with chronic opioid use, these findings may help guide surgeons' clinical decision-making process when encountering patients with a history of opioid use.

INTRODUCTION/BACKGROUND:The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA. METHODS:The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS:Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1). CONCLUSION/CONCLUSIONS:TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis. LEVEL OF EVIDENCE/METHODS:Level III Retrospective Case-control study.

BACKGROUND:There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. METHODS:A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. RESULTS:The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. CONCLUSION/CONCLUSIONS:The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

BACKGROUND:Dilute betadine wash has been used for the prevention of prosthetic joint infection (PJI). Appropriateness for this purpose has recently come into question as the Food and Drug Administration determined that several commercial products did not pass the standards of proper sterility. The goal of this study is to determine if change in our institution's perioperative infection protocol to sterile chlorhexidine gluconate wash affected rates of PJI. METHODS:This is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty and total hip arthroplasty. Chart review was performed to determine 90-day and 1-year readmissions and the development of PJI as per the diagnostic criteria of the Musculoskeletal Infection Society. RESULTS:A total of 2386 consecutive patients were included in this study. There were no significant demographic differences between the 2 groups. There was no statistically significant difference in the rate of PJI requiring a return trip to the operating room between the 2 cohorts: 4 in chlorhexidine vs 7 in betadine at 3 months (P = .61); and 9 in chlorhexidine and 14 in betadine at 1 year (P = .48, respectively). There was also no difference in the rate of wound complications between the betadine and chlorhexidine use (P = .93). CONCLUSION/CONCLUSIONS:When comparing patients who received a betadine wash intraoperatively to those who received a chlorhexidine gluconate wash, there were no statistically significant differences in the rate of postoperative PJIs or return trips to the operating room. Although chlorhexidine gluconate and betadine have equal efficacy in the prevention of PJI, betadine is a far less expensive alternative if their sterility concerns are unwarranted LEVEL OF EVIDENCE: Therapeutic Level III.

BACKGROUND:Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS:Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS:The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION/CONCLUSIONS:An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.