Faculty Bibliography

INTRODUCTION/BACKGROUND:Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS:We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS:In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION/CONCLUSIONS:More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE/METHODS:III, Retrospective Review.

Prosthetic joint infection (PJI) remains a major cause of failure in total joint arthroplasty. This complication begets an increase in morbidity and mortality along with significant costs to the healthcare system. The use of prophylactic antibiotics has significant decreased the incidence of this complication. However, the incidence of PJI has not drastically decreased over the last 50 years. This review explores the history, current concepts, and future developments for prevention of PJI prior to incision in total joint arthroplasty.

INTRODUCTION/BACKGROUND:Previous studies have attempted to validate the risk assessment and prediction tool (RAPT) in primary total hip arthroplasty (THA) patients. The purpose of this study was to: (1) identify patients who had an extended length of stay (LOS) following THA; and (2) compare the accuracy of 2 previously validated RAPT models. METHODS:We retrospectively reviewed all primary THA patients from 2014 to 2021 who had a completed RAPT score. Youden's J computational analysis was used to determine the LOS where facility discharge was statistically more likely. Based on the cut-offs proposed by Oldmeadow and Dibra, patients were separated into high- (O: 1 to 5 versus D: 1 to 3), medium- (O: 6 to 9 versus D: 4 to 7), and low- (O: 10 to 12 versus D: 8 to 12) risk groups. RESULTS:We determined that an LOS of greater than 2 days resulted in a higher chance of facility discharge. In these patients (n = 717), the overall predictive accuracy (PA) of the RAPT was 79.8%. The Dibra model had a higher PA in the high-risk group (D: 68.2 versus O: 61.2% facility discharge). The Oldmeadow model had a higher PA in the medium-risk (O: 78.7 versus D: 61.4% home discharge) and low-risk (O: 97.0 versus D. 92.5% home discharge) groups. CONCLUSIONS:As institutions continue to optimize LOS, the RAPT may need to be defined in the context of a patient's hospital stay. In patients requiring an LOS of greater than 2 days, the originally established RAPT cut-offs may be more accurate in predicting discharge disposition. LEVEL OF EVIDENCE/METHODS:III Retrospective Cohort Study.

AIMS/UNASSIGNED:Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. METHODS/UNASSIGNED:Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. RESULTS/UNASSIGNED:Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. CONCLUSION/UNASSIGNED:The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

Postoperative stiffness is a challenging problem in the setting of primary total knee arthroplasty. There remains a relatively high prevalence of patients suffering from this condition, and it can lead to unsatisfactory outcomes and need for revision surgery as well as a large financial burden on the health care system. There are a number of factors that predispose patients to developing arthrofibrosis, including patient-specific factors and intraoperative and postoperative considerations. Arthrofibrosis can be treated effectively in the early stages with manipulation under anesthesia with or without lysis of adhesions, however, those who fail to respond to these interventions may require revision surgery, which generally has poorer outcomes when performed for this indication. Current research is focused on understanding the pathologic cascade of arthrofibrosis and novel targeted therapeutics that may decrease stiffness in these patients and improve outcomes.

BACKGROUND:The Hip Disability and Osteoarthritis Outcome Score (HOOS JR) is a widely used patient-reported outcome measures questionnaire for total hip arthroplasty (THA). However, not all patients choose to complete HOOS JR, and thus, a subset of the THA population may be underrepresented. This study aims to investigate the association between patient demographic factors and HOOS JR response rates. METHODS:This was a retrospective cohort study of adult, English-speaking patients who underwent primary THA by a fellowship-trained arthroplasty surgeon between 2017 and 2023 at a single, high-volume academic institution. The HOOS JR completion status-complete or incomplete-was recorded for each patient within 90 days of surgery. Standard statistical analyses were performed to assess completion against multiple patient demographic factors. RESULTS:Of the 2,908 total patients, 2,112 (72.6%) had complete and 796 (27.4%) had incomplete HOOS JR questionnaires. Multivariate analysis yielded statistical significance (P < .05) for the distribution of patient age, race, insurance, marital status, and income quartile with respect to questionnaire completion. Patient sex or religion did not affect response rates. Failure to complete HOOS JR (all P < .001) was associated with patients aged 18 to 39 (59.8%), who identified as Black (36.4%) or "other" race (39.6%), were never married (38%), and were in the lower half income quartiles (43.9%, 35.9%) when compared to the overall incomplete rate. CONCLUSIONS:Multiple patient demographic factors may affect the HOOS JR response rate. Overall, our analyses suggest that older patients who identify as White and are of higher socioeconomic status are more likely to participate in the questionnaire. Efforts should focus on capturing patient groups less likely to participate to elucidate more generalizable trends in arthroplasty outcomes.

INTRODUCTION/BACKGROUND:Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status. METHODS:We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion. RESULTS:Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12 pm (P < 0.001), with a BMI > 30 kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP. CONCLUSION/CONCLUSIONS:Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.

Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive ligamentous laxity. Although revision TKA with exchange of the polyethylene to a varus-valgus-constrained liner can reduce laxity due to MCL insufficiency, isolated liner exchange in the setting of collateral ligament insufficiency may lead to greater strain at the cement-bone or implant-cement interface and possibly a greater rate of aseptic loosening. Anatomic MCL reconstruction can be performed in conjunction with liner exchange to restore stability and reduce strain compared with liner exchange alone. The purpose of this Technical Note is to describe a technique for MCL reconstruction and liner exchange for treatment of valgus instability after TKA.

INTRODUCTION/BACKGROUND:The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA. METHODS:We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were five, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (liters/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using T-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests. RESULTS:There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < 0.001), heart rate (101 versus 98.3; P = 0.007), minute ventilation (21.7 versus 18.7; P < 0.001), and energy expenditure per hour (349 versus 295; P < 0.001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = 0.001). CONCLUSION/CONCLUSIONS:Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

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.