BACKGROUND:Ambulatory surgery centers (ASCs) have been shown to deliver high-quality care to patients at major cost savings to the health care system. The objective of this investigation was to examine trends in the Medicare facility and surgeon professional fee payments for hip and knee arthroplasty. METHODS:Publicly available Medicare data were analyzed to determine professional and facility fee payments for unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), and total hip arthroplasty (THA) to ASCs and hospitals between 2018 and 2024. The Physician Fee Schedule Lookup Tool and the Medicare ASC payment rate files were used to determine professional fee payments and facility fee reimbursements, respectively. Descriptive statistics were used to calculate means and percent change over time. The compound annual growth rates were calculated. RESULTS:After adjusting for inflation, Medicare professional fees declined significantly over the study period for UKA ($1,487.44 versus $1,147.50; P = 0.003), TKA ($1,738.99 versus $1,278.59; P = 0.003), and THA ($1,740.73 versus $1,280.52; P = 0.003). Medicare ASC facility fees also declined, albeit to a lesser degree for UKA ($9,007.62 versus $8,905.71; P = 0.764), TKA ($10,204.46 versus $9,048.76; P = 0.027), and THA ($9,982.66 versus $9,238.05; P = 0.308). Facility fee reimbursement decreased year over year, with annual percent change ranging from -0.19% for UKA to -2.49% for THA. Trends in Medicare hospital facility fees directly mirrored ASC facility fees over the study period. Professional fees also declined year over year, with annual percent changes ranging from -3.81% for UKA to -4.41% for TKA and THA. CONCLUSIONS:The ASC facility fees and professional fees both declined over the study period, with declines in professional fees far outpacing those of facility fees. Urgent reform of the Medicare payment structure is needed to ensure orthopaedic practice solvency and access to high-quality care for beneficiaries.

BACKGROUND:Intraoperative femoral fractures are a rare, but serious complication of primary total hip arthroplasty (THA), and little is known about the rates of complications and reoperations in these patients. The objective of this investigation was to describe the two-year outcomes and revision rates in patients who sustain an intraoperative femoral fracture during THA. METHODS:A large administrative claims database was queried for patients who sustained an intraoperative femoral fracture during primary and elective THA from 2015 to 2022. Patients requiring THA for tumors or fractures were excluded. Patients who sustained an intraoperative fracture were matched 1:1 based on age, sex, and comorbidity burden. The incidence of medical and surgical complications was compared between cohorts. Kaplan-Meier and multivariate analyses were used to compare two-year outcomes between groups. RESULTS:Among matched cohorts of 2,795 patients, those who sustained an intraoperative femoral fracture experienced higher rates of periprosthetic joint infection (PJI) (odds ratio [OR]: 2.0, P < 0.001), instability (OR: 1.6, P = 0.013), revision THA (OR: 2.7, P < 0.001), deep vein thrombosis (OR: 3.0, P < 0.001), and transfusion (OR: 2.8, P < 0.001) at 90 days and demonstrated significantly longer length of stay (5.7 ± 6.3 versus 3.6 ± 4.5 days, P < 0.001). At a 2-year follow-up, patients who had an intraoperative femoral fracture were more likely to develop a PJI (OR: 2.1, P < 0.001), periprosthetic fracture (OR: 1.6, P = 0.030), aseptic loosening (OR: 3.0, P < 0.001), and instability (OR: 1.7, P = 0.001) and undergo all-cause revision (OR: 2.3, P < 0.001). CONCLUSIONS:Patients who sustained an intraoperative femoral fracture during primary THA were significantly more likely to develop PJI, periprosthetic fracture, aseptic loosening, instability, undergo revision THA, and experience medical complications. Strategies to mitigate intraoperative fracture during THA are necessary to improve outcomes in these high-risk patients.

BACKGROUND:The impact of previous pelvic osteotomy (PO) on outcomes following conversion to total hip arthroplasty (THA) remains unclear. Our systematic review aimed to compare the outcomes of patients undergoing THA following PO to those undergoing primary THA. METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search of five online databases was performed to identify articles published between January 1, 2000, and January 1, 2024, reporting on outcomes of patients who did and did not have previous PO undergoing THA. Articles with a minimum 2-year follow-up were included. The risk of bias was evaluated through the methodological index for nonrandomized studies tool. A total of 17 articles reporting on 542 THAs with previous POs were included. All articles were of moderate or high quality. RESULTS:Although the data was mixed for certain outcomes, a majority of included studies demonstrated that patients who had a previous PO had similar functional outcomes and survivorship, as well as complication and reoperation rates, compared to patients undergoing primary THA. However, a history of PO resulted in consistently longer operative times, higher estimated blood loss, and less medialization of the acetabular component. CONCLUSIONS:Patients who had a previous PO were found to have comparable functional outcomes, complication rates, and survivorship following THA relative to controls who did not have a previous surgical history. The differences in acetabular component positioning and intraoperative outcomes allude to the increased operative complexity of conversion THA. More information is needed to determine how factors such as osteotomy type and timing between osteotomy and THA impact the evaluated outcomes.

BACKGROUND:Revision of a unicompartmental to a total knee arthroplasty (TKA) is often compared to primary TKA with regard to its technical difficulty and complication rates. We sought to compare medical and surgical complications following revision unicompartmental knee arthroplasty (UKA) to those following primary TKA and aseptic revision TKA. METHODS:A national administrative claims database was queried for patients undergoing revision UKA between 2010 and 2019. Patients undergoing revision of a UKA were matched to patients undergoing primary TKA and aseptic revision TKA based on age, sex, Elixhauser Comorbidity Index, payer status, and a history of obesity, osteoporosis, tobacco use, and alcohol use disorder. Revision-free survivorship as well as 2-year and 90-day complication rates were compared. Multivariable logistic regression analysis was performed to determine the independent risk of medical and surgical complications. RESULTS:A total of 3,924 matched primary TKAs, revision of a failed UKA, and aseptic revision TKA patients were included. Overall survivorship was 96.9% (95% confidence interval [CI] 95.9 to 97.8) for primary TKA, 93.4% (95% CI 92.1 to 94.8) for revision UKA, and 89.8% (95% CI 88.2 to 91.5) for aseptic revision TKA at 2-year follow-up (P < 0.001). At two years, revision UKA patients had higher rates of aseptic loosening (2.2 versus 0.8%, P = 0.004), instability (2.4 versus 0.8%, P = 0.002), and mechanical failures (3.0 versus 1.5%, P = 0.012) than primary TKA patients. The 90-day complication rates were comparable between primary TKA and revision UKA patients (all P > 0.05); the risk of reoperation, acute kidney injury, wound dehiscence, hematoma, and transfusion were all higher in the revision TKA than in the revision UKA cohort (all P < 0.05). CONCLUSIONS:Revision-free survivorship and arthroplasty-related complications at two years following revision UKA are lower than that for primary TKA, but higher than that for aseptic revision TKA, whereas medical complications are similar to those following primary TKA.

Background: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. Methods: Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. Results: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively). Conclusion: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care. Level of evidence: Level IV; Economic Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: The clinical and financial burden of revision total hip arthroplasty (rTHA) continues to grow. Therefore, further investigation is needed to characterize case volume, reason for failure, and postoperative complications. The purpose of this study was to characterize contemporary indications for and complications following rTHA. Methods: Patients undergoing rTHA between 2010 and 2021 were identified within the PearlDiver database. Adjusted rTHA incidence was calculated by dividing the annual rTHA volume by the annual primary total hip arthroplasty (THA) and multiplying by 100,000. Mann-Kendall trend tests were utilized to trend revision volume, etiology, and 90-day postoperative complications. A total of 225,958 rTHAs were identified. Results: The annual volume of rTHA did not change over the study period (18,871 to 15,994; P = 0.064). However, the adjusted incidence of rTHA significantly decreased (20,169.3 to 13,061.2 per 100,000 THAs; P < 0.001). The most common causes of rTHA were aseptic implant loosening (21.5%), instability (19.8%), and infection (19.1%). The adjusted incidences of revision due to infection (4,659.9 to 2,596.1 per 100,000 THAs; P < 0.001) and aseptic implant loosening (4,651.4 to 2,493.2 per 100,000 THAs; P < 0.001) decreased over time. The adjusted rate of instability (3,149.8 to 3,245.3 per 100,000 THAs; P = 0.304) did not change. Rates of post-revision deep vein thrombosis, hematoma, surgical site infection, and transfusion significantly decreased over the study period (P < 0.05), while rates of emergency department visits and readmission did not change. Conclusions: In addition to a decreased adjusted incidence of rTHA, our analysis demonstrated a decreased incidence of infection, aseptic loosening, and various postoperative complications. However, no difference in the adjusted incidence of instability and periprosthetic fracture was seen over our study period. Continued study is necessary to further decrease the need for rTHA with a focus on the etiologies and complications that have remained unchanged. (c) 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background Serving as a principal investigator for a clinical trial can bring national visibility and recognition to physicians, and it can have a substantial impact on their promotion and tenure. In the field of orthopaedics, there is a well-known gender gap in terms of representation and leadership. Examining the representation of women in clinical trial leadership may help to inform and enable the design of targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership. Questions/purposes (1) What is the proportion of women principal investigators in orthopaedic clinical trials, and has this changed over time? (2) Are there trial characteristics (trial phase, status, funding source, and intervention) associated with women principal investigators? (3) What is the geographic distribution globally and regionally within the United States of clinical trials led by women principal investigators? Methods A cross-sectional survey of clinical trials using the ClinialTrials.gov registry and results database provided by the NIH was performed on August 22, 2022. Trial characteristics included principal investigator names and gender, trial phase, type, funding source, intervention, and location (defined by continent and US Census region). Our primary outcome was the overall proportion of women orthopaedic principal investigators over time. We assessed this by comparing the proportion of women principal investigators from 2007 to 2022. Our secondary outcomes were trial characteristics (trial phase, status, funding source, and intervention) and geographic distribution (globally and within the United States) associated with women principal investigators. Baseline characteristics of the clinical trials were calculated using frequencies and percentages for categorical variables. Fisher exact tests were conducted to evaluate differences in gender proportions based on the included clinical trial characteristics. Univariate linear regression was applied to analyze trends in the annual proportion of women principal investigators over time. Results The overall proportion of women principal investigators was 18% (592 of 3246), and this proportion increased over the study period. Specifically, the proportion of women leading clinical trials was 13% (16 of 121) in 2007 and 22% (53 of 242) in 2022 (r(2) = 0.68; p < 0.001). This trend was also observed when evaluating only US women principal investigators (r(2) = 0.47; p = 0.003) and non-US women principal investigators over the study period (r(2) = 0.298; p = 0.03). There was no difference in the distribution of trial phases between men and women principal investigators. Most men and women were involved in not applicable or Phase IV trials. Similarly, there was no difference in trial status or funding source. However, women principal investigators had a higher proportion of studies involving behavioral interventions (11% [67 of 592]) compared with men principal investigators (3% [74 of 2654]; p = 0.03). The proportion of women principal investigators over the study period by world region revealed a higher proportion of women principal investigators in Asia (23% [88 of 391]), followed by South America (24% [12 of 49]), North America (18% [306 of 1746]), and Europe (16% [136 of 833]). Among all US trials over the study period, the proportion of women principal investigators across the US Census region was Northeast (19% [62 of 329]), South (18% [90 of 488]), West (20% [97 of 492]), and Midwest (13% [22 of 168]). Conclusion Although there has been a notable increase in the proportion of women principal investigators over time, the overall representation remains relatively low. The disparities observed in trial characteristics and geographic distribution of women principal investigators further emphasize the need for targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership. Clinical Relevance These results underscore the importance of adopting practices and strategies that foster gender equity in the leadership of orthopaedic clinical trials. By establishing mentorship and sponsorship programs, early-career women surgeons can be connected with experienced leaders, cultivating a supportive network and offering valuable career guidance. Additionally, addressing geographic disparities in the representation of women principal investigators can involve the implementation of mentorship and sponsorship programs in regions with lower representation. (C) 2023 by the Association of Bone and Joint Surgeons

Introduction: Unicompartmental knee arthroplasty (UKA) has been shown to improve pain and function in appropriately selected patients. Limited data exists regarding outcomes and complication rates following UKA among octogenarians. Methods: The PearlDiver Mariner database was queried for patients undergoing primary UKA between 2010-2022. Patients < 80 years old were matched 4:1 to the octogenarian cohort (>= 80 years old) by sex, year, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 1,334 octogenarians and 5,313 controls were included in our analysis. Multivariate logistic regression was utilized to compare medical complications at 90-days post-operatively and surgical complications at 1- and 2-years post-operatively. Our regression analysis controlled for sex, ECI, tobacco use, obesity, and diabetes. Results: Octogenarians had an increased risk of acute kidney injury (OR: 2.306, 95% CI: 1.393-3.749; p < 0.001), pneumonia (OR: 2.367, 95% CI: 1.301-4.189; p = 0.003), UTI (OR: 1.846, 95% CI: 1.304-2.583; p < 0.001), ED visits (OR: 2.229, 95% CI: 1.586-3.105; p < 0.001), and any complication (OR: 1.575, 95% CI: 1.304-1.895; p < 0.001) at 90-days post-operatively. Octogenarians had lower odds of all-cause revision at 2-years (OR: 0.607, 95% CI: 0.382-0.923; p = 0.026). No differences were demonstrated between cohorts in rates of PJI (OR: 0.832, 95% CI: 0.334-1.796; p = 0.664), periprosthetic fracture (OR: 0.516, 95% CI: 0.120-1.520; p = 0.289), or aseptic loosening (OR: 0.285, 95% CI: 0.045-1.203; p = 0.088) at 2-years. Discussion: These findings suggest that despite an increased risk of certain medical complications within the acute post-operative period, octogenarians undergoing UKA experienced similar rates of surgical complications to younger matched controls at 2-year follow-up.

INTRODUCTION:Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS:The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS:In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION:Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Background Outpatient primary total knee arthroplasty (TKA) has been well-established as a safe and effective procedure; however, the safety of outpatient revision TKA remains unclear. Therefore, this study utilized a large database to compare outcomes between outpatient and inpatient revision TKA. Methods An all-payor database was queried to identify patients undergoing revision TKA from 2010 to 2022. Patients who had diagnosis codes related to periprosthetic joint infection (PJI) were excluded. Outpatient surgery was defined as a length of stay < 24 hours. Cohorts were matched by age, sex, Elixhauser Comorbidity Index, comorbidities (diabetes, obesity, tobacco use), components revised (1-versus 2-component), and revision etiology. Medical complications at 90 days and surgical complications at 1 and 2 years postoperatively were evaluated through multivariate logistic regression. A total of 4,342 aseptic revision TKAs were included. Results No differences in patient characteristics, procedure type, or revision etiologies were seen between groups. The outpatient cohort had a lower risk of PJI (odds ratio (OR): 0.547, 95% confidence interval (CI): 0.337 to 0.869; P = .012), wound dehiscence (OR: 0.393, 95% CI: 0.225 to 0.658; P < .001), transfusion (OR: 0.241, 95% CI: 0.055 to 0.750; P = .027), reoperation (OR: 0.508, 95% CI: 0.305 to 0.822; P = .007), and any complication (OR: 0.696, 95% CI: 0.584 to 0.829; P < .001) at 90 days postoperatively. At 1 year and 2 years postoperatively, outpatient revision TKA patients had a lower incidence of revision for PJI (OR: 0.332, 95% CI: 0.131 to 0.743; P = .011 and OR: 0.446, 95% CI; 0.217 to 0.859; P = .020, respectively) and all-cause revision (OR: 0.518, 95% CI: 0.377 to 0.706; P < .001 and OR: 0.548, 95% CI: 0.422 to 0.712; P < .001, respectively). Conclusions Our findings suggest that revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA. However, we could not ascertain case complexity in either cohort, and despite controlling for several potential confounders, other less tangible differences could exist between groups.

Objective:To evaluate outcomes, survivorship, and complication rates among patients who underwent concomitant periacetabular osteotomy (PAO) and hip arthroscopy and compare them to patients undergoing isolated PAO. Design:Systematic review and meta-analysis. Setting:Medline, EBSCO host, and Google Scholar databases were searched to identify all studies describing concomitant PAO and HA through May 9, 2023 (PROSPERO study protocol registration: CRD42023426191). Patients:Patients who underwent concomitant PAO and hip arthroscopy compared to patients who underwent isolated PAO. Interventions:Randomized controlled trials and cohort studies reporting clinical outcomes after concomitant PAO and hip arthroscopy. Main outcome measures:Patient-reported outcome measures (PROMs), radiographic outcomes, range of motion scores, complications, re-operations, and survivorship. Results:Thirteen studies reporting on a total of 697 patients (726 hips) were included. Significant improvements in PROMs and radiographic measures were demonstrated for most included studies. Pooled analyses demonstrated significant improvements in post-operative modified Harris Hip Score (mHHS) (mean difference (MD): 26.97, 95%CI: 30.19 to -23.75; p < 0.00001) and lateral-center edge angle (LCEA; MD: 13.94, 95%CI: 16.95 to -10.93; p < 0.0001) values. Patients undergoing combined procedures experienced 136 complications for 690 hips (19.71 %) with 29 (21.32 %) classified as major. There were 27 re-operations for 614 hips (4.40 %), and post-operative survivorship estimated at minimum 85 % after 3.5 years follow-up. However, for most outcome measures, there were no differences between concomitant procedures and isolated PAO. Conclusions:Based on the available literature, patients undergoing concomitant PAO and hip arthroscopy experience excellent outcomes. However, there is limited evidence to indicate that performing both procedures result in different outcomes compared to PAO alone.

Background:In 2020, the American Society of Shoulder and Elbow Therapists (ASSET) published an evidence-based consensus statement outlining postoperative rehabilitation guidelines following anatomic total shoulder arthroplasty (TSA). Purpose:The purpose of this study was to (1) quantify the variability in online anatomic TSA rehabilitation protocols, and (2) assess their congruence with the ASSET consensus guidelines. Methods:This study was a cross-sectional investigation of publicly available, online rehabilitation protocols for anatomic TSA. A web-based search was conducted in April 2022 of publicly available rehabilitation protocols for TSA. Each collected protocol was independently reviewed by two authors to identify recommendations regarding immobilization, initiation, and progression of passive (PROM) and active range of motion (AROM), as well as the initiation and progression of strengthening and post-operative exercises and activities. The time to initiation of various components of rehabilitation was recorded as the time at which the activity or motion threshold was permitted by the protocol. Comparisons between ASSET start dates and mean start dates from included protocols were performed. Results:Of the 191 academic institutions included, 46 (24.08%) had publicly available protocols online, and a total of 91 unique protocols were included in the final analysis. There were large variations seen among included protocols for the duration and type of immobilization post-operatively, as well as for the initiation of early stretching, PROM, AROM, resistance exercises, and return to sport. Of the 37 recommendations reported by both the ASSET and included protocols, 31 (83.78%) were found to be significantly different between groups (p\<0.05). Conclusion:Considerable variability was found among online post-operative protocols for TSA with substantial deviation from the ASSET guidelines. These findings highlight the lack of standardization in rehabilitation protocols following anatomic TSA. Level of Evidence:3b.

Introduction: As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes. Methods: 5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs). Results: No differences between the DAA and other approaches were observed when evaluating HOOS (MD −0.28; 95% CI, −1.98–1.41; p = 0.74), HHS (MD 2.38; 95% CI, −0.27–5.03; p = 0.08), OHS (MD 1.35; 95% CI, −2.00–4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, −0.36–12.12; p = 0.06), VAS-pain (MD −0.32; 95% CI, −0.68–0.04; p = 0.08), and WOMAC-pain (MD −0.73; 95% CI, −3.85–2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54–4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01–0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis. Conclusions: Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

Background:With the advent of outpatient total joint arthroplasty (TJA), the days of routinely drawing postoperative labs (complete blood counts [CBCs] and metabolic panels [CMPs/BMPs]) to monitor for complications are behind us. However, there does exist a subset of at-risk patients that may benefit from diligent postoperative monitoring, though the circumstances under which labs should be ordered remains unclear and subject to surgeon discretion. A systematic review of the literature was therefore conducted to evaluate the utility of postoperative laboratory testing, approaches to targeted patient selection and associated cost-savings. Methods:The PubMed, MEDLINE, EBSCOhost, and Google Scholar electronic databases were searched on August 17, 2023, to identify all studies published since January 1, 2000, that evaluated the role of postoperative lab testing in TJA. (PROSPERO study protocol registration: CRD42023437334). Articles were included if a full-text English manuscript was available and the study assessed the utility of routine postoperative labs in TJA. 19 studies were included comprising 34,166 procedures. The mean Methodological index for Nonrandomized Studies score was 18.2 ± 1.5. Results:Abnormal postoperative lab results were common and infrequently required clinical intervention. Among several identified risk factors for patients that may benefit from postoperative laboratory monitoring, preoperative lab values proved excellent discriminators of transfusion requirement and metabolite-associated intervention. Selective testing demonstrated the ability to generate substantial cost-savings. Conclusion:Routine postoperative laboratory testing offers little clinical utility and produces unnecessary expenditures. Preoperative lab values offer the greatest predictive utility for postoperative transfusion requirement and metabolite-associated clinical intervention, with a preoperative hemoglobin threshold of 111.5 g/L offering an area under the curve (AUC) of 0.93 for predicting postoperative transfusion. Further investigations are needed for metabolic panel predictive models and should incorporate preoperative lab values. The refinement of such models can enable targeted patient selection to avoid unnecessary labs and generate substantial cost savings without compromising patient safety.

Cerebral palsy (CP) is a neurodevelopmental condition that can result in altered gait biomechanics, joint dysfunction, and imbalance. The complications associated with total knee arthroplasty (TKA) in patients with CP have not yet been well described. Therefore, our analysis sought to compare the 90-day and 2-year complications following TKA in patients with and without CP. The PearlDiver Mariner database was utilized to identify patients with CP undergoing primary TKA between 2010 and 2020. This cohort was matched 1:4 to a control cohort without neurodegenerative disorders based on age, sex, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 3,257 patients (657 CP patients 2,600 controls) were included in our final analysis. A multivariable logistic regression analysis was utilized to determine the risk of CP on medical and surgical complications at 90 days and all-cause revision rates at 2 years. Patients with CP had an increased risk of acute kidney injury (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.07-2.5; p = 0.019), pneumonia (OR: 5.63; 95% CI: 3.69-8.67; p < 0.001), urinary tract infection (OR: 5.01; 95% CI: 3.85-6.52; p < 0.001), and transfusion (OR: 2.21; 95% CI: 1.50-3.23; p < 0.001). CP patients additionally had a higher incidence of emergency department (ED) visits (OR: 5.24; 95% CI: 3.76-7.32; p < 0.001) and readmissions (OR: 5.24; 95% CI: 2.57-4.96; p < 0.001). There were no differences in rates of periprosthetic joint infection (PJI; OR: 1.23; 95% CI: 0.69-2.10; p = 0.463), surgical site infection (SSI; OR: 0.51; 95% CI: 0.12-1.46; p = 0.463), and reoperation (OR: 1.35; 95% CI: 0.71-2.43; p = 0.339) at 90 days postoperatively. The all-cause revision rates at 2 years were comparable (OR: 1.02; 95% CI: 0.67-1.51; p = 0.927). In this database review, we found that CP patients have a higher risk of medical complications in the acute postoperative period following TKA. The 90-day surgical complication and 2-year revision rates in CP patients were comparable to matched controls.

BACKGROUND:Understanding the trends and patterns of research funding can aid in enhancing growth and innovation in orthopaedic research. We sought to analyze financial trends in public orthopaedic surgery funding and characterize trends in private funding distribution among orthopaedic surgeons and hospitals to explore potential disparities across orthopaedic subspecialties. METHODS:We conducted a cross-sectional analysis of private and public orthopaedic research funding from 2015 to 2021 using the Centers for Medicare & Medicaid Services Open Payments database and the National Institutes of Health (NIH) RePORTER through the Blue Ridge Institute for Medical Research, respectively. Institutions receiving funds from both the NIH and the private sector were classified separately as publicly funded and privately funded. Research payment characteristics were categorized according to their respective orthopaedic fellowship subspecialties. Descriptive statistics, Wilcoxon rank-sum tests, and Mann-Kendall tests were employed. A p value of <0.05 was considered significant. RESULTS:Over the study period, $348,428,969 in private and $701,078,031 in public research payments were reported. There were 2,229 unique surgeons receiving funding at 906 different institutions. The data showed that a total of 2,154 male orthopaedic surgeons received $342,939,782 and 75 female orthopaedic surgeons received $5,489,187 from 198 different private entities. The difference in the median payment size between male and female orthopaedic surgeons was not significant. The top 1% of all practicing orthopaedic surgeons received 99% of all private funding in 2021. The top 20 publicly and top 20 privately funded institutions received 77% of the public and 37% of the private funding, respectively. Private funding was greatest (31.5%) for projects exploring adult reconstruction. CONCLUSION:While the amount of public research funding was more than double the amount of private research funding, the distribution of public research funding was concentrated in fewer institutions when compared with private research funding. This suggests the formation of orthopaedic centers of excellence (CoEs), which are programs that have high concentrations of talent and resources. Furthermore, the similar median payment by gender is indicative of equitable payment size. In the future, orthopaedic funding should follow a distribution model that aligns with the existing approach, giving priority to a nondiscriminatory stance regarding gender, and allocate funds toward CoEs. CLINICAL RELEVANCE:Securing research funding is vital for driving innovation in orthopaedic surgery, which is crucial for enhancing clinical interventions. Thus, understanding the patterns and distribution of research funding can help orthopaedic surgeons tailor their future projects to better align with current funding trends, thereby increasing the likelihood of securing support for their work.

Background and Objectives: The optimal timing between preoperative embolization of hypervascular metastatic bone lesions and surgery has yet to be established. Our analysis sought to evaluate embolization timing impacts blood loss, transfusion risk, and operative time in patients with hypervascular primary tumors. Methods: We identified patients with renal cell (RCC) or thyroid carcinoma under going surgery between 1992 and 2023. Patients were segregated into the following cohorts: (1) no embolization preoperatively, (2) surgery <24 h of embolization, and (3) surgery >24 h after embolization. Multivariate logistic regression analyses were performed to assess the effect of embolization timing while controlling for confounding variables. Results: No differences were seen in all evaluated outcomes between immediate and delayed embolization cohorts. No differences in estimated blood loss were seen between the immediate (OR: 0.685, 95% CI: 0.159-2.949;p= 0.611) and delayed (OR: 0.568, 95%CI: 0.093-3.462;p= 0.539) surgery cohorts compared with patients without embolization. Surgery >24 h after embolization was not associated with a higher risk of prolonged operative time (OR: 13.499, 95% CI: 0.832-219.146;p= 0.067).Conclusions: These findings suggest that surgery may be safely delayed beyond 24 h from embolization without a higher risk of bleeding. In appropriately selected cohorts, embolization may not be needed preoperatively.

Knee cartilage damage poses significant clinical challenges, with osteoarthritis and focal defects compromising joint integrity. Numerous surgical and nonsurgical approaches address cartilage pathology. These aim to repair defects, provide symptom relief, restore function, and prevent disease progression. Outcomes vary based on lesion characteristics and patient factors. While certain interventions demonstrate encouraging results, limitations persist regarding indications, technique standardization, and evidence quality. Comprehensive data through rigorous study is essential to establish definitive treatment guidelines. Ongoing research into novel methodologies continues to expand the realm of possibilities for maximal knee preservation.

PURPOSE:To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS:A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS:Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS:At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE:Level II, meta-analysis of Level I to II studies.