AbstractThe long-term survival of ceramic-on-ceramic bearings in young, active patients with osteonecrosis undergoing total hip arthroplasty (THA) is unknown. A previously published study demonstrated a high activity level in these young patients at 5-year follow-up, and this is a second follow-up report on this previously reported series. The purpose of this study is to determine whether high activity level is associated with ceramic-on-ceramic THA failure at long-term follow-up. This is a retrospective review of a single-surgeon consecutive series of index cases performed between 2003 and 2010. Inclusion criteria were ceramic-on-ceramic THA articulations in patients younger than 50 with a diagnosis of osteonecrosis. Mean follow-up was 12.5 years (range 9–17). Data were collected by survey via mail, telephone, e-mail, and social media. Preoperative and postoperative Western Ontario and McMaster University (WOMAC) Arthritis Index and University of California at Los Angeles (UCLA) activity scores were collected. Student t-tests were used as appropriate. There were 97 patients in this series. Mean age at THA was 36 (range 14–50). Since the prior report, four more patients have been confirmed deceased, and four more have been lost to follow-up. We confirmed that six patients were deceased and 42 were otherwise lost to follow-up. The response rate was 54%. The vast majority of patients were highly active at latest follow-up (73% with UCLA scores between 7 and 10). UCLA scores (1–10 scale) improved from a preoperative mean of 3.4 to postoperative 7.1 (p < 0.001). WOMAC scores (1–100 scale) increased from preoperative mean of 38.7 to postoperative 86.1 (p < 0.001). At latest follow-up, four patients had undergone revision surgery. There were no ceramic component failures. One patient underwent early revision for femoral component loosening, one was revised for chronic pain at another institution. Since the prior report there have been two additional revisions; one patient was revised for instability at 5-year postop, and one patient was revised for periprosthetic fracture at 10 years. Despite additional loss to follow-up and lack of clinical and radiographic measures, this survey study suggests that at long-term follow-up ceramic bearings accommodate high activity level with excellent component survivorship (93%) in young patients undergoing THA.

BACKGROUND:With the increasing number of young patients undergoing primary total knee arthroplasty (TKA), there will be an increase in the number of patients who require revision. While the results of TKA in younger patients are well known, there is little information regarding to the outcomes of revision TKA in this population. The purpose of this study was to evaluate the clinical outcomes in patients <60 years of age undergoing aseptic revision TKA. METHODS:We retrospectively reviewed 433 patients undergoing aseptic revision TKA between 2008 and 2019. There were 189 patients <60 years compared to a group of 244 patients >60 years undergoing revision TKA for aseptic failures in terms of implant survivorships, complications, and clinical outcomes. Patients were followed for a mean of 48 months (range, 24 to 149). RESULTS:A total of 28 (14.8%) patients less than 60 years of age required repeat revision compared to 25 (10.2%) 60 years or older (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.73-5.22, P = .187). There were no differences regarding postprocedural Patient-Reported Outcomes Measurement Information System (PROMIS) physical health scores (72.3 ± 13.7 versus 72.0 ± 12.0, P = .66) and PROMIS mental health scores (66.6 ± 17.4 versus 65.8. ± 14.7, P = .72), at an average of 32.9 and 30.7 months, respectively. Postoperative infection occurred in 3 (1.6%) patients <60 years of age, while 12 (4.9%) postoperative infections occurred in patients 60 years or older (OR 0.75, 95% CI 0.06-10.2, P = .83). CONCLUSION:There were no statistically significant differences in clinical outcomes between patients <60 versus > 60 years of age undergoing aseptic revision TKA.

Background: Wound complications following revision TKA can be catastrophic and can compromise joint and even limb. The purpose of this study was to determine the prevalence of superficial wound complications requiring return to the OR in revision TKA, rates of subsequent deep infection, factors that increase the risk of superficial wound complications, and the outcomes of revision TKA following development of superficial wound complications. Methods: We retrospectively reviewed 585 consecutive TKA revisions with at least two years follow-up, including 399 aseptic revisions and 186 reimplantations. Superficial wound complications without deep infection requiring return to the OR within 120 days were compared to controls. Results: Fourteen patients following revision TKA (2.4%) required return to the OR for a wound complication, including 7 of 399 (1.8%) patients who underwent aseptic revision TKA and 7 of 186 (3.8%) patients undergoing reimplantation TKA (p = 0.139). Aseptic revisions with wound complications were more likely to develop subsequent deep infection (HR 10.04, CI 2.24-45.03, p = 0.003), but this did not hold true for reimplantations (HR 1.17, CI 0.28-4.91, p = 0.829). Risk factors for wound complication included atrial fibrillation when all patients were combined (RR 3.98, CI 1.15-13.72, p = 0.029), connective tissue disease in the aseptic revision group (RR 7.1, CI 1.1-44.7, p = 0.037), and a history of depression in the re-implantation group (RR 5.8, CI 1.1-31.5, p = 0.042). (c) 2023 Published by Elsevier B.V.

Introduction: Total joint arthroplasty (TJA) volume and the number of orthopaedic surgeons in the United States have increased in recent years, but local growth variation has not been studied. This study assesses recent changes in state-level distribution of orthopaedic surgeons in the United States and corresponding local trends in TJA volume. Methods: Data from the National Inpatient Sample database (2000 to 2014) were reviewed. Urban versus rural setting and teaching versus nonteaching hospitals were identified among TJA procedures for comparison. Data from the American Academy of Orthopaedic Surgeons (2002 to 2016) detailing orthopaedic surgeon practice location were evaluated, and linear regression analysis was used to correlate state population data with orthopaedic surgeon density. Results: From 2000 to 2014, there was a 0.1% to 0.3% (P < 0.01) annual decrease in the proportion of TJA procedures conducted in rural hospitals. No notable change was observed in the proportion of TJA procedures conducted at urban teaching versus nonteaching hospitals. Linear regression analysis demonstrated that decreased state population was associated with higher orthopaedic surgeon density (adjusted R2 = 0.114, P < 0.01). States with a higher percentage of population living in rural areas had a lower density of orthopaedic surgeons in the South region and a higher density of orthopaedic surgeons in the remainder of the county. Conclusions: Less populated, rural states have a higher density of orthopaedic surgeons than states with increased population and less rural areas. Although TJA volume has increased since 2000, the proportion of TJA procedures conducted at rural hospitals has decreased. No change was found in the proportion of TJA procedures conducted at urban teaching versus nonteaching hospitals. This may indicate that more patients living in rural areas are seeking TJA care in urban centers. Future studies are needed to confirm this and ensure that patients living in rural areas have appropriate access to TJA care.

BACKGROUND/METHODS:We retrospectively reviewed 89 patients with acute prosthetic joint infection treated with debridement, antibiotics, and implant retention (DAIR) or 2-DAIR. Patients had <3 weeks of symptoms and met Musculoskeletal Infection Society criteria for infection. Sixty-three patients were treated with DAIR, whereas 26 patients were managed using a 2-DAIR protocol where patients underwent initial debridement, antibiotic bead placement, and subsequent return to the operating room at an average of 16.3 days for repeat debridement and modular component exchange. Patients received a 6-week course of intravenous antibiotics and 3 months of oral antibiotics for suppression. Demographics, comorbidities, implant retention rates, and complications were compared between the groups. The McPherson host type and infection type classification system were used to categorize patients in both the DAIR and 2-DAIR groups. Regression analysis was performed to control postoperative vs acute hematogenous infection, procedure, and comorbidities. The McPherson host types and infection types were not different between DAIR and 2-DAIR patients, P = .728 and P = .061, respectively.RESULTS:There was no difference in the overall implant retention rate between DAIR and 2-DAIR (63.49% vs 69.23%, P = .605). The average days to reinfection was significantly longer for the 2-DAIR cohort compared with DAIR (271.3 vs 165.3, P = .024) in patients who failed treatment. However, when controlling for infection, microorganism, index procedure, and comorbidities, there was no difference in days to reinfection (P = .679). There were no differences in complications, 90-day readmission, or revision rates between the groups.CONCLUSIONS:A staged debridement for acute prosthetic joint infection did not improve the rates of infection control. Randomized trials are needed to define indications and potential benefits of 2-DAIR.

Background: Dual eligible Medicare/Medicaid patients undergoing total hip arthroplasty (THA) have worse outcomes compared to other insurance payors.Prior literature fails to control for the heterogeneity of care provided amongst a large cohort of hospitals and surgeons as well as differences in patient populations treated.This study compares dual eligible THA patients and Medicaid and Medicare only THA patients at a single high volume tertiary center.Methods: We retrospectively reviewed patients who underwent THA for aseptic osteoarthritis of the hip over a three-year period with either Medicaid or Medicare insurance.3,329 THA patients were included, of which 439 were Medicaid payor, 182 were dual eligible, and 2,708 were Medicare payor.Groups were compared using appropriate tests for direct comparisons and regression analysis.Results: Dual eligible patients were less likely to be white and married, and were more likely to be current smokers and have COPD, liver disease, renal disease, and human immunodeficiency virus (HIV) compared to Medicare patients.These patients also had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients (2.4 vs 3.4, P < .001).When controlling for smoking status, age, BMI and major medical comorbidities, dual eligible and Medicaid patients had increased length of stay (LOS) (0.58, 0.66 days, P < .001),higher risk of discharge to subacute rehabilitation (RR 1.97, 3.19, P < .001),and dual eligible patients more often returned to the ED within 90 days (RR 2.74, P < .001)compared to Medicare patients.Conclusion: This study supports the implementation of socioeconomic risk stratification efforts to properly evaluate value-based healthcare metrics in total hip arthroplasty patients.

Background: Medicare/Medicaid dual-eligible patients who undergo primary total knee arthroplasty (TKA) demonstrate poor outcomes when compared to patients with other payers. We compare Medicare/Medicaid dual-eligible patients vs Medicare and Medicaid only patients at a single hospital center. Methods: All patients who underwent TKA for aseptic arthritis between August 9, 2016 and December 30, 2020 with either Medicare or Medicaid insurance were retrospectively reviewed. 4599 consecutive TKA (3749 Medicare, 286 Medicare/Medicaid dual eligibility, and 564 Medicaid) were included. Groups were compared using appropriate tests for direct comparisons and regression analysis. Results: Patients with dual eligibility and Medicaid insurance were less likely to be white and married, more likely to be female and current smokers, and more likely to have COPD, mild liver disease, diabetes mellitus, malignancy, and HIV/ AIDS, but had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients. When controlling for smoking status and medical comorbidities, patients with dual eligibility and Medicaid insurance stayed in the hospital 0.64 and 0.39 additional days (P <.001), respectively, were more likely to be discharged to subacute rehab (RR 2.01, 1.49, P <.001) and acute rehab (RR 2.22, 2.46, P = .007, <.001), and were 2.14 and 1.73 times more likely to return to the ED within 90 days (P <.001) compared to Medicare patients. Conclusion: Value-based healthcare may disincentivize treating patients with low socioeconomic status, represented by Medicaid and dual-eligible insurance status, by their association with increased postoperative healthcare utilization, and less risky patients may be prioritized. (C) 2022 Elsevier Inc. All rights reserved.

The free vascularized osteocutaneous flap from the medial femoral condyle is an attractive option for limb salvage given its low donor morbidity site and reliable vascular supply. Its use was originally described for the use of nonunions with small bony defects and has shown reliable results for a variety of reconstructive needs.

Background: The goal of kinematically aligned (KA) total knee arthroplasty (TKA) is to restore native knee anatomy. However, there are concerns about patellofemoral tracking problems with this technique that lead to early revision. We measured the differences between preoperative anatomic alignment and postoperative component alignment in a consecutive series of KA TKA and evaluated the association between alignment changes and the likelihood of early revision. Methods: The charts of 219 patients who underwent 275 KA TKA procedures were reviewed. Preoperative anatomic alignment and postoperative tibial and femoral component alignment were measured radiographically. The difference in component alignment compared with preoperative anatomic alignment was compared between patients who underwent aseptic revision and those who did not at a minimum of 12 months of follow-up. Receiver operating characteristic curves were created for statistically significant variables, and the Youden index was used to determine optimal alignment thresholds with regard to likelihood of revision surgery. Results: Change in tibial component alignment compared with native alignment was greater (P = .005) in the revision group (5.0 degrees +/- 3.7 degrees of increased varus compared with preoperative anatomic tibial angle) than in the nonrevision group (1.3 degrees +/- 4.2 degrees of increased varus). The Youden index indicated that increasing tibial varus by >2.2 degrees or more is associated with increased likelihood of revision. Preoperative anatomic alignment and change in femoral alignment and overall joint alignment (ie, Q angle) were not associated with increased likelihood of revision. Conclusion: Small increases in tibial component varus compared with native alignment are associated with early aseptic revision in patients undergoing KA TKA. (C) 2020 Elsevier Inc. All rights reserved.

BACKGROUND Total joint arthroplasty is one of the most common surgeries performed in the United States with total knee arthroplasty (TKA) being one of the most successful surgeries for restoring function and diminishing pain. Even with the demonstrated success of TKA and a higher prevalence of arthritis and arthritis related disability among minorities, racial and gender disparity remains a constant issue in providing care for the adult reconstruction patient. AIM To assess the role of demographics and expectations on differences in perioperative patient reported outcomes (PRO) following TKA. METHODS One hundred and thirty-three patients scheduled for primary unilateral TKA secondary to moderate to severe osteoarthritis were enrolled in this two-institution prospective study. Validated PRO questionnaires were collected at four time points. Statistical analysis was conducted to determine the impact of gender, ethnic background and expectation surveys responses to assess PRO at these time points. RESULTS Females were associated with worse preoperative Knee Injury and Osteoarthritis Outcome Scores (KOOS) for symptoms, pain, and activities of daily living. African Americans were associated with worse KOOS for pain, activities of daily living, and quality of life. Despite worse preoperative scores, no difference was noted in these categories between the groups postoperatively. Additionally, all pre-operative psychometric scales were equivalent across groups except Geriatric Depression scale, which was significantly different between groups within the Race and Age Group (P < 0.05). Conversely, Pain Catastrophizing Scale, was significantly different for all subscales and total score within Age Group (P < 0.05), and the Magnification, Helplessness subscales as well as the Total score were significantly different between groups for Race and Relationship Status (P < 0.01). CONCLUSION We conclude that female and African American patients have lower preoperative KOOS scores compared to white male patients. No postoperative differences in outcomes between these groups.

Introduction: While there are many factors known to predict the outcomes of hip and knee arthroplasty procedures, there is a growing interest in predictors that take into consideration the social and psychological preparedness of patients prior to surgery. This study's aim was to determine whether patients' preoperative social support and pain catastrophizing characteristics are independently associated with the outcomes of postoperative length of stay or discharge disposition following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).Methods: Data on a prospective sample of 189 THA and TKA adult patients using the pain catastrophizing scale and the medical outcomes study social support expectation score were analyzed. Demographic characteristics, such as age, gender, and race (Caucasian versus non-Caucasian), which served as covariates, were also collected. Bivariate associations between our outcome variables and covariates using Pearson's and Spearman's rank correlation coefficients and Mann Whitney U test for continuous variables (age, MOS-SSS) and Chi-squared tests for categorical variables (gender, race, ethnicity, procedure, catastrophizing) were employed. Statistical significance was set at p <= 0.05. Data are presented as median with range values, frequencies with percentages, or adjusted odds ratios (OR) and betas (beta) with 95% confidence intervals (CI).Results: There were 73 (38.6%) patients categorized as catastrophizers. Median score for social support was 90.8 (range: 3.9 to 100). No statistically significant associations between pain catastrophizing or social support were observed for length of stay (beta: 0.03, 95% CI: -0.24-0.31, p = 0.81; beta: -0.002, 95% CI: -0.010--0.006, p = 0.58) and discharge disposition (OR: 1.15, 95% CI: 0.51-2.55, p = 0.74; OR: 0.99, 95% CI: 0.97-1.01, p = 0.37). Significant associations with discharge to a rehabilitation facility included non-Caucasian (OR: 5.4, 95% CI: 2.4-11.8, p < 0.001) and longer length of stay (OR: 1.6, 95% CI: 1.01-2.4, p = 0.04). Female gender and non-Caucasian were associated with longer length of stay (beta: 0.3, 95% CI: 0.03-0.6, p = 0.03; and beta: 0.4, 95% CI: 0.1-0.6, p=0.008, respectively).Conclusion: We did not find a significant association between pain catastrophizing behavior and level of social support with length of stay or discharge disposition.