BACKGROUND:Large language models (LLMs) show promise for perioperative decision support, but persistent issues, including hallucinations, miscalibration, and biases, indicate they require rigorous evaluation before clinical use. As LLM adoption increases in perioperative settings, systematic evaluation is needed to determine how patient and surgical factors affect performance. METHODS:We evaluated five general-purpose LLMs (DeepSeek 3.2, Gemini 2.5 Flash, GPT-5, GPT-5 mini, GPT-5 nano) using 216 standardized hip fracture surgery vignettes crossing six surgery types, two sexes, and 18 patient variables. We generated 50 samples per combination for 54,000 total responses and collected both structured recommendations and free-text justifications. We used logistic regression to estimate effects on three primary outcomes: anesthesia type, peripheral nerve block placement, and arterial line placement. In a limited sensitivity analysis, we evaluated two clinical LLMs (OpenEvidence, Doximity GPT) with 36 responses each. RESULTS:All models favored neuraxial over general anesthesia (76.1%-88.6% of responses), and all but DeepSeek 3.2 appropriately adjusted recommendations for relevant medical contraindications. All models except GPT-5 nano recommended preoperative peripheral nerve blocks (92.6%-99.3%) and were appropriately conservative regarding arterial line placement. However, free-text justifications frequently cited neuraxial benefits unsupported by recent randomized trials, and most models issued strong neuraxial recommendations despite a lack of clinical justification. We identified limited sociodemographic biases, with only one significant and clinically meaningful effect across 150 comparisons. Clinical LLMs provided similar recommendations to general-purpose models. CONCLUSIONS:While LLMs provided generally reasonable recommendations, systematic preferences diverging from contemporary evidence suggest uncritical use could shift practice patterns without improving patient outcomes.

BACKGROUND:Cementless total knee arthroplasty (TKA) has reemerged with advances in implant design promoting improved durability. However, differences in the utilization of emerging orthopaedic technologies persist, and the influence of race and socioeconomic status on cementless fixation adoption remains unclear. This study evaluated national trends in cementless TKA utilization across race and socioeconomic status. METHODS:Medicare fee-for-service claims (2016 to 2022) were used to identify adult patients who underwent primary, elective, inpatient TKA via International Classification of Diseases, Tenth Revision, Procedure Coding System codes. Patients were grouped by race (White, Black, or Hispanic) and dual Medicare-Medicaid eligibility (yes/no) as a proxy for socioeconomic status. Procedures were categorized as cementless or cemented fixation. Cochran-Armitage trend tests and compound annual growth rate (CAGR) were used to evaluate annual trends. Multivariable logistic regression models examined the association between race-socioeconomic subgroups and cementless fixation, adjusting for demographic, clinical, and hospital factors. RESULTS:Among 1,044,345 TKAs, 4.8% (50,141) were cementless, increasing from 2.4% in 2016 to 9.9% in 2022 (CAGR 26.7%; P < 0.0001). The CAGR for cementless TKA was highest for Hispanic non-dual-eligible (CAGR 30.6%) and White non-dual-eligible (CAGR 27.3%) patients and lowest among Hispanic dual-eligible patients (CAGR 16.9%). After multivariable adjustment, Black dual-eligible (odds ratio (OR) 0.92; P = 0.015), Hispanic dual-eligible (OR 0.86; P = 0.004), and Hispanic non-dual-eligible (OR 0.84; P = 0.030) patients had significantly lower odds of receiving cementless fixation versus White non-dual-eligible counterparts. Black non-dual-eligible patients demonstrated higher odds (OR 1.05; P = 0.041). Although several differences reached statistical significance, the magnitude of adjusted odds ratios was modest. CONCLUSION:Cementless TKA grew across all race-socioeconomic categories among Medicare beneficiaries. However, most minority and lower-income subgroups were less likely to receive this reemerging technique, with differences concentrated among Hispanic and dual-eligible patients. These findings highlight variation in adoption of emerging orthopaedic technologies across patient populations.

BACKGROUND:Bisphosphonate (BP) use is not uncommon among total hip arthroplasty (THA) candidates. While the impact of BP therapy post-THA has been investigated, there is a paucity of literature discussing the impact of BP therapy pre-THA. Using a national dataset, we aimed to study the association between preoperative BP use and surgical outcomes in primary THA recipients. METHODS:This retrospective cohort study used a commercial claims and Medicare Supplemental database to identify adults aged ≥ 18 years who had an index nonfracture-related primary THA from 2016 to 2020. The use of BP was defined as ≥ 6 months of BP therapy in the year prior to THA. Outcomes were 90-day all-cause readmission, 90-day readmission related to periprosthetic fracture (PPF), 90-day and 1-year all-cause revision, 1-year PPF-related revision, and 1-year diagnosis of PPF. In a 1:5 propensity score-matched analysis, each THA patient who had preoperative BP use was matched to five THA patients who did not have preoperative BP use. Logistic regression models were fitted; we report odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS:Of 91,907 THA patients, 1,018 (1.1%) used BP preoperatively. In the propensity score-matched cohort (1,018 preoperative BP users and 5,090 controls), preoperative BP use was significantly associated with increased odds of 90-day all-cause revision surgery (OR 1.67; 95% CI 1.10 to 2.53; P = 0.02), 1-year PPF-related revision (OR 2.23; 95% CI 1.21 to 4.10; P = 0.01), and 1-year PPF diagnosis (OR 1.88; 95% CI 1.10 to 3.20; P = 0.02). There were no statistically significant associations between preoperative BP use and the other outcomes in the matched cohort. CONCLUSIONS:These findings suggest that preoperative BP use is associated with an increased risk of revision surgery and PPF in both the short and long term. This information can help in preoperative planning and patient counseling, potentially leading to improved surgical outcomes and reduced complication rates.

BACKGROUND:Online resources are important for patient self-education and reflect public interest. We described commonly asked questions regarding the direct anterior versus posterior approach (DAA, PA) to total hip arthroplasty (THA) and the quality of associated websites. METHODS:We extracted the top 200 questions and websites in Google's "People Also Ask" section for 8 queries on January 8, 2023, and grouped websites and questions into DAA, PA, or comparison. Questions were categorized using Rothwell's classification (fact, policy, value) and THA-relevant subtopics. Websites were evaluated by information source, Journal of the American Medical Association Benchmark Criteria (credibility), DISCERN survey (information quality), and readability. RESULTS:We included 429 question/website combinations (questions: 52.2% DAA, 21.2% PA, 26.6% comparison; websites: 39.0% DAA, 11.0% PA, 9.6% comparison). Per Rothwell's classification, 56.2% of questions were fact, 31.7% value, 10.0% policy, and 2.1% unrelated. The THA-specific question subtopics differed between DAA and PA (P < .001), specifically for recovery timeline (DAA 20.5%, PA 37.4%), indications/management (DAA 13.4%, PA 1.1%), and technical details (DAA 13.8%, PA 5.5%). Information sources differed between DAA (61.7% medical practice/surgeon) and PA websites (44.7% government; P < .001). The median Journal of the American Medical Association Benchmark score was 1 (limited credibility, interquartile range 1 to 2), with the lowest scores for DAA websites (P < .001). The median DISCERN score was 55 ("good" quality, interquartile range 43 to 65), with the highest scores for comparison websites (P < .001). Median Flesch-Kincaid Grade Level scores were 12th grade level for both DAA and PA (P = .94). CONCLUSIONS:Patients' informational interests can guide counseling. Internet searches that explicitly compare THA approaches yielded websites that provide higher-quality information. Providers may also advise patients that physician websites and websites only describing the DAA may have less balanced perspectives, and limited information regarding surgical approaches is available from social media resources.

IntroductionDespite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA.MethodsThis nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported.ResultsOral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THAs and TKAs (18.4% of 24,857 THA, 15.5% of 48,158 TKA) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole/trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < 0.001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < 0.001 to 0.01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < 0.001). Additionally, regional and time-based variations were noted.ConclusionPerioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Objective: To study the effect of the Comprehensive Care for Joint Replacement (CJR) bundled payment program on postoperative home health and outpatient physical therapy (PT) for total hip or knee arthroplasty (THA/TKA). Design: Retrospective cohort with national Medicare data (5% claims) using a difference-in-differences analysis comparing January 2013- September 2015 (before) versus October 2016-September 2019 (after). Setting: Administrative claims from hospitals in 34 metropolitan statistical areas with mandatory CJR participation as of 2018 and 42 control metropolitan statistical areas. Participants: Episodes in fee-for-service Medicare beneficiaries (5% claims) undergoing elective THA (n=6327) or TKA (n=10,764) with community discharge. Interventions: Implementation of CJR bundled payment program. Main Outcome Measures: Home health and outpatient PT, including any use and number of visits. Results: Program implementation was associated with an increased percentage of THA episodes using home health PT (+8.0 percentage-point change; 95% CI, +3.5 to +12.6; P=.001) but a decreased per-episode number of home health PT visits for THA (-1.1; 95% CI,-1.6 to-0.6; P<.001) and TKA (-1.1; 95% CI,-1.4 to-0.7; P<.001). The program was also associated with an increased per-episode number of outpatient PT visits for TKA in the primary but not sensitivity analyses (+0.8; 95% CI, +0.1 to +1.4; P=.02). Conclusions: Findings of increased home health PT may reflect an intentional shift in care from the inpatient postacute setting to the community to decrease costs. Alternatively, the limited effect of CJR, particularly on outpatient PT, could reflect challenges with care coordination in a retrospective bundle spanning multiple care settings. (c) 2024 by the American Congress of Rehabilitation Medicine.

INTRODUCTION:For patients unsuitable for prosthesis reimplantation or temporary spacer placement, Girdlestone resection arthroplasty (GRA) is a suitable option to eliminate infection. Using a large-scale database, this study aims to determine factors associated with reimplantation. METHODS:This study included patients who underwent GRA and subsequent total hip arthroplasty (2012 to 2015 Medicare Limited Data Set with ≥5-year follow-up). A mixed-effects model measured associations between patient characteristics and reimplantation. Odds ratios (OR) with 95% confidence intervals (CI) were reported. RESULTS:Among 2,772 GRA cases, 2,025 (73.1%) were reimplanted (median time to reimplantation 3.0 months). In multivariable analysis, patient factors associated with reduced odds of reimplantation were increased age (OR 0.96; CI, 0.94 to 0.97; P < 0.0001), Black race (OR, 0.58; CI, 0.37 to 0.90; P = 0.0149), obesity (OR, 0.74; CI, 0.58 to 0.94; P = 0.0150), and increased Deyo-Charlson comorbidities (1 comorbidity: OR, 0.78; CI, 0.61 to 0.99; P = 0.0453; two comorbidities: OR, 0.53; CI, 0.39 to 0.71; P < 0.0001; ≥3 comorbidities: OR, 0.69; CI, 0.49 to 0.95; P = 0.0244). Male (versus female) patients, however, had increased odds of reimplantation (OR, 1.64; CI, 1.32 to 2.02; P < 0.0001). DISCUSSION:Age, race, and comorbidities influence the likelihood of reimplantation after GRA. Owing to variability in patients who undergo additional surgery, additional studies should be conducted to determine the rationale of patient selection.

RATIONALE:Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation.OBJECTIVE:We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature.METHODS:We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems.RESULTS:We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction).CONCLUSION:Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.

A growing body of literature has demonstrated racial and socioeconomic disparities in total joint arthroplasty (TJA) utilisation, outcomes and related care, such as the type of anaesthesia.[1 2][1] However, identification of associated factors is lacking. One proposed factor behind disparities is

INTRODUCTION:Spanish-speaking individuals may experience language-based disparities related to elective orthopaedic procedures. Because patients often seek online health information, we assessed the readability, credibility, and quality of Spanish-language educational websites for knee arthroplasty. METHODS:We queried "Google," "Yahoo," and "Bing" using the term "reemplazo de rodilla" (knee replacement in Spanish) and extracted the top 50 websites per search engine. Websites were categorized by information source (physician/community hospital, university/academic, other) and presence of HONcode certification. Information was assessed for readability (Fernández-Huerta formula), credibility (Journal of the American Medical Association benchmark criteria), and quality (Brief DISCERN tool); scores were compared between the categories. RESULTS:A total of 77 unique websites were included (40.3% physician/community hospital, 35.1% university/academic). The median readability score was 59.4 (10th to 12th-grade reading level); no websites achieved the recommended level of ≤6th grade. The median Journal of the American Medical Association benchmark score was 2 (interquartile range 1 to 3), with only 7.8% of websites meeting all criteria. The median Brief DISCERN score was 16 (interquartile range 12 to 20), with 50.7% meeting the threshold for good quality. University/academic websites had better readability ( P = 0.02) and credibility ( P = 0.002) but similar quality ( P > 0.05) compared with physician/community hospital websites. In addition, HONcode-certified websites had better quality scores ( P = 0.045) but similar readability and credibility ( P > 0.05) compared with noncertified websites. DISCUSSION:We identified limitations in readability, credibility, and quality of Spanish-language online educational resources for knee arthroplasty. Healthcare providers should be aware of these patient education barriers when counseling patients, and efforts should be made to support the online information needs of Spanish-speaking orthopaedic patients and mitigate language-based disparities.

Background: Poor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups. Methods: Elective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (>= 75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoper-ative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately. Results: Median postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA,-4.0 high-THA, and-4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B =-0.94 --0.68,P < .001-P = .01) but with improvements in joint health only in the low-THA group (B =-0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group. Conclusion: Patients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and pre-operative counseling.(c) 2022 Elsevier Inc. All rights reserved.

Background The COVID-19 pandemic has been associated with increased risks of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, there is limited literature investigating prothrombotic states and complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We investigated (1) trends in VTE, PE, and DVT rates post-THA and TKA from 2016 to 2019 compared to 2020 to 2021 and (2) associations between prior COVID-19 diagnosis and VTE, PE, and DVT. Methods A national dataset was queried for elective THA and TKA cases from 2016 to 2021. We first assessed trends in 90-day VTE prevalence between 2016 to 2019 and 2020 to 2021. Second, we investigated associations between previous COVID-19 and 90-day VTE with regression models. Results From 2016 to 2021, a total of 2,422,051 cases had an annual decreasing VTE prevalence from 2.2 to 1.9% (THA) and 2.5 to 2.2% (TKA). This was evident for both PE and DVT (all trend tests P < .001). After adjusting for covariates (including vaccination status), prior COVID-19 was associated with significantly increased odds of developing VTE in TKA patients (odds ratio 1.2, 95% confidence interval 1.1 to 1.4, P = .007), but not DVT or PE (P > .05). There were no significant associations between prior COVID-19 and VTE, DVT, or PE after THA (P > .05). Conclusions Our study suggests that a previous diagnosis of COVID-19 is associated with increased odds of VTE, but not DVT or PE, in TKA patients. Ongoing data monitoring is needed given our effect estimates, emerging COVID-19 variants, and evolving vaccination rates.

Background: Both pain catastrophizing and neuropathic pain have been suggested as prospective risk factors for poor postoperative pain outcomes in total joint arthroplasty (TJA). Objective: We hypothesized that pain catastrophizers, as well as patients with pain characterized as neuropathic, would exhibit higher pain scores, higher early complication rates and longer lengths of stay following primary TJA. Methods: A prospective, observational study in a single academic institution included 100 patients with end-stage hip or knee osteoarthritis scheduled for TJA. In pre-surgery, measures of health status, socio-demographics, opioid use, neuropathic pain (PainDETECT), pain catastrophizing (PCS), pain at rest and pain during activity (WOMAC pain items) were collected. The primary outcome measure was the length of stay (LOS) and secondary measures were the discharge destinations, early postoperative complications, readmissions, visual analog scale (VAS) levels and distances walked during the hospital stay. Results: The prevalence of pain catastrophizing (PCS ≥ 30) and neuropathic pain (PainDETECT ≥ 19) was 45% and 20.4%, respectively. Preoperative PCS correlated positively with PainDETECT (rs = 0.501, p = 0.001). The WOMAC positively correlated more strongly with PCS (rs = 0.512 p = 0.01) than with PainDETECT (rs = 0.329 p = 0.038). Neither PCS nor PainDETECT correlated with the LOS. Using multivariate regression analysis, a history of chronic pain medication use was found to predict early postoperative complications (OR 38.1, p = 0.47, CI 1.047–1386.1). There were no differences in the remaining secondary outcomes. Conclusions: Both PCS and PainDETECT were found to be poor predictors of postoperative pain, LOS and other immediate postoperative outcomes following TJA.

Background: Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep. Methods: This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep. Results: The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks (P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks (P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively. Discussion: Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep. Study design: Retrospective analysis of prospectively collected data.

Background: Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type. Methods: This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported. Results: The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients. Conclusion: Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

BACKGROUND:Osteonecrosis of the femoral head is a common indication for total hip arthroplasty (THA). It is unclear to what extent the COVID-19 pandemic has impacted its incidence. Theoretically, the combination of microvascular thromboses and corticosteroid use in patients who have COVID-19 may increase the risk of osteonecrosis. We aimed to (1) assess recent osteonecrosis trends and (2) investigate if a history of COVID-19 diagnosis is associated with osteonecrosis.METHODS:This retrospective cohort study utilized a large national database between 2016 and 2021. Osteonecrosis incidence in 2016 to 2019 was compared to 2020 to 2021. Secondly, utilizing a cohort from April 2020 through December 2021, we investigated whether a prior COVID-19 diagnosis was associated with osteonecrosis. For both comparisons, Chi-square tests were applied.RESULTS:Among 1,127,796 THAs performed between 2016 and 2021, we found an osteonecrosis incidence of 1.6% (n = 5,812) in 2020 to 2021 compared to 1.4% (n = 10,974) in 2016 to 2019; P < .0001. Furthermore, using April 2020 to December 2021 data from 248,183 THAs, we found that osteonecrosis was more common among those who had a history of COVID-19 (3.9%; 130 of 3,313) compared to patients who had no COVID-19 history (3.0%; 7,266 of 244,870); P = .001).CONCLUSION:Osteonecrosis incidence was higher in 2020 to 2021 compared to previous years and a previous COVID-19 diagnosis was associated with a greater likelihood of osteonecrosis. These findings suggest a role of the COVID-19 pandemic on an increased osteonecrosis incidence. Continued monitoring is necessary to fully understand the impact of the COVID-19 pandemic on THA care and outcomes.

While adverse local tissue reactions are well described in the total hip arthroplasty literature, there have only been case reports and case series in the total knee arthroplasty literature. There have been no cases described in the setting of a distal femoral replacement. In this case, we describe a 69-year-old female with a complex history of left knee revision arthroplasty with a distal femoral and proximal tibial replacement who presented with left knee pain and was found to have extensive adverse local tissue reaction with corrosion at the femoral stem-extension piece junction and the extension piece-distal femoral component junction. The femoral taper was then manually cleaned and modular components replaced. Corrosion at the stem-distal femoral component junction can result in adverse local tissue reaction in patients with distal femoral replacements. It is important to consider this diagnosis when evaluating patients with knee pain following distal femoral replacement.

Background:Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment. Methods:PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed. Results:Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all). Conclusion:This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.

Background: Despite the extensive literature on racial disparities in care and outcomes after total knee arthroplasty (TKA), data on manipulation under anesthesia (MUA) is lacking. We aimed to determine (1) the relationship between race and rate of (and time to) MUA after TKA, and (2) annual trends in racial differences in MUA from 2013 to 2018. Methods: This retrospective cohort study (using 2013-2018 Medicare Limited Data Set claims data) included 836,054 primary TKA patients. The primary outcome was MUA < 1 year after TKA; time from TKA to MUA in days was also recorded. A mixed-effects multivariable model measured the association between race (White, Black, Other) and odds of MUA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. A Cochran Armitage Trend test was conducted to assess MUA trends over time, stratified by race. Results: MUA after TKA occurred in 1.7%, 3.2% and 2.1% of White, Black, and Other race categories, respectively (SMD 1/4 0.07). After adjustment for covariates, (Black vs White) patients had increased odds of requiring an MUA after TKA: odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.86-2.10, P < .0001. Moreover, White (compared to Black) patients had significantly shorter time to MUA after TKA: 60 days (interquartile range [IQR] 46-88) versus 64 days (interquartile range [IQR] 47-96); P < .0001. These disparities persisted from 2013 through 2018. Conclusion: Continued racial differences exist for rates and timing of MUA following TKA signifying the continued need for efforts aimed toward understanding and eliminating inequalities that exist in total joint arthroplasty (TJA) care. (C) 2022 Elsevier Inc. All rights reserved.