The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis.

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF. INTRODUCTION: Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs. METHODS: Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates. RESULTS: Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500. CONCLUSION: The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.

Risk of revision total knee arthroplasty for patients with prior bariatric surgery or class III obesity.

BACKGROUND: Bariatric surgery (BS) is indicated for select class III obesity patients undergoing total knee arthroplasty (TKA) to reduce obesity-related complications. This study assessed the effect of BS on TKA revision rates compared to the general population and class III obesity patients without a history of BS. METHODS: A national database identified patients who had primary TKA. They were divided into two groups: those with BS prior to TKA and those without. Patients without BS formed two control groups, a matched general population, and a matched class III obese cohort. The BS group was matched with controls based on age, Charlson Comorbidity Index (CCI), gender, and diabetes mellitus. Revision rates were analyzed using Kaplan-Meier survival analysis and hazard ratios (HR), calculated using Cox proportional hazard modeling. RESULTS: 14,292 BS patients were compared to 57,006 matched general population controls, and 19,504 BS patients were compared to 77,846 matched class III obesity control patients. BS patients had a higher risk of 5-year all-cause revision (HR: 1.13; P = 0.014) and revision due to periprosthetic fracture (HR: 1.39; P < 0.001) compared to the general population. Compared to class III obesity controls, BS patients had a lower risk of 5-year revision due to prosthetic joint infection (HR: 0.77; P = 0.001), with no difference in all-cause revision (P = 0.362). CONCLUSION: BS does not reduce all-cause TKA revision risk compared to the general or matched class III obesity population. However, it lowers the risk of revision due to prosthetic joint infection when compared to patients with class III obesity. LEVEL OF EVIDENCE: IV.

AIDS but not asymptomatic HIV is associated with lower 2-10-year implant survivorship following total knee arthroplasty.

INTRODUCTION: Prior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. METHODS: Patients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. RESULTS: The 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02-1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77-1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51-4.99, p < 0.001; HR 2.19, 95% CI 1.17-4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54-15.51, p = 0.007; HR 3.86, 95% CI 1.12-13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16-2.74, p = 0.002; HR 3.82, 95% CI 1.08-13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DISCUSSION: This study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients' serum CD4 level is sufficient, ideally in the normal range of 500-1500 cells per mm3, before undergoing TKA.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis.

BACKGROUND: There is no clear research showcasing bariatric surgery's (BS's) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. METHODS: Patients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). RESULTS: When compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). CONCLUSIONS: Those who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

The Feasibility, Acceptability, and Effectiveness of Electronic Patient-Reported Outcome Symptom Monitoring for Immune Checkpoint Inhibitor Toxicities: A Systematic Review.

PURPOSE: Increasing use of immune checkpoint inhibitors (ICIs) in routine cancer care will increase the incidence of immune-related adverse events (irAEs). Systems are needed to support remote monitoring for irAEs. Electronic patient-reported outcome (ePRO) symptom monitoring systems can help monitor and manage symptoms and side effects. We assessed the content and features of ePRO symptom monitoring systems for irAEs, and their feasibility, acceptability, and impact on patient outcomes and health care utilization. METHODS: A systematic literature search was conducted in May 2022 on MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials. Quantitative and qualitative data relevant to the review questions were extracted and synthesized in tables. RESULTS: Seven papers describing five ePRO systems were included. All systems collected PROs between clinic visits. Two of five used validated symptom questionnaires, 3/5 provided prompts to complete questionnaires, 4/5 provided reminders to self-report, and 3/5 provided clinician alerts for severe/worsening side effects. Four of five provided coverage of ≥26/30 irAEs in the ASCO irAE guideline. Feasibility and acceptability were demonstrated with consent rates of 54%-100%, 17%-27% of questionnaires generating alerts, and adherence rates of 74%-75%. One paper showed a reduction in grade 3-4 irAEs, treatment discontinuation, clinic visit duration, and emergency department presentations, while another showed no difference in these outcomes or the rate of steroid use. CONCLUSION: There is preliminary evidence of the feasibility and acceptability of ePRO symptom monitoring for irAEs. However, further studies are needed to confirm the impact on ICI-specific outcomes, such as the frequency of grade 3-4 irAEs and duration of immunosuppression. Suggestions for the content and features of future ePRO systems for irAEs are provided.

Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty?

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.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Impact of Large Database Studies on Orthopedic Surgery Literature: Are We Advancing the Field?

Background: While database studies have become more prevalent in the literature, there is concern over their value. In addition, the questions they are suitable to answer are limited. Questions/Purposes: We sought to determine the incidence of database studies in the orthopedic literature and in each subspecialty. In addition, we wanted to assess the impact of database studies on the literature by determining whether citations and Altmetric Attention Scores (AAS) varied by study type (studies using internal or external databases and those not using databases). Methods: We searched PubMed for articles published in impactful orthopedic surgery journals in the year 2018. All articles were discoverable on the Altmetric explorer portal database. Impact was determined by journal impact factor. Study design, subspecialty, number of citations, and AAS were obtained. Univariable analyses were conducted between study type, demographic variables, and the outcome of either citation count or AAS. Multivariable analyses were performed to identify independent predictors of the primary outcomes. Subgroup analyses were performed to differentiate the impact of external and internal database studies compared with non-database studies. Results: A total of 2684 total articles were eligible for inclusion. Of these, 366 studies (13.6%) were database studies. Hip and knee articles had the greatest incidence of database studies. Database studies had significantly more citations (5.9 vs 4.0) and significantly higher AAS (12.8 vs 11.3) compared with non-database studies. External database studies had significantly more citations (6.7 vs 4.8) and significantly higher AAS (14.0 vs 10.7) than internal database studies. Internal database studies had higher traditional citation counts but similar AAS to non-database studies. Conclusions: In 2018, database studies in well-reputed orthopedic journals had a greater number of citations but similar AAS compared with non-database studies. Further studies are warranted.

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease.

BACKGROUND: Literature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD. METHODS: Patients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan-Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control. RESULTS: Compared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019). CONCLUSION: Independent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.

Risks of Immunosuppressive Therapy in Patients Undergoing Open Reduction Internal Fixation for Ankle Fractures.

Chronic steroid and immunosuppressant use have been shown to increase the risk for postoperative complications in orthopedic surgery. Further understanding of the risks of immunosuppression is necessary to aid in risk stratification and patient counseling. However, these risks have not yet been explored in ankle fracture patients. Thus, the purpose of this study is to determine whether patients taking immunosuppressives are at an increased risk for morbidity and mortality following open reduction and internal fixation (ORIF) of ankle fractures. Patients undergoing operative treatment for ankle fractures from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were categorized based on their use of immunosuppressive medications. Postoperative outcomes assessed included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, urinary tract infection, renal failure, blood transfusion requirement, deep vein thrombosis, sepsis, cardiac arrest, extended length of hospital stay, readmission, reoperation, and mortality. Univariate and multivariate analyses were performed. In total, 10,331 patients underwent operative treatment for ankle fracture. Total 10,153 patients (98.3%) were not taking immunosuppressants and 178 (1.7%) were taking these medications. In multivariate analysis, patients taking immunosuppressants were at increased risk of pulmonary embolism (odds ratio [OR] 4.382; p = .041) and hospital readmission (OR 2.131; p = .021). Use of immunosuppressive medications is an independent risk factor for pulmonary embolism and readmission following ORIF for ankle fractures. Notably, no association with wound complications, infections, or sepsis was identified.

Implementation of a clinical practice guideline for assessment and management of renal colic in the emergency department.

INTRODUCTION: Renal colic is a common emergency department (ED) presentation. Variations in assessment and management of suspected renal colic may have significant implications on patient and hospital outcomes. We developed a clinical practice guideline to standardize the assessment and management of renal colic in the ED. We subsequently compared outcomes before and after guideline implementation. METHODS: The guideline standardizes the analgesia regimen, urology consult criteria, imaging modality, patient education, and followup instructions. This is a single-center, observational cohort study of patients presenting to the ED with renal colic prospectively collected after guideline implementation (December 2018 to May 2019) compared to a control group retrospectively collected before guideline implementation (December 2017 to May 2018). A total of 528 patients (pre-guideline n=283, post-guideline n=245) were included. Statistical analysis was performed with SPSS using multivariate linear regression. RESULTS: ED length of stay (LOS) was significantly shorter after guideline implementation (pre-guideline 295.82±178.8 minutes vs. post-guideline 253.2±118.2 minutes, p=0.017). The number of computed tomography (CT) scans patients received was significantly less after guideline implementation (pre guideline 1.35±1.34 vs. post-guideline 1.00±0.68, p=0.034). Patients discharged for conservative management had a lower re-presentation rate in the post-guideline group (12.6%) than the pre-guideline group (17.2%); however, this did not reach statistical significance (p=0.18). CONCLUSIONS: Implementation of a clinical practice guideline for ureteric stones reduces the ED LOS and the total number of CT scan in patients who present with renal colic. Standardizing assessment and management of ureteric stones can potentially improve patient and hospital outcomes without compromising the quality of care.

The Association of Prior Fragility Fractures on 8-Year Periprosthetic Fracture Risk Following Total Hip Arthroplasty.

BACKGROUND: Fragility fractures are often the initial clinical presentation of osteoporosis. Patients who have a history of fragility fractures undergoing total hip arthroplasty (THA) have an increased risk of 2-year postoperative complications. However, the association of recent fragility fractures with complications beyond 2 years following THA remains unknown. The purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision THA, periprosthetic fracture (PPF), and secondary fragility fracture. METHODS: Patients aged 50 years and more who underwent THA for osteoarthritis were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to THA. There were 18,529 patients who had a prior fragility fracture and 408,753 who did not have a prior fragility fracture. Demographics and comorbidities were collected. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, PPF, and secondary fragility fracture within 8 years of index surgery. RESULTS: Patients who had recent fragility fracture had significantly higher risks of revision THA (Hazard Ratio [HR] 1.7; P < .001), PPF (HR 2.2; P < .001), and secondary fragility fracture (HR 4.9; P < .001). CONCLUSION: Prior fragility fracture was shown to be a significant risk factor for revision THA, PPF, and secondary fragility fracture within 8 years of THA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

Comparison of Arthroscopy versus Open Arthrotomy for Treatment of Septic Arthritis of the Native Knee: Analysis of 90-Day Postoperative Complications.

Septic arthritis is an orthopaedic emergency, often necessitating surgical debridement, and the knee joint is most frequently affected. Arthroscopic and open irrigation and debridement (I&D) are the two commonest surgical treatments for septic arthritis of the native knee. Several studies have compared outcomes of open and arthroscopic management without coming to a clear conclusion which yields superior outcomes. The purpose of this study was to compare the results of these two surgical techniques to treat septic arthritis of the native knee using a large nationwide database. Patients who underwent arthroscopic or open I&D as treatment for knee septic arthritis from 2010 to 2019 were identified using a national insurance database. The primary outcome was the 90-day reoperation rate. Secondary outcomes included surgical site infection, readmission, and other postoperative complications. A total of 1,139 patients were identified, 618 of whom (54%) underwent open treatment and 521 (46%) underwent arthroscopic treatment. The two groups did not differ significantly by age, gender, or most comorbidities. There was no significant difference in 90-day reoperation rate between the groups (15.0.% open and 18.0% arthroscopic, p = 0.174). Patients who underwent open treatment had increased odds of readmission to the hospital (odds ratio [OR] = 1.46 [1.14-1.86]; p = 0.003), postoperative anemia (OR = 1.71 [1.08-2.75]; p = 0.025), and blood transfusion (OR = 1.76 [1.04-3.06]; p = 0.040) compared with those who underwent arthroscopic surgery. Using administrative claims data, we found that arthroscopic and open I&D have similar rates of reoperation and most 90-day postoperative outcomes. Lower rates of readmission, postoperative anemia, and blood transfusion were found with arthroscopic I&D, suggesting that arthroscopy may be preferable to open treatment in the management of septic arthritis of the native knee in cases in which other case- and surgeon-specific factors do not otherwise dictate the best treatment modality.

Reduced Early Revision Surgery and Medical Complications in Computer-assisted Knee Arthroplasty Compared With Non-computer-assisted Arthroplasty.

BACKGROUND: Computer assistance can help surgeons achieve mechanical accurate alignment, but the clinical effect of this technology in different arthroplasty types remains controversial because of conflicting functional outcomes, revision rates, and complication rates. The goal of this study was to compare 90-day medical complications and 1 and 2-year revision surgeries after computer-assisted patellofemoral arthroplasty, unicompartmental knee arthroplasty (CA-UKA), bicompartmental knee arthroplasty (CA-BKA), and total knee arthroplasty (CA-TKA) with non-computer-assisted procedures. METHODS: A retrospective cohort analysis was conducted using the Mariner data set of the PearlDiver Patient Records Database from 2010 to 2018. Current Procedural Terminology codes were used to identify patients who underwent patellofemoral arthroplasty, unicompartmental knee arthroplasty, bicompartmental knee arthroplasty, and total knee arthroplasty with or without computer assistance for osteoarthritis. All included patients were followed up for 2 years. Univariate and multivariable analyses were conducted. RESULTS: On multivariable analysis, revision within 1 year was decreased in patients who underwent computer-assisted patellofemoral arthroplasty (odds ratio [OR]: 0.541, P = 0.031), CA-UKA (OR: 0.798, P = 0.019), and computer-assisted bicompartmental knee arthroplasty (OR: 0.186, P = 0.025) compared with the same surgeries without technology assistance. CA-TKA had decreased odds of revision for aseptic loosening at 2 years (OR: 0.789, P < 0.001). CA-UKA and CA-TKA had decreased risk of overall 90-day medical complications (OR: 0.838, P < 0.001; OR: 0.903, P < 0.001, respectively) and major complications (OR: 0.750, P = 0.004; OR: 0.822, P < 0.001, respectively). DISCUSSION: Complication rates and revision surgeries for all arthroplasty types were equivalent or more favorable when computer assistance was used during surgery. Our results quantify some early benefits to using computer assistance in total and partial knee arthroplasties.

Analysis of revision rates and complication rates among patients undergoing unicompartmental and bicompartmental knee Arthroplasties when compared to Total knee arthroplasty.

BACKGROUND: With recent advances in partial knee arthroplasty, there is conflicting data regarding the outcomes and revision rates for bicompartmental knee arthroplasty (BKA) and unicompartamental knee arthroplasty (UKA) compared to total knee arthroplasty (TKA). This study uses national data to compare surgical and medical complications of UKA, BKA, and TKA to aid surgical decision-making. METHODS: A retrospective cohort analysis was done using the Mariner dataset of the PearlDiver patient records database from 2010-2019. Current Procedural Terminology (CPT) codes were used to identify patients who underwent UKA, BKA, and TKA for a primary indication of osteoarthritis (OA). Univariate and multivariable analyses were performed to determine 1-year and 2-year revision, prosthetic joint infection (PJI), and loosening, 1-year manipulation under anesthesia (MUA), and 90-day postoperative medical complications. RESULTS: The BKA cohort was found to have higher odds of one and two-year revision compared to UKA and TKA cohorts. Additionally, the UKA cohort had higher odds of one and two-year revision but lower odds of 1-year MUA than the TKA cohort. However, both the BKA and UKA cohorts had lower odds of any 90-day postoperative complications when compared to the TKA cohort. CONCLUSIONS: Even with modern implants and approaches, our study found that revision rates are highest for BKA followed by UKA and TKA at two years postoperatively. Notably, medical complications were much less common after all partial knee replacement types when compared to TKA. These findings may be used to guide patients in selecting the appropriate surgery to meet their goals and expectations.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019.

The purpose of this study was to determine whether there has been any change in osteoporosis treatment following primary fragility fractures and what agents were being given. The study found an overall low utilization rate with no difference in treatment utilization from 2011 to 2019. PURPOSE: The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed. METHODS: Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1 year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type. RESULTS: This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74 years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74 years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001). CONCLUSION: Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

Patient Characteristics and Positive Outcomes Associated With a Novel Youth Inpatient Program for Concurrent Disorders.

ABSTRACT: Concurrent substance use and mental health disorders in youth are a major public health concern and require specialized and comprehensive services. In this paper, a novel inpatient tertiary care facility serving youth aged 13 to 18 with significant concurrent substance use and mental health issues is introduced. The development of this unit was prompted by the opioid overdose crisis in British Columbia and serves as the third concurrent disorders unit in Canada catered specifically to an adolescent population. From its opening in 2017, preadmission and postadmission data from each patient was gathered with the aim of providing a robust image of the serviced patient population as well as the efficacy of this service model. Patients admitted to this program had significantly higher quality of life ( d = 0.65) and significantly lower suicidality ( d = 0.86) at discharge, compared with at admission. Patients identifying as female had significantly lower quality of life, higher suicidality, and higher prevalence of adverse childhood events compared with patients identifying as male. Results from this program evaluation outline the efficacy of a novel concurrent disorders program for youth while further providing an overview of clinical and relevant demographic characteristics from an underanalyzed patient population.

Human Immunodeficiency Virus Status Does Not Independently Predict 2-Year Complications Following Total Knee Arthroplasty.

With improved treatment for human immunodeficiency virus (HIV), the demand for total knee arthroplasty (TKA) in this population has increased. Studying the relationship between HIV and postoperative complications following TKA will allow orthopaedic surgeons to accurately assess their patients' surgical risk and provide appropriate counseling. This study aims to understand how HIV impacts surgical and medical complications following TKA for osteoarthritis (OA). Patients identified in a national insurance database who underwent TKA for OA from 2010 to 2019 were divided into three cohorts: no HIV, asymptomatic HIV, and acquired immunodeficiency syndrome (AIDS). Univariate and multivariable regression analyses were performed to determine 90-day postoperative complications as well as 2-year surgical complications (revision surgery, prosthetic joint infection, aseptic loosening, and manipulation under anesthesia). A total of 855,373 patients were included, of whom 1,338 had asymptomatic HIV and 268 had AIDS. After multivariable regression analysis, patients with HIV had no difference in 2-year surgical complications relative to the control cohort. Within 90 days postoperatively, patients with asymptomatic HIV had increased odds of arrhythmia without atrial fibrillation and lower odds of anemia. Patients with AIDS had increased odds of anemia and renal failure. Patients with HIV and AIDS are at an increased risk for developing 90-day medical complications and 2-year surgical complications. However, after accounting for their comorbidities, the risk of 90-day complications was only mildly increased and the risk of 2-year surgical complications approximated the control cohort. Surgeons should pay particular attention to these patients' overall comorbidities, which appear to be more closely associated with postoperative risks than HIV status alone. Level of evidence: III.

The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures.

BACKGROUND: Displaced femoral neck fractures in older adults are generally treated with hip arthroplasty. One concern following hip arthroplasty is the risk for periprosthetic fractures (PPFs). Most patients who have hip fractures are candidates for antiosteoporotic therapy, but the impact of this treatment on PPFs is unknown. Therefore, the primary objective of this study was to evaluate whether patients treated with antiosteoporotic medical therapy had lower odds of PPFs following arthroplasty for hip fracture. METHODS: Patients at least 65 years old who underwent hip arthroplasty for femoral neck fractures from 2010 to 2020 were identified in a national database. Patients were stratified based on whether they initiated antiosteoporotic therapy within 1 year of hip arthroplasty. Minimum follow-up was 1 year, and maximum follow-up was 10.6 years. The primary endpoint was cumulative incidence of PPF as determined using Kaplan-Meier and Cox proportional hazards regression analyses. Overall, 2,026 patients who underwent arthroplasty for femoral neck fracture received antiosteoporotic medications within 1 year following surgery (mean follow up 4.8 years; range 1.0 to 10.6 years) and 33,639 patients did not (mean follow up 4.1 years; range 1.1 to 10.3 years). RESULTS: The 10-year cumulative incidence of PPF for patients treated for osteoporosis was 3.88% compared to 5.92% for those who were untreated (P < .001). Adjusting for covariates, patients who received osteoporosis treatment had a significantly lower risk for PPF than those who were untreated (hazard ratio (HR): 0.663; 95% confidence interval (CI): 0.465-0.861; P = .038). CONCLUSION: The present study suggests that osteoporosis treatment is associated with lower incidence of PPF following hip arthroplasty for femoral neck fractures. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty.

Legacy Chemical Pollutants in House Dust of Homes of Pregnant African Americans in Atlanta.

We developed and applied a method for measuring selected persistent organic pollutants (POPs) (i.e., polybrominated diphenyl ethers (PBDEs), organochlorine pesticides, and polychlorinated biphenyls (PCBs)) in dust collected from pregnant African Americans (AAs) in Atlanta using isotope dilution gas chromatography-tandem mass spectrometry. Limits of quantification were ranged from 0.10 to 2.50 ng/g dust. NIST standard reference material measurements demonstrated the robustness of our method. Our accuracies ranged from 82 to 108%, relative standard deviations ranged from 2 to 16%, and extraction recoveries ranged from 76 to 102%. We measured POPs in dust collected from 34 homes of pregnant AAs participating in the Atlanta AA birth cohort study who were enrolled from 2016 to 2019. Concentrations of POPs were detected in all samples with the frequencies of detection ranging from 8 to 100%. Concentrations of PBDE congeners 99 and 47, p,p'-DDT, and PCB153 were detected at some of the highest concentrations with geometric means of 1270, 730, 63.4 and 240 ng/g, respectively. The ratio of DDT/DDE was quite large (~2.7) indicating that p,p'-DDT remains intact in homes for long periods of time. These data demonstrate that care should be taken to remediate POPs in indoor dust, especially in vulnerable, disparate segments of the population.