Early Postoperative Infections After Closed Reduction and Percutaneous Pinning in Type II and Type III Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Supracondylar humerus fractures (SCHF) are the most common elbow fracture type in children, and one of the most common pediatric fracture types overall. Excellent outcomes are generally reported with closed reduction and pinning (CRPP), but the technique involves leaving the pins outside the skin. External pins can act as a nidus for infection. We characterize the infection complications from SCHF treatment at a single-centre tertiary children's hospital over 10 years. This is the largest series on infectious outcomes after CRPP of SCHF reported to date. METHODS: Pediatric patients undergoing CRPP for a type II or type III SCHF from 2011 to 2021 with postsurgical infections within 90 days were identified. Demographic and clinical data were retrieved from medical records. Descriptive statistics were estimated and reported as means or medians with range values or counts with percentages. RESULTS: A total of 18 patients met inclusion criteria, 10 and 8 with type II and III SCHF, respectively. The average age at diagnosis of fracture was 4.7 (2 to 9) years. The average operating time for the index surgery was 29 minutes (12 to 42). The average number of postoperative days until pin removal was 29.8 (18 to 52), and the average number of postoperative days until readmission or visit with symptoms was 38.9 (18 to 77). There was a documented history of a wet cast in 6 patients (33%). Ten (56%) patients presented with fever, and the most common positive culture was methicillin-sensitive Staphylococcus aureus (9, 50%). Thirteen (72%) patients returned to the operating room for incision and drainage. There were no cases with continued complications after the original infection after a median follow-up of 63 days (8 to 559). Infection after CRPP of SCHF is a rare adverse event. In our series, it was most often associated with common pathogens and wet casts. The necessity of return to the operating room will vary with the presentation, but if efficaciously treated afterwards with oral antibiotics, there is a low chance of recurrence or subsequent complications. Patients should be carefully instructed in cast care and demonstrate understanding of risks and complications, and to contact their orthopaedist if their cast demonstrates lack of integrity. LEVEL OF EVIDENCE: Prognostic level IV.

All-epiphyseal versus trans-epiphyseal screw fixation for tillaux fractures: Does it matter?

BACKGROUND: Tillaux fractures occur primarily in adolescents due to the pattern of physeal closure and are classified as Salter-Harris type III physeal fractures. Operative management with screw fixation is recommended for more than 2 mm of displacement or more than 1 mm of translation. However, the efficacy and complications of trans-physeal vs all-physeal screw fixation have not been investigated extensively. AIM: To compare the clinical and functional outcomes of trans-physeal (oblique) and all-epiphyseal (parallel) screw fixation in management of Tillaux fractures among pediatric patients. METHODS: This was an ethics board approved retrospective review of pediatric patients who presented to our tertiary children's care facility with Tillaux fractures. We included patients who had surgical fixation of a Tillaux fracture over a 10 year period. Data analysis included demographics, mode of injury, management protocols, and functional outcomes. The patients were divided into group 1 (oblique fixation) and group 2 (parallel fixation). Baseline patient characteristics and functional outcomes were compared between groups. Statistical tests to evaluate differences included Fisher's Exact or Chi-squared and independent samples t or Mann Whitney tests for categorical and continuous variables, respectively. RESULTS: A total of 42 patients (28 females and 14 males) were included. There were no significant differences in body mass index, sex, age, or time to surgery between the groups [IK2]. Sports injuries accounted for 61.9% of the cases, particularly non-contact (57.1%) and skating (28.6%) injuries. Computed Tomography (CT) scan was ordered for 28 patients (66.7%), leading to diagnosis confirmation in 17 patients and change in management plan in 11 patients. [GRC3] Groups 1 and 2 consisted of 17 and 25 patients, respectively. For mid to long-term functional outcomes, there were 14 and 10 patients in groups 1 and 2, respectively. Statistical analysis revealed no significant differences in the functional outcomes, pain scores, or satisfaction between groups. No infections, non-unions, physeal arrest, or post-operative ankle deformities were reported. Two (4.8%) patients had difficulty returning to sports post-surgery due to pain. One was a dancer, and the other patient had pain while running, which led to hardware removal. Both patients had parallel fixation. Hardware removal for groups 1 and 2 were 4 (23.5%) and 5 (20.0%) patients, respectively. The reasons for removal was pain in 2 patients, and parental preference in the remaining. CONCLUSION: This is the largest reported series of pediatric patients with Tillaux fractures comparing functional outcomes of different methods of screw fixation orientation to the physis, which showed no difference regarding functional outcomes.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis.

Objective: To compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure will be associated with better postoperative outcomes. Methods: We collected data on pediatric patients diagnosed with NMS who underwent first time spinal instrumentation between 1 January 2018 and 31 May 2021. Patient demographics, length of surgery, spinal levels fused and operative variables, wound complication rate, treatments, and need for wound washout were reviewed in depth and recorded. Results: In total, 86 patients were reviewed: 46 with OC and 40 with PMC. There was a significant increase in operating room (OR) time with PMC compared with OC (6.7±1.2 vs 7.3±1.3, p=0.016). There was no difference in complication rate, mean postoperative day of complication or unplanned return to the OR for OC and PMC, respectively. There was a slightly significant increase in the number of patients going home with a drain in the PMC cohort compared with the OC cohort (2.1% vs 15%, p=0.046). Conclusions: PMC demonstrated longer OR times than OC and did not demonstrate a statistically significant reduction in wound complications or unplanned returns to the OR. However, other studies have demonstrated statistical and clinical significance with these variables. Surgical programs should review internal patient volumes and outcomes for spinal fusion in NMS patients and consider if PMC after spinal fusions in pediatric patients with NMS or other scoliosis subtypes is an appropriate option in their institution to minimize postoperative wound complications.

Pediatric osteoarticular infection: trend in surgically treated patients and association of methicillin-resistant Staphylococcus aureus with requirement of secondary procedures.

Acute pediatric osteoarticular infection demonstrates variability in both presentation and response to treatment. Many respond to antibiotics ± single operation, while some require multiple surgeries. Currently, it is difficult to predict who may require additional procedures. Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have been associated with more complications. The purpose of this study is to determine MRSA trends and degree of association with the occurrence of multiple procedures. We performed a retrospective analysis of surgically treated pediatric (1 month-18 years) patients for acute osteomyelitis and septic arthritis at a tertiary children's hospital from 2003-2017. The cohort was divided into single-procedure and multiple-procedure groups. A total of 753 patients were studied with a mean age of 7.05 years (2.4 months-17.9 years). We identified 645/753 (85.6%) patients who were treated with a single-procedure and 108/753 (14.4%) patients who required multiple- procedures. The lower extremity (hip, knee, tibia, and femur) was most commonly involved. The epidemiologic trend runs almost parallel between two groups with a peak in 2009. The odds ratio for multiple-procedures was 2.0 [95% confidence interval (CI), 1.2-3.1; P = 0.002] with dual infection (osteomyelitis + septic arthritis), 2.6 (95% CI, 1.6-4.4; P = 0.001) with high-risk conditions and 4.6 (95% CI, 3.0-7.1; P < 0.001) if MRSA was present. MRSA significantly predicts the requirement of additional operative procedures for the treatment of osteoarticular infections in children. Besides clinical deterioration and other markers, the presence of MRSA can be a considerable indicator for a planned secondary-procedure. Level III retrospective cohort study.

Tension Band Plate (TBP)-guided Hemiepiphysiodesis in Blount Disease: 10-Year Single-center Experience With a Systematic Review of Literature.

BACKGROUND: Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS: We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS: In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS: Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE: Level III-retrospective comparative study with a systematic review.

Who Gets Compartment Syndrome?: A Retrospective Analysis of the National and Local Incidence of Compartment Syndrome in Patients With Supracondylar Humerus Fractures.

PURPOSE: Although acute compartment syndrome (ACS) is associated with pediatric supracondylar humerus (SCH) fractures, there are limited data describing its incidence and risk factors. The purpose of our study was to report the local and national incidence of ACS with SCH and floating elbow (concomitant SCH and forearm) fracture patterns and the associated risk factors. METHODS: We retrospectively queried data for SCH fracture patients over a 4-year period from our institution (a level I pediatric trauma center) and the National Trauma Data Bank (NTDB). Data on demographics, mechanism of injury, open versus closed fracture, length of stay, presence or absence of forearm fractures, and incidence of traumatic compartment syndrome were analyzed. The student t and χ tests were utilized for group comparisons of continuous and categorical variables, respectively. Logistic regression was used to identify risk factors for compartment syndrome. Results are summarized as means with SD or odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was set at P<0.05. RESULTS: At our institution, 839 patients with SCH fractures met inclusion criteria. In total, 814 (97.02%) patients (average age, 5.96±2.58 y) sustained isolated SCH fractures during the indicated timeframe. SCH fractures with an associated forearm fracture were identified in 25 (2.98%) patients (average age, 7.00±3.03 y). Three patients (0.36%) with isolated SCH fractures were observed to have compartment syndrome. No compartment syndromes were identified in the patients with floating elbows.Within the same time period, the NTDB identified 31,234 SCH fractures met inclusion criteria. Of those, 31,167 patients had isolated SCH fractures (average age, 5.5±2.7 y). In total, 67 of the SCH patients (0.2%, P<0.0001) had documented ACS (average age, 7.3±3.5 y). The NTDB identified 1565 patients with floating elbows, including 13 (0.8%, P≤0.0001) who developed compartment syndrome (average age, 6.47±2.71 y). The NTDB query also identified 530 patients with neurovascular injury (NVI), with 4.5% (n=24) that developed compartment syndrome. In the regression analysis, older age (OR, 1.1; 95% CI, 1.0-1.2; P<0.0092), male sex (OR, 2.7; 95% CI, 1.5-4.8; P=0.0005), floating elbow fracture pattern (OR, 3.2; 95% CI, 1.7-6.1; P=0.0003) and NVI (OR, 25.0; 95% CI, 14.6-42.8; P≤0.0001) were identified as risk factors for developing compartment syndrome. CONCLUSIONS: Data from our institution and NTDB reveal that acute traumatic compartment syndrome is rare, occurring in ∼2 to 3 fractures of 1000. However, there is a significantly increased risk with NVI, floating elbow fractures, males, and older patients. SIGNIFICANCE: Characterizing the incidence and associated risk factors of ACS with concomitant SCH and forearm fracture patterns can improve clinical understanding and management of pediatric patients.

Impact of Social Support and Pain Coping Abilityon Length of Stay and Discharge Disposition following Hip and Knee Arthroplasty A Prospective Study.

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 (ß) 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 (ß: 0.03, 95% CI: - 0.24-0.31, p = 0.81; ß: - 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 (ß: 0.3, 95% CI: 0.03-0.6, p = 0.03; and ß: 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.

Effect of Tranexamic Acid on Transfusion Rates Following Total Joint Arthroplasty: A Cost and Comparative Effectiveness Analysis.

Tranexamic acid (TXA) is used to reduce blood loss in orthopedic total joint arthroplasty (TJA). This study evaluates the effectiveness of TXA in reducing transfusions and hospital cost in TJA. Participants undergoing elective TJA were stratified into 2 cohorts: those not receiving and those receiving intravenous TXA. TXA decreased total hip arthroplasty (THA) transfusions from 22.7% to 11.9%, and total knee arthroplasty (TKA) from 19.4% to 7.0%. The average direct hospital cost reduction for THA and TKA was $3083 and $2582, respectively. Implementation of a TJA TXA protocol significantly reduced transfusions in a safe and cost-effective manner.

Interventions to improve hospital patient satisfaction with healthcare providers and systems: a systematic review.

BACKGROUND: Many hospital systems seek to improve patient satisfaction as assessed by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. A systematic review of the current experimental evidence could inform these efforts and does not yet exist. METHODS: We conducted a systematic review of the literature by searching electronic databases, including MEDLINE and EMBASE, the six databases of the Cochrane Library and grey literature databases. We included studies involving hospital patients with interventions targeting at least 1 of the 11 HCAHPS domains, and that met our quality filter score on the 27-item Downs and Black coding scale. We calculated post hoc power when appropriate. RESULTS: A total of 59 studies met inclusion criteria, out of these 44 did not meet the quality filter of 50% (average quality rating 27.8%±10.9%). Of the 15 studies that met the quality filter (average quality rating 67.3%±10.7%), 8 targeted the Communication with Doctors HCAHPS domain, 6 targeted Overall Hospital Rating, 5 targeted Communication with Nurses, 5 targeted Pain Management, 5 targeted Communication about Medicines, 5 targeted Recommend the Hospital, 3 targeted Quietness of the Hospital Environment, 3 targeted Cleanliness of the Hospital Environment and 3 targeted Discharge Information. Significant HCAHPS improvements were reported by eight interventions, but their generalisability may be limited by narrowly focused patient populations, heterogeneity of approach and other methodological concerns. CONCLUSIONS: Although there are a few studies that show some improvement in HCAHPS score through various interventions, we conclude that more rigorous research is needed to identify effective and generalisable interventions to improve patient satisfaction.

The Present and Future of Genomics in Adult Reconstructive Orthopaedic Surgery.

As of 2015, members of the "baby boomer generation" comprise 75 million people in the growing United States population. Many of these individuals will be facing the need for total hip or knee replacement. Currently, the age of onset of osteoarthritis continues to decrease and the need for total joint replacements continues to increase. In current practice, nearly all patients undergoing joint replacement receive similar preoperative, intraoperative, and postoperative management strategies. However, wide variability in outcomes and satisfaction with total joint replacement still remain. The key to understanding the cause for such varied outcomes may lie in our understanding of the genetic basis of degenerative joint disease. The future of "orthogenomic" research should be centered on clinical application focusing on early preoperative identification of at-risk patients. The goal is to establish twenty-first-century patient-specific strategies for optimizing results and expectations after adult reconstructive surgery.

Disparities in Discharge Destination After Lower Extremity Joint Arthroplasty: Analysis of 7924 Patients in an Urban Setting.

BACKGROUND: Discharge destination is an important factor to consider to maximize care coordination and manage patient expectations after total joint arthroplasty (TJA). It also has significant impact on the cost-effectiveness of these procedures given the significant cost of post-acute inpatient care. Therefore, understanding factors that impact discharge destination after TJA is critical. METHODS: An evaluation of socioeconomic, geographic, and racial/ethnic factors associated with discharge destination to either home or institution (ie, rehabilitation, skilled nursing facility, and so forth) following joint arthroplasty of the lower extremity was conducted. We analyzed data on patients admitted between 2011 and 2014 for primary or revision hip or knee arthroplasty at a single institution. Bivariate and multivariate statistical techniques were applied to determine associations. RESULTS: Included in the analysis were 7924 cases of lower extremity joint procedures, of which 4836 (61%), 785 (10%), and 2770 (35%) were of female gender, low socioeconomic status, and nonwhite race/ethnicity, respectively. A total of 5088 (64%) and 2836 (36%) cases were discharged to home and institution, respectively. Significant predictors of discharge to an institution in the multivariate analysis include SES (low and middle SES [odds ratio {OR}: 1.27, 95% confidence interval {CI}: 1.02-1.57, P = .029; and OR: 1.26, 95% CI: 1.10-1.44, P = .001]), age (OR: 1.05, 95% CI: 1.049-1.060, P < .001), female gender (OR: 1.69, 95% CI: 1.52-1.89, P < .001) and TKA procedure (OR: 1.48, 95% CI: 1.33-1.64, P < .001). Patients of nonblack race/ethnicity were more likely to be discharged home (white OR: 0.84, 95% CI: 0.72-0.98, P = .027; other OR: 0.80, 95% CI: 0.67-0.95, P = .009). CONCLUSION: Socioeconomic status and race/ethnicity are important factors related to discharge destination following TJA. Thoroughly understanding and addressing these factors may help increase the rates of discharge to home as opposed to institution.

Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care.

BACKGROUND: In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." METHODS: A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. RESULTS: Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. CONCLUSION: Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. LEVEL OF EVIDENCE: IV economic and decision analyses-developing an economic or decision model.

Orthopedic Implant Waste: Analysis and Quantification.

The steadily increasing demand for orthopedic surgeries and declining rates of reimbursement by Medicare and other insurance providers have led many hospitals to look for ways to control the cost of these surgeries. We reviewed administrative records for a 1-year period and recorded total number of surgical cases, number of cases in which an implant was wasted, and cost of each wasted implant. We determined cost incurred because of implant waste, percentage of cases that involved waste, percentage of total implant cost wasted, and average cost of waste per case. We then analyzed the data to determine if case volume or years in surgical practice affected amount of implant waste. Results showed implant waste represents a significant cost for orthopedic procedures within all subspecialties and is an important factor to consider when developing cost-reduction strategies.

Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty: A Readmission Risk Assessment Tool.

BACKGROUND: Preoperative risk stratification and optimization of preoperative care may be helpful in reducing readmission rates after primary total joint arthroplasty. Assessment of the predictive value of individual modifiable risk factors without a tool to assess cumulative risk may not provide proper risk stratification of patients with regard to potential readmissions. As part of a Perioperative Orthopaedic Surgical Home model, we developed a scoring system, the Readmission Risk Assessment Tool (RRAT), which allows for risk stratification in patients undergoing elective primary total joint arthroplasty at our institution. The purpose of this study was to analyze the relationship between the RRAT score and readmission after primary hip or knee arthroplasty. METHODS: The RRAT, which is scored incrementally on the basis of the number and severity of modifiable comorbidities, was used to generate readmission scores for a cohort of 207 readmitted patients and two cohorts (one random and one age-matched) of 234 non-readmitted patients each. Regression analysis was performed to assess the strength of association of individual risk factors and the RRAT score with readmissions. We also calculated the odds and odds ratio (OR) at each RRAT score level to identify patients with relatively higher risk of readmission. RESULTS: There were 207 (2.08%) readmissions among 9930 patients over a six-year period (2008 through 2013). Surgical site infection was the most common cause of readmission (ninety-three cases, 45%). The median RRAT scores were 3 (IQR [interquartile range], 1 to 4) and 1 (IQR, 0 to 2) for readmitted and non-readmitted groups, respectively. An RRAT score of ≥3 was significantly associated with higher odds of readmission. CONCLUSIONS: Population health management, cost-effective care, and optimization of outcomes to maximize value are the new maxims for health-care delivery in the United States. We found that the RRAT score had a significant association with readmission after joint arthroplasty and could potentially be a clinically useful tool for risk mitigation.

Role of Sociodemographic, Co-morbid and Intraoperative Factors in Length of Stay Following Primary Total Hip Arthroplasty.

We aimed to examine and quantify the combined association of patient sociodemographic, preoperative comorbidities and intraoperative factors with extended and prolonged length of stay (LOS) following primary total hip arthroplasty. Longer LOS was associated with Age (≥65 years), BMI ≥30 kg/m(2), ASA score >2, minority race/ethnicity, low SES, general anesthesia, comorbidities of the Circulatory, Genitourinary and Respiratory systems, and operating time. Collectively, being of low SES, advanced age (≥65 years) and minority race/ethnicity was most significantly associated with prolonged LOS (>7 days). The combined associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities presented a synergistically elevated risk for longer LOS and may warrant the need to consider sociodemographic status when allocating resources to hospitals serving such patients.

Can Administrative Data Be Used to Analyze Complications Following Total Joint Arthroplasty?

We hypothesized that the Centers for Medicare and Medicaid Services Limited Dataset (CMS-LDS) could be used to validate the complications associated with total hip and knee arthroplasty (THA and TKA) endorsed by the Hip and Knee Societies. Using ICD-9 procedure and diagnosis codes, cases were extracted from the first three quarters of the 2009 CMS-LDS to allow all complications within 90-days be captured in the same calendar year. We were unable to validate the Hip and Knee Societies' complications as we could not connect readmissions or outpatient visits to index admissions. In addition, well-known complications were not detected, raising concerns about coding accuracy and stratification. Furthermore, the assignment of outpatient and inpatient codes allows for duplication of complications which may falsely elevate the true incidence.

Risk Factors for Infection Following Total Knee Arthroplasty: A Series of 3836 Cases from One Institution.

Higher PJI rates may be related to identifiable risk factors, which may or may not be modifiable. Identifying risk factors preoperatively provides opportunities for modification and potentially decreasing the incidence of PJI. The purposes of this study were to: (1) retrospectively identify and quantify risk factors for PJI following primary TKA, and (2) to classify those significant risk factors as either non-modifiable or modifiable for intervention prior to surgery. Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of periprosthetic joint infection after primary TKA, thereby reducing morbidity and the costs associated with treating those infections.

The Combined Influence of Sociodemographic, Preoperative Comorbid and Intraoperative Factors on Longer Length of Stay After Elective Primary Total Knee Arthroplasty.

This study assessed the collective association of sociodemographic, preoperative comorbid and intraoperative factors with longer length of stay (LOS) following elective primary total knee arthroplasty. Sociodemographic characteristics examined on 2638 adult cases included age, race/ethnicity, gender and socioeconomic status (SES). Intraoperative factors included operating time and anesthesia type. The collective associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities do present a synergistically elevated risk for longer LOS. In a value-driven healthcare environment, these findings further warrant the need for policymakers and payers to consider sociodemographic status when allocating resources to hospitals serving such patients.

The Otto Aufranc Award: Modifiable versus nonmodifiable risk factors for infection after hip arthroplasty.

BACKGROUND: Periprosthetic joint infections (PJIs) are associated with increased morbidity and cost. It would be important to identify any modifiable patient- and surgical-related factors that could be modified before surgery to decrease the risk of PJI. QUESTIONS/PURPOSES: We sought to identify and quantify the magnitude of modifiable risk factors for deep PJIs after primary hip arthroplasty. METHODS: A series of 3672 primary and 406 revision hip arthroplasties performed at a single specialty hospital over a 3-year period were reviewed. All deep PJIs were identified using the Centers for Disease Control and Prevention case definitions (ie, occurs within 30-90 days postoperatively, involves deep soft tissues of the incision, purulent drainage, dehiscence and fever, localized pain or tenderness). Univariate and multivariate analyses determined the association between patient and surgical risk factors and PJIs. For the elective patients, the procedure was performed on the day of admission ("same-day procedure"), whereas for the fracture and nonelective patients, the procedure was performed 1 or more days postadmission ("nonsame-day procedure"). Staphylococcus aureus colonization, tobacco use, and body mass index (BMI) were defined as patient-related modifiable risk factors. RESULTS: Forty-seven (1.3%) deep PJIs were identified. Infection developed in 20 of 363 hips of nonsame-day procedures and 27 of 3309 same-day procedures (p=0.006). There were eight (2%) infections in the revision group. After controlling for confounding variables, our multivariate analysis showed that BMI≧40 kg/m2 (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.3-12.88; p=0.01), operating time>115 minutes (OR, 3.38; 95% CI, 1.23-9.28; p=0.018), nonsame-day surgery (OR, 4.16; 95% CI, 1.44-12.02; p=0.008), and revision surgery (OR, 4.23; 95% CI, 1.67-10.72; p<0.001) are significant risk factors for PJIs. Tobacco use and S aureus colonization were additive risk factors when combined with other significant risk factors (OR, 12.76; 95% CI, 2.47-66.16; p=0.017). CONCLUSIONS: Nonsame-day hip and revision arthroplasties have higher infection rates than same-day primary surgeries. These characteristics are not modifiable and should be categorized as a separate cohort for complication-reporting purposes. Potentially modifiable risk factors in our patient population include operating time, elevated BMI, tobacco use, and S aureus colonization. Modifying risk factors may decrease the incidence of PJIs. When reporting deep PJI rates, stratification into preventable versus nonpreventable infections may provide a better assessment of performance on an institutional and individual surgeon level. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of the first-generation AAOS clinical guidelines on the prophylaxis of venous thromboembolic events in patients undergoing total joint arthroplasty: experience with 3289 patients from a single institution.

BACKGROUND: Patients undergoing total hip or total knee arthroplasty have risks that include venous thromboembolism. The American Academy of Orthopaedic Surgeons has promulgated guidelines for the preoperative assessment of patients with the primary objective of preventing pulmonary embolism. We aimed to evaluate and establish the utility of the first-generation American Academy of Orthopaedic Surgeons guidelines for the prophylaxis of venous thromboembolism in patients undergoing total joint arthroplasty at a single institution. METHODS: A prospective analysis of 3289 consecutive patients managed with total hip or total knee arthroplasty at the Connecticut Joint Replacement Institute between June 1, 2009, and April 30, 2011, was conducted. Data on age, sex, body mass index, American Society of Anesthesiologists classification, and a personal or family history of blood clots requiring long-term warfarin use were analyzed, as were data on a personal history of a malignant tumor, a bleeding disorder, gastrointestinal bleeding, or a hemorrhagic cerebrovascular accident. All patients were managed prophylactically with a specific algorithm based on the American Academy of Orthopaedic Surgeons guidelines. All of the patients were mobilized on postoperative day one, and pneumatic foot-pump compression was used for the duration of the hospitalization. RESULTS: Thirty-six major venous thromboembolic events were documented with Doppler ultrasound or computed tomography angiography, for a ninety-day incidence of 1.1% (95% confidence interval, 0.8% to 1.5%). A personal history of blood clots was significantly associated with a blood clot in the proximal part of the thigh or a pulmonary embolism, but a family history of blood clots and a personal history of a malignant tumor did not show a significant relationship with venous thromboembolism. The ninety-day incidence of venous thromboembolism was significantly different between total hip arthroplasty patients (0.56%; 95% confidence interval, 0.30% to 1.15%) and total knee arthroplasty patients (1.46%; 95% confidence interval, 1.01% to 2.10%). The risk was greater in high-risk total knee arthroplasty patients compared with high-risk total hip arthroplasty patients despite comparable prophylaxis with enoxaparin sodium for twenty-eight days. CONCLUSIONS: The prospective use of the first-generation American Academy of Orthopaedic Surgeons guidelines resulted in a low incidence of clinically important thromboembolic events in total hip and total knee arthroplasty patients. When properly used in these patients, the guidelines to minimize adverse outcomes are executable and effective. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.