Retrieval Analysis of Titanium Nitride Coatings for Orthopaedic Implants.

BACKGROUND: The first generation of titanium nitride (TiN) coatings for orthopaedic implants was clinically introduced in the 1990s because of their promising biocompatibility, wear resistance, and corrosion resistance. This study evaluated the in vivo performance of early TiN-coated knee and hip implants, focusing on the bearing surfaces and mechanisms of in vivo damage. METHODS: There were thirteen TiN-coated implants (5 knee and 8 hip) retrieved from 8 patients as part of a multi-institutional implant retrieval program. The average implantation time was 4.25 years for knees and 17.5 years for hips. Implant revisions occurred for various reasons, including PE wear, loosening, pain, infection, and instability. Components were examined using a semiquantitative scoring method, and surface roughness measurements were performed using white-light interferometry (WLI). Surface morphology, chemistry, and particle characterization were also assessed using scanning electron microscopy. RESULTS: For hips, mild corrosion was found on femoral head tapers, along with severe scratching on certain femoral heads. Knee implants exhibited low burnishing and scratching for both mechanisms. Roughness measurements (Sa) were 37.3 nm (Interquartile Range, IQR = 22.0 to 62.4) for hips and 85.3 nm (IQR = 66.3 to 110) for knees. The observed scratch depth in both hip and knee implants due to 3rd body particles ranged from 0.3 to 1.3 µm. The coating coverage remained intact in the majority of the implants, with two cases of small, localized cohesive chipping and substrate exposure. CONCLUSIONS: The results of this study confirm the potential in vivo durability of early TiN coatings and will be useful in benchmarking wear tests for modern TiN-coated orthopaedic implants.

Establishing minimal clinically important differences and patient acceptable symptom state thresholds following birmingham hip resurfacing.

INTRODUCTION: Birmingham Hip Resurfacing (BHR) has emerged as a compelling and innovative alternative to total hip arthroplasty (THA), especially among young, active patients. However, the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds have not yet been determined for patients undergoing BHR. Therefore, the current study aimed to (1) determine the MCID and PASS thresholds for both the Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS physical function shortform (PS), for patients who underwent BHR; and (2) identify factors influencing the achievement of MCID and PASS for HOOS-Pain and HOOS-PS. METHODS: Prospectively collected data from patients undergoing BHR was analyzed. Patients with osteoarthritis and completed preoperative and 1-year postoperative PROMs were included. Distribution-based and anchored-based approaches were used to estimate MCID and PASS, respectively. The optimal cut-off point for PASS thresholds was calculated using the Youden index. RESULTS: MCID for HOOS-Pain and PS were calculated to be 9.2 and 9.3, respectively. The PASS threshold for HOOS-Pain and PS were ≥ 77.7 and ≥ 87.3, respectively. The current study identified several factors affecting postoperative achievement of thresholds. Baseline Mental Component Summary (MCS) scores were a predictor for achieving MCID for postoperative HOOS-Pain, achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Furthermore, baseline HOOS-Pain was a significant predictor for achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. CONCLUSIONS: MCID and PASS thresholds were established for HOOS-Pain and PS domains following BHR with most patients achieving these clinically meaningful benchmarks. Additionally, several factors affecting achievement of MCID and PASS were identified, including modifiable risk factors that may allow clinicians to implement optimization strategies and further improve outcomes.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

INTRODUCTION: In orthopaedic surgery, particularly total knee arthroplasty (TKA), the management of surgical wounds is critical for optimal wound healing and successful patient outcomes. Despite advances in surgical techniques, challenges persist in effectively managing surgical wounds to prevent complications and infections. This study aimed to identify and address the critical evidence gaps in wound management in TKA, including preoperative optimization, intraoperative options, and for the avoidance of postoperative complications. These are important issues surrounding wound management, which is essential for improving patient recovery and the overall success of the surgery. METHODS: Utilizing the Delphi method, this study brought together 20 experienced orthopaedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 specific statements about wound management in TKA based on a comprehensive literature review. During these three stages and after further panel review, an alternative goal of the Delphi panel was to also identify critical evidence gaps in the current understanding of wound management practices for TKA. RESULTS: While the panel reached consensus on various wound management practices, they highlighted several major evidence gaps. Also, there was general consensus on issues such as wound closure methods including the use of mesh-adhesive dressings, skin glue, staples, sutures (including barbed sutures),and negative-pressure wound therapy (NPWT). However, it was deemed necessary that further evidence needs to be generated to address the cost-effectiveness of each and develop best practices for promoting patient outcomes. The identification of these gaps points to areas requiring more in-depth research and improvements to enhance wound care in TKA. DISCUSSION: The identification of these major evidence gaps underscores the need for targeted research in wound management surrounding TKA. Addressing these evidence gaps is crucial for the future development of more effective, efficient, and patient-friendly wound care strategies. Future research should prioritize these areas, focusing on comparative effectiveness studies and further developing clear guidelines for the use of emerging technologies. Bridging these gaps has the potential to improve patient outcomes, reduce complications, and elevate the overall success rate of TKA surgeries.

Conversion Birmingham Hip Resurfacing in Managing Post-traumatic Arthritis With Retained Femoral Hardware: A Case Report.

CASE: A 70-year-old man with a year-long history of arthritic pain in his left hip presented to our clinic. He had a left intertrochanteric hip fracture 6 years ago, fixed with an open reduction internal fixation with a cephalomedullary nail. He underwent a conversion Birmingham Hip Resurfacing (BHR) with removal of the proximal helicoidal blade and retention of the intramedullary nail. At 7-year follow-up, the patient reported satisfactory clinical outcomes and excellent radiographic fixation. CONCLUSION: This case highlights using conversion BHR in patients with post-traumatic arthritis with retained femoral hardware as an alternative to conventional total hip arthroplasty.

Oxidation and Damage Mechanisms of 2nd Generation Highly Cross-Linked Polyethylene Tibial Inserts.

INTRODUCTION: After clinical introduction in 2005, sequentially annealed, highly crosslinked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices (OI) of SA HXLPE and conventional gamma-inert sterilized (Gamma Inert) ultra-high molecular weight polyethylene tibial inserts implanted for > 5 years. METHODS: There were 74 total knee arthroplasty (TKA) tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for > 5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semi-quantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials (ASTM) 2102. Differences between cohorts were assessed with Mann-Whitney U-Tests. RESULTS: Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = 0.022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = 0.002) and anterior-posterior (AP) faces (P = 0.023). No difference was observed at the backside surface (P = 0.060). CONCLUSIONS: Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty.

BACKGROUND: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider. METHODS: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio. RESULTS: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187). CONCLUSIONS: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons.

INTRODUCTION: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics. METHODS: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted. RESULTS: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance (P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons. CONCLUSION: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon. STUDY DESCRIPTION: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

How-To Create an Orthopaedic Systematic Review: A Step-by-step Guide Part II: Study Execution.

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review.

Predictive Modeling of Medical- and Orthopaedic-Related 90-Day Readmissions Following Primary Total Hip Arthroplasty.

BACKGROUND: The rate of unplanned hospital readmissions following total hip arthroplasty (THA) varies from 3 to 10%, representing a major economic burden. However, it is unknown if specific factors are associated with different types of complications (ie, medical or orthopaedic-related) that lead to readmissions. Therefore, this study aimed to: (1) determine the overall, medical-related, and orthopaedic-related 90-day readmission rate; and (2) develop a predictive model for risk factors affecting overall, medical-related, and orthopaedic-related 90-day readmissions following THA. METHODS: A prospective cohort of primary unilateral THAs performed at a large tertiary academic center in the United States from 2016 to 2020 was included (n = 8,893 patients) using a validated institutional data collection system. Orthopaedic-related readmissions were specific complications affecting the prosthesis, joint, and surgical wound. Medical readmissions were due to any other cause requiring medical management. Multivariable logistic regression models were used to investigate associations between prespecified risk factors and 90-day readmissions, as well as medical and orthopaedic-related readmissions independently. RESULTS: Overall, the rate of 90-day readmissions was 5.6%. Medical readmissions (4.2%) were found to be more prevalent than orthopaedic-related readmissions (1.4%). The area under the curve for the 90-day readmission model was 0.71 (95% confidence interval: 0.69 to 0.74). Factors significantly associated with medical-related readmissions were advanced age, Black race, education, Charlson Comorbidity Index, surgical approach, opioid overdose risk score, and nonhome discharge. In contrast, risk factors linked to orthopaedic-related readmissions encompassed body mass index, patient-reported outcome measure phenotype, nonosteoarthritis indication, opioid overdose risk, and nonhome discharge. CONCLUSIONS: Of the overall 90-day readmissions following primary THA, 75% were due to medical-related complications. Our successful predictive model for complication-specific 90-day readmissions highlights how different risk factors may disproportionately influence medical versus orthopaedic-related readmissions, suggesting that patient-specific, tailored preventive measures could reduce postoperative readmissions in the current value-based health care setting.

24-Year-Old Patient with Klippel-Trenaunay Syndrome Underwent Cementless Robotic Cruciate-Retaining TKA: A Case Report.

CASE: A 24-year-old man with Klippel-Trenaunay syndrome (KTS) presented with severe knee osteoarthritis unresponsive to conservative measures. Owing to end-stage, debilitating arthritic symptoms, surgery was pursued. Careful preoperative, multidisciplinary planning/treatment included magnetic resonance imaging to characterize the venous malformations throughout the right lower extremity, preoperative sclerotherapy, sirolimus, and robotic-assisted cementless total knee arthroplasty (TKA). CONCLUSION: Cementless robotic-assisted TKA with selective patellar resurfacing can be a viable option for young KTS patients with severe osteoarthritis when a meticulous multidisciplinary approach, including sclerotherapy and advanced imaging, is undertaken to analyze vascular abnormalities, minimize surgical risks, preserve bone stock, and optimize outcomes.

Short-term Comparison of Survivorship and Functional Outcomes for Metaphyseal Cones with Short and Long Stems in Revision Total Knee Arthroplasty.

Printed porous titanium metaphyseal cones have become a mainstay for managing bone loss in revision total knee arthroplasty (rTKA). A short or long stem is routinely used when implanting a cone to augment fixation and offload stresses. This retrospective analysis compared the short-term survivorships and functional outcomes for use of a short or long stem with a metaphyseal cone.A total of 179 cases using metaphyseal cones and stems with median follow-up of 1.95 years (interquartile range, 1.00-2.14) were compared based on stem type. There were 55 cases with long stem(s) and 124 cases with short stem(s). Cases with both long and short stems were excluded. Demographics, Kaplan-Meier survivorships, and preoperative and 1-year postoperative patient-reported outcome measures (PROMs; 2011 Knee Society Score [KSS] objective knee score, function, and satisfaction scores; EuroQol five-dimension scale; and Short Form Survey Physical Component Summary and Mental Component Summary scores) were compared using t-tests with a significance level of α = 0.05. There were no significant differences in body mass index (mean ± standard deviation) or sex (men [%]) between the short and long stem cohorts (32.3 ± 5.3, 36.3% and 31.5 ± 5.5, 38.2%, respectively; p > 0.05). Patients who had short stems were younger (65.9 ± 8.8 vs. 69.0 ± 9.4, p = 0.0323).Revision-free survivorship for the femoral or tibial component was 100% for long stems and 98.2% for short stems at 1 and 2 years, respectively (log-rank p = 0.6330). The two revisions in the short group were for infection, thus the survivorship for aseptic loosening was 100% at 2 years for both cohorts. There were no significant differences in preoperative or postoperative PROMs.This study demonstrated that highly porous printed metaphyseal cones provided rTKA with excellent early survivorship and similar PROMs whether a short or long stem was used. Additional studies will be needed to discern longer term differences.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

Custom Triflange Acetabular Implants for Complex Hip Revisions: A Case Series.

Revision total hip arthroplasty (THA) presents a formidable challenge when addressing extensive acetabular defects, particularly in severe cases classified under Paprosky types 3A and 3B and American Academy of Orthopaedic Surgeons types 3 and 4. Traditional methods often fall short, prompting the potential use of custom triflange acetabular components or patient-specific acetabular implants (PSAIs). These implants are specifically designed to conform to an individual's anatomy, aiming to enhance defect reconstruction and pelvic stabilization. This case series describes the utilization of advanced 3-dimensional printing and rapid prototyping technologies to construct customized acetabular components, which can be instrumental in enabling precise preoperative planning and surgical execution for these difficult acetabular cases and potentially leading to improved surgical outcomes.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient.

BACKGROUND: Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care. METHODS: A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant. RESULTS: High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI. CONCLUSIONS: Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost. LEVEL OF EVIDENCE: III.

Leukocyte-Poor Platelet-Rich Plasma as an Adjuvant to Arthroscopic Rotator Cuff Repair Reduces the Retear Rate But Does Not Improve Functional Outcomes: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Whether the use of PRP as an adjuvant of rotator cuff repairs leads to improved tendon healing and better functional outcomes remains unclear in clinical evidence. PURPOSE: The main purpose of this study was to assess whether the use of leukocyte-poor platelet-rich plasma (LP-PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) decreases the rate of retears compared with a control group. The secondary objective was to analyze whether LP-PRP improves patient-reported outcomes. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a double-blind randomized controlled trial at a single center. A consecutive series of 96 patients with rotator cuff tears <3 cm were enrolled and randomly allocated to the control group (double-row suture-bridge ARCR alone [n = 48]) and the PRP group (double-row suture-bridge repair, followed by 1 LP-PRP injection during surgery [n = 48]). The visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and the Pittsburgh Sleep Quality Index (PSQI) were administered preoperatively and at 6- and 12-month follow-up. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity at 6-month follow-up. Both patients and assessors were blinded to the intervention received during surgery. RESULTS: The mean patient age was 56.1 ± 2.98 years. Of the 96 patients, 90 had MRI performed at 6 months after surgery (94% radiological follow-up). The retear rate in the PRP group was 15.2% (7/46 [95% CI, 6%-28%]), which was lower than that in the control group of 34.1% (15/44 [95% CI, 20%-49%]) (P = .037). Therefore, the risk ratio of ruptures in patients exposed to LP-PRP was 0.44 (95% CI, 0.2-0.9; P = .037). Overall, the ASES, VAS, SANE, and PSQI scores showed a statistical improvement after surgery (P < .001). There were no significant differences in functional scores between the groups. Most of the patients exceeded the minimal clinically important difference for the ASES, SANE, and VAS without significant differences between the groups. CONCLUSION: In patients with rotator cuff tears <3 cm undergoing double-row suture-bridge repair, a 5-mL dose of LP-PRP injected at the tendon-bone interface significantly reduced the retear rate. However, the use of LP-PRP in terms of postoperative pain and patient-reported outcomes failed to show clinically meaningful effects. REGISTRATION: NCT04703998 (ClinicalTrials.gov identifier).

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future.

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices. This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA.

BACKGROUND: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it. QUESTIONS/PURPOSES: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms? METHODS: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs. RESULTS: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]). CONCLUSION: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study.

BACKGROUND: Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs). METHODS: This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities. RESULTS: There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 µg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 µg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control. CONCLUSIONS: The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.

Enabling Personalized Medicine in Orthopaedic Surgery Through Artificial Intelligence: A Critical Analysis Review.

¼ The application of artificial intelligence (AI) in the field of orthopaedic surgery holds potential for revolutionizing health care delivery across 3 crucial domains: (I) personalized prediction of clinical outcomes and adverse events, which may optimize patient selection, surgical planning, and enhance patient safety and outcomes; (II) diagnostic automated and semiautomated imaging analyses, which may reduce time burden and facilitate precise and timely diagnoses; and (III) forecasting of resource utilization, which may reduce health care costs and increase value for patients and institutions.¼ Computer vision is one of the most highly studied areas of AI within orthopaedics, with applications pertaining to fracture classification, identification of the manufacturer and model of prosthetic implants, and surveillance of prosthesis loosening and failure.¼ Prognostic applications of AI within orthopaedics include identifying patients who will likely benefit from a specified treatment, predicting prosthetic implant size, postoperative length of stay, discharge disposition, and surgical complications. Not only may these applications be beneficial to patients but also to institutions and payors because they may inform potential cost expenditure, improve overall hospital efficiency, and help anticipate resource utilization.¼ AI infrastructure development requires institutional financial commitment and a team of clinicians and data scientists with expertise in AI that can complement skill sets and knowledge. Once a team is established and a goal is determined, teams (1) obtain, curate, and label data; (2) establish a reference standard; (3) develop an AI model; (4) evaluate the performance of the AI model; (5) externally validate the model, and (6) reinforce, improve, and evaluate the model's performance until clinical implementation is possible.¼ Understanding the implications of AI in orthopaedics may eventually lead to wide-ranging improvements in patient care. However, AI, while holding tremendous promise, is not without methodological and ethical limitations that are essential to address. First, it is important to ensure external validity of programs before their use in a clinical setting. Investigators should maintain high quality data records and registry surveillance, exercise caution when evaluating others' reported AI applications, and increase transparency of the methodological conduct of current models to improve external validity and avoid propagating bias. By addressing these challenges and responsibly embracing the potential of AI, the medical field may eventually be able to harness its power to improve patient care and outcomes.

How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide. Part III: Executing a Meta-Analysis.

At the top of the evidence-based pyramid, systematic reviews stand out as the most powerful, synthesizing findings from numerous primary studies. Specifically, a quantitative systematic review, known as a meta-analysis, combines results from various studies to address a specific research question. This review serves as a guide on how to: (1) design; (2) perform; and (3) publish an orthopedic arthroplasty systematic review. In Part III, we focus on how to design and perform a meta-analysis. We delineate the advantages and disadvantages of meta-analyses compared to systematic reviews, acknowledging their potential challenges due to time constraints and the complexities posed by study heterogeneity and data availability. Despite these obstacles, a well-executed meta-analysis contributes precision and heightened statistical power, standing at the apex of the evidence-based pyramid. The design of a meta-analysis closely mirrors that of a systematic review, but necessitates the inclusion of effect sizes, variability measures, sample sizes, outcome measures, and overall study characteristics. Effective data presentation involves the use of forest plots, along with analyses for heterogeneities and subgroups. Widely-used software tools are common in this domain, and there is a growing trend toward incorporating artificial intelligence software. Ultimately, the intention is for these papers to act as foundational resources for individuals interested in conducting systematic reviews and meta-analyses in the context of orthopaedic arthroplasty, where applicable.