Effect of Lawsuits on Professional Well-Being and Medical Error Rates Among Orthopaedic Surgeons.

INTRODUCTION: Orthopaedic surgery is one of the most cited specialties among legal claims. Malpractice lawsuits are financially burdensome, increase defensive practices, and incur a notable emotional toll on defendants. We sought to determine the effect of malpractice lawsuits on professional well-being and self-reported medical errors among orthopaedic surgeons. METHODS: We surveyed 305 members of the American Orthopaedic Association to collect information on experiences with medical malpractice lawsuits, demographic and practice characteristics, professional well-being on the Professional Fulfillment Index, and self-reported medical errors. Multivariable logistic regression identified predictors of malpractice lawsuits, professional well-being, and self-reported medical errors. RESULTS: Seventy-three percent (224 of 305) respondents had been involved in a medical malpractice lawsuit. The odds of experiencing a malpractice lawsuit increased by seven percent with each year in practice (OR = 1.07, 95% CI: 1.04 to 1.10, P < 0.001) and with specialization in spine surgery. Respondents with a lawsuit in 2 years before the survey reported comparable professional well-being and medical error rates with those without a lawsuit. However, compared with respondents without a lawsuit, respondents with a lawsuit more than 2 years in the past were less likely to report burnout (OR = 0.43, 95% CI: 0.20 to 0.90, P = 0.03) and more likely to report a medical error in the past year, which resulted in patient harm (OR = 3.51, 95% CI: 1.39 to 8.91, P = 0.008). DISCUSSION: While malpractice lawsuits negatively affect professional well-being, this effect resolves with time. The effect on medical errors may be more permanent; orthopaedic surgeons who have experienced a lawsuit reported greater rates of medical errors even after these legal issues have been settled. Among orthopaedic surgeons dealing with lawsuits, supportive interventions to protect professional well-being and mitigate the factors which lead to greater medical errors are needed. LEVEL OF EVIDENCE: Prognostic Level III.

Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database.

BACKGROUND: Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear. QUESTIONS/PURPOSES: (1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA? METHODS: Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race. RESULTS: After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001). CONCLUSION: These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research. LEVEL OF EVIDENCE: Level III, therapeutic study.

Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses.

Background: This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods: This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results: Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (ß 7.1; P < .001) and with medication (ß 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (ß 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion: One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.

The burden and utility of routine follow-up at one year after primary arthroplasty.

AIMS: Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers. METHODS: All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit. RESULTS: Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed. CONCLUSION: Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85-89.

The Distribution of Underrepresented Minorities in U.S. Orthopaedic Surgery Residency Programs.

BACKGROUND: Orthopaedic surgery has generally lagged behind other surgical subspecialties with respect to racial and ethnic diversity in its U.S. residency programs. Efforts have been made to increase the number of underrepresented minorities (URMs) applying to orthopaedic surgery residencies; however, the impact on diversity at the residency program level is unknown. The purpose of this study was to determine whether orthopaedic surgery residency programs have become more racially diverse over time. METHODS: The Graduate Medical Education Track database was queried for individual racial/ethnic identification of orthopaedic surgery residents in U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited programs for 15 consecutive years (2002-2003 through 2016-2017). The number of URMs in each residency program during each academic year was recorded. The number of programs per year with no URMs, 1 URM, 2 URMs, and >2 URMs was recorded, and the change over time was assessed. RESULTS: The number of programs per year with >1 URM resident decreased over time, from 61 programs in 2002 to 53 programs in 2016, with the trough being 31 programs in 2010 (p < 0.0001). The number of programs per year without any URM residents increased over the period of study, from 40 programs in 2002 to 60 programs in 2016, with the peak being 76 programs in 2011 (p < 0.0001). CONCLUSIONS: The number of residency programs with >1 URM resident has decreased significantly over time, suggesting that diversity at the program level is limited. Program-level diversity should be further examined as a potential barrier to the recruitment of URMs to orthopaedics. Difficulty attracting URM residents to certain programs may have the unintended consequence of effectively limiting potential positions for these candidates, which can decrease the odds of minority students matching into orthopaedics and, therefore, perpetuate the cycle of lack of diversity in our field.

What is the Impact of Social Deprivation on Physical and Mental Health in Orthopaedic Patients?

BACKGROUND: The complex interrelationship among physical health, mental health, and social health has gained the attention of the medical community in recent years. Poor social health, also called social deprivation, has been linked to more disease and a more-negative impact from disease across a wide variety of health conditions. However, it remains unknown how social deprivation is related to physical and mental health in patients presenting for orthopaedic care. QUESTIONS/PURPOSES: (1) Do patients living in zip codes with higher social deprivation report lower levels of physical function and higher levels of pain interference, depression, and anxiety as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) at initial presentation to an orthopaedic provider than those from less deprived areas; and if so, is this relationship independent of other potentially confounding factors such as age, sex, and race? (2) Does the relationship between the level of social deprivation of a patient's community and that patient's physical function, pain interference, depression, and anxiety, as measured by PROMIS remain consistent across all orthopaedic subspecialties? (3) Are there differences in the proportion of individuals from areas of high and low levels of social deprivation seen by the various orthopaedic subspecialties at one large, tertiary orthopaedic referral center? METHODS: This cross-sectional evaluation analyzed 7500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index, a composite measure of community-level social deprivation, based on multiple census metrics such as income, education level, and housing type for a given nine-digit zip code was used to estimate individual social deprivation. Statistical analysis determined the effect of disparate area deprivation (based on most- and least-deprived national quartiles) for the entire sample as well as for patients categorized by the orthopaedic subspecialty providing care. Comparisons of PROMIS scores among these groups were based on an MCID of 5 points for each PROMIS domain (Effect size 0.5). RESULTS: Patients living in zip codes with the highest levels of social deprivation had worse mean scores across all four PROMIS domains when compared with those living in the least-deprived quartile (physical function 38 +/- 9 versus 43 +/- 9, mean difference 4, 95% CI, 3.7-5.0; p < 0.001; pain interference 64 +/- 8 versus 60+/-8, mean difference -4, 95% CI, -4.8 to -3.7; p < 0.001; depression 50+/-11 versus 45+/-8, mean difference -5, 95% CI, -6.0 to -4.5; p < 0.001; anxiety 56+/-11 versus 50 +/-10, mean difference -6, 95% CI, -6.9 to -5.4; p < 0.001). There were no differences in physical function, pain interference, depression, or anxiety PROMIS scores between patients from the most- and least-deprived quartiles who presented to the subspecialties of spine (physical function, mean 35+/-7 versus 35+/-7; p = 0.872; pain interference, 67+/-7 versus 66+/-7; p = 0.562; depression, 54+/-12 versus 51 +/-10; p = 0.085; and anxiety, 60+/-11 versus 58 +/-9; p = 0.163), oncology (physical function, mean 33+/-9 versus 38 +/-13; p = 0.105; pain interference, 68+/-9 versus 64+/-10; p = 0.144; depression, 51+/-10 versus 52+/-13; p = 0.832; anxiety, 59+/-11 versus 59+/-10 p = 0.947); and trauma (physical function, 35+/-11 versus 32+/-10; p = 0.268; pain interference, 66+/-7 versus 67+/-6; p = 0.566; depression, 52+/-12 versus 53+/-11; p = 0.637; and anxiety, 59+/-12 versus 60+/-9 versus; p = 0.800). The social deprivation-based differences in all PROMIS domains remained for the subspecialties of foot/ankle, where mean differences ranged from 3 to 6 points on the PROMIS domains (p < 0.001 for all four domains), joint reconstruction where mean differences ranged from 4 to 7 points on the PROMIS domains (p < 0.001 for all four domains), sports medicine where mean differences in PROMIS scores ranged from 3 to 5 between quartiles (p < 0.001 for all four domains), and finally upper extremity where mean differences in PROMIS scores between the most- and least-deprived quartiles were five points for each PROMIS domain (p < 0.001 for all four domains). The proportion of individuals from the most- and least-deprived quartiles was distinct when looking across all seven subspecialty categories; only 11% of patients presenting to sports medicine providers and 17% of patients presenting to upper extremity providers were from the most-deprived quartile, while 39% of trauma patients were from the most-deprived quartile (p < 0.001). CONCLUSIONS: Orthopaedic patients must be considered within the context of their social environment because it influences patient-reported physical and mental health as well as has potential implications for treatment and prognosis. Social deprivation may need to be considered when using patient-reported outcomes to judge the value of care delivered between practices or across specialties. Further studies should examine potential interventions to improve the perceived health of patients residing in communities with greater social deprivation and to determine how social health influences ultimate orthopaedic treatment outcomes. LEVEL OF EVIDENCE: Level II, prognostic study.

Patient Perceptions of the Safety of Outpatient Total Knee Arthroplasty.

BACKGROUND: Outpatient total joint arthroplasty is considered safe in a selected group of patients, based primarily on complications. However, patient perception of the safety of outpatient total joint arthroplasty is unknown. This study assesses patient perceptions of the potential benefits of and barriers to outpatient total knee arthroplasty among a cohort of patients who have recently undergone the procedure. METHODS: Patients who underwent unilateral primary total knee arthroplasty between March 1, 2017, and September 30, 2017 at our institution were given a questionnaire, in which they were asked about prior knowledge regarding outpatient total knee arthroplasty, their perceived ability to undergo the procedure as an outpatient, and their perceived risks and benefits to outpatient surgery. RESULTS: Three hundred forty-six patients completed the survey. Over 70% of patients did not think that they would be able to undergo total knee arthroplasty as an outpatient. Their primary concerns were pain, being able to go to the bathroom, and falls. CONCLUSIONS: Patients in this study largely would not feel safe undergoing total knee arthroplasty on an outpatient basis. Payers should not only take into account existing literature but also the concerns and perceived needs of patients, before encouraging widespread implementation of outpatient total knee arthroplasty.

Patient Perceptions of Home Health Care Services After Total Joint Replacement.

Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].

The Impact of Hospital Volume on Racial Differences in Complications, Readmissions, and Emergency Department Visits Following Total Joint Arthroplasty.

BACKGROUND: Minority patients are at higher risk for complications and readmissions after total hip and knee arthroplasty. They are also more likely to undergo joint replacement in lower volume centers, which is associated with poorer outcomes. It is unknown whether these disparities simply reflect disproportionate use of lower volume centers. This study evaluates the impact of hospital volume on racial differences in outcomes following joint replacement. METHODS: Patients who underwent total hip or knee arthroplasty between 2006 and 2013 in New York and Florida were identified through the Healthcare Cost and Utilization Project State Inpatient Databases. Complications, readmissions, and emergency department (ED) visits within 90 days were compared by hospital volume. Relative risks were calculated with generalized estimating equations for risk factors associated with adverse outcomes. RESULTS: Race/ethnicity was not associated with readmission following hip replacement. Black race was associated with readmission following knee replacement (relative risk [RR] 1.16). Black race was associated with ED visits following hip replacement (RR 1.29) and knee replacement (RR 1.33). Hispanic ethnicity was associated with ED visits following knee replacement (RR 1.15), but not hip replacement. These associations did not change after adjusting for hospital volume. CONCLUSION: Adjusting for hospital volume does not alter the risk of readmissions and ED use associated with minority race/ethnicity, suggesting that hospital volume alone may be insufficient to explain racial differences in outcome.

Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study.

BACKGROUND: Although HbA1c is commonly used for assessing glycemic control before surgery, there is no consensus regarding its role and the appropriate threshold in predicting adverse outcomes. This study was designed to evaluate the potential link between HbA1c and subsequent periprosthetic joint infection (PJI), with the intention of determining the optimal threshold for HbA1c. METHODS: This is a multicenter retrospective study, which identified 1645 diabetic patients who underwent primary total joint arthroplasty (1004 knees and 641 hips) between 2001 and 2015. All patients had an HbA1c measured within 3 months of surgery. The primary outcome of interest was a PJI at 1 year based on the Musculoskeletal Infection Society criteria. Secondary outcomes included orthopedic (wound and mechanical complications) and nonorthopedic complications (sepsis, thromboembolism, genitourinary, and cardiovascular complications). A regression analysis was performed to determine the independent influence of HbA1c for predicting PJI. RESULTS: Overall 22 cases of PJI occurred at 1 year (1.3%). HbA1c at a threshold of 7.7 was distinct for predicting PJI (area under the curve, 0.65; 95% confidence interval, 0.51-0.78). Using this threshold, PJI rates increased from 0.8% (11 of 1441) to 5.4% (11 of 204). In the stepwise logistic regression analysis, PJI remained the only variable associated with higher HbA1c (odds ratio, 1.5; confidence interval, 1.2-2.0; P = .0001). There was no association between high HbA1c levels and other complications assessed. CONCLUSION: High HbA1c levels are associated with an increased risk for PJI. A threshold of 7.7% seems to be more indicative of infection than the commonly used 7% and should perhaps be the goal in preoperative patient optimization.

Perspectives of Orthopedic Surgeons on Racial/Ethnic Disparities in Care.

OBJECTIVES: Racial/ethnic disparities in healthcare, including orthopedics, have been extensively documented. However, the level of knowledge among orthopedic surgeons regarding racial/ethnic disparities is unknown. The purpose of this study is to determine the views of orthopedic surgeons on (1) the extent of racial/ethnic disparities in orthopedic care, (2) patient and system factors that may contribute, and (3) the potential role of orthopedic surgeons in the reduction of disparities. METHODS: Three hundred five members of the American Orthopaedic Association completed a survey to assess their knowledge of racial/ethnic disparities and their perceptions about the underlying causes. RESULTS: Twelve percent of respondents believe that patients often receive different care based on race/ethnicity in healthcare in general, while 9 % believe that differences exist in orthopedic care in general, 3 % believe that differences exist within their hospitals/clinics, and 1 % reported differences in their own practices. Despite this, 68 % acknowledge that there is evidence of disparities in orthopedic care. Fifty-one percent believe that a lack of insurance significantly contributes to disparities. Thirty-five percent believe that diversification of the orthopedic workforce would be a "very effective" strategy in addressing disparities, while 25 % percent believe that research would be "very effective" and 24 % believe that surgeon education would be "very effective." CONCLUSION: Awareness regarding racial/ethnic disparities in musculoskeletal care is low among orthopedic surgeons. Additionally, respondents were more likely to acknowledge disparities within the practices of others than their own. Increased diversity, research, and education may help improve knowledge of this problem.

The Use of MRI in Evaluating Knee Pain in Patients Aged 40 Years and Older.

INTRODUCTION: The use of MRI is increasing when evaluating patients with knee pain because it is highly sensitive for detecting intra-articular pathology. However, such changes can be associated with degenerative joint disease, which may be demonstrated with weight-bearing radiographs. The purpose of this study was to determine how often MRI was obtained before orthopaedic referral in patients aged ≥40 years with knee pain, how often weight-bearing radiographs were obtained before MRI, and whether such imaging influenced treatment recommendations. METHODS: In a study of 599 new patients, participating physicians documented the presence of a prereferral MRI and/or plain radiographic studies, the results of weight-bearing radiographs, treatment recommendations, and the impact of any prereferral imaging. RESULTS: Prereferral use of MRI occurred in 130 patients (22%). Of these patients, plain radiographic studies were obtained for 58% before MRI and 13% had weight-bearing radiographs. Ultimately, 17% had weight-bearing radiographs that demonstrated >50% loss of joint space. Forty-eight percent of prereferral MRIs did not contribute to treatment recommendations. In patients with >50% loss of joint space, MRI was considered unnecessary in 95% of the cases. DISCUSSION: Many prereferral MRIs do not contribute to clinical decision making. Weight-bearing radiographs can help identify those patients in whom MRI is unlikely to be helpful. LEVEL OF EVIDENCE: Level III.

Removal of Well-Fixed Cementless Acetabular Components in Revision Total Hip Arthroplasty.

The Zimmer Explant Acetabular Cup Removal System (Warsaw, Indiana) has been touted as a superior method for removing well-fixed cementless acetabular components while minimizing bone loss; however, no comparative data support this. This study compares bone loss following the removal of well-fixed acetabular components with Aufranc gouges and with the Explant System. A review of 623 revision total hip arthroplasties (THAs) at the authors' institution between 2002 and 2013 identified cases involving the revision of well-fixed cementless hemispherical acetabular components for any reason except infection. Twenty-four cases using Aufranc gouges and 27 cases using the Explant System were included. The following surrogates for bone loss were used: (1) the difference between the initial acetabular component outer diameter (OD) and the final reamer OD; (2) the difference between the initial acetabular component OD and the new acetabular component OD; and (3) the use of impaction bone grafting. A 2-tailed Wilcoxon-Mann-Whitney test was used to assess the difference in bone loss between the 2 groups. The use of bone grafting was compared between the groups with the chi-square test. The median differences between the initial acetabular component and the final reamer (P=.004), as well as between the initial and new acetabular components (P=.002), were 2 mm less with the Explant System. Hips in the Aufranc group were more likely to have bone grafting (54% vs 26%; P=.04). These results suggest less bone loss when removing well-fixed acetabular components with the Zimmer Explant System compared with Aufranc gouges.

Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial.

BACKGROUND: Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES: We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS: Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS: Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS: Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Case report: Pseudotumor associated with corrosion of a femoral component with a modular neck and a ceramic-on-polyethylene bearing.

Pseudotumor is a rare complication that can occur following hip arthroplasty. This complication may present with pain, swelling, and decreased function and may lead to bone and soft-tissue destruction. We report a case of pseudotumor formation resulting from corrosion of a modular neck in a hip replacement with a ceramic-on-polyethylene bearing. The patient underwent successful revision surgery using an extended trochanteric osteotomy, removal of the entire stem, and implantation of a new femoral stem and ceramic-polyethylene bearing without a modular neck.

Revision Total Hip Arthroplasty with Retained Acetabular Component.

BACKGROUND: Aseptic loosening and osteolysis commonly limit the survivorship of total hip prostheses. Retention of a well-fixed acetabular component, rather than full acetabular revision, has multiple advantages, but questions have lingered regarding the clinical success and prosthetic survivorship following this procedure. We examined the impact of acetabular component position, polyethylene type, liner insertion technique, femoral head size, and simultaneous revision of the entire femoral component (as opposed to head and liner exchange) or bone-grafting on mid-term to long-term prosthetic survival following such limited revisions. METHODS: One hundred hips in 100 patients with osteolysis, polyethylene wear, or femoral component loosening underwent revision total hip arthroplasty with retention of the acetabular component. Acetabular component inclination and anteversion were measured on prerevision radiographs and were categorized according to predetermined positional safe zones (inclination of 35° to 55° and anteversion of 5° to 25°). Operative reports were reviewed for femoral head size, polyethylene liner type (conventional or highly cross-linked), liner insertion technique (use of the existing locking mechanism or cementation), whether the patient had revision of the entire femoral component, and use of bone graft. Outcomes of interest included the Harris hip score, University of California at Los Angeles (UCLA) activity score, episodes of instability, and need for repeat revision. RESULTS: At an average of 6.6 years (range, two to fourteen years) postoperatively, the Harris hip and UCLA activity scores were both significantly improved compared with the preoperative scores (p < 0.0001 and p < 0.01, respectively). Overall, the failure rate was 13%. In addition, 6% of the patients had postoperative instability. Hips in which the acetabular component was outside of the safe zone for inclination had a higher rate of failure (p = 0.048). Use of conventional, rather than highly cross-linked, polyethylene at the time of revision was also associated with an increased rate of repeat revision (p = 0.025). CONCLUSIONS: Revision total hip arthroplasty with retention of the acetabular component is associated with good outcomes in hips with an appropriately positioned, well-fixed acetabular component. Acetabular components outside the safe zone for inclination were at a higher risk for failure, as was use of conventional polyethylene. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.