Generative AI in orthopedics: an explainable deep few-shot image augmentation pipeline for plain knee radiographs and Kellgren-Lawrence grading.

OBJECTIVES: Recently, deep learning medical image analysis in orthopedics has become highly active. However, progress has been restricted by the absence of large-scale and standardized ground-truth images. To the best of our knowledge, this study is the first to propose an innovative solution, namely a deep few-shot image augmentation pipeline, that addresses this challenge by synthetically generating knee radiographs for training downstream tasks, with a specific focus on knee osteoarthritis Kellgren-Lawrence (KL) grading. MATERIALS AND METHODS: This study leverages a deep few-shot image augmentation pipeline to generate synthetic knee radiographs. Despite the limited availability of training samples, we demonstrate the capability of our proposed computational strategy to produce high-fidelity plain knee radiographs and use them to successfully train a KL grade classifier. RESULTS: Our experimental results showcase the effectiveness of the proposed computational pipeline. The generated synthetic radiographs exhibit remarkable fidelity, evidenced by the achieved average Frechet Inception Distance (FID) score of 26.33 for KL grading and 22.538 for bilateral knee radiographs. For KL grading classification, the classifier achieved a test Cohen's Kappa and accuracy of 0.451 and 0.727, respectively. Our computational strategy also resulted in a publicly and freely available imaging dataset of 86 000 synthetic knee radiographs. CONCLUSIONS: Our approach demonstrates the capability to produce top-notch synthetic knee radiographs and use them for KL grading classification, even when working with a constrained training dataset. The results obtained emphasize the effectiveness of the pipeline in augmenting datasets for knee osteoarthritis research, opening doors for broader applications in orthopedics, medical image analysis, and AI-powered diagnosis.

Wireless In-Ear Communication for Total Joint Arthroplasty: A Simulated Operating Room Evaluation.

Effective communication is vital for patient safety, yet failures are common, often due to outdated methods. This study aimed to assess whether in-ear communication devices improve communication in orthopedic surgery simulations compared to traditional loud voice methods. Fifteen participants underwent simulations using both in-ear wireless devices and standard communication. Results showed significant improvements with in-ear devices in correctly identifying phrases (78.6% vs 44%), effectiveness (7.9/10 vs 4.9/10), and clarity (8/10 vs 4/10), all P < .001. Participants also favored in-ear devices in usability assessments. Sound levels recorded were comparable between groups. In conclusion, in-ear communication is safe and effective in orthopedic settings, potentially enhancing efficiency and safety. These devices can mitigate loud noises, benefiting surgeon well-being and patient outcomes.

Development and Validation of a Mobile Phone Application for Measuring Knee Range of Motion.

Knee range of motion (ROM) is an important indicator of knee function. Outside the clinical setting, patients may not be able to accurately assess knee ROM, which may impair recovery following trauma or surgery. This study aims to validate a smartphone mobile application developed to measure knee ROM compared to visual and goniometer ROM measurements. A knee ROM Android mobile application was developed to measure knee ROM. Patients ≥ 18 years old presenting to an orthopaedic clinic with native knee complaints were approached to participate. Knee ROM was measured bilaterally by an arthroplasty-trained surgeon using (1) vision, (2) goniometer, and (3) the mobile application. Measurements were compared in flexion and extension using a one-way analysis of variance with post hoc Tukey test (alpha = 0.05). Eighty-four knee ROM measurements (40 left, 44 right) were obtained in 47 patients. Median Kellgren-Lawrence grade from available radiographs was grade 3. In flexion, mobile application (117.6 ± 14.7 degrees) measurements were not significantly different from visual (116.1 ± 13.6 degrees) or goniometer (116.2 ± 13.6 degrees) measurements. In extension, mobile application (4.8 ± 7.3 degrees) measurements were significantly different from visual (1.9 ± 4.1 degrees) measurements on post hoc analysis (p < 0.01), while no differences were present compared to goniometer (3.1 ± 5.8 degrees) measurements. Our study found that a mobile application for evaluating knee ROM was noninferior to goniometer-based measurements performed by an arthroplasty-trained surgeon. Future studies will investigate this application's utility in (1) remote patient care, (2) accelerating recovery during rehabilitation, (3) detecting early postoperative complications including arthrofibrosis, and (4) adding additional functionalities to the application to provide more detail-oriented descriptive analyses of patient knee function.

Fair AI-powered orthopedic image segmentation: addressing bias and promoting equitable healthcare.

AI-powered segmentation of hip and knee bony anatomy has revolutionized orthopedics, transforming pre-operative planning and post-operative assessment. Despite the remarkable advancements in AI algorithms for medical imaging, the potential for biases inherent within these models remains largely unexplored. This study tackles these concerns by thoroughly re-examining AI-driven segmentation for hip and knee bony anatomy. While advanced imaging modalities like CT and MRI offer comprehensive views, plain radiographs (X-rays) predominate the standard initial clinical assessment due to their widespread availability, low cost, and rapid acquisition. Hence, we focused on plain radiographs to ensure the utilization of our contribution in diverse healthcare settings, including those with limited access to advanced imaging technologies. This work provides insights into the underlying causes of biases in AI-based knee and hip image segmentation through an extensive evaluation, presenting targeted mitigation strategies to alleviate biases related to sex, race, and age, using an automatic segmentation that is fair, impartial, and safe in the context of AI. Our contribution can enhance inclusivity, ethical practices, equity, and an unbiased healthcare environment with advanced clinical outcomes, aiding decision-making and osteoarthritis research. Furthermore, we have made all the codes and datasets publicly and freely accessible to promote open scientific research.

Implementation of the New Medicare-Mandated Patient-Reported Outcomes After Joint Arthroplasty Performance Measure.

A new mandatory hospital-level, risk-standardized performance measure for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on patient-reported outcomes (THA/TKA PRO-PM) has been implemented by the Centers for Medicare & Medicaid Services (CMS). All THA and TKA in Medicare fee-for-service beneficiaries at inpatient facilities are included. The THA/TKA PRO-PM is the proportion of risk-standardized THA or TKA patients meeting or exceeding the substantial clinical benefit threshold between preoperative and postoperative outcomes measures (Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Knee injury and Osteoarthritis Outcome Score for Joint Replacement). This binary outcome (yes/no) is then divided by all eligible patients creating a percentage of patients reaching substantial clinical benefit. The percentile score among hospitals will be reported. Following 2 voluntary reporting periods, mandatory reporting will begin in 2025. The CMS requires 50% reporting rates; failure leads to annual payment reduction in fiscal year 2028. The CMS intends the THA/TKA PRO-PM to be a patient-centered, meaningful, and relatable measure of hospital performance reported to the public. For surgeons, this is an opportunity to collaborate with hospitals for developing and implementing a THA/TKA data collection system to avoid penalties for the hospital. Further implementation for outpatient surgery and in ambulatory surgery centers has been announced by CMS. Major resources will be needed to succeed in the expected capture rates.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty.

BACKGROUND: A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. METHODS: A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. RESULTS: Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. CONCLUSIONS: The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. LEVEL OF EVIDENCE: III.

HexAI-TJAtxt: A textual dataset to advance open scientific research in total joint arthroplasty.

Total joint arthroplasty (TJA) is the most common and fastest inpatient surgical procedure in the elderly, nationwide. Due to the increasing number of TJA patients and advancements in healthcare, there is a growing number of scientific articles being published in a daily basis. These articles offer important insights into TJA, covering aspects like diagnosis, prevention, treatment strategies, and epidemiological factors. However, there has been limited effort to compile a large-scale text dataset from these articles and make it publicly available for open scientific research in TJA. Rapid yet, utilizing computational text analysis on these large columns of scientific literatures holds great potential for uncovering new knowledge to enhance our understanding of joint diseases and improve the quality of TJA care and clinical outcomes. This work aims to build a dataset entitled HexAI-TJAtxt, which includes more than 61,936 scientific abstracts collected from PubMed using MeSH (Medical Subject Headings) terms within "MeSH Subheading" and "MeSH Major Topic," and Publication Date from 01/01/2000 to 12/31/2022. The current dataset is freely and publicly available at https://github.com/pitthexai/HexAI-TJAtxt, and it will be updated frequently in bi-monthly manner from new abstracts published at PubMed.

Favourable mid-term outcomes following unicompartmental knee arthroplasty with wider patient selection: A single-centre experience.

OBJECTIVE: The purpose of this study was to determine surgical outcomes of robotic-assisted UKAs utilizing a wider set of indications than traditionally utilized. Additionally, we seek to determine alternate predictive factors as potential surgical indications and contraindications. METHODS: A prospectively maintained institutional joint registry was queried at a single academic centre for all patients that underwent robotic-assisted UKA between January 2010-December 2016. Surgical indication included isolated medial or lateral compartment degenerative disease with a stable knee based on physical exam. In 2013, haemoglobin A1C levels over 7.5% were considered contraindications, which was lowered to 7.0% in 2015. Preoperative alignment, age, activity level and degree of pain were not contraindications for surgery. Preoperative demographics, Oxford scores, radiographic (joint space), comorbidities and operative data were collected and reviewed to determine factors related to conversion to TKA and survivorship of the primary implant. RESULTS: In total, 1878 cases were performed; however, excluding multi-joint knees, there were a total of 1186 knees in 1014 patients with a minimum 4-year follow-up. The mean age was 63.4 â€‹± â€‹10.7 years and mean follow-up was 76.4 â€‹± â€‹17.4 months. Mean BMI was 32.3 â€‹± â€‹6.5 â€‹kg/m2. (52.9% females, 47.1% males). There were 901 patients undergoing medial UKA, 122 patients undergoing lateral UKA and 69 patients undergoing patellofemoral UKA. In total, 85 (7.2%) knees underwent conversion to TKA. Preoperative factors such as the degree of preoperative valgus deformity (p â€‹= â€‹0.01), greater operative joint space (p â€‹= â€‹0.04), previous surgery (p â€‹= â€‹0.01), inlay implant (p â€‹= â€‹0.04) and pain syndrome (p â€‹= â€‹0.01) were associated with increased risk of revision surgery. Factors associated with decreased implant survivorship included patients with history of previous surgery (p â€‹< â€‹0.01), history of pain syndrome (p â€‹< â€‹0.01) and greater preoperative joint space (>2 â€‹mm) (p â€‹< â€‹0.01). There was no association of BMI to conversion to TKA. CONCLUSION: Robotic-assisted UKA with wider patient selection demonstrated favourable outcomes at 4 years with survivorship greater than 92%. The present series agree with emerging indications that do not exclude patients based on age, BMI, or degree of deformity. However, increased operative joint space, inlay design, history of surgery and coexistence of pain syndrome are factors that increase risk of conversion to TKA. LEVEL OF EVIDENCE: Level III.

Shared and unique risk factors for readmission exist following upper and lower extremity arthroplasty in the 30-day postoperative period.

PURPOSE: Joint arthroplasty has become increasingly more common in the United States, and it is important to examine the patient-based risk factors and surgical variables associated with hospital readmissions. The purpose of this study was to identify stratified rates and risk factors for readmission after upper extremity (shoulder, elbow, and wrist) and lower extremity (hip, knee, and ankle) arthroplasty. METHODS: All patients undergoing upper and lower extremity arthroplasty from 2008-2018 were identified using the National Surgical Quality Improvement Program dataset. Patient demographics, medical comorbidities and surgical characteristics were examined utilizing uni- and multi-variate analysis for significant predictors of 30-days hospital readmission. RESULTS: A total of 523,523 lower and 25,215 upper extremity arthroplasty patients were included in this study. A number of 22,183 (4.2%) lower and 1072 (4.4%) upper extremity arthroplasty patients were readmitted within 30 days of discharge. Significant risk factors for 30-days readmission after lower extremity arthroplasty included age, Body Mass Index (BMI), operative time, dependent functional status, American Society of Anesthesiologists (ASA) score ≥3, increased length of stay, and various medical comorbidities such as diabetes, tobacco dependency, and chronic obstructive pulmonary disease (COPD). An overweight BMI was associated with a lower odds of 30-days readmission when compared to a normal BMI for lower extremity arthroplasty. Analysis for upper extremity arthroplasty revealed similar findings of significant risk factors for 30-days hospital readmission, although diabetes mellitus was not found to be a significant risk factor. CONCLUSION: Nearly one in 25 patients undergoing upper and lower extremity arthroplasty experiences hospital readmission within 30-days of index surgery. There are several modifiable risk factors for 30-days hospital readmission shared by both lower and upper extremity arthroplasty, including tobacco smoking, COPD, and hypertension. Optimization of these medical comorbidities may mitigate the risk short-term readmission following joint arthroplasty procedures and improve overall cost effectiveness of perioperative surgical care.

Oxidized Zirconium Versus Cobalt Chromium for Primary TKA: No Difference in Midterm Revision Rates From the American Joint Replacement Registry.

BACKGROUND: Cobalt chromium (CoCr) is the most commonly used material in TKA; however, the use of oxidized zirconium (OxZr) implants has increased. The advantages to this material demonstrated in basic science studies have not been borne out in clinical studies to date. QUESTION/PURPOSE: In the setting of the American Joint Replacement Registry (AJRR), how do revision rates differ between CoCr and OxZr after primary TKA? METHODS: The AJRR was accessed for all primary TKAs performed between 2012 and 2020 for osteoarthritis, resulting in 441,605 procedures (68,506 with OxZr and 373,099 with CoCr). The AJRR is the largest joint replacement registry worldwide and collects procedure-specific details, making it ideal for large-scale comparisons of implant materials in the United States. Competing risk survival analyses were used to evaluate the all-cause revision rates of primary TKAs, comparing CoCr and OxZr implants. Data from the Centers for Medicare and Medicaid Services claims from 2012 to 2017 were also cross-referenced to capture additional revisions from other institutions. Revision rates were tabulated and subclassified by indication. Multivariate Cox regression was used to account for confounding variables such as age, gender, region, and hospital size. RESULTS: After controlling for confounding variables, there were no differences between the OxZr and CoCr groups in terms of the rate of all-cause revision at a mean follow-up of 46 ± 23 months and 44 ± 24 months for CoCr and OxZr implants, respectively (hazard ratio 1.055 [95% confidence interval 0.979 to 1.137]; p = 0.16) The univariate analysis demonstrated increased rates of revisions for pain and instability in the OxZr group (p = 0.003 and p < 0.001, respectively). CONCLUSION: These findings suggest there is no difference in all-cause revision between OxZr and CoCr implants in the short-term to mid-term. However, further long-term in vivo studies are needed to monitor the safety and all-cause revision rate of OxZr implants compared with those of CoCr implants. OxZr implants may be favorable in patients who have sensitivity to metal. Despite similar short-term to mid-term all-cause revision rates to CoCr implants, because of the limitations of this study, definitive recommendations for or against the use of OxZr cannot be made. LEVEL OF EVIDENCE: Level III, therapeutic study.

An Innovative Seven-year Physician Scientist Residency Training Program That Addresses the Shortage of Academic Surgeons.

Due to the declining number of scientifically trained physicians and increasing demand for high-quality literature, our institution pioneered a seven-year Physician Scientist Training Program (PSTP) to provide research-oriented residents the knowledge and skills for a successful academic career. The present study sought to identify orthopaedic surgeons with MD/PhD degrees, residency programs with dedicated research tracks, and to assess the effectiveness of the novel seven-year program in training prospective academic orthopaedic surgeons. Surgeons with MD/PhD degrees account for 2.3% of all 3,408 orthopaedic faculty positions in U.S. residency programs. During the last 23 years, our PSTP residents produced 752 peer-reviewed publications and received $349,354 from 23 resident-authored extramural grants. Eleven of our seven-year alumni practice orthopaedic surgery in an academic setting. The seven-year PSTP successfully develops clinically trained surgeon scientists with refined skills in basic science and clinical experimental design, grant proposals, scientific presentations, and manuscript preparation. (Journal of Surgical Orthopaedic Advances 31(3):144-149, 2022).

Gout As a Predictor of Total Knee Arthroplasty Outcomes and Costs.

Gout is the most common inflammatory arthritis and affects approximately 4% of the U.S. population. As the prevalence of gout and the number of total knee arthroplasties (TKAs) performed continue to increase, the literature on TKA in patients with gout remains scant. The purpose of this study was to evaluate the outcomes of patients with gout following TKA at a population level, that is, how patient with gout fair after TKA. We hypothesized that patients with gout have higher rates of complications and higher costs compared with controls. A case-control study was designed to evaluate two cohorts of Medicare patients who underwent TKA whose only distinguishing feature was the presence or absence of gout. Matching was performed to decrease confounding at a 1:1 ratio based on age, gender, and Charlson comorbidity index (CCI), (10-year survival predictor). The Medicare standard analytical files were queried through International Classification of Disease and current procedural terminology codes. A total of 15,238 patients were evaluated with 7,619 in each cohort. There were no age, gender, or CCI differences and 57.4% were females. Day of surgery and 90-day post-surgery costs were both significantly greater in those with gout (p < 0.001 for both). Multivariate analysis revealed that gout patients had increased odds of infection (odds ratio [OR] 1.229, p = 0.019), cardiac arrest (OR 1.354, p = 0.002), pneumonia (OR 1.161, p < 0.001), hematoma (OR 1.204, p = 0.002), and development of capsulitis (OR 1.208, p = 0.012). Nonetheless these patients had a decreased risk of pulmonary emboli (OR 0.835, p = 0.016). Our results support our hypothesis that patients with gout have higher rates of postoperative complications and increased day of surgery and 90-day costs of care after TKA. Given the high prevalence of gout in the United States, additional study on the utility of preoperative gout optimization for TKA patients is warranted. The level of evidence of this study is III, and it is a retrospective case-control study.

Trends and risk factors for opioid administration for non-emergent lower back pain.

BACKGROUND: Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint. AIM: To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED. METHODS: Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The "year" variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05. RESULTS: Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast. CONCLUSION: From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.

Removing Well-Fixed, Collared and Noncollared Tapered Hip Stems Without an Extended Trochanteric Osteotomy Using a Novel Stem Removal System.

Improvements in materials, components, and surgical techniques in cementless total hip arthroplasty are resulting in improved femoral stem fixation through bony ongrowth or ingrowth. While improved femoral stem fixation is one reason for the current excellent total hip survivorship, indications for stem removal such as infection, implant fracture, or osteolysis remain. A commonly used technique for fully ingrown femoral stems is an extended trochanteric osteotomy which can result in comminuted fractures of the proximal femur during stem removal requiring additional fixation. Therefore, a novel hip stem removal was developed to facilitate removal of these well-ingrown stems without the need for an extended trochanteric osteotomy. This study describes the removal system and surgical technique and presents a case series of successfully removed ingrown stems.

Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections.

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.

Revision Total Joint Arthroplasty: Final Stop Tertiary Referral Center.

High complication rates associated with revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) may unequally burden tertiary referral centers, which manage medically complex patients. The authors aimed to quantify TKA and THA referral patterns at a tertiary referral center based on travel distance and patient comorbidities. All patients who underwent primary or revision TKA or THA at the investigating institution from 2012 to 2016 were identified. Travel distance was calculated using each patient's home address and stratified into less than 25 miles, 25 to 74 miles, and 75 miles or more. Age, body mass index, Charlson Comorbidity Index, and postoperative clinical data were identified. Patients were analyzed based on procedure performed and travel distance. A total of 4245 procedures were included for analysis (1754 primary TKAs, 432 revision TKAs, 1503 primary THAs, and 556 revision THAs). Patients living 75 miles or more away had significantly higher odds of undergoing revision arthroplasty compared with patients living within 25 miles (knee: odds ratio [OR], 2.43; hip: OR, 2.61; P<.001). Charlson Comorbidity Index did not increase with travel distance. Patients traveling 75 miles or more were more likely to have periprosthetic fracture (OR, 3.91; P=.011) and less likely to have dislocation (OR, 0.54; P=.026) as the surgical indication for revision. Patients referred to a tertiary center were more likely to necessitate revision total joint arthroplasty but did not differ in comorbidity profile compared with local patients. Periprosthetic fracture, a particularly high-risk surgical indication, was overrepresented among referral patients. These data suggest that factors such as underlying diagnosis, but not preoperative medical comorbidities, may influence referral patterns. [Orthopedics. 2021;44(4):e477-e481.].

Dermatomyositis and polymyositis in total hip arthroplasty.

BACKGROUND: Idiopathic inflammatory myopathies (IIM) are systemic autoimmune disorders such as dermatomyositis (DM), polymyositis (PM), inclusion body myopathy, and autoimmune necrotizing myopathy that, similar to osteoarthritis, affect quality of life and activities of daily living. Moreover, these patients are often burdened with chronic pain and disability; however, the outcomes and risk of total hip arthroplasty (THA) in this patient population remain unclear. AIM: To evaluate 90-d complications and costs in patients with these conditions. METHODS: A retrospective case control study was designed by accessing data from the Medicare dataset available on the PearlDiver server. Patients with IIM, here, those with DM and PM were matched based on possible confounding variables to a cohort without these diseases and with the same 10-year risk of mortality as defined by the Charlson Comorbidity Index Score (CCI). Univariate and multivariate analysis were performed to evaluate complications and t-tests to evaluate 90-d Medicare reimbursements as markers of costs after THA. RESULTS: The total sample was 1090 patients with each cohort comprised of 545. Females were 74.9% of the population. The mean CCI was 5.89 (SD 2.11). Those with IIM had increased rates of pneumonia [odds ratio (OR) 1.45, P < 0.001] and pulmonary embolism (OR 1.46, P = 0.035) and decreased hematoma risks (OR 0.58, P = 0.00). 90-d costs were on average $1411 greater for those with IIM yet not significantly different (P = 0.034). CONCLUSION: Patients with IIM have an increased 90-d rate of pneumonia and pulmonary embolism concomitant with a decreased hematoma rate consistent with their pro-coagulatory state. Further attention to increased resource utilization in these patients is also warranted.

Spaceflight and hind limb unloading induces an arthritic phenotype in knee articular cartilage and menisci of rodents.

Reduced knee weight-bearing from prescription or sedentary lifestyles are associated with cartilage degradation; effects on the meniscus are unclear. Rodents exposed to spaceflight or hind limb unloading (HLU) represent unique opportunities to evaluate this question. This study evaluated arthritic changes in the medial knee compartment that bears the highest loads across the knee after actual and simulated spaceflight, and recovery with subsequent full weight-bearing. Cartilage and meniscal degradation in mice were measured via microCT, histology, and proteomics and/or biochemically after: (1) ~ 35 days on the International Space Station (ISS); (2) 13-days aboard the Space Shuttle Atlantis; or (3) 30 days of HLU, followed by a 49-day weight-bearing readaptation with/without exercise. Cartilage degradation post-ISS and HLU occurred at similar spatial locations, the tibial-femoral cartilage-cartilage contact point, with meniscal volume decline. Cartilage and meniscal glycosaminoglycan content were decreased in unloaded mice, with elevated catabolic enzymes (e.g., matrix metalloproteinases), and elevated oxidative stress and catabolic molecular pathway responses in menisci. After the 13-day Shuttle flight, meniscal degradation was observed. During readaptation, recovery of cartilage volume and thickness occurred with exercise. Reduced weight-bearing from either spaceflight or HLU induced an arthritic phenotype in cartilage and menisci, and exercise promoted recovery.

Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis.

BACKGROUND: The purpose of this study was to perform an epidemiological evaluation and an economic analysis of 90-day costs associated with non-fatal gunshot wounds (GSWs) to the extremities, spine and pelvis requiring orthopaedic care in the United States. METHODS: A retrospective epidemiological review of the Medicare national patient record database was conducted from 2005 to 2014. Incidence, fracture location and costs associated where evaluated. Those patients identified through International Classification of Disease (ICD)-9 revision codes and Current Procedural Terminology (CPT) Codes who sustained a fracture secondary to a GSW. Any type of surgical intervention including incision and drainage, open reduction with internal fixation, closed reduction and percutaneous fixation, etc. were identified to analyze, and evaluate costs of care as seen by charges and reimbursements to the payer. The 90-day period after initial fracture care was queried. RESULTS: A total of 9,765 patients required surgical orthopaedic care for GSWs. There was a total of 2,183 fractures due to GSW treated operatively in 2,201 patients. Of these, 22% were femur fractures, 18.3% were hand/wrist fractures and 16.7% were ankle/foot fractures. A majority of patients were male (83.3%) and under 65 years of age (56.3%). Total charges for GSW requiring orthopedic care were $513,334,743 during the 10-year study period. Total reimbursement for these patients were $124,723,068. Average charges per patient were highest for fracture management of the spine $431,021.33, followed by the pelvis $392,658.45 and later by tibia/fibula fractures $342,316.92. CONCLUSIONS: The 90-day direct charges and reimbursements of orthopedic care for non-fatal GSWs are of significant amounts per patient. While the number of fatal GSWs has received much attention, non-fatal GSWs have a large economic and societal impact that warrants further research and consideration by the public and policy makers.

Addressing National Opioid Prescribing Practices for Knee Osteoarthritis: An Analysis of an Estimated 41,389,332 Patients With Knee Arthritis.

INTRODUCTION: Knee osteoarthritis (OA) is a chronic pathology that is treated across multiple specialties. Opioid prescribing practices for knee OA have not been described on a national level. The purpose of this study was to (1) investigate the trends in opioid prescriptions for knee OA, (2) characterize and identify predominant opioid based medications prescribed for knee OA, and (3) identify patient- and provider-related factors influencing opioid prescribing patterns in the treatment of knee OA in the outpatient setting. METHODS: The National Ambulatory Medical Care Survey (NAMCS) was used to identify all patients in the United States who presented to an outpatient clinic for knee OA between 2007 and 2016. New opioid prescriptions were determined using a previously published algorithm. Generalized linear models were used to assess trends. RESULTS: A total of 41,389,332 patients were included, of which 12.8% were prescribed an opioid-based medication. Opioid prescription rose from 2007/2008 to 2013/2014. Analysis of the opioid type demonstrated that the prescription of hydrocodone-based medication and "other" traditional opioids followed the aforementioned trends. However, tramadol prescription demonstrated a sustained increase throughout the years peaking at 2015/2016. Patient income in the lowest quartile, a worker's compensation status, and depression were independently associated with higher odds of opioid prescription for knee OA. CONCLUSIONS: Opioid prescription for knee OA remains high. Decreases in traditional opioid prescription have been countered by increase in tramadol prescription. The risks and addictive potential of tramadol and patient and provider risk factors should be emphasized.