The Impact of Diagnosed Chronic Sleep Disorders on Outcomes Following Total Knee Arthroplasty.

BACKGROUND: Up to 20% of patients undergoing total knee arthroplasty (TKA) remain dissatisfied with their outcome, leading to the identification of risk factors for poor outcomes. The purpose of this study was to analyze the effect of chronic sleep disorders on patient-reported outcomes after primary TKA. METHODS: A retrospective review of patients undergoing primary TKA was conducted using a prospectively collected database of patients from a single institution between 2018 and 2022. The cohort was split based on the presence of documented chronic sleep disorders, identified preoperatively from the electronic medical record using Current Procedural Terminology (CPT) codes. The sample was further restricted to include all patients who have sleep disorders (SD), as well as a 3:1 propensity-matched (on age, sex, Body Mass Index (BMI), and American Society of Anesthesiologists (ASA) class) cohort of patients who had no documented sleep disorders (NSD) prior to surgery. The final sample included 172 patients (SD: 43; NSD: 129). Repeated measures linear mixed model analysis was used to analyze the progression of Knee Injury and Osteoarthritis Outcome Score (KOOS) scores through time between groups. RESULTS: Those who had SD had a lower preoperative mean total KOOS score (40.2) compared to the NSD group (44.1), however, this was not significantly different (P = 0.108). At one year postoperatively, those who had a SD had a significantly higher mean total KOOS score (87.2) when compared to the NSD group (80.4), P = 0.005. When comparing total KOOS scores by group, over each time period, the SD group showed a better progression when compared to the NSD group, P = 0.001. CONCLUSION: Compared to patients who did not have documented chronic sleep disorders, patients who had a prior history of chronic sleep disorders reported significantly greater improvements in most KOOS domains in the 12-month period following TKA.

Perceptions of Preference Signaling in Orthopaedic Surgery: A Survey of Applicants and Program Directors.

INTRODUCTION: To improve transparency between candidates and training programs, a preference signaling program (PSP) was implemented before the 2022 to 2023 orthopaedic surgery match. The PSP allows applicants to 'signal' up to 30 programs, informing the program of the applicant's particular interest in interviewing for their available position(s). This study reports the perspectives of orthopaedic surgery residency applicants and program directors (PDs) on the effects of preference signaling on the orthopaedic match. METHODS: Electronic surveys were distributed to PDs and applicants. RESULTS: Almost all programs participated in the PSP (90%), and most of the applicants (97.6%) used 25 to 30 of their allotted preference signals. Most of the applicants (67.2%) thought that their likelihood of obtaining an interview was improved at 'signaled' programs but decreased at programs without a 'signal' designation (85.3%). Both applicants and PDs considered preference signaling to be one of the three most important factors for interview selection, along with Step 2 CK score and letters of recommendation. The applicants did not think that their likelihood of matching would improve with fewer allotted signaling tokens (35.2%), and 55.2% of PDs believed 21 to 30 tokens were optimal. CONCLUSION: Preference signaling is highly regarded by applicants and PDs. Signaling a program will likely improve an applicant's chance to interview. The optimal number of signaling tokens remains unknown, although both groups favored a larger allotment of tokens than has been seen in other specialties. Universal guidelines and recommendations for applicants and PDs would improve the utility of preference signaling.

Factors Affecting Anxiety-Related Symptoms, Diagnosis, and Treatment Among Collegiate Student-Athletes in the National College Health Assessment.

CONTEXT: Increased attention continues to be placed on best practices for assisting student-athletes who show symptoms of a mental health illness. One of the most common mental health concerns for student-athletes is feeling overwhelmed or anxious. Early recognition of these symptoms can help student-athletes find early intervention. OBJECTIVE: To elucidate specific attributes associated with an increased likelihood of anxiety symptoms and treatment avoidance to help athletic trainers and other practitioners better identify and assist high-risk individuals. DESIGN: Cross-sectional study. SETTING: Colleges and universities in the United States. PATIENTS OR OTHER PARTICIPANTS: A total of 51 882 varsity athletes who completed the National College Health Assessment between 2011 and 2019. MAIN OUTCOME MEASURE(S): Survey responses (self-report) to questions related to anxiety symptoms and disorders cross-sectioned into 9 predictors: year in school, gender, sexual orientation, race and ethnicity, international student status, school type, received information on stress reduction or depression or anxiety, anxiety about impeding academic performance, and history of mental health treatment in the last year. RESULTS: More than three-fourths (82.9%, n = 43 016) of student-athletes reported feeling overwhelmed because of all that they had to do in their daily activities, whereas only half (47.5%, n = 24 645) of student-athletes described overwhelming anxiety as a symptom. Gender, sexual orientation, race and ethnicity, school type, and previous mental health treatment had large effects on these 2 symptoms. However, of the student-athletes who reported overwhelming anxiety as a symptom, only one-fourth (22.9%, n = 5649) indicated they received a diagnosis of anxiety with or without treatment. CONCLUSIONS: Factors such as the year in school and availability of mental health information appeared to have little effect on the experience of anxiety-related symptoms and the propensity to seek treatment. However, other factors, including gender, sexual orientation, race and ethnicity, school type, and previous mental health treatment, did have important effects. Our study provides additional evidence that the stresses placed on collegiate student-athletes frequently led to feelings of being overwhelmed and, eventually, anxiety disorder diagnoses. However, most student-athletes experiencing anxiety-related symptoms still did not seek a diagnosis with or without treatment.

Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion.

PURPOSE: The goal of this study was to compare our institution's recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores. METHODS: This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis. RESULTS: We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P<0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P < 0.01). We found no difference in pain scores between the two groups. CONCLUSION: Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients.

Radiographic Measurements Correlate to Isolated Posterolateral Corner (PLC) Injury in a Novel Cadaveric Model.

INTRODUCTION:  Injury to the posterolateral corner (PLC) of the knee often requires surgical reconstruction. There remains no consensus on treatment for PLC injury, and, therefore, it is imperative to have a reproducible injury model to improve the general knowledge of PLC injuries. A novel cadaveric model of isolated PLC injury is proposed and evaluated using radiographic parameters as well as gross dissection. MATERIAL AND METHODS:  All protocols were reviewed by the Human Investigation and Research Committee of the home institution and were approved. Translational force in a defined posterior and lateral direction was applied to cadaveric native knees to induce PLC injury. Varus and recurvatum stress fluoroscopic imaging was obtained of each specimen before and after the injury model. Lateral joint distance and recurvatum angle after stress was measured on each image via picture archiving and communication software (PACS) imaging software. After the injury model, injured structures were assessed via saline loading and gross dissection. Any specimens found to be fractured were excluded from the analysis of stress radiography. RESULTS:  A total of 12 knees underwent testing and 6/12 successfully induced PLC injury without fracture. The lateral capsule was torn in every specimen. The popliteofibular ligament (PFL) was torn in 83% of specimens and the fibular collateral ligament (FCL) in 66.7% of specimens. The median lateral gapping after injury under varus stress radiography was 5.39 mm and the median recurvatum angle after injury was 14.25°. Radiographic parameters had a direct relationship with a number of structures injured. CONCLUSIONS:  This is the first successful cadaver model of PLC injury. The lateral capsule was injured in every specimen emphasizing the importance of this structure to the PLC.

Use of single agent Cefotetan for Gustilo-Anderson type III open fracture prophylaxis.

INTRODUCTION: The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within orthopedic surgery as a prophylactic intravenous agent. PATIENTS AND METHODS: Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/literature-supported and otherwise) was studied for patient encounters between September 2010 and December 2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics, and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor within the non-cefotetan cohort. RESULTS: The nested variable accounting for standard/literature-supported antibiotic regimens had no significant effect in any model for any outcome (for each, P ≥ 0.302). Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan (n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773). Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719). CONCLUSION: Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone fractures. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Trends in Collegiate Student-Athlete Mental Health in the National College Health Assessment, 2011-2019.

CONTEXT: Recently, the athletic training community has paid increased attention to collegiate student-athlete mental health, mental health treatment-seeking behavior, and the effects of mental health factors on athletic and academic performance. Ongoing efforts to better educate and equip athletic trainers to help student-athletes in this regard should result in improved mental health-related outcomes. OBJECTIVE: To examine changes in the mental health of student-athletes over the past decade compared with that of nonathlete students. DESIGN: Cross-sectional study. SETTING: Colleges and universities in the United States. PATIENTS OR OTHER PARTICIPANTS: Varsity athletes (athletes; n = 54 479) and nonathlete students (nonathletes; n = 448 301) who completed the National College Health Assessment between 2011 and 2019. MAIN OUTCOME MEASURE(S): Surveys included responses (self-reported) to questions in 5 mental health-related categories: recent mental health symptoms, recent mental health diagnosis, mental health treatment-seeking behavior, receiving mental health information from the institution, and the recent effect of mental health factors on academic performance. RESULTS: Athletes consistently described lower symptom and diagnosis rates compared with nonathletes, except for attempted suicide, substance abuse, and eating disorders. Rates of diagnosis increased over time in both groups but remained lower in athletes. Treatment-seeking behavior and openness to future treatment increased over time in both groups but remained lower in athletes. Athletes received more information on stress reduction, substance abuse, eating disorders, and handling distress or violence compared with nonathletes. Both groups received information more frequently over time. Athletes reported fewer academic effects, especially for depression and anxiety, but these effects grew over time in both groups. The effects of injuries and extracurricular activities on academic performance were greater in athletes than in nonathletes. CONCLUSIONS: Athletes described overall lower levels of mental health symptoms, diagnoses, and academic effects compared with nonathletes. Whereas the rates in nonathletes climbed over the past decade, the rates in athletes broadly remained flat or climbed less rapidly. Increasingly positive attitudes toward treatment were encouraging, but the deficit in athletes relative to nonathletes persisted. Ongoing efforts of athletic trainers to educate athletes and guide them to mental health resources are needed to continue, or better yet to accelerate, the observed positive trends in information dissemination and treatment-seeking behavior.

Backout of Distal Interlocking Screws After Retrograde Femoral Nailing With a Novel Device: A Case Series.

OBJECTIVE: To report upon a series of patients who have experienced the backout of distal interlocking screws after retrograde femoral nailing with the DePuy Synthes RFN-Advanced Retrograde Femoral Nailing System (DePuy Synthes, Raynham, MA). DESIGN: Retrospective case series. PATIENTS: Twenty-seven skeletally mature patients with femoral shaft or distal femur fractures who underwent operative fixation with the DePuy Synthes RFN-Advanced Retrograde Femoral Nailing System with 8 patients subsequently experiencing backout of distal interlocking screws. INTERVENTION: The study intervention included retrospective review of patient charts and radiographs. MAIN OUTCOME MEASURE: The incidence rate of distal interlocking screw backout. RESULTS: Thirty percent of patients experienced the backout of at least 1 distal interlocking screw (mean: 1.625) after undergoing retrograde femoral nailing with the RFN-Advanced system. Thirteen total screws backed out postoperatively. Screw backout was identified an average of 61 days postoperatively (range: 30-139 days). All patients complained of implant prominence and pain along the medial or lateral aspect of the knee. Five patients elected to return to the operating room to remove the symptomatic implant. The oblique distal interlocking screws comprised 62% of screw backouts. CONCLUSIONS: Given the high incidence rate of this complication, the associated costs of reoperation, and patient discomfort, we believe that a further investigation into this implant complication is warranted. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Funding has no effect on studies evaluating viscosupplementation for knee osteoarthritis: A systematic review of bibliometrics and conflicts of interest.

Background: Viscosupplementation for knee osteoarthritis (OA) may raise concerns regarding conflicts of interest (COI). Evidence of inconclusive study results and publication bias in previous studies has led to concern that financial COI have influenced viscosupplementation outcomes. It is critical to ensure that clinical practice is guided by informed decision making and evidence-based medicine. Methods: A systematic review was conducted following PRISMA guidelines. PubMed, MEDLINE, and Web of Science databases were searched for articles pertaining to hyaluronic acid (or similarly derived) injections to native knees with primary OA only. Bibliometric data, financial COI, and study outcomes were assessed. Results: 67 studies met inclusion criteria for analysis, 53 of which (79.1%) presented Level I evidence, and 21 of which (31.3%) reported at least one author with COI. All studies reporting COI also disclosed industry funding. There were no relationships between reported COI and study outcomes (Χ 2  = 0.31, P = 0.577), levels of evidence (Χ 2  = 3.48, P = 0.176), or relative citation ratio (RCR) (S = 743, P = 0.591). Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors (IF) (reporting COI: IF = 3.5 ± 2.0; no COI: IF = 1.8 ± 1.1; S = 950, P < 0.001). Study outcomes were not related to the probability of being published in an open access journal (Χ 2  = 0.01, P = 0.960), nor to level of evidence (Χ 2  = 2.67, P = 0.263), RCR (S = 618, P = 0.835), or IF (S = 563, P = 0.655). Conclusions: Investigator COIs (and commercial funding of studies) have not significantly influenced the frequency of favorable outcomes or study level of evidence regarding contemporary viscosupplementation for the treatment of knee OA. Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors. Results overwhelmingly supported using viscosupplementation to treat knee OA. Level of evidence: Level V Systematic Review.

The statistical fragility of intramedullary reaming in tibial nail fixation: a systematic review.

PURPOSE: To report the statistical stability of prospective clinical trials evaluating the effect of intramedullary reaming on rates of non-union in tibial fractures through calculation of the fragility metrics for non-union rates and all other dichotomous outcomes. METHODS: Literature search was conducted for prospective clinical trials evaluating the effect of intramedullary reaming on non-union rates in tibial nailing. All dichotomous outcomes were extracted from the manuscripts. The fragility index (FI) and reverse fragility index (RFI) were calculated by determining the number of event reversals required for a statistically significant outcome to lose significance and vice-versa. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI or RFI by the sample size, respectively. Outcomes were defined as "fragile" if the FI or RFI was found to be less than or equal to the number of patients lost to follow-up. RESULTS: Literature search identified 579 results which produced ten studies meeting the criteria for review. There were 111 outcomes identified for analysis, of which 89 (80%) exhibited statistical fragility. For reported outcomes across the studies the median and mean FI was 2, the median FQ was 0.019, the mean FQ was 0.030, the median RFI was 4, the mean RFI was 3.95, the median RFQ was 0.045, and the mean RFQ was 0.030. Four studies reported outcomes which were found to have an FI of 0. CONCLUSIONS: The studies evaluating the effect of intramedullary reaming on tibial nail fixation demonstrate considerable fragility. On average, two event reversals for significant findings, and four event reversals for insignificant findings are sufficient to alter statistical significance. LEVEL OF EVIDENCE: Level II, systematic review of Level I and Level II studies.

Examining the incidence of reporting mental health diagnosis between college student athletes and non-athlete students and the impact on academic performance.

Objective: Compare collegiate athletes to non-athlete students for mental health diagnosis, treatment, and mental health impacts on academic performance. Participants: Students, including club and varsity athletes, from a large Midwestern U.S. NCAA Division 1 university (N = 2167). Methods: American College Health Association (ACHA)-NCHA II (2010-2016) survey data were analyzed using chi square tests for between-groups differences and gender effects on mental health diagnoses, treatment, and academic impacts of mental health. Results: Compared to athletes, non-athletes reported higher rates of anxiety, eating, mood, sleep, and other disorders. Controlling for gender, these differences were not significant. Regardless of gender, athletes sought treatment less often than non-athletes. Athletes reported anxiety, sleep, alcohol/drugs, extracurricular activities and injuries as major academic impediments. Conclusions: Mental health diagnosis rates were lower in athletes, but appeared to be an artifact of gender differences between groups. However, less treatment-seeking and academic impacts mean that ongoing attention to mental health is vital to student-athlete well-being.

Accuracy of self-reported opioid use in orthopaedic trauma patients.

PURPOSE: Opioids have long been a mainstay of treatment for pain in patients with orthopaedic injuries, but little is known about the accuracy of self-reported narcotic usage in orthopaedic trauma. The purpose of this study is to evaluate the accuracy of self-reported opioid usage in orthopaedic trauma patients. METHODS: A retrospective review of all new patients presenting to the orthopaedic trauma clinic of a level 1 trauma centre with a chief complaint of recent orthopaedic-related injury over a 2-year time frame was conducted. Participants were administered a survey inquiring about narcotic usage within the prior 3 months. Responses were cross-referenced against a query of a statewide prescription drug monitoring program system. RESULTS: The study comprised 241 participants; 206 (85.5%) were accurate reporters, while 35 (14.5%) were inaccurate reporters. Significantly increased accuracy was associated with hospital admission prior to clinic visit (ß = - 1.33; χ2 = 10.68, P < 0.01; OR: 0.07, 95% CI 0.01-0.62). Decreased accuracy was associated with higher pre-visit total morphine equivalent dose (MED) (ß = 0.002; χ2 = 11.30, P < 0.01), with accurate reporters having significantly lower pre-index visit MED levels compared to underreporters (89.2 ± 208.7 mg vs. 249.6 ± 509.3 mg; P = 0.04). An Emergency Department (ED) visit prior to the index visit significantly predicted underreporting (ß = 0.424; χ2 = 4.28, P = 0.04; OR: 2.34, 95% CI 1.01-5.38). CONCLUSION: This study suggests that most new patients presenting to an orthopaedic trauma clinic with acute injury will accurately report their narcotic usage within the preceding 3 months. Prior hospital admissions increased the likelihood of accurate reporting while higher MEDs or an ED visit prior to the initial visit increased the likelihood of underreporting.

Effects of pubertal growth variation on knee mechanics during walking in female and male adolescents.

INTRODUCTION: Puberty substantially alters the body's mechanical properties, neuromuscular control, and sex differences therein, likely contributing to increased, sex-biased knee injury risk during adolescence. Female adolescents have higher risk for knee injuries than male adolescents of similar age engaging in similar physical activities, and much research has investigated sex differences in mechanical risk factors. However, few studies address the considerable variation in pubertal growth (timing, pace), knee mechanics, and injury susceptibility within sexes, or the impact of such growth variation on mechanical injury risk. OBJECTIVES: The present study tested for effects of variation in pubertal growth on established mechanical knee injury risk factors, examining relationships between and within sexes. METHODS: Pubertal growth indices describing variation in the timing and rate of pubertal growth were developed using principal component analysis and auxological data from serial stature measurements. Linear mixed models were applied to evaluate relationships between these indices and knee mechanics during walking in a sample of adolescents. RESULTS: Later developing female adolescents with slower pubertal growth had higher extension moments throughout stance, whereas earlier developers had higher valgus knee angles and moments. In male adolescents, faster and later growth were related to higher extension moments throughout gait. In both sexes, faster growers had higher internal rotation moments at foot-strike. CONCLUSIONS: Pubertal growth variation has important effects on mechanical knee injury risk in adolescence, affecting females and males differently. Earlier developing females exhibit greater injury risk via frontal plane factors, whereas later/faster developing males have elevated risk via sagittal plane mechanisms.

Funding has no effect on clinical outcomes of total joint arthroplasty emerging technologies: a systematic review of bibliometrics and conflicts of interest.

BACKGROUND: The use of new total joint arthroplasty technologies, including patient-specific implants/instrumentation (PSI), computer-assisted (CA), and robotic-assisted (RA) techniques, is increasing. There is an ongoing debate regarding the value provided and potential concerns about conflicts of interest (COI). METHODS: PRISMA guidelines were followed. PubMed, MEDLINE, and Web of Science databases were searched for total hip and knee arthroplasties, unicompartmental knee arthroplasties (UKA), PSI, CA, and RA. Bibliometric data, financial COI, clinical/functional scores, and patient-reported outcomes were assessed. RESULTS: Eighty-seven studies were evaluated, with 35 (40.2%) including at least one author reporting COI, and 13 (14.9%) disclosing industry funding. COI and industry funding had no significant effects on outcomes (P = 0.682, P = 0.447), and there were no significant effects of conflicts or funding on level of evidence (P = 0.508, P = 0.826). Studies in which author(s) disclosed COI had significantly higher relative citation ratio (RCR) and impact factor (IF) than those without (P < 0.001, P = 0.032). Subanalysis demonstrated RA and PSI studies were more likely to report COI or industry funding (P = 0.045). RA (OR = 6.31, 95% CI: 1.61-24.68) and UKA (OR = 9.14, 95% CI: 1.43-58.53) had higher odds of reporting favorable outcomes than PSI. CONCLUSIONS: Author COIs (about 40%) may be lower than previously reported in orthopedic technologies/techniques reviews. Studies utilizing RA and PSI were more likely to report COI, while RA and UKA studies were more likely to report favorable outcomes than PSI. No statistically significant association between the presence of COIs and/or industry funding and the frequency of favorable outcomes or study level of evidence was found. LEVEL OF EVIDENCE: Level V Systematic Review.

Effects of veterans' mental health service-connections on patient-reported outcomes following total joint arthroplasty.

Background: Studies report poor outcomes of elective orthopaedic surgeries among civilian patients receiving Workers' Compensation (WC). However, little is known about surgical outcomes in veterans receiving similar benefits through the Veterans Affairs (VA) service-connected (SC) disability compensation program. Methods: Veterans undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a VA Medical Center between 07/2019-12/2021 were analyzed by SC status. Outcomes were evaluated using Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores collected preoperatively and at 2- and 12-months postoperatively. Repeated measures mixed models were used to test for the effect of SC on HOOS-JR/KOOS-JR scores, controlling for baseline age, sex, and Charlson Comorbidity Index (CCI). SC and baseline joint function (stratified into quartiles using baseline HOOS-JR/KOOS-JR scores) were analyzed for effects on achieving substantial clinical benefit (SCB) at 12-month follow-up. Results: The analysis included 67 hips and 142 knees. SC and non-SC (NSC) veterans had similar baseline HOOS-JR/KOOS-JR and CCI. HOOS-JR remained similar between groups through 12 months (79.9 ± 19.2 vs. 82.7 ± 18.8) as did KOOS-JR (70.4 ± 15.6 vs. 74.6 ± 15.3). The designation of any SC and mental health SC reached significance for KOOS-JR (P = 0.034 and P = 0.032, respectively). For HOOS-JR and KOOS-JR, baseline function score quartile significantly influenced final score (P < 0.001), with patients in the lowest quartiles (i.e., worst baseline function) exhibiting significantly greater improvements than patients in higher quartiles. Conclusions: Mental health SC and high preoperative functional status are variables that may have unfavorable influences on self-reported outcomes of TKA in veteran patients. SC status does not appear to influence the outcomes of THA or the likelihood of achieving SCB after either THA or TKA. Regardless of SC status, most veterans can expect significant clinical improvements after total joint arthroplasty.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty.

BACKGROUND: Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research. CONCLUSION: Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.

Outcomes of Darrach and Sauvé-Kapandji Procedures: A Systematic Review.

BACKGROUND: To review the available literature on Darrach and Sauvé-Kapandji (SK) procedures and perform a systematic review to identify differences in clinical outcomes. We hypothesized that SK would have a higher complication rate without significant clinical benefit. METHODS: A literature search was conducted using PubMed, EMBASE, Cochrane Library, and SCOPUS (from inception to January 2020) to identify studies evaluating outcomes of Darrach and SK procedures. Primary outcome measures included the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, range of motion, grip strength, complications, and overall satisfaction. RESULTS: A total of 103 articles were identified and screened, and of these, 44 full-text articles were used for data extraction and qualitative analysis. Outcomes were similar for QuickDASH scores, grip strength, and range of motion, as was overall satisfaction. Specifically, satisfaction rates for stabilized SK and Darrach procedures in patients without rheumatoid arthritis were comparable at 70.2% and 72.6%, respectively. Average QuickDASH scores were similar (21 for Darrach and 29 for SK). Mechanical symptoms due to stump instability occur with either procedure but were higher with the Darrach procedure (12.5% compared with 6.8%). The SK had more surgery-related complications such as nonunions (2.3%), symptomatic hardware, and reoperations (6.8% compared with 3.2%). CONCLUSIONS: Both Darrach and SK procedures provide comparable satisfaction rates regardless of the underlying pathology. Improvement in range of motion, strength, and overall function is similar for both procedures; however, the reoperation rate is higher with SK.

Screw Thread Configuration Has No Effect on Outcomes of In Situ Fixation for Stable Slipped Capital Femoral Epiphysis.

BACKGROUND: No consensus exists regarding the optimal surgical management of slipped capital femoral epiphysis (SCFE). Treatment goals include avoiding slip progression and sequelae such as avascular necrosis (AVN). Factors associated with surgical implants merit further research. This study investigates the effect of screw thread configuration and the number of screws on surgical outcomes. METHODS: A total of 152 patients undergoing cannulated, stainless steel, in situ screw fixation of SCFE between January 2005 and April 2018 were included. Procedure laterality, screw number and thread configuration (partially threaded/fully threaded), bilateral diagnosis, Loder classification, final follow-up, patient demographics, and endocrinopathy history were analyzed. Primary outcomes were return to the operating room (ROR), AVN, hardware failure/removal, and femoroacetabular impingement (FAI). RESULTS: Most patients received a single (86.2%), partially threaded (81.6%) screw; most were unilateral (67.8%) and stable (79.6%). Mean follow-up was 2.0±2.7 years, with a 15.8% rate of ROR, 5.3% exhibiting AVN, 6.6% exhibiting FAI, and 9.2% experiencing hardware failure/removal. Number of screws was the sole predictor of ROR [odds ratio (OR)=3.35, 95% confidence interval (CI): 1.18-9.49]. Unstable SCFE increased the odds of AVN (OR=38.44; 95% CI: 4.35-339.50) as did older age (OR=1.43, 95% CI: 1.01-2.03). Female sex increased risk for FAI (OR=4.87, 95% CI: 1.20-19.70), and bilateral SCFE elevated risk for hardware failure/removal versus unilateral SCFE (OR=4.41, 95% CI: 1.39-14.00). Screw thread configuration had no significant effect on any outcome (for each, P ≥0.159). CONCLUSIONS: Rates of ROR, AVN, FAI, and hardware failure/removal did not differ between patients treated with partially threaded or fully threaded screws. The use of 2 screws was associated with an increased likelihood of ROR. These findings suggest that screw thread configuration has no impact on complication rates, whereas screw number may be an important consideration in SCFE fixation. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures.

Purpose Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options. Methods The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA). Results Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room. Conclusions This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures.