Genicular nerve radiofrequency ablation: a systematic review of application for perioperative pain control in total knee arthroplasty and as treatment for chronic pain in well-appearing total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA. METHODS: PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA. RESULT: Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed. CONCLUSIONS: Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision.

BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Scheduling and Vendor Consistency Improves Turnover Time Efficiency in Total Joint Arthroplasty.

BACKGROUND: Maximizing operative room (OR) efficiency is important for hospital efficiency, patient care, and positive surgeon and staff morale. Reducing turnover time (TOT) has become a popular focus to improve OR efficiency. The present study evaluated if TOT is influenced by changing case type, implant vendor, and/or laterality. METHODS: In total, 444 turnovers from January to July 2023 were retrospectively analyzed. All turnovers were same-surgeon turnovers between primary arthroplasty cases in dedicated, overlapping rooms. Single linear regression models tested the predictability of TOT based on case type, vendor, and laterality. A multivariate multiple regression and 1-way Analyses of Variance analyzed variables against each other. Independent sample t-tests evaluated TOTs when all variables were the same or different. RESULTS: Changing versus keeping the same case type increased TOT by 2.4 minutes (95% confidence interval [CI] = 0.7, 4.0; P = .004). Changing vendors increased TOT by 2.9 minutes (95% CI = 1.1, 4.7; P = .002). Laterality did not affect TOT, with a change of 0.9 minutes (95% CI = -0.6, 2.5; P = .229). Vendor (P = .030) independently predicted TOT when analyzed as a covariate with case type (P = .410). The TOT with same case type and vendor (mean 38.2 minutes; range, 22 to 62) was less than that of different case types and vendors (mean 41.4 minutes; range, 26 to 73) (P = .017). Mean TOT differed by 5.5 minutes when keeping all variables the same versus all different (P = .018). CONCLUSIONS: Maintaining a consistent case type, vendor, and laterality had a synergistic effect in reducing TOT in arthroplasty ORs with the same primary surgeon running 2 overlapping rooms. Changing vendor representatives was found to independently predict TOT increases, which is likely attributed to a disruption in workflow and collaboration of the multidisciplinary OR team. LEVEL OF EVIDENCE: Level III.

Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty.

INTRODUCTION: The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD. METHODS: Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD. RESULTS: Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate. DISCUSSION: Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities.

BACKGROUND: Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS: We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS: Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS: In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.

Patient-reported outcomes measurement information system instruments in knee arthroplasty patients: a systematic review of the literature.

BACKGROUND: The purpose of this study is to provide a systematic review of the literature pertaining to Patient-Reported Outcome Measurement Information System (PROMIS) validation and utilization as an outcomes metric in total knee arthroplasty (TKA) patients. This is the first systematic review on PROMIS use in total knee arthroplasty patients. METHODS: A systematic search of the Pubmed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, psychometric properties (Pearson and Spearman correlation) with legacy patient-reported outcome measurement (PROM) instruments, floor and ceiling effects, responsiveness, and minimum clinically important difference (MCID) and PROMIS outcomes were recorded and analyzed. RESULTS: Fifteen studies investigating PROMIS in 11,140 patients were included. The weighted-average Pearson correlation coefficient comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.62 [standard error (SE) = 0.06] and the weighted-average Spearman correlation comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.59 (SE = 0.06), demonstrating moderate-to-strong correlation and validity. There were no differences in weighted average floor [0.03% (SE = 3.1) versus 0% (SE = 0.1) versus 0.01% (SE = 1.1); p = 0.25] or ceiling effects [0.01% (SE = 0.7) versus 0.02% (SE = 1.4) versus 0.04% (SE = 3.5); p = 0.36] between PROMIS and legacy instruments. The weighted average for percentage of patients achieving MCID was 59.1% for global physical health (GPH), 26.0% for global mental health (GMH), 52.7% for physical function (PF), 67.2% for pain interference (PI), and 37.2% for depression. CONCLUSION: Notably, PROMIS global physical health, physical function, and pain interference were found to be significantly responsive, with PROMIS pain interference most effectively capturing clinical improvement as evidenced by the achievement of MCID.

Collateral Ligament Tension and Balance Alone Does Not Ensure Improved Outcome After Total Knee Arthroplasty.

BACKGROUND: It is hypothesized that suboptimal soft tissue and collateral ligament balance is a cause of patient dissatisfaction following total knee arthroplasty (TKA). This analysis examined the association between compartment pressures during TKA and patient-reported outcome measurements (PROMs). METHODS: This single-institution, retrospective cohort study of prospectively collected compartment pressure data measured during TKA comprised 145 patients who underwent surgery between 2015 and 2021 and completed 1-year follow-up PROMs. The primary outcome included pressures, in pounds (lbs), of the medial and lateral compartments in extension (5°), mid-flexion (45°), and flexion (90°), and associated PROMs. The difference been the 1-year and preoperative PROMs was used to separate the top 25% from the bottom 75% performers. Pressures were compared using Student's T-tests and multivariate linear regressions, while controlling for preoperative deformity. A subgroup analysis of the most popular implant was performed. RESULTS: Higher medial compartment pressures were seen in our total cohort (Knee Society Score (KSS) mid-flexion 24 versus 18 lbs, P = .03, flexion 24 versus 17 lbs P = .01) and within our subgroup analysis (Short form- Mental (SF-M) extension 32 versus 21 lbs P = .01, KSS mid-flexion 27 versus 16 lbs P = .005, extension 31 versus 20 lbs P = .003). This trend persisted in the subgroup analysis when controlling for preoperative deformity (KSS extension +16.22 lbs P ≤ .001, mid-flexion +17.6 lbs. P = .001, and flexion +9.2 lbs, P = .005). CONCLUSION: Several groups demonstrated higher medial versus lateral pressures. However, this pattern was not consistent across PROMs, suggesting that compartment pressures at the time of TKA are an important factor but not the sole predictor of patient satisfaction.

Bilateral Total Knee Arthroplasty: Current Concepts Review.

¼: Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days. ¼: Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others. ¼: While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA. ¼: When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart. ¼: Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

The current utilization of the patient-reported outcome measurement information system (PROMIS) in isolated or combined total knee arthroplasty populations.

Patient reported outcome measures (PROMs) are essential for clinical research and patient-centric care because they allow us to capture patient perspectives on their health condition. In knee arthroplasty, PROMs are frequently used to assess the risks and benefits of new interventions, surgical approaches, and other management strategies. A few examples of PROMs used in total knee arthroplasty (TKA) include the Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Forgotten Joint Score (FJS) (collectively referred to as "legacy" PROMs). More recently, attention has been brought to another PROM called the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS was developed by the National Institute of Health (NIH) and has over 300 domains assessing various aspects of patient health, including pain, physical function, and mental health. With the use of PROMIS increasing in TKA literature, there is a need to review the advancements being made in understanding and applying PROMIS for this population. Thus, the purpose of this study is to provide insight on the utilization, advantages, and disadvantages of PROMIS within the field of knee arthroplasty and to provide a comparison to legacy PROMs.

Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty.

BACKGROUND: The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA. METHODS: This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m2, diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications. RESULTS: One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ2 = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ2 = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI. CONCLUSION: Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

Preoperative Anemia Is Associated With 30-Day Morbidity in Total Knee Arthroplasty.

Given the heightened focus on decreasing length of stay and readmissions following total joint arthroplasty, meticulous preoperative optimization has become increasingly important. The goal of this study was to evaluate the association between preoperative anemia and postoperative morbidity and mortality at 30 days. We used the National Surgical Quality Improvement Program database to identify patients who underwent primary total knee arthroplasty (TKA) between 2006 and 2016. Cohorts were defined based on preoperative hemoglobin and were evaluated for 30-day complications as well as 30-day readmission and non-home discharge. The survey of the National Surgical Quality Improvement Program database yielded 198,233 patients who underwent TKA between 2006 and 2016. Preoperative anemia was found to be a risk factor for all complications (4.73% vs 3.22%, P<.001) as well as non-home discharge (37.0% vs 24.2%, P<.001) and unplanned readmission (4.99% vs 3.14%, P<.001) using both bivariate analysis and multivariate analysis. Meticulous optimization of patients at risk for complications is critical in the era of bundled care and increased focus on rapid transition from inpatient to outpatient care. Preoperative anemia was associated with the total postoperative complication rate at 30 days following TKA as well as non-home discharge and unplanned readmission. Surgeons should attempt to identify patients with preoperative anemia and correct underlying low blood levels to help minimize the rate of postoperative complications. [Orthopedics. 2022;45(2):e86-e90.].

Anterior-Based Muscle-Sparing (ABMS) Approach for Total Hip Arthroplasty.

The anterior-based muscle-sparing (ABMS) technique for total hip arthroplasty (THA) has gained popularity in recent years because of its proposed advantages in terms of postoperative pain and periprosthetic dislocation risk. Description: The procedure is performed with the patient in the supine position. A minimally invasive Watson-Jones approach is utilized to access the hip. Fluoroscopy can be utilized intraoperatively to assess acetabular cup position, version, and inclination. Femoral canal fill and leg lengths can also be assessed with use of fluoroscopy. Alternatives: Nonoperative alternatives for the treatment of hip osteoarthritis include nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections into the hip joint. Surgical alternatives to this procedure include the posterior approach (Moore or Southern), the direct lateral approach (Hardinge), and the direct anterior approach (Smith-Petersen). The Watson-Jones approach can also be performed with the patient in the lateral decubitus position (unlike in our technique where the patient is supine). Rationale: The anterolateral (Watson-Jones) approach to the hip has been shown to be superior to the historically more common posterior approach with regard to length of hospital stay and dislocation risk1,2. Supine positioning for this approach offers multiple advantages compared with lateral decubitus positioning. Leg lengths can be assessed intraoperatively both fluoroscopically and with manual palpation of the medial malleoli. Cup position can be assessed radiographically as well3. Supine positioning also allows for easily reproducible patient positioning. Expected Outcomes: Compared with the historically common posterior approach to the hip for THA, the anterolateral approach to the hip leads to, on average, a lower risk of hip dislocation1,2. In a 2002 study by Masonis and Bourne, the dislocation rate for the posterior approach was 3.23% (193 of 5,981), whereas the dislocation rate was 2.18% (18 of 826) for patients who underwent THA via the anterolateral approach1. In a study by Ritter et al. in 2001, which followed patients for 1 year postoperatively, no patients in the anterolateral approach group experienced a dislocation compared with 4.21% of patients in the posterior approach group2. With use of the present technique, patients will benefit from the advantages of the anterolateral approach to the hip; however, they will also benefit from easy intraoperative leg length assessment and from radiographic assistance with regard to determining the appropriate position of the femoral and acetabular components3. In a study of 199 patients (including 98 patients who had intraoperative fluoroscopy and 101 who did not), 80% of implants in the fluoroscopy group were within the combined safe zone compared with 63% in the non-fluoroscopy group. However, this approach is not without its limitations. As mentioned in the above studies, dislocation remains a possible complication of the procedure, and a minimally invasive anterior-based approach can lead to intraoperative femoral fractures when exposure and releases are inadequate4. Femoral nerve palsies are also possible with excessive medial retraction during acetabular exposure. Additionally, the benefit of a reduction in the incidence of hip dislocation compared with a posterior approach might be overstated given improvement in posterior-approach dislocation rates if posterior soft-tissue repair is used5. Both direct anterior and anterolateral approaches have the same risks of fracture with poor exposure and of neurapraxia with excessive retraction, and there does not appear to be any difference in dislocation risk between these 2 approaches6. Important Tips: Although a pannus is more detrimental to a direct anterior approach, it could overlie the desired incision in the ABMS approach as well. The pannus could be held out of the field by taping it to the contralateral shoulder before preparing and draping.The preparative process is more time-consuming because both legs must be sterile for this procedure.Acetabular exposure often requires an assistant standing on the contralateral side of the table.Although not often needed, the obturator internus and gemelli might need to be released in order to ensure adequate exposure of the femur.If femoral canal exposure is still insufficient, a femoral suspension hook system might be needed. Acronyms & Abbreviations: ASIS = anterior superior iliac spineTFL = tensor fasciae lataeITB = iliotibial bandPOD = postoperative dayIV = intravenousBID = twice daily.

Imageless robotic-assisted total knee arthroplasty leads to similar 24-month WOMAC scores as compared to conventional total knee arthroplasty: a retrospective cohort study.

PURPOSE: Robotic-assisted total knee arthroplasty (RA-TKA) was introduced to improve limb alignment, component positioning, soft-tissue balance and to minimize surgical outliers. This study investigates perioperative outcomes, complications, and early patient-reported outcome measures (PROMs) of one imageless RA-TKA system compared to conventional method TKA (CM-TKA) at 24-month follow-up. METHODS: This multi-surgeon retrospective cohort analysis compared 111 imageless RA-TKA patients to 110 CM-TKA patients (n = 221). Basic demographic information, intraoperative and postoperative data, and PROMs, including the functional score of the Knee Society Score (KSS-FS), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form 12 Mental and Physical scores (SF-12M and P), were collected and recorded preoperatively, at 3-, 12- and 24-months postoperatively. Range of motion (ROM), estimated blood loss (EBL), surgical duration, and complications were also collected. RESULTS: There were no baseline patient demographic differences between groups. EBL (240 vs. 190 mL, p < 0.001) and surgical duration (123 vs. 107 min, p < 0.001) were significantly greater in RA-TKA. There were no significant differences in postoperative complications, ROM, length of stay (LOS), and PROMs between cohorts at 3-, 12-, 24-months postoperatively. CONCLUSIONS: Imageless RA-TKA is associated with greater EBL and surgical duration compared to CM-TKA. However, at 24-month follow-up, there were no significant differences in ROM, LOS, complications and PROMs between cohorts. Imageless robotic surgery leads to similar 24-month clinical outcomes as compared to CM-TKA. LEVEL OF EVIDENCE: III.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review.

BACKGROUND: The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). METHODS: We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. RESULTS: We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012). CONCLUSIONS: This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. LEVEL OF EVIDENCE: Level I; Systematic Review.

Increased Glenoid Index as a Risk Factor for Pediatric and Adolescent Anterior Glenohumeral Dislocation: An MRI-Based, Case-Control Study.

BACKGROUND: In adults, anterior glenohumeral instability has been associated with a tall and narrow glenoid morphology, assessed using the glenoid index (GI; glenoid height-to-width ratio) on magnetic resonance imaging (MRI). This morphological association has not been assessed in children and adolescents. PURPOSE/HYPOTHESIS: To examine the association of GI and other MRI measurements of interest supported in studies on adults with anterior glenohumeral dislocation in patients aged ≤19 years. We hypothesized that these patients would have a significantly greater GI (relatively taller and narrower glenoid morphology) compared with healthy controls. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: An institutional radiology database was queried over a 10-year period to identify patients aged ≤19 years who had been diagnosed with radiographically confirmed anterior shoulder dislocation and who underwent glenohumeral magnetic resonance arthrography as well as those without dislocation with normal shoulder arthrogram studies (controls). Patients with bony Bankart lesions were excluded. The following glenohumeral dimensions were measured on shoulder arthrogram: GI, glenoid version, coracohumeral interval, and rotator interval width/depth. Comparative analysis between the 2 groups was performed using the Student t test for each variable, followed by receiver operating characteristic (ROC) analysis to determine discriminative ability when statistically significant. RESULTS: Overall, 55 participants (33 male and 22 female patients; mean age, 15.4 ± 2.1 years) were enrolled; 22 patients were in included in the dislocator group and 33 patients comprised the control group. The mean GI in the dislocator group was significantly greater than the control group (1.55 ± 0.14 vs. 1.38 ± 0.08; P < .001). ROC analysis revealed adequate discrimination of GI in predicting glenohumeral dislocation (area under the curve = 0.88). A GI ≥1.45 was 83% sensitive and 79% specific for predicting dislocation in the study cohort. CONCLUSION: Patients with anterior glenohumeral dislocation had increased GI (taller and narrower glenoid morphology) than controls. This useful MRI measurement may help identify patients at risk for primary or recurrent anterior glenohumeral instability events and may therefore help with guiding treatment and prevention.

Intraoperative Scrub Nurse Handoffs Are Associated With Increased Operative Times for Total Joint Arthroplasty Patients.

BACKGROUND: Surgeons typically remain scrubbed in for the duration of a surgical case, while scrub nurses are shift-workers who handoff mid-operation. These handoffs can intuitively create inefficiencies, but currently, no orthopedic research has studied the impact of these handoffs. This study analyzed the effect of intraoperative scrub nurse handoffs on operative times for total joint arthroplasties (TJAs). METHODS: A retrospective chart review was performed for primary total hip (THA) and total knee arthroplasties (TKA) performed between May 2014 and May 2018. Operative times, number of scrub nurse handoffs, surgeon, and patient information were collected. A multivariable linear regression was performed to assess the association between patient and surgeon characteristics, intraoperative handoffs, and operative times. RESULTS: A total of 1109 TKA and 1032 THA patients were identified. Multivariable linear regression demonstrated that for TKAs, 1 handoff was associated with a 3.89-minute longer operative time (P value = .02), and 2+ handoffs were associated with a 15.99-minute longer case (P value < .001). For THA patients, 1 handoff was associated with a 6.20-minute longer operative time (P value < .001), and 2+ handoffs were associated with an 18.52-minute longer case (P value < .001). CONCLUSIONS: Although causation cannot be established, when controlling for multiple confounders, intraoperative scrub nurse handoffs were associated with statistically significant increases in operative times for TJAs. Optimizing scrub nurse staffing models to decrease intraoperative handoffs could thus have practical ramifications on TJA patients.

Effects of Skilled Nursing Facility Partnerships on Outcomes Following Total Joint Arthroplasty.

INTRODUCTION: Post-total joint arthroplasty (TJA) discharge to a skilled nursing facility (SNF) is associated with higher costs and more complications than home discharge; however, some patients still require postoperative SNF care. To improve outcomes for patients requiring postoperative SNF care, this article analyzed the effect of SNF-surgeon partnerships on TJA postoperative costs and patient outcomes. METHODS: This was a retrospective study of primary TJA patients who were part of Medicare's Comprehensive Care for Joint Replacement (CJR) pilot program at our urban, academic medical center. We identified all patients discharged to SNF and designated SNFs as "preferred" if they maintained a partnership with our surgical team. SNF costs, total 90-day postoperative costs, average length of stay in SNF, 90-day readmission rates, and readmission diagnoses were recorded. Data were compared using Student t-tests. Readmission rates and the presence of a readmission diagnosis were analyzed using z-scores. RESULTS: Our search identified 189 patients (22.9%) discharged to SNFs, with 128 (67.8%) discharged to preferred and 61 (32.2%) discharged to nonpreferred facilities. Over the 4-year CJR pilot program, SNF costs ($10,981.23 versus $7,343.34; P < 0.005) and overall postdischarge costs ($23,952.52 versus $18,339.26; P = 0.07) were higher for patients discharged to nonpreferred SNFs versus preferred SNFs. Patients discharged to nonpreferred SNFs also had increased length of stay (14.8 versus 10.1 days; P < 0.005) and increased readmission rates (19.7% versus 3.9%; P < 0.005). These differences became more pronounced across the study period. CONCLUSION: For patients undergoing primary TJA, hospital partnership with SNFs can improve CJR performance by cost reduction and overall outcomes for TJA patients.

Risks and Complications After Arthroplasty for Pathological or Impending Pathological Fracture of the Hip.

BACKGROUND: Treatment options for metastatic osseous lesions of the proximal femur include hemiarthroplasty (HA) or total hip arthroplasty (THA) depending on lesion characteristics and patient demographics. Studies assessing short-term outcomes after HA/THA in this patient population are limited. Therefore, the purpose of this present study was to identify short-term rates of morbidity and mortality after HA/THA for pathological proximal femur fractures, as well as readmission and reoperation rates and reasons. METHODS: This study utilized a large, prospectively collected registry to identify patients who underwent HA/THA between 2011 and 2018. Patients were stratified by indication for surgery, including pathological fracture, nonpathological fracture, and osteoarthritis. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis. RESULTS: In total, 883 patients undergoing HA/THA for a pathological fracture were identified. Relative to an osteoarthritis cohort, these patients tended to be older, had a lower body mass index, and had significantly more preoperative comorbidities. These patients had high rates of total complications (13.93%), including thirty-day mortality (3.29%), unplanned return to the operating room (4.98%), and pulmonary complications (3.85%). Patients with pathological fracture had a longer operative duration relative to osteoarthritis and nonpathological cohorts (+27 and +25 minutes, respectively), despite having high rates of HAs performed. CONCLUSION: Patients undergoing hip arthroplasty for pathologic proximal femur fracture have increased morbidity and mortality relative to an osteoarthritis cohort. However, patients with a pathological fracture have similar rates of morbidity and mortality when compared with a nonpathological fracture cohort, but did experience higher rates of perioperative blood transfusion and unplanned readmissions. LEVEL OF EVIDENCE: III.

Quantifying the Surgeon's Increased Burden of Postoperative Work for Modern Arthroplasty Surgery.

BACKGROUND: Arthroplasty payment traditionally includes 118 minutes for postoperative rounds and 69 minutes for postoperative office visits, amounting to 187 minutes and 7 work relative value units. Rapid recovery, ambulatory procedures, and bundled payments have altered the burden of care, with multiple studies showing an increase in physician work. Policy changes during the COVID-19 pandemic allow for precise documentation of patient touchpoints. We analyzed the duration of video, telephone, and text messaging to quantify modern arthroplasty work. METHODS: Consecutive primary hip, knee, and partial knee arthroplasties, performed 30 days before March 15, 2020 (date of practice closure), were included from a single institution, yielding 47 cases. We retrospectively quantified the duration of video telehealth documentation, telephone logs, and text messages over 90 days to calculate the postoperative work required in modern arthroplasty using descriptive statistics. RESULTS: An average of 9.4 touchpoints (2-14) by the surgeons occurred during the global period for this cohort, totaling 219 minutes (51-247 minutes). This included an average of 21 minutes of day-0 calls to family, 117 minutes for video visits, 52 minutes for phone calls, and 29 minutes for text messaging and wound photos. CONCLUSION: We found an undervaluation of 32 minutes of work. AAHKS leadership advocates for the fair payment of modern arthroplasty work. Cell phones have opened channels of contact that did not exist before, including phone accessibility, text messaging, and video calls. These data help defend against current payer efforts to cut work relative value units for arthroplasty. LEVEL OF EVIDENCE: II.