Safely Implementing the Direct Anterior Total Hip Arthroplasty: A Methodological Approach to Minimizing the Learning Curve.

INTRODUCTION: Orthopaedic surgeons often cite concern for a learning curve as a barrier to adopting the direct anterior approach (DAA) for total hip arthroplasty (THA) while transitioning from other approaches. Studies both assessing and describing a practical approach and strategy to safely accomplish this transition, as well as the effect on clinical outcomes, are not well described. METHODS: This prospective study compares a single surgeon's operative results and complications for the first consecutive 100 direct anterior THA to the last 100 consecutive posterior THA after 7 years in practice. The regimented and disciplined learning strategy used to implement the DAA is detailed in this study. The data were analyzed using univariate and multivariate regression models. RESULTS: Univariate analyses identified significant differences in sex, age, Asian race, and diagnostic cause for THA between the two cohorts. Multivariate analyses controlled for these differences and showed that relative to posterior THA, direct anterior THA cases were associated with 7-minute longer procedures (P = 0.002) and lengths of stay that were 0.7 days fewer (P = 0.013). No significant differences were present in the estimated blood loss, and importantly, no significant differences in death or surgical complication rates between cohorts. DISCUSSION: This study suggests that the DAA for THA can be safely implemented without the increased and adverse risk to the patient when a structured learning process is maintained and meticulously performed.

Epidemiology of Fireworks-Related Injuries to the Upper Extremity in the United States From 2011 to 2017.

Purpose: Fireworks may result in a wide spectrum of injury to the upper extremity ranging from mild burns to amputation. In this cross-sectional study, we describe the epidemiology of upper-extremity injuries in the United States associated with fireworks using the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS). Methods: The NEISS database was queried between 2011 and 2017 for all injuries of the upper extremity (from shoulder to fingertip) associated with fireworks. There were 806 unique cases, yielding a total weighted estimate of 31,430 national cases presenting to emergency departments in the United States during this time frame. National estimates, standard errors, and 95% confidence intervals were calculated using parameters provided by the NEISS database. Significance of trends was determined using adjusted Wald tests, for which P values less than .05 were considered significant. Results: The weighted estimate was 4,490 yearly cases from 2011 until 2017. Trend analysis did not show a significant change in the number of yearly cases during that time frame. Most injuries (62%) occurred around June 27 until July 11. Nearly 50% of those injured were aged 10 to 29 years and were male. Fireworks with low pyrotechnic content such as sparklers, snakes, and poppers resulted in 26% of injuries. Although 83% of patients were treated and released from the emergency department, other injuries were more severe, with a 4.5% rate of amputation, 7% rate of hospital admission, and 8% rate of transfer to another hospital. Conclusions: Fireworks injuries to the hand and upper extremity continue to represent a serious burden of disease to the United States population and the health care system. Increased awareness, legislation, and targeted public education about the dangers of fireworks should be considered ways to reduce the incidence of these injuries. Type of study/level of evidence: Prognostic III.

Discharge Home is Associated With Decreased Early Complications Following Primary Total Joint Arthroplasty.

BACKGROUND: Primary total hip (THA) and total knee arthroplasty (TKA) volume has increased over the past decade. Patients discharged home (HD) have demonstrated improved postoperative outcomes compared with non-home discharge (NHD) patients. We reviewed trends in HD over the past decade and compared complication rates between HD and NHD primary total joint arthroplasty (TJA) patients. METHODS: Retrospective analysis of the National Surgical Quality Improvement Program was performed on TJA cases and patients were grouped by discharge type. Trends in the prevalence of HD were compared by chi-square test, from 2011 to 2016. Univariate and bivariate statistics were performed. Multivariate logistic and propensity score-matched analyses were used to control for confounding variables. RESULTS: During the 6-year review, HD increased significantly for THA (71.2% to 83.6%) and TKA (65.6% to 80.7%). Overall HD was 75.4% of THA and 71.0% of TKA patients. Propensity matching identified 16,580 THA pairs and 34,952 TKA pairs. Compared with NHD patients, HD patients had shorter operative times, were younger, and had shorter lengths of stay. Controlling for confounders, the HD patients had lower risk of death within 30 days, lower risk of major medical morbidity, decreased risk of reoperation, and decreased risk of readmission compared with NDH patients. Multivariate models demonstrated similar findings. CONCLUSION: HD in both THA and TKA independently predicts decreased early (30-day) postoperative complications after controlling for confounding variables. Given the improved outcomes, we advocate for continued emphasis on HD rather than NHD when clinically appropriate.