Aims. To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. Methods. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). Results. The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Conclusion. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making. Cite this article: Bone Jt Open 2023;4(3):168–181

Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort. Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach. After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001). While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns

Introduction. Robotic assisted Total Knee Arthroplasty (rTKA), provides surgeons with preoperative planning and real-time data allowing for continuous assessment of ligamentous tension and range-of-motion. Using this technology, soft tissue protection, reduced early post-operative pain and improved patient satisfaction have been shown. These advances have the potential to enhance surgical outcomes and may also reduce episode-of-care (EOC) costs for patients, payers, and hospitals. The purpose of this study was to compare robotic assisted vs. manual total knee arthroplasty: 1) 90-day episode-of-care (EOC) costs; 2) index costs; 3) lengths-of-stay (LOS); 4) discharge disposition; and 5) readmission rates. Methods. TKA procedures were identified using the Medicare 100% Standard Analytic Files including; Inpatient, Outpatient, Skilled Nursing (SNF) and Home Health. Members included patients with rTKA or manual TKA (mTKA) between 1/1/2016-3/31/2017. To account for potential baseline differences, propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual based on age, sex, race, geographic division, and comorbidities. After PSM, 519 rTKA and 2,595 mTKA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, discharge disposition and readmission rates were assessed. Results. Overall 90-day EOC costs were $2,391 less for rTKA patients ($18,568 vs. $20,960; p<.0001). Index facility cost and LOS were also less for rTKA patients by $640 ($12,384 vs. $13,024; p=.0001) and 0.7 days (p<.0001). Additionally, rTKA patients were discharged to SNF less frequently (12.52% vs. 21.70%; p<.0001) and home with health aid (56.65% vs. 46.67%; p<.0001) or self-care (27.55% vs. 23.62%; p=.0566) more frequently and had a 90-day readmission reduction of 33% (p=.0423). Conclusion. Robotic assisted TKA resulted in an overall lower 90-day episode-of-care cost when compared to manual TKA. The 90-day EOC cost savings of rTKA were driven by reduced facility costs, LOS and readmissions, and an economically beneficial discharge destination

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis. The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts. Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care). General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates

Aim. Traditionally, serum white blood count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been utilized as markers to evaluate septic arthritis (SA). Recently, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as prognostic factors for treatment failure, mortality and morbidity in various clinical settings. To date, these markers have not been utilized for evaluating outcomes after hip and knee SA. Thus, the purpose of this study was to determine the ability of admission NLR and PLR to predict treatment failure and postoperative 90-day mortality in hip and knee SA. Method. A retrospective study was performed using our institutional research patient database to identify 235 patients with native hip and knee septic arthritis from 2000–2018. Patient demographics, comorbidities and social factors (alcohol intake, smoking and intravenous drug use) were obtained, and NLR and PLR were calculated based on complete blood count values (absolute neutrophil, lymphocyte and platelet count) on admission. Treatment failure was defined as any reoperation or readmission within 90 days after surgery. Receiver operating curves were analyzed, and optimal thresholds for NLR and PLR were determined using Youden's test. Univariate and multivariate analyses were performed to determine if these ratios were independent predictors of treatment failure and 90-day mortality after surgery. These ratios were compared to serum WBC, CRP, and ESR. Results. Optimal thresholds for NLR was 9.49 (sensitivity=60%, specificity=84%) and PLR was 303 (sensitivity=54%, specificity=77%). With univariate analysis, NLR>9.49 was associated with failure (odds ratio [OR]=7.64, 95%. Confidence Interval [CI]=4.10–14.21) and 90-day mortality (OR=9.83, 95% CI=2.74–35.25). PLR>303 was associated with increased failure (OR=3.85, 95% CI=2.12–7.00). In multivariate analysis controlling for patient demographics, comorbidities and social factors, elevated NLR remained an independent predictor of failure (OR=7.04, 95% CI=3.78–13.14) and 90-day mortality (OR=5.98, 95% CI=1.60–22.32), whereas PLR remained a predictor of failure (OR=3.58, 95% CI=1.95–6.58). NLR was a better predictor of failure and 90- day mortality compared to serum WBC, CRP, and ESR. Conclusions. This study demonstrates that NLR is a good estimate of SA and performs better than serum WBC, CRP and. ESR to predict treatment failure and 90-day mortality. Elevated NLR is a reliable novel biomarker that may be utilized when evaluating SA patients, and this accessible test could be utilized in the musculoskeletal infection field

Background. Operative treatment of complex proximal humerus fractures remains controversial. The transition to value-based health care demands a better understanding of the costs associated with surgery. The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and non-operative treatment and compare the costs associated with the initial-day and subsequent 89-days of care. Methods. A query of the Humana insurance claims database was performed through the PearlDiver Supercomputer (Warsaw, IN) from 2010 to 2014 using the diagnosis codes for proximal humerus fractures together with current procedural terminology codes (CPT) for hemiarthroplasties (HA), open reduction internal fixation (ORIF), reverse shoulder arthroplasty (RSA) and nonoperative treatment (NO). Reimbursement from the insurance claims database was used as a marker for costs. The same day, subsequent 89-day, and ninety day costs were analyzed trough the use of descriptive and comparative statistical analysis. Results. RSA was the most costly procedure for the same-day and 90-day costs (p<0.001) (Figure 1). Mean initial-day reimbursement costs were significantly different amongst treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), ORIF ($6,745) and lastly, NO ($1,932). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA and ORIF (p=0.112) (Figure 1 and 2); however, NO treatment incurred significantly lower costs (p=0.008) (Figure 3). Conclusion. The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial-day costs. RSA was associated with the highest cost, followed by HA and ORIF. NO management incurred the lowest costs

Introduction. Patients undergoing TJA have higher rates of anxiety and/or depression than the general population and higher costs of care. These preoperative diagnoses lead to higher levels of postoperative dissatisfaction and depression patients alone have higher readmission rates. There is significant crossover between anxiety and depressive disorders, and many patients are classed as combined. Our goal was to evaluate readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression or both. Methods. Our hospital's prospectively collected data from our statewide total joint database (MARCQI) was reviewed from 2013–2018. Rates of anxiety and/or depression were determined based preoperative anxiolytic or antidepressant medications using national drug codes. Independent sample t-tests compared continuous variables and Chi-square tests (or Fisher's exact tests) compared categorical variables. Potential risk factors were identified by multivariable logistic regression modeling. Results. 4,107 cases (1,261 THA and 2,846 TKA) were included. 176 patients (4.28%) had a readmission within the 90-day global period. 476 patients (12%) had history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (p=0.017). When patients were stratified based on THA or TKA, patients taking anxiolytic medication undergoing TKA were 120% more likely to undergo readmission within 90 days (p=0.021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (p=0.991). For THA patients neither diagnosis appeared a risk factor for readmission (p=0.852). Conclusions. Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90-days compared to patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. THA on the other hand did not appear to share this risk profile

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

Introduction. Previous research has indicated that preoperative modification of risk factors associated with obesity may reduce complications after TKA. However, the optimal method is still debated. This study aims to investigate whether a preoperative Risk Stratification Tool (RST) devised by our institution to optimize obese patients can reduce unexpected ICU transfers, and 90-day ED visits, readmissions, and reoperations. Methods. We retrospectively reviewed 1,724 consecutive risk stratified patients undergoing primary unilateral TKA. The mean age was 64.8 years and average body mass index (BMI) was 34.2 kg/m2. All patients underwent preoperative optimization using the RST. We first compared our primary variables of interest between obese (BMI>30, n=1,189) and non-obese patients (n=535). Patients were then divided into 3 groups (I-non-obese, II-obese (30–39.9 kg/m2) and III-morbidly obese ((>40 kg/m2)) and logistic regression was used to evaluate outcomes among the groups adjusted for age, sex, smoking history and diabetes. Results. Overall, obese patients had an increased rate of discharge to facility compared to non-obese patients (38.0% vs 25.9%, p<0.001). After stratifying by BMI (group I (n=535), II (n=793), III (n=396)), discharge to facility remained higher relative to non-obese (25.9%) in both obese (34.0%, OR 1.6, CI 1.3–2.1) and morbidly obese (45.8%, OR 3.0, CI 2.2–4.1) patients. However, there was no difference in unexpected ICU transfer (0.6% non-obese vs 1.0% obese [OR 1.9, CI 0.5–7.3] vs 1.8% morbidly obese [OR 4.1, CI 1.0–17.2]), ED visits (8.6% vs 10.5% [OR 1.3, CI 0.9–1.9] vs 10.3% [OR 1.2, CI 0.7–1.9]), readmissions (4.7% vs 4.3% [OR 1.0, CI 0.6–1.8] vs 4.8% [OR 1.3, CI 0.7–2.6]), or reoperations (2.4% vs 3.3% [OR 1.3, CI 0.6–2.5] vs 3.0% [OR 1.0, CI 0.7–2.2]). Conclusion. Use of a preoperative risk stratification tool is effective at lowering the risk of short-term complications after TKA in obese patients to similar levels as non-obese patients. For any figures or tables, please contact the authors directly

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to hospital in the English NHS (hospital episode statistics, HES). This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale in the NHS. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between January 2005 and February 2010 in the English NHS were identified. Patients were subdivided based on Charlson co-morbidity score. HES data in the form of OPCS and ICD-10 codes were used to establish 30-day medical complication rates from myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications, and provides robust information for the consenting process. It also shows that the risk of mortality for fit patients without post-operative complications was very low - a group which is thought to have a high rate of ‘silent’ fatal PEs

Background. Direct anterior approach (DAA), total hip arthroplasty (THA, performed with the patient in the supine position, creates a unique opportunity to do bilateral THA under one anesthesia. Previous studies evaluating this option are limited by small sample size or lack of control group. The purpose of this study is to compare early clinical outcomes of simultaneous bilateral, unilateral and staged bilateral DAA-THA. Methods. Using an institutional registry database, we reviewed 3977 DAA-THA performed in 3334 patients at minimum 90-days follow up. A single surgeon performed all surgeries. Simultaneous bilateral DAA-THA group included 512 hips in 256 patients, unilateral DAA-THA group 2691 hips and staged bilateral DAA-THA group 774 hips in 387 patients. We reviewed 90-day postoperative complications, readmissions, length of stay, and rate of home discharge between all three groups. Results. There were no statistical differences in readmission (range 0.77–1.8%), postoperative clinical complications, and rate of home discharge (96.1–98.1%) between simultaneous bilateral, unilateral, or staged bilateral groups. The number of transfusions in the simultaneous bilateral group (9/256, 3.5%) was significantly higher than in the unilateral (24/2691, 0.89%, p=0.002) or the staged bilateral group (4/387, 1.0%, p=0.04). The total length of stay (LOS) in the simultaneous bilateral group (1.8 ± 0.8 days) was longer (p<0.001) than in the unilateral group (1.2 ± 1.0 days) but shorter (p<0.001) than the two added LOS in the staged bilateral group (2.8 ± 2.2 days). Conclusion. Our large cohort in a single surgeon case showed that simultaneous bilateral DAA-THA is comparable with unilateral or staged bilateral surgery in regards to postoperative clinical complications, readmission rate, and rate of home discharge but with an increased rate of transfusion. We believe that simultaneous bilateral DAA-THA is a reasonable and safe option in properly selected patients who require bilateral THA

Introduction: Venous thromboembolism is a major cause of morbidity and mortality in hospitalised patients and patients undergoing major orthopaedic surgery are at high risk from venous thromboembolism. Thromboprophylaxis, both mechanical and chemical, is commonly administrated to reduce fatality from thromboembolism after surgery. However, there is no convincing evidence in the literature demonstrating that routine chemothromboprophylaxis reduces death rates from pulmonary embolus. Furthermore, it is unclear from the literature which thromboprophylactic agent, if any, should be used. Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that aspirin, which is a low cost prophylactic agent, is effective in preventing DVT and PE after orthopaedic surgery. The aim of this study was to determine the 90-day mortality rate after THR using aspirin as a prophylactic agent. Patients and Methods: Between 2003–2006, 2,286 patients underwent primary THR and 372 patients underwent revision hip replacement (RHR). Routine chemothromboprophylaxis consisting of aspirin 75mg daily for 6 weeks. In addition all patients were treated with anti-thromboembolic stockings. 40mg of subcutaneous clexane, in lieu of aspirin, was given daily to all patients who had previously suffered from a pulmonary embolus or deep venous thrombosis. Patients who died within 90 days of surgery had their death certificates examined. Retrieval at 90 days with regard to death was 100%. Results:. Primary THR. One patient (0.04%) died within 30 days of surgery and a further 3 (0.13%) died between day 30 and day 90, giving a total mortality at 90 days of 0.17% (4/2,286). One patient (0.04%) died from PE and the other 3 patients (0.13%) died from non-vascular causes. Revision hip replacement. One patient (0.27%) died within 30 days of surgery and a further 1 patient (0.27%) died between day 30 and day 90, giving a total mortality at 90 days of 0.54% (2/367). Both patients died from non-vascular causes. Discussion: This study found that the 30-day mortality rate for primary THR and RHR was 0.08% and the 90-day mortality rate was 0.23%. In this study, there was only one death from PE and no deaths from arterial complications. Therefore, although NICE guidelines suggest the use of heparin, this study found that routine aspirin administration is beneficial in protecting against early death after THR because of both thromboembolism and adverse arterial events

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA).

The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance.

In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65).

Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect.

Aims. The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). Methods. This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC. Results. The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively. Conclusion. When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates. Cite this article: Bone Joint J 2022;104-B(9):1060–1066

Aims. The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype. Methods. The Premier Healthcare Database was queried to identify all patients who were diagnosed with metastatic bone disease from January 2015 to December 2020. The prevalence of all primary tumour subtypes was tabulated. Rates of long bone pathological fracture, 90-day mortality, and 360-day mortality following surgical treatment of pathological fracture were assessed for each primary tumour subtype. Patient characteristics and postoperative outcomes were analyzed based upon whether patients had impending fractures treated prophylactically versus treated completed fractures. Results. In total, 407,893 unique patients with metastatic bone disease were identified. Of the 14 primary tumours assessed, metastatic bone disease most frequently originated from lung (24.8%), prostatic (19.4%), breast (19.3%), gastrointestinal (9.4%), and urological (6.5%) malignancies. The top five malignant tumours resulting in long bone pathological fracture were renal (5.8%), myeloma (3.4%), female reproductive (3.2%), lung (2.8%), and breast (2.7%). Following treatment of pathological fractures of long bones, 90-day mortality rates were greatest for lung (12.1%), central nervous system (10.5%), lymphoma (10.4%), gastrointestinal (10.1%), and non-renal urinary (10.0%) malignancies. Finally, our study demonstrates improved 90-day and 360-day survival in patients treated for impending pathological fracture compared to completed fracture, as well as significantly lower rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and blood transfusion. Conclusion. This study defines the contemporary characteristics of primary malignancies resulting in metastatic bone disease. These data should be considered by surgeons when prognosticating patient outcomes during treatment of their metastatic bone disease. Cite this article: Bone Jt Open 2023;4(6):424–431

Aims. This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. Methods. A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. Results. The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. Conclusion. Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a ‘silver lining’ to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871–878

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Hip dysplasia is a common cause of hip pain in young adults. Pelvic osteotomy (PO) techniques are the gold standard for treating symptomatic patients, albeit technically demanding. This study aimed to (1) evaluate the 90-day complication rate, and (2) investigate the reasons, frequency and timing of reoperations following primary PO procedures. We retrospectively analysed the National Hospital Episode Statistics database, examining all patients aged over 14 who underwent PO in NHS England hospitals from 2010 to 2023. We identified index procedures and reoperations using relevant OPCS-4 codes. We analysed patient demographics, 90-day complications, and readmission rates for ipsilateral metalwork removal, revision PO, hip arthroscopy (HA), and THR conversion, and calculated the mean time to reoperations. This study included 1,348 PO cases (mean age: 28.7±9.1 years, 89.5% female). The mean hospital stay was 5.4±3.9 days, with a 90-day readmission rate of 0.52% at a mean of 51.0±17.2 days. The most common causes were infection (0.22%) and reoperation (0.15%). The 90-day rate of pulmonary embolism and deep vein thrombosis was 0.074%. One patient died within 90 days. Overall, 810 patients (60.1%) were readmitted for a subsequent hip procedure at a mean of 2.12±1.90 years following their primary PO. Metalwork removal was required in 616 patients (45.7%) at a mean of 1.70±1.19 years. Readmission rates for revision PO, HA, and THR, were 4.23% (mean time: 2.89±0.82 years), 4.15% (mean time: 2.91±2.28 years) and 6.01% (mean time: 5.24±3.08 years) respectively. This study highlights a low 90-day complication rate following primary PO, but a high reoperation rate, mainly for metalwork removal. We provide the most up-to-date report of revision PO, HA and THR conversion rates in England. These findings provide valuable insight that can facilitate informed decision-making, expectation-setting, and post-operative planning, also establishing a benchmark for future quality improvement

Aims. Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. Methods. We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. Results. Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). Conclusion. ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA. Cite this article: Bone Jt Open 2022;3(7):543–548