In recent years, cementless stems have dominated the North American market. There are several categories of cementless stems, but in the past 20 years, the two most popular designs in the United States have been the extensively coated cylindrical cobalt-chrome (CoCr) stem and the proximally coated tapered titanium stem, which in recent years has become the most common. The 10-year survival for both stem types has been over 95% with a distinction made on factors other than stem survival, including thigh pain, stress shielding, complications of insertion, and ease of revision. Conventional wisdom holds that proximally coated titanium stems have less stress shielding, less thigh pain, and a higher quality clinical result. Recent studies, however, including randomised clinical trials have found that the incidence of thigh pain and clinical result is essentially equivalent between the stem types, however, there is a modest advantage in terms of stress shielding for a tapered titanium stem over an extensively coated CoCr stem. One study utilizing pain drawings did establish that if a CoCr cylindrical stem was utilised, superior clinical results in terms of pain score and pain drawings were obtained with a fully coated versus a proximally coated stem. In spite of the lack of a clinically proven advantage in randomised trials, tapered titanium stems have been favored because of the occasional occurrence of substantial stress shielding, the increased clinical observation of thigh pain severe enough to warrant surgical intervention, ease of use of shorter tapered stems that involve removal of less trochanteric bone and less risk of fracture both at the trochanter and the diaphysis due to the shorter, and greater ease of insertion through more limited approaches, especially anterior approaches. When tapered stems are utilised, there may be an advantage to a more rectangular stem cross-section in patients with type C bone. In spite of the numerous clinical advantages of tapered titanium stems, there still remains a role for more extensively coated cylindrical stems in patients that have had prior surgery of the proximal femur, particularly for a hip fracture, which makes proximal fixation, ingrowth, and immediate mechanical stability difficult to assure consistently. Cement fixation should also be considered in these cases. While the marketplace and the clinical evidence strongly support routine use of tapered titanium proximally coated relatively short stems with angled rather than straight proximal lateral geometry in the vast majority of cases, there still remains a role for more extensively coated cylindrical and for specific indications.

Aims. Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Methods. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. Results. No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. Conclusion. No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome. Cite this article: Bone Jt Open 2023;4(2):96–103

INTRODUCTION

A recent PRCT failed to demonstrate superiority of HRA over THA at low speeds. Having seen HRA walk much faster, we wondered if faster walking speed might reveal larger differences.

We therefore asked two simple questions:

Does fast or uphill walking have an effect on the observed difference in gait between limbs implanted with one HRA and one THA?

If there is a difference in gait between HRA and THA implanted legs, which is more normal?

Aims. The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods. Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results. The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion. Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients’ health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. Cite this article: Bone Joint J 2024;106-B(4):394–400

Introduction. The Center for Medicare and Medicaid Services (CMS) is faced with a challenge of decreasing the cost of care for total knee arthroplasty (TKA), but must make efforts to prevent patient selection bias in the process. Currently, no appropriate modifier codes exist for primary TKA based on case complexity. We sought to determine differences in perioperative parameters for patients with “complex” primary TKA with the hypothesis that they would require increased cost of care, prolonged care times, and have worse postoperative outcome metrics. Methods. We performed a single center retrospective review from 2015 to 2018 of all primary TKA. Patient demographics, medial proximal tibial angle (mPTA), lateral distal femoral angle (lDFA), flexion contracture, cost of care, and early postoperative outcomes were collected. ‘Complex’ patients were defined as those requiring stems or augments, and multivariable logistic regression analysis and propensity score matching were performed to evaluate perioperative outcomes. Results. 1046 primary TKA were studied and 84 patients (8.3%) were classified as “complex”. For this cohort, surgery duration was greater (117 vs 82 minutes; p<0.001), cost of care excessive (p<0.001), and patients had a greater likelihood for 90-day hospital return. Deviation of mPTA and lDFA was significantly greater preoperatively before and after propensity score matching. Cutpoint analysis demonstrated that preoperative mPTA <83o or >91o, lDFA <84o or >90o, flexion contracture >10o, and BMI > 35.7 were associated with ‘Complex’ procedures. Conclusions. Complex primary TKA may be identifiable preoperatively and are associated prolonged operative time, excess hospital cost of care and increased 90-day hospital returns. This should be considered in future reimbursement models to prevent patient selection bias, and a complexity modifier is warranted

The current evidence favors replacement for the treatment of displaced femoral neck fractures in the older patients. Controversies remain whether total hip replacement (THR), or hemiarthroplasty (HA) would result in better outcomes. The purpose of this study is to compare the outcomes, and the complications in patients who underwent THR or HA for displaced femoral neck fractures. There were 345 consecutive patients who had undergone either a THR or HA at a single institution. THR was done in 137, and HA was done in 208 patients, respectively. Standard peri-operative data were collected. The mean values for the data in the THR group are: age 69 years, ASA 2.7, OR time was 99 minutes, estimated blood loss 354 ml, and the length of stay 8 days. The mean values for the data in the HA group are: age 75 years, ASA 3.0, OR time 88 minutes, estimated blood loss 200 ml, and the length of stay 10 days. The overall complications were 8.8% (THR), and 9.1% (HA), respectively. The mortality rates for the patients were: at the 1-year (9.5% THR vs 16.3% HA), at the 3-year (15.3% THR vs 24.0% HA), and at the 5-year (19.7% THR vs 26.9% HA), respectively. Our data demonstrated similar peri-operative data and short-term complications between the two groups. There was a difference in the mortality rates between the two groups at all 3-time intervals following the surgery. This could be a reflection of the patient selection bias for each of the operations

Background and aims. The Keele STarT Back approach is effective for stratifying patients with low back pain in primary care, but a similar approach has not been tested with a broader range of patients with musculoskeletal (MSK) pain. We report a feasibility and pilot trial examining the feasibility of a future main trial of a primary care based, risk-stratification (STarT MSK) approach for patients with back, neck, knee, shoulder or multi-site pain. Methods. A pragmatic, two-parallel arm, cluster randomised controlled trial (RCT) in 8 GP practices (4 stratified care involving use of the Keele STarT MSK tool and matched treatment options: 4 usual care). Following screening, adults with one of the five most common MSK pain presentations were invited to take part in data collection over 6 months. Feasibility outcomes included exploration of selection bias, recruitment and follow-up rates, clinician engagement with using the Keele STarT MSK tool and matching patients to treatments. Results. 524 participants (231-stratified care, 293-usual care) were recruited (target n=500) over 7 months (target 3 months), with 15-withdrawals (5-intervention, 10-controls). Minimal selection bias was identified between participants/non-participants, or trial arms. The pain-intensity follow-up rate was 88%. Clinicians used the STarT MSK tool in 41% of relevant consultations (judged as ‘partial success’) and adhered to recommended matched treatments in 69% of cases (judged as ‘success’). Conclusions. A future main RCT is feasible, with some amendments in the wording of the tool and the matched treatment options, to determine the clinical and cost-effectiveness of stratified care versus usual care for patients with MSK pain. Conflicts of interest: ‘No conflicts of interest’. Sources of Funding: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010). Nadine Foster is a NIHR Senior Investigator and was supported through an NIHR Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care

Aim. The objective of this systematic review is to evaluate the current evidence for or against this up-and-coming treatment modality. Method. A comprehensive literature search in accordance with the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA) guidelines was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Exclusion criteria included patients < 18 years of age, follow-up <11 months, and a score < 6 on the National Institute of Health quality assessment tool. Results. 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The quality of many studies was impeded by a retrospective design (14/15), a relative small study population (10 out of 15 studies had less than 50 patients), selection bias, and remarkable heterogeneity in terms of catheter type, antibiotic type, dose and duration of IA antibiotics and techniques of surgical revision. 347 were chronic infections, 66 acute infections and 218 unknown. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (499/631, 79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (77/631, 12.2%), DAIR with adjuvant IA antibiotic infusion (36/631, 5.7%) or two-stage revision with adjuvant IA antibiotic infusion (19/631, 3.0%). Mean duration of IA antibiotic infusion was 19 days (range 3–50), although most patients received a combination of both IA and systemic (IV or PO) antibiotics. An overall failure rate (defined as failures of infection eradication/total PJIs) of approximately 11% was found. The use of IA antibiotic infusion as a stand-alone treatment was associated with a higher failure rate. In total 117 complications occurred in 631 cases (18.5%). Of these, 71 were non-catheter-related (60.7%) and 46 were catheter-related (39.3%). The most common catheter-related complications were premature loss of the catheter (18/46), developing a fistula (5/46), and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). Conclusions. Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. From a theoretical point of view it seems likely that is should not be used as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs, labour and catheter-related complications of this treatment modality

Introduction. Previous registry studies of ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) have focused on revision outcomes following primary surgery. Less is known about the effect of ceramic bearings on infection, dislocation, and mortality as outcomes following primary total hip arthroplasty (THA) for the Medicare population. We asked (1) does the use of C-PE bearings influence outcomes following THA as compared with metal-on-polyethylene (M-PE); and (2) does the use of COC bearings influence outcomes following THA as compared with M-PE?. Methods. A total of 315,784 elderly Medicare patients (65+) who underwent primary THA between 2005 and 2014 with known bearing types were identified from the Medicare 100% inpatient sample administrative database. Outcomes of interest included relative risk of 90-day readmission, infection, dislocation, revision, or mortality at any time point after primary surgery. Propensity scores were developed to adjust for selection bias in the choice of bearing type at index primary surgery. Cox regression incorporating propensity score stratification (10 levels) was then used to evaluate the impact of bearing surface selection on outcomes, after adjusting for patient-, hospital-, and surgeon-related factors. Results. For primary THA patients treated with C-PE bearings and COC bearings, there was significantly reduced risk of infection relative to M-PE bearings (C-PE Hazard Ratio, HR: 0.86, p=0.001; COC Hazard Ratio, HR: 0.74, p=0.01). For the C-PE cohort, we also observed reduced risk of 90-day readmission (HR: 0.94, p<0.001); dislocation (HR: 0.81, p<0.001); and mortality (HR: 0.92, p<0.001). There was no significant difference in risk of revision for either the C-PE or COC bearing cohorts when compared with M-PE. For the COC cohort, there was no significant difference in readmission, dislocation, or mortality risk. Conclusions. The results indicate that, after adjusting for selection bias and various confounding patient-, surgeon-, and hospital-related factors, Medicare patients treated with primary THA with ceramic bearings exhibit lower risk of infection than those treated with M-PE bearings. In addition, C-PE bearings were associated with lower risk of dislocation and mortality. As in previous registry studies, we found that ceramic bearings have similar revision risk as M-PE bearings in primary THA at between 8 and 9 years of follow-up. The findings of this study support further research into the long-term association between ceramic bearings in primary THA and clinical outcomes

Telemedicine is the delivery of healthcare from a remote location using integrated computer/communication technology. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation particularly during our current pandemic where patient contact is limited. Databases of PubMed, Scopus and CINHAL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools. Twenty studies were included consisting of nine RCTs across numerous orthopaedic subspecialties including fracture care, elective orthopaedics and oncology. Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient reported outcome measures. Telemedicine was reported to be a safe method of consultation. However, studies were of variable methodological quality with selection bias. In conclusion, evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment with high patient/clinician satisfaction. Further work with high quality RCTs is required to elucidate long term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use in the current COVID-19 pandemic and beyond

Introduction. Previous studies of ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) hip bearings have focused on outcomes following primary surgery. Less is known about the utilization or outcomes of ceramic bearings in revision total hip arthroplasty (R-THA) for the Medicare population in the US. We asked (1) what is the utilization of ceramic bearings for R-THA in the Medicare population and how has it evolved over time; (2) does the use of C-PE bearings influence outcomes following R-THA as compared with metal-on-polyethylene (M-PE); and (3) does the use of COC bearings influence outcomes following R-THA as compared with M-PE?. Methods. A total of 31,809 Medicare patients (aged > 65y) who underwent R-THA between 2005 and 2013 with known bearing types were identified from the Medicare 100% inpatient sample administrative database. Outcomes of interest included relative risk of readmission (90 days) or infection, dislocation, rerevision, or mortality at any time point after revision. Propensity scores were developed to adjust for selection bias in the choice of bearing type at revision surgery. Cox regression incorporating propensity score stratification (10 levels) was then used to evaluate the impact of bearing surface selection on outcomes, after adjusting for patient-, hospital-, and surgeon-related factors. Results. The utilization of C-PE and COC bearings in RHA increased from 5.3% to 26.6% and from 1.8% to 2.5% between 2005 and 2013, respectively. For R-THA patients treated with C-PE bearings, there was reduced risk of 90-day readmission (Hazard Ratio, HR: 0.90, 95% CI: 0.84–0.96, p=0.007). We also observed a trend for reduced risk of infection with C-PE (HR: 0.88, 95% CI: 0.74–1.04) that did not reach statistical significance (p = 0.14). For R-THA patients treated with COC, there was reduced risk of dislocation (Hazard Ratio, HR: 0.76, 95% CI: 0.58–0.99, p=0.04). There was no significant difference in risk of rerevision or mortality for either the C-PE or COC bearing cohorts when compared with M-PE. Discussion. The results indicate that, after adjusting for selection bias and various confounding patient-, surgeon-, and hospital-related factors, Medicare patients treated in a revision scenario with ceramic bearings exhibit similar risk of rerevision, infection, or mortality as those treated with M-PE bearings. Conversely, we found an association between the use of specific ceramic bearings in R-THA and reduced risk of readmission (C-PE) and dislocation (COC). The findings of this study support further research into the association between ceramic bearings in R-THA and lower risk of hospital readmission, dislocation, and, potentially, infection

Introduction:. The direct anterior approach for total hip arthroplasty has shown to improve multiple early outcome measures. However, criticisms suggest improved results may be due to selection bias and protocol changes. This study compares mini-incision posterior approach to direct anterior approach performed by one surgeon, controlling for influences other than the surgical approach itself. Methods:. An IRB approved retrospective review was conducted on 150 consecutive primary total hip arthroplasty patients; the first 50 from mini-incision posterior approach, followed by 50 during the learning curve for direct anterior approach, and 50 subsequent cases when the approach was routine. Peri-operative protocols were alike for all groups. Data collection included patient demographics, anesthesia, operative times, discharge disposition, length of stay, VAS pain scores, progression from assistive devices, and narcotic use at follow-up of two and six weeks. Statistical methods included Wilcoxon rank sum, ANOVA, Kruskal-Wallis, chi-square, fisher exact and t-tests. P-value of <.05 was considered significant. Results:. The groups were well-matched for demographics. The anterior group trended towards higher age, BMI, ASA and pre-op VAS scores. Factors favoring the anterior group reaching statistical significance included: decreased length of stay of 1.02 (learning curve) and 1.26 (routine) days (p < .0001); discharge to home instead of a rehab facility, 80% and 84% anterior versus 56% posterior (p = 0.0028); VAS pain scores at two weeks 2.7 and 2.2 anterior versus 5.2 posterior (p < .0001); less narcotic pain medication use at two weeks, 44% and 30% versus 86% (p < .0001). In the anterior groups, walker use was less at two weeks, 20% and 12% versus 74% (p < .0001) and at six weeks, 4% and 2% versus 20% (p=.0018). Conclusion:. Primary total hip arthroplasty using the anterior approach versus the posterior approach allows for more rapid recovery in patients with no significant selection bias or protocol changes, even during the learning curve period

Surgical treatment options for Femoroacetabular impingement (FAI) includes both surgical dislocation and hip arthroscopy techniques. The primary aim of this study was to evaluate and compare the survivorship of arthroscopies (scope) and surgical dislocations (SD) at minimum 5-year follow-up. The secondary aim was to describe differences in functional outcomes between the 2 groups. This was a retrospective, single surgeon, consecutive, case-series from a large tertiary care centre. We evaluated all surgeries that were performed between 2005 and 2011. Our institutional database was queried for any patient undergoing surgery for FAI (pincer (n=23), cam (n=306), or mixed (n=103) types). Patients with childhood pathologies i.e. Legg Calve Perthes and slipped capital femoral epiphysis were excluded. This resulted in 221 hips (169 males, 52 females) who underwent either SD (94, 42.5%) or scope (127, 57.5%). A manual chart review was completed to identify patients who sustained a complication, underwent revision surgery or progressed to a total hip arthroplasty (THA). In addition, we reviewed prospectively collected patient reported outcome measure (PROMs) using (SF12, HOOS, and UCLA). Survivorship outcome was described for the whole cohort and compared between the 2 surgical groups. PROMs between groups were compared using The Mann-Whitney U test and the survival between groups was assessed using the Kaplan-Meier Analysis and the Log-Rank Mantel Cox test. All analyses were performed in SPSS (IBM, v. 26.0). The cohort included 110 SDs and 320 arthroscopies. The mean age of the whole cohort was 34±10; patients in the SD group (32±9) were younger compared to the arthroscopy group (39±10) (p<0.0001). There were 16 post-operative complications (similar between groups) and 77 re-operations (more common in the SD group (n=49) due to symptomatic metal work (n=34)). The overall 10-year survival was 91±3%. Survivorship was superior in the arthroscopy group at both 5- (96% (95%CI: 93 – 100)) and 8- years 94% (95%CI: 90 – 99%) compared to the SD Group (5-yr: 90% (95%CI: 83 – 98); 8-yr: 84% (95%CI:75 – 93)) (p=0.003) (Figure 1). On average HOOS improved from 54±19 to 68±22 and WOMAC from 65±22 to 75±22. The improvement in PROMs were similar between the 2 groups. We report very good long-term joint preservation for the treatment of FAI, which is similar to those reported in hip dysplasia. In addition, we report satisfactory improvement in function following such treatment. The differences reported in joint survival likely reflect selection biases from the treating surgeon; more complex cases and those associated with more complex anatomy were more likely to have been offered a SD in order to address the pathology with greater ease and hence the inferior joint preservation identified in this group. For any figures or tables, please contact the authors directly

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. Background: Trochanteric bursitis is a common and poorly understood complication following total hip arthroplasty (THA). The purpose of this study was to evaluate the incidence of symptomatic trochanteric bursitis and the change in hip offset among THA patients before and after the introduction of robotic assistance. Methods. Retrospective chart review of THAs performed by a single over a 3-year period between 1/5/2013 and 6/28/2016. Between 1/5/2013 and 11/11/2014 101 consecutive patients were identified that underwent manual posterior-lateral THA that utilized traditional cup positioning method based on AP Pelvis radiograph. The subsequent six-month period during a complete transition to robotic arm assistance for posterior-lateral THA was excluded to eliminate any learning curve or selection bias. Between 6/2015 and 6/2016 109 consecutive patients that underwent robotic arm-assisted. Medical records were reviewed for symptomatic trochanteric bursitis within two years of surgery. Hip offset was measured on preoperative and postoperative AP pelvis radiographs and postoperative joint reactive forces were calculated using Martell's Hip Analysis Suite. Results. The rate of symptomatic trochanteric bursitis was 21% in the manual THA population and 10.4% in the population of THAs performed with robotic assistance (P=0.02). The post-operative change in hip offset was significantly higher in patients undergoing traditional THA than patients undergoing robotic arm-assisted THA (5.95 mm vs 4.40 mm; p = 0.0071). Discussion/Conclusion. Transition to robotic arm-assisted THA was associated with decreased incidence of symptomatic trochanteric bursitis and a decreased post-operative change in hip offset

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment. To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA). Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73). When accounting for other variables, late irrigation does not independently increase risk of reoperation

Introduction. This study sought to evaluate the patient experience and short-term clinical outcomes associated with the hospital stay of patients who underwent robotic arm-assisted total knee arthroplasty (TKA). These results were compared to a cohort of patients who underwent TKA without robotic assistance performed by the same surgeon. Methods. A cohort of consecutive patients undergoing primary TKA for the diagnosis of osteoarthritis by a single fellowship trained orthopaedic surgeon over a 39-month period was identified. Patients who underwent TKA during the year this surgeon transitioned his entire knee arthroplasty practice to robotic assistance were excluded to eliminate selection bias and control for the learning curve. A final population of 538 TKAs was identified. Of these, 314 underwent TKA without robotic assistance and 224 underwent robotic arm-assisted TKA. All patients received the same prosthesis and post-operative pain protocol. Patient demographic characteristics and short-term clinical data were analyzed. Results. Robotic arm-assisted TKA was associated with shorter length of stay (2.3 versus 2.6 days, p< 0.001), a 50% reduction in morphine milligram equivalent utilization (from 213 to 105, p< 0.001), decreased visual analog scale pain score on post-op day 1 and 2 (p< 0.001), and a mean increase in procedure time of 8.2 minutes (p=0.08). There were no post-operative infections in either cohort. Additionally, there were no significant differences in rates of manipulation under anesthesia, emergency department visits, readmissions, or return to the operating room. Conclusions. This analysis corroborates existing literature suggesting that robotic arm-assisted TKA can be correlated with improved short-term clinical outcomes. This study reports on a single surgeon's experience with regard to analgesic requirements, length of stay, pain scores, and procedure time following a complete transition to robotic arm-assisted TKA. These results underscore the importance of continued evaluation of clinical outcomes as robotic arthroplasty technology continues to grow. For any figures or tables, please contact authors directly

Background. The purpose of this study was to report functional outcome scores following arthroscopic acetabular chondral procedures using the U.K. Non-Arthroplasty Hip Registry (NAHR). Methods. Data on adult patients who underwent hip arthroscopy between January 2012 and December 2018 was extracted from the NAHR. Patients who underwent femoral sided chondral procedures were excluded. Patients who underwent osteophyte excision or a concurrent extra-articular procedure were also excluded. Cases were then classified according to the acetabular chondral procedure performed – ‘chondroplasty’, ‘microfracture’ or ‘none’ (no chondral procedure recorded). Outcomes comprised EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool 12 (iHOT-12), preoperatively and at 6 and 12 months. Results. A total of 4,978 arthroscopies were identified (chondroplasty 26.4%, microfracture 5.4%, none 68.2%). Patients who underwent microfracture were significantly older (37.9y vs 37.3y) and of higher BMI (26.4 vs 25.8 kg/m2) than patients who underwent chondroplasty. Pre-operative, 6 and 12-month follow-up were available for 77%, 42% and 38% of cases respectively. This registry study found significant clinical improvement in all groups based on arthroscopic chondral procedure following hip arthroscopy. Patients who have microfracture seem to take longer to improve and have lower peak scores as compared with chondroplasty. All groups saw significant (p <0.0001) EQ-5D and iHOT-12 gain compared to pre-operative baseline scores at 6 months which was maintained at 12 months (12 month iHOT-12 gain: chondroplasty = +27.6 (95%CI 25.0 to 30.2), microfracture = +22.6 (95%CI 17.6 to 27.6), none = +25.4 (23.8 to 27.0)). There were no statistically significant between group differences in iHOT-12 gain. Comparing <40y vs >40y age groups, all saw significant improvements in baseline scores maintained up to 12 months however patients over 40y were slower to improve, particularly in microfracture with significantly poorer iHOT-12 gain at 6 months in comparison to patients under 40y but significance was lost by 12 months. Conclusion. Whilst patient selection is crucial (and we acknowledge selection bias as a key limitation), all three chondral procedures were effective at improving patient outcomes for both younger and older patients

Simultaneous bilateral total hip arthroplasties (THAs) present unique and unwarranted dangers to the patient and surgeon alike. These include a significantly increased risk of blood transfusion (up to 50% in contemporary series even with the use of tranexamic acid), longer operative times, longer length of stays, and higher mortality rates in patients with minimal risk factors (age > 75 years, rheumatoid arthritis, higher ASA class, and/or male sex). This is even in light of the fact that the vast majority of literature has a substantial selection bias in which only the healthiest, youngest, non-obese, and most motivated patients are included. Traditionally, simultaneous bilateral THAs were completed in the lateral decubitus position. This required the surgeon and surgical team to reposition the patient onto a fresh wound, as well as additional prepping and draping. To mitigate these additional limitations of simultaneous bilateral THAs, there has been a recent trend towards utilizing the direct anterior approach. However, this particular approach presents its own unique set of complications such as an increased risk of periprosthetic femoral fracture and early femoral failure, an increased risk of impaired wound healing (particularly in obese patients), potential injury to the lateral femoral cutaneous nerve with subsequent neurogenic pain, and traction-related neurologic injuries. When compounded with the risks of simultaneous bilateral THAs, the complication profile becomes prohibitive for an elective procedure with an otherwise very low morbidity