Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

Dual mobility (DM) bearings are an attractive treatment option to obtain hip stability during challenging primary and revision total hip arthroplasty (THA) cases. The purpose of this study was to analyze data submitted to the American Joint Replacement Registry (AJRR) to characterize utilization trends of DM bearings in the USA.

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) following treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population. A retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral centre between 2008–2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An “acute” complication was defined as need for two or more surgical procedures, hospital stay longer than 14-days, or recurrence despite IV antibiotics. A “chronic” complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathological fracture, frozen joint or dislocation. 151 cases met inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication. Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by need for surgical management and failed CRP reduction by 50% at day 4/5. We conclude that CRP trends over 96 hours following commencement of treatment differentiate patients with AHO likely to experience severe disease

Introduction. Total joint arthroplasty rates have increased dramatically in recent decades. However, a comprehensive analysis of trends in revision total hip arthroplasty has not been performed recently to address the changing volume, costs, and location of these complex cases. We sought to identify trends in volume of these procedures, geographic distribution changes, and cost trends using a national sample. Materials and methods. The National Inpatient Sample, a representative sample of all hospital discharges within the United States, was used to determine the volume of revision total hip arthroplasty (THA) from 1993 to 2014. Procedures were identified by ICD-9 codes corresponding to revision THA. Annual incidence of revision THA was compared to annual incidence of primary THA to determine whether relative growth of revisions differed proportionally from the primary procedure. State-specific data was analyzed where available to develop geographic trend maps in the incidence of revision THA procedures using the estimated state population for years under review. Trends were also reviewed for hospital location (urban versus rural; teaching versus non-teaching) and total hospital charges. Analysis of trends was performed using linear regression models. Results. Volume of revision THA increased slower than primary THA from 1993 to 2014. Revision THA volume increased from 28,429 in 1993 to 48,295 in 2014. However, the relative proportion of revision compared to primary THA during this time period decreased from 21.3% in 1993 to 13.0% in 2014. While revision THA grew significantly at 925 additional procedures per year (p <0.001), the revision/primary proportion declined at a rate of −0.4 percentage points annually (p <0.001). Nationally, only one state demonstrated statewide incidence rate of revision THA >100 / 100,000 residents in 2001, while 31 of 36 states reporting in 2014 demonstrated statewide incidence rate of revision THA >100 / 100,000 residents. Revision THA shifted dramatically away from rural and urban non-teaching hospitals to urban teaching hospitals. In the year 2000, 52.3% of revision THA was performed in urban teaching hospitals, which had increased to 71.2% by 2014. Only 5.2% of revision THA was performed in rural hospitals in 2014. Similarly, hospital charges for revision THA increased significantly from a mean of $32,007 in 2000 to $83,927 in 2014. Discussion. Dramatic changes in the geographic distribution, hospital type, and cost of revision THA have occurred over the past two decades. The importance of this cannot be overstated, especially within the context of shifting payment models including mandated and voluntary bundles that have been applied to total joint arthroplasty procedures. With the burden of these costly, complex surgical cases falling predominantly on urban teaching hospitals, there must be a mechanism for adequately valuing these procedures to allow surgeons to be able to properly care for these patients. For any tables or figures, please contact the authors directly

Introduction

Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we look at trends in the use and outcomes of TAR in Scotland.

Summary Statement. Navigated total knee arthroplasty (TKA) is becoming increasingly popular in the United States. Compared to traditional unnavigated TKA, the use of navigation is associated with decreased blood transfusions and shorter hospital stays. Introduction. Navigated total knee arthroplasty (TKA) is a recent modification to standard TKA with many purported benefits in regards to component positioning. Controversy currently exists though regarding its clinical benefits. The purpose of this study was to assess recent national trends in navigated and unnavigated total knee arthroplasty and to evaluate perioperative outcomes for each group. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after navigated and unnavigated TKA for each year between 2005 and 2010. Data regarding patient demographics, hospitalization length, discharge disposition, blood transfusions, deep vein thrombosis, pulmonary embolism, mortality, and hospital location were gathered from the NHDS. Trends were evaluated by linear regression with Pearson's correlation coefficient (r) and statistical comparisons were made using Student's t-test, z-test for proportions, and chi-square analysis with a significance level of 0.05. Results. 22,443 patients admitted for TKA were identified. 578 (2.6%) of these patients had a TKA utilizing navigation. After adjusting for fluctuations in annual TKA performed, the use of navigation in TKA demonstrated a strong positive correlation with time (r=0.71), significantly increasing from an average utilization rate of 2.2% between 2005–2007 to 3.2% between 2008–2010 (p<0.01). The location of the hospital was found to significantly impact the utilization of navigation, with the lowest rate seen in the Midwest region (2.0%) of the US and the highest rate seen in the South region (3.0%). The mean age of navigated patients was 66.0 years. This group included 211 men and 367 women. The unnavigated group had a mean patient age that was insignificantly higher at 66.4 years (p=0.37) and included 7,815 men and 14,047 women. Gender was also not significantly different (p=0.71) between those with navigated TKA and those with unnavigated TKA. The number of medical co-morbidities was significantly higher in those with navigation (mean 5.4 diagnoses) than those without navigation (mean 5.1 diagnoses, p=0.01). Average hospitalization length also varied based on navigation status, with significantly shorter stays for those with navigation (3.3 days, range 1–11) compared to those without (3.6 days, range 1–73, p<0.01). The rate of blood transfusion was significantly lower in the navigated group (13.0%) versus the unnavigated group (17.4%, p<0.01). There was no difference in the rate of deep vein thrombosis (0.69% vs 0.53%, p=0.64) or pulmonary embolism (0.17% vs 0.47%, p=0.10). Mortality was also not significantly different for navigated TKA (0.17%) when compared to unnavigated TKA (0.08%, p=0.61). Discharge disposition did not significantly vary based on navigation status either, with 65.5% of navigated patients and 67.0% of unnavigated patients able to go directly home (p=0.55) after their inpatient stay. Discussion/Conclusion. This study demonstrates that the use of navigated TKA in the US is rising. Additionally, despite having more medical co-mobidities, the navigated population required less blood transfusions and shorter lengths of stay. Interestingly, navigation utilization demonstrated variability based on hospital region. The reasons for this are not immediately clear, but may be related to differences in regional training

Summary Statement. Pulmonary embolism (PE) after total knee arthroplasty can have a significant impact on patient outcomes and healthcare costs. Efforts to prevent or minimise PE over the last 10 years have not had a significant impact on its occurrence at the national level. Introduction. Pulmonary embolism (PE) is a rare but known potentially devastating complication of total knee arthroplasty (TKA). Significant healthcare resources and pharmaceutical research has been recently focused on preventing this complication but limited data exists regarding the early results of this great effort. The purpose of this study was to assess recent national trends in PE occurrence after TKA and evaluate patient outcomes related to this adverse event. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after primary TKA for each year between 2001 and 2010. ICD-9 diagnosis codes were then used to identify patients from this population who developed an acute PE during the same admission. Data regarding patient demographics, hospitalization length, discharge disposition, deep vein thrombosis, mortality, and hospital size/location were gathered from the NHDS. Trends were evaluated by linear regression with Pearson's correlation coefficient (r) and statistical comparisons were made using Student's t-test, z-test for proportions, and chi-square analysis with a significance level of 0.05. Results. 35,220 patients admitted for a primary TKA were identified. 159 (0.045%) of these patients developed an acute PE during the same admission. After adjusting for fluctuations in annual TKA performed, the development of PE after TKA demonstrated a weak negative correlation with time (r=0.17), insignificantly decreasing from an average rate of 0.049% between 2001–2005 to 0.041% between 2006–2010 (p=0.26). The size of the hospital was found to significantly impact the incidence of PE and primary TKA, with the lowest rate seen in hospitals under 100 beds (0.23%) and the highest rate seen in those with over 500 beds (0.65%, p=0.01). No significant differences in PE incidence were noted based on US region (p=0.38). The mean age of patients with PE was 67.7 years. This group included 54 men and 105 women. The non-PE group had a mean patient age that was insignificantly lower at 66.6 years (p=0.21) and included 12,450 men and 22,611 women. Gender was also not significantly different (p=0.68) between those with PE and those without PE. The number of medical co-morbidities was significantly higher in those with PE (mean 6.42 diagnoses) than those without PE (mean 4.89 diagnoses, p<0.01). Average hospitalization length also varied based on PE status, with significantly longer stays for those with PE (8.2 days, range 2–53) compared to those without PE (3.7 days, range 1–95, p<0.01). The rate of deep vein thrombosis was higher in the PE group (12.7%) versus the non-PE group (0.48%, p<0.01). Mortality was also significantly higher for the PE group (3.9%) compared to the non-PE group (0.09%, p<0.01). Discharge disposition did not significantly vary based on PE status, with 61.5% of PE and 64.0% of non-PE patients able to go directly home (p=0.59) after their inpatient stay. Discussion/Conclusion. This study demonstrates that PE can have a significant impact on patient outcomes and healthcare costs, with an associated 43-fold increase in mortality and a doubling of the inpatient admission duration. Additionally, although the risk of PE after primary TKA remains rare, it still persists. Efforts to prevent or minimise this complication over the last 10 years have not had a significant impact on its occurrence at the national level. This risk of PE appears to be greatest in patients with multiple medical co-morbidities and established DVTs. Interestingly, the PE rate also demonstrated variability based on hospital size. The reasons for this are not clear, but we suspect larger hospitals are more likely to be tertiary-care centers and thus care for more medically-complex patients

Summary Statement. Total hip arthroplasty and hemi-arthroplasty are becoming increasingly popular in the treatment of femoral neck fractures in the United States. Both appear to be safe and effective treatment options, with rare acute adverse events and low mortality. Introduction. Femoral neck fractures are one of the most frequent orthopaedic injuries seen in the United States (US). Total hip arthroplasty (THA) and hemiarthroplasty (HA) are commonly used to treat displaced intra-capsular femoral neck fractures, but controversy currently exists regarding the preferred modality. The purpose of this study was to assess recent national trends in THA and HA performed for femoral neck fracture and to evaluate perioperative outcomes for each treatment group. Methods. International Classification of Disease - 9th Revision (ICD-9) diagnosis codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after femoral neck fracture for each year between 2001 and 2010. ICD-9 procedure codes were then used to identify patients from this fracture population who underwent THA or HA. Data regarding patient demographics, hospitalization length, discharge disposition, in-hospital adverse events (pulmonary embolus, deep vein thrombosis, blood transfusion, mortality) and hospital size/location were gathered from the NHDS. Trends were evaluated by linear regression with Pearson's correlation coefficient (r) and statistical comparisons were made using Student's t-test, z-test for proportions, and chi-square analysis with a significance level of 0.05. Results. 12,757 patients with a femoral neck fracture were identified. 582 (4.6%) were treated with THA and 6,697 (52.5%) received HA. After adjusting for fluctuations in annual fracture incidence, the use of THA to treat femoral neck fractures demonstrated a strong positive correlation with time (r=0.91), significantly increasing from an average rate of 4.2% between 2001–2005 to 5.0% between 2006–2010 (p=0.04). Similarly, the use of HA demonstrated a strong positive correlation with time (r=0.89) and significantly increased from an average rate of 51.0% to 54.7% (p<0.01). The frequency of THA use also demonstrated significant (p=0.01) differences based on US region, with a rate of 3.3% in the West region and 5.2% in the South. No regional differences were seen for HA (p=0.07). Hospital size significantly impacted HA use, with the lowest rate seen in hospitals under 100 beds (47.4%) and the highest rate in those with 200–299 beds (56.0%, p<0.01). No size differences were seen for THA (p=0.10). The THA group had a mean patient age of 76.9 years and included 164 men and 418 women. The HA group had a mean patient age that was significantly higher at 81.1 years (p<0.01) and included 1744 men and 4953 women. Gender was not significantly different (p=0.27) between the groups. Average hospitalization length was significantly longer for THA (7.8 days, range 1–312) compared to HA (6.7 days, range 1–118, p<0.01). Discharge disposition also varied by treatment group, with 23.2% of THA patients able to go directly home compared to only 11.6% of HA patients (p<0.01). Blood transfusion rate was significantly higher for THA (30.4%) compared to HA (25.7%, p=0.02). No significant difference was noted between THA and HA in regards to rate of PE (0.5% versus 0.7%, p=0.52), rate of DVT (1.2% versus 0.8%, p=0.50) or mortality (1.8% versus 2.9%, p=0.09). Discussion/Conclusion. This study demonstrates that the use of THA and HA in the treatment of femoral neck fractures are rising and that both are safe and effective treatment options, with equally rare acute adverse events and low mortality. Interestingly, treatment choice demonstrated variability based on hospital region and size. The reasons for this are not immediately clear, but may be related to differences in regional training and availability of trauma/reconstruction subspecialists

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population.

Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA.

While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful.

Total ankle replacement (TAR) is performed for inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1998. In this study, we look at trends in the use and outcomes of TAR in Scotland.

We identified patients from the SAP who underwent TAR between 1998 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and examined trends in implant type over the following time periods: 1998–2005; 2006–2010 and 2011–2015. Age, gender, indication, outcomes and trends in implants used for each time period were examined.

There were 499 primary TAR procedures with an overall incidence of 0.5/105 population per year. Eight implants were identified with significant changes in the numbers of each type used over time. The peak incidence of TAR was in the 6th decade and mean age of patients increased from 59 years in 1998–2005, to 65 years in 2011–15 (p<0.0001). The percentage of patients with inflammatory arthropathy was 49% in 1998–2005, compared with 10% in 2011–2015. Arthrodesis and infection rates appeared to be higher during the first time period. The male to female ratio changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=<0.0001).

This study examines a large number of TARs from an established arthroplasty registry. The rate of TAR has increased significantly in Scotland from 1998 to 2015. Indications and patient age have changed over time and could impact outcomes after ankle replacement.

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability.

A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications.

Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods.

Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels.

Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery.

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates.

The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates.

There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection.

The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces.

Abstract

Abstract

Hip arthroscopy (HA) and pelvic osteotomy (PO) are surgical procedures used to treat a variety of hip pathology affecting young adults, including femoroacetabular impingement and hip dysplasia respectively. This study aimed to investigate the trends and regional variation in the provision of HA and PO across England from 2010 to 2023 to inform healthcare resource allocation.

We analysed the National Hospital Episode Statistics database for all HA and PO procedures in NHS England using specific OPCS-4 codes: HA: ‘W83+Z843’ or ‘W84+Z843’; PO: ‘X222+Z75’. We collected patient demographics, age, sex, and region of treatment. We performed descriptive and regression analyses to evaluate temporal trends in PO volume, age, sex and regional variation.

22,401 HAs and 1,348 POs were recorded between 2010 and 2023. The annual number of HAs declined by 28.4%, whilst the number of POs increased by 64% (p<0.001). Significantly more females underwent PO vs HA (90% vs 61.3%) and were older than males undergoing the same procedure (PO: 29.0±8.7 vs 25.8±9.2 years; HA: 36.8±12.0 years vs 35.8±11.2 years, p<0.001). For HA, the mean age of both sexes decreased by 3.3 and 2.9 years respectively (p<0.001), whereas the age of PO patients did not change significantly over the study period. There were significant regional variations with a mean incidence of 1.60/100,00 for HA (ranging from 0.70–2.66 per 100,000) and 0.43/100,000 for PO (ranging from 0.08–2.07 per 100,000).

We have observed a decline in HA volume in England, likely due to improved patient selection and the impact of COVID-19, whilst PO volume has significantly increased, with regional variation persisting for both procedures. These trends highlight the need for equitable HA and PO access to improve patient outcomes and call for strategic healthcare planning and resource allocation to reduce disparities and improve training opportunities.

Aims

The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada.

Aims

The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA.

Aims

The purpose of this study was to evaluate trends in opioid use after unicompartmental knee arthroplasty (UKA), to identify predictors of prolonged use and to compare the rates of opioid use after UKA, total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

Abstract

To describe the longitudinal trends in patients with obesity and Metabolic Syndrome (MetS) undergoing TKA and the associated impact on complications and lengths of hospital stay.

We identified patients who underwent primary TKA between 2006 – 2017 within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We recorded patient demographics, length of stay (LOS), and 30-day major and minor complications. We labelled those with an obese Body Mass Index (BMI ≥ 30), hypertension, and diabetes as having MetS. We evaluated mean BMI, LOS, and 30-day complication rates in all patients, obese patients, and those with MetS from 2006-2017. We used multivariable regression to evaluate the trends in BMI, complications, and LOS over time in all patients and those with MetS, and the effect of BMI and MetS on complication rates and LOS, stratified by year.

270,846 patients underwent primary TKA at hospitals participating in the NSQIP database. 63.71% of patients were obese (n = 172,333), 15.21% were morbidly obese (n = 41,130), and 12.37% met criteria for MetS (n = 33,470). Mean BMI in TKA patients increased at a rate of 0.03 per year (0.02-0.05; p < 0 .0001). Despite this, the rate of adverse events in obese patients decreased: major complications by an odds ratio (OR) of 0.94 (0.93-0.96; p < 0 .0001) and minor complications by 0.94 (0.93-0.95; p < 0 .001). LOS also decreased over time at an average rate of −0.058 days per year (-0.059 to −0.057; p < 0 .0001). The proportion of patients with MetS did not increase, however similar improvements in major complications (OR 0.94 [0.91-0.97] p < 0 .0001), minor complications (OR 0.97 [0.94-1.00]; p < 0 .0330), and LOS (mean −0.055 [-0.056 to −0.054] p < 0 .0001) were found. In morbidly obese patients (BMI ≥ 40), there was a decreased proportion per year (OR 0.989 [0.98-0.994] p < 0 .0001). Factors specifically associated with major complications in obese patients included COPD (OR 1.75 [1.55-2.00] p < 0.0001) and diabetes (OR 1.10 [1.02-1.1] p = 0.017). Hypertension (OR 1.12 [1.03-1.21] p = 0.0079) was associated with minor complications. Similarly, in patients with MetS, major complications were associated with COPD (OR 1.72 [1.35-2.18] p < 0.0001). Neuraxial anesthesia was associated with a lower risk for major complications in the obese cohort (OR 0.87 [0.81-0.92] p < 0.0001). BMI ≥ 40 was associated with a greater risk for minor complications (OR 1.37 [1.26-1.50] p < 0.0001), major complications (1.11 [1.02-1.21] p = 0.015), and increased LOS (+0.08 days [0.07-0.09] p < 0.0001).

Mean BMI in patients undergoing primary TKA increased from 2006 - 2017. MetS comorbidities such as diabetes and hypertension elevated the risk for complications in obese patients. COPD contributed to higher rates of major complications. The obesity-specific risk reduction with spinal anesthesia suggests an improved post-anesthetic clinical course in obese patients with pre-existing pulmonary pathology. Encouragingly, the overall rates of complications and LOS in patients with obesity and MetS exhibited a longitudinal decline. This finding may be related to the decreased proportion of patients with BMI ≥ 40 treated over the same period, possibly the result of quality improvement initiatives aimed at delaying high-risk surgery in morbidly obese patients until healthy weight loss is achieved. These findings may also reflect increased awareness and improved management of these patients and their elevated risk profiles.

Aims

The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT).

Introduction

This is a report of the outcome of management of congenital pseudoarthrosis of the tibia (CPT) at skeletal maturity.

Introduction

Dual mobility (DM) total hip arthroplasty (THA) prostheses are designed to increase stability. In the setting of primary and revision THA, DM THA are used most frequently for dysplasia and instability diagnoses, respectively. As the use of DM THA continues to increase, with 8,031 cases logged in the American Joint Replacement Registry from 2012–2018, characterizing in vivo damage and clinical failure modes are important to report.

Introduction

The purpose of this study was to analyze trends in the surgical management of ON in recent years. Specifically, we evaluated the annual prevalences of: 1) joint preserving procedures (osteotomies and core decompression/grafts) and 2) joint non-preserving procedures (total hip arthroplasties [THAs], revision THAs, partial THAs) for the treatment of osteonecrosis of the femoral head (ONFH) between 2009 and 2016.

Introduction

Bundled Payments (BP) were a revolutionary new experiment for CMS that tested whether risk sharing for an episode of care would improve quality and reduce costs. The initial success of BP accelerated their growth as evidence by the launch of both mandatory and commercial bundles. Success in BP is dependent on the target price and the opportunity to reduce avoidable costs during the episode of care. There is concern that the aggressive target pricing methodology in the new model (BPCI-Advanced) penalizes high performing groups that already achieved low episode costs through prior experience and investment in BP. We hypothesize that this methodology incorporates unsustainable downward trends on target prices to a point beyond reasonableness for efficient groups to reduce additional costs and will lead to a large percentage of groups opting out of BPCI-A in favor of a return to fee for service (FFS) reimbursement.

Proper positioning of the acetabular cup deters dislocation after total hip arthroplasty (THA) and is therefore a key focus for orthopedic surgeons. The concept of a safe zone for acetabular component placement was first characterized by Lewinnek et al. and furthered by Callanan et al. The safe zone concept remains widely utilized and accepted in contemporary THA practice; however, components positioned in this safe zone still dislocate. This study sought to characterize current mass trends in cup position identified across a large study sample of THA procedures completed by multiple surgeons. This retrospective, observational study reviewed acetabular cup position in 1,236 patients who underwent THA using computer-assisted navigation (CAS) between July 2015 and November 2017. Outcomes included acetabular cup position (inclination and anteversion) measurements derived from the surgical navigation device and surgical approach. The overall mean cup position of all recorded cases was 21.8° (±7.7°, 95% CI = 6.7°, 36.9°) of anteversion and 40.9° (±6.5°, 95% CI = 28.1°, 53.7°) of inclination (Table 1). For both anteversion and inclination, 65.5% (809/1236) of acetabular cup components were within the Lewinnek safe zone and 58.4% (722/1236) were within the Callanan safe zone. Acetabular cups were placed a mean of 6.8° of anteversion (posterior/lateral approach: 7.0°, anterior approach: 5.6°) higher than the Lewinnek and Callanan safe zones whereas inclination was positioned 0.9° higher than the reported Lewinnek safe zone and 3.4° higher than the Callanan safe zone (Figure 1,2). Our data shows that while the majority of acetabular cups were placed within the traditional safe zones, the mean anteversion orientation is considerably higher than those suggested by the Lewinnek and Callanan safe zones. The implications of this observation warrant further investigation.

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Aims

The aim of this study was to assess the current trends in the estimation of survival and the preferred forms of treatment of pathological fractures among national and international general and oncological orthopaedic surgeons, and to explore whether improvements in the management of these patients could be identified in this way.

Background

Dual mobility bearings are an attractive treatment option to obtain hip stability during challenging primary and revision total hip arthroplasty (THA) cases. Despite growing enthusiasm in the United States, long-term results of modern dual mobility implants are lacking. The purpose of this study is to analyze data submitted to the American Joint Replacement Registry (AJRR) to characterize utilization trends of dual mobility bearings in the United States.

Background

Fractures of the femoral neck occurring outside the capsule of the hip joint are assumed to have an intact blood supply and hence their conventional management is by fixation rather than arthroplasty. The dynamic hip screw and its variants have been used over many years to fix such fractures but have inherent vulnerabilities; they require an intact lateral femoral cortex, confer a relatively long moment arm to the redistribution of body weight and may cause a stress riser due to the plate with which they are fixed to the femur. Intramedullary devices for fixation of proximal femoral fractures have a shorter moment arm, can be distally locked with reduced perforation of the femoral cortex and are believed to be inherently more stable. For these reasons, a number of surgeons believe them to be superior to the DHS for all extracapsular fractures and their use is now widespread. In this study, we present the usage trends of both devices in extracapsular fractures over the last five years and set these results in the context of patient demographics.

Aim

Spondylodiscitis and vertebral osteomyelitis can lead to long-term sequelae if not diagnosed and treated promptly and appropriately. The Royal National Orthopaedic Hospital (RNOH) has devised a new spinal infection referral system within the UK that allows cases to be discussed in a specialist multi-disciplinary (MDT) forum. National guidelines were devised in 2013 to help guide treatment, which recommends both tissue biopsies from the affected region and a MRI of the entire spine. The aims of this study were to assess the current treatment and referral practices and compare them with the set guidelines. It is hypothesised that a high percentage of patients are started on antibiotics without a biopsy or a positive set of blood cultures, a low percentage of patients are referred without undergoing a MRI of the full spine and that there is a long delay in referral to the MDT.

Background

Distal femoral fractures are 10 times less common than hip fractures. 12-month mortality has been reported as 25–30% but there is no longer-term data. In Northumbria hip fractures have a 5-year mortality of 68%.

Introduction

Patellar resurfacing is performed in more than 90% of primary total knee arthroplasties (TKAs) in the United States, yet far fewer patellae are resurfaced internationally. Multiple randomized controlled trials have shown decreased revision rates in patients with resurfaced patellas (RP) vs. non-resurfaced (NR). However, most of these studies showed no difference in patient satisfaction, anterior knee pain, or knee society scores. (Figure 1) Given uncertain benefits, the purpose of this study was to determine if the rates of patellar resurfacing have changed over the past 10 years worldwide.

The treatment of osteochondral lesions and osteoarthritis remains an ongoing clinical challenge in orthopaedics. This review examines the current research in the fields of cartilage regeneration, osteochondral defect treatment, and biological joint resurfacing, and reports on the results of clinical and pre-clinical studies. We also report on novel treatment strategies and discuss their potential promise or pitfalls. Current focus involves the use of a scaffold providing mechanical support with the addition of chondrocytes or mesenchymal stem cells (MSCs), or the use of cell homing to differentiate the organism’s own endogenous cell sources into cartilage. This method is usually performed with scaffolds that have been coated with a chemotactic agent or with structures that support the sustained release of growth factors or other chondroinductive agents. We also discuss unique methods and designs for cell homing and scaffold production, and improvements in biological joint resurfacing. There have been a number of exciting new studies and techniques developed that aim to repair or restore osteochondral lesions and to treat larger defects or the entire articular surface. The concept of a biological total joint replacement appears to have much potential.

Cite this article: Bone Joint Res 2013;2:193–9.

INTRODUCTION

The advent of CT based 3D preoperative planning software for reverse total shoulder arthroplasty (RTSA) provides surgeons with more data than ever before to prepare for a case. Interestingly, as the usage of such software has increased, further questions have appeared over the optimal way to plan and place a glenoid implant for RTSA. In this study, a survey of shoulder specialists from the American Shoulder and Elbow Society (ASES) was conducted to examine thought patterns in current RTSA implant selection and placement.

INTRODUCTION

3D preoperative planning software for anatomic total shoulder arthroplasty (ATSA) provides surgeons with increased ability to visualize complex joint relationships and deformities. Interestingly, the advent of such software has seemed to create less of a consensus on the optimal way to plan an ATSA rather than more. In this study, a survey of shoulder specialists from the American Shoulder and Elbow Society (ASES) was conducted to examine thought patterns in current ATSA implant selection and placement.

Hip dysplasia represents a wide spectrum of disease, and interest in the treatment of the disorder has increased with the development of newer surgical techniques and a greater understanding of young adult hip disorders. National hospital episode statistics (HES) were studied from 1999 to 2010. This data remains the current best source of information on surgical procedures outside of dedicated registries. Age stratified data was analysed for 7 separately coded operations for the treatment of hip dysplasia. Overall in the paediatric population there were 898 procedures in 2010 compared to 793 procedures in 2000, but with no detectable trend across that period. Equally, there were no great fluctuations in the small numbers of arthroplasty procedures recorded in either the paediatric or adult populations. There was, however, a clear increase in surgery being performed in adult patients. 210 primary pelvic osteotomies were performed in 2010, compared with only 77 in 2000, with a noticeable increase from 2005 onwards. A similar trend in other extra-articular procedures is seen, rising from 2 to 55 per year over the period studied. Overall, the level of surgical intervention has steadily risen from 104 procedures in 2000 to 422 in 2010, representing a fourfold rise in the number of operations being performed for hip dysplasia in the adult population over an 11 year period. The reasons for this are unclear. It may reflect improvements in the ability to diagnose and intervene earlier to prevent disease progression, but further research is also needed to better define the aetiology underlying these cases that present to the hip surgeon later in life.

Summary Statement

With increasing emphasis on evidence-based medicine in healthcare, there is global increase in proportion of Level-1 and -2 articles in PUBMED. This study shows the trend of orthopaedic publications from different countries in comparison to other specialties.

There has been considerable activity in the past year as a result of the Justice Department Investigation into the medical device industry. There has been an over reaction by many which may negatively impact future research, development and reporting of clinical outcomes. This paper will review some of these activities. A review of professional standards and guidelines has been conducted looking at health care compliance issues as they related to commercial relationships, professional medical societies, individual surgeons, and health care workers with specific focus on disclosure.

Within any important issue, there are always aspects no one wishes to discuss: conflict of interest. Perception of a conflict of interest is often enough to bring about a review of activity.

Overreaction has occurred as a result of government intervention into the medical device industry. Continuing medical education, professional societies by-laws, clinical/surgical publications, medical/legal exposure, product research, development and industry marketing activities have all been impacted.

When professionals fail to provide a proper review process on standards and guidelines on ethical behavior they set themselves up for government oversight and restrictions on their behavior. Be informed and disclose. Know what, when and how to disclose. Protect yourself, no one else will.

BACKGROUND

This study aims to identify recent trends in discharge disposition following bilateral total knee arthroplasty (TKA) as well as factors that predispose patients to enter inpatient rehabilitation facilities (IRF) or skilled nursing facilities (SNF) versus home-rehabilitation (HR). The goal was to identify risk factors that predispose prolonged hospital stays and identify changes in management over time that may be responsible for decreased length of stay (LOS) and a HR program.

Spinal cord injury is an inevitable but rare occurrence in sports. Identifying trends and working to minimise risk is an integral part of sports management. All patients suffering a spinal cord injury in Scotland will be transferred to the Queen Elizabeth National Spinal Injuries Unit (QENSIU). Our records give an accurate account of trends in spinal cord injury. This study details the number of spinal cord injuries caused by sports and leisure pursuits in Scotland since 1992.

1451 patients have suffered a spinal cord injury in Scotland from 1992-2008. 142 (9.8%) arose from injuries during sport. The average age at injury was 32, and patients were predominantly male (91%). The commonest cause was diving (40, 28%) followed by cycling (29, 20%) climbing and hillwalking (15, 11%) and rugby union (12, 8%). Smaller numbers were seen in horse-riding (11), aerial sports (6), motor sports (6), snow sports (5), and football (5). Overall, there was evidence of an increasing trend in the number and severity of injuries in rugby and cycling.

The number of spinal injuries, caused by diving, rugby and cycling remains disproportionally high and the increasing trends identified merit further investigation.

Aims

Joint arthroplasties may be associated with a blood loss, which necessitates transfusion. Especially, hip arthroplasties are highly associate with transfusion to compensate perioperative bleeding. Orthopaedic surgeons and patients have increasing concerns regarding complications of blood transfusions. Although various methods to reduce transfusions have been attempted in TJA, a high percentage of patients require a transfusion during and after the procedures. The purposes of this study were to evaluate the trends of the transfusion(transfusion rates, transfusion amounts, economic burden) in hip arthroplasties, using nationwide data from the National Health Insurance Service (NHIS).

Introduction:

Due to improvement in overall prosthesis designs and surgical methods, there have been increasing numbers of total ankle arthroplasty performed with encouraging intermediate results. While European registries have been able to perform long term follow-ups and analysis on total ankle arthroplasty patients, majority of the US studies have been based on experiences at a single institution. There is currently limited data on the recent trends of total ankle arthroplasty. The purpose of our study is to evaluate the in-patient demographics, complications and readmission rate in patients after total ankle arthroplasty at academic medical centers in United States.

The World Health Organisation (WHO) has recently identified musculoskeletal care as a major global health issue in the developing world. However, little is known about the quality and trends of orthopaedic research in resource-poor settings. The purpose of this study was to perform a systematic review of orthopaedic research in low-income countries (LIC). The primary objective was to determine the quality and publication parameters of studies performed in LIC. Secondary objectives sought to provide recommendations for successful strategies to implement research endeavors in LIC.

A systematic review of the literature was performed by searching MEDLINE (1966-November 2014), EMBASE and the Cochrane Library to identify peer-reviewed orthopaedic research conducted in LICs. The PRISMA guidelines for performing a systematic review were followed. LIC were defined by the WHO and by the World Bank as countries with gross national income per capita equal or less than 1045US$. Inclusion criteria were (1) studies performed in a LIC, (2) conducted on patients afflicted by an orthopaedic condition, and (3) evaluated either an orthopaedic intervention or outcome. The Oxford Centre for Evidence-Based Medicine Levels of Evidence, and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to objectively rate the overall methodological quality of each study. Additional data collected from these studies included the publication year, journal demographics, orthopaedic subspecialty and authors' country of origin.

A total of 1,809 articles were screened and 277 studies met our inclusion criteria. Eighty-eight percent of studies conducted in LIC were of lower quality evidence according to the GRADE score and consisted mostly of small case series or case reports. Bangladesh and Nepal were the only two LIC with national journals and produced the highest level of research evidence. Foreign researchers produced over 70% of the studies with no collaboration with local LIC researchers. The most common subspecialties were trauma (42%) and paediatrics (14%). The 3 most frequent countries where the research originated were the United States (42%), United Kingdom (11%), and Canada (8%). The 3 most common locations where research was conducted were Haiti (18%), Afghanistan (14%), and Malawi (7%).

The majority of orthopaedic studies conducted in LIC were of lower quality and performed by foreign researchers with little local collaboration. In order to promote the development of global orthopaedic surgery and research in LIC, we recommend (1) improving the collaboration between researchers in developed and LIC, (2) promoting the teaching of higher-quality and more rigorous research methodology through shared partnerships, (3) improving the capacity of orthopaedic research in developing nations through national peer-reviewed journals, and (4) dedicated subsections in international orthopaedic journals to global healthcare research.

The bearing surface is the critical element in determining the longevity of a total hip arthroplasty. Over the past decade problems associated with bearing surfaces and modular femoral tapers have had an impact on surgeon selection of both acetabular liners and modular femoral heads. The purpose of this study was to analyse THA bearing surface trends from 2007 through 2014 using a large national database.

A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted from 2007 to 2014. All patients who underwent a primary THA were identified using International Classification of Diseases, 9th edition (ICD-9) procedure codes. Bearing surface data was extracted by identifying patients with ICD-9 procedure modifier codes. Patient and hospital characteristics were recorded for each patient. Descriptive statistics were employed to characterise bearing surface trends for the following bearing surfaces: metal on polyethylene (MoP); ceramic on polyethylene (CoP); ceramic on ceramic (CoC) and metal on metal (MoM). Univariate analysis was performed to identify differences between the bearing surface groups.

During the study period, 2,460,640 primary THA discharges were identified, of which 1,059,825 (43.1%) had bearing surface data available for further analysis. The breakdown of the bearing surfaces used for these THAs were as follows: MoP − 49.1% (496,713); CoP − 29.1% (307,907); CoC − 4.2% (44,823); and MoM − 19.9% (210,381). MoM utilization peaked in 2008 with 51,033 cases representing 40.1% of THAs implanted that year. The usage steadily declined and by 2014 there were only 6,600 MoM cases representing only 4.0% of the THAs. From 2007 to 2014, the use of CoP bearing surfaces increased from 11,482 discharges (11.1% of cases) in 2007, to 83,300 discharges (50.8% of cases) in 2014. CoP utilization surpassed MoP in 2014. MoP accounted for 54.7% of discharges in 2011 and just 42.1% in 2014.

During the study period, MoM bearing surface usage declined precipitously, while CoP surpassed MoP as the most prevalent bearing surface used in total hip arthroplasty patients. These changes in bearing surface usage over time were clearly influenced by concerns regarding high failure rates associated with MoM articulations and reports of taper corrosion associated with modular metal femoral heads.

Prospectively collected data is an important source of information subjected to change over time. What surgeons were doing in 1999 might not be the case anymore in 2016 and this change in time also applies to a number of factors related to the performance and outcome of total hip replacement. We evaluated the evolution of factors related to the patient, the surgical procedure, socio-economy and various outcome parameters after merging the databases of the Swedish Hip Arthroplasty Register, Statistics Sweden and the National Board of Health and Welfare.

Data on 193,253 THRs (164,113 patients) operated between 1999 and 2012 were merged with databases including general information about the Swedish population and about hospital care. We studied the evolution of surgical volume, patient demographics, socio-economic factors, surgical factors, length of stay, mortality rate, adverse events, re-operation and revision rates and PROMs.

Most patients were operated because of primary osteoarthritis and this share increased further during the period at the expense of decreasing number of patients with inflammatory OA and hip fracture. Comorbidity and ASA scores increased for each year. The share of all cemented implants has dropped from 92% to 68% with a corresponding increase of all uncemented from 2% to 16%.

Length of stay decreased with about 50 percent to 4.5 days in 2012. The 30- and 90-day mortality rate dropped to 0.4% and 0.7%. Re-operation and revision rates at 2 years were lower in the more recent years. The postoperative PROMs are improving despite the preoperative pain scores getting worse.

Even in Sweden, always been considered as a very conservative country with regards to hip replacement surgery, the demographics of the patients, the comorbidities and the primary diagnosis for surgery are changing. Despite these changes the outcomes like mortality, re-operations, revisions and PROMs are improving.