Aims. The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. Results. In all, one patient was lost to follow-up prior to 12 months. The remaining 22 patients were followed for a mean of 46 months (12 to 92). At latest follow-up, four patients (18%) had undergone amputation for failure of treatment and persistent infection. For the other 18 patients, 11 patients (50%) had maintained a knee prosthesis in place while seven patients had undergone resections for persistent infection but retained their limbs (32%). Reoperations were common following coverage and reimplantation. The median number of additional procedures was two (0 to 6). Clinical function was poor in patients who underwent reimplantation and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (0 to 70) and 30 (0 to 65), respectively. All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusion. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (82%) but clinical outcomes in salvaged limbs were poor. Cite this article: Bone Joint J 2020;102-B(6 Supple A):176–180

Introduction. Infection following TKA can be a catastrophic complication that can cause significant pain, morbidity and jeopardize limb viability. The integrity of the soft tissue envelope is critical to successful treatment and infection control. While local tissue flaps can provide adequate coverage for most soft tissue defects around the knee, there are cases that require salvage using microvascular free tissue transfers. The purpose of this study is to evaluate the 1) rate of limb salvage; 2) infection control; and 3) clinical function following free flap coverage for salvage of the infected TKA. Materials and Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and 7 women with a mean age of 61.2 years (range 39–81). The median number of procedures performed prior to soft tissue coverage was 5 (range 2–9) and all patients had failed at least one 2 stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. The rate of limb salvage and infection control were recorded. Results. One patient was lost to follow up prior to 12 months. The remainder 22 patients were followed for a mean of 46 months (range 12–92 months). At latest follow up, 4 patients (18%) had undergone amputation for failure of treatment and persistent infection. For the remainder 18 patients, 11 patients (50%) have maintained a knee prosthesis in place while 7 patients had undergone resections for persistent infection but maintained their limbs (32%). Reoperations were common following coverage and reimplantation procedure. The median number of additional procedures was 2 (range 0–6). Clinical function was poor in patients who were reimplanted and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (range 0–70) and 30 (range 0–65). All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusions. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (81%) but clinical outcomes in salvaged limbs were poor. The data should be used to counsel patients when contemplating limb salvage in these severe, end-stage cases. For figures, tables, or references, please contact authors directly

Objectives. There remains a lack of data on the reliability of methods to estimate tibial coverage achieved during total knee replacement. In order to address this gap, the intra- and interobserver reliability of a three-dimensional (3D) digital templating method was assessed with one symmetric and one asymmetric prosthesis design. Methods. A total of 120 template procedures were performed according to specific rotational and over-hang criteria by three observers at time zero and again two weeks later. Total and sub-region coverage were calculated and the reliability of the templating and measurement method was evaluated. Results. Excellent intra- and interobserver reliability was observed for total coverage, when minimal component overhang (intraclass correlation coefficient (ICC) = 0.87) or no component overhang (ICC = 0.92) was permitted, regardless of rotational restrictions. Conclusions. Measurement of tibial coverage can be reliable using the templating method described even if the rotational axis selected still has a minor influence

Aims. Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. Methods. This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. Results. In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). Conclusion. Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized. Cite this article: Bone Jt Open 2022;3(1):35–41

Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to intramedullary fixation (8%; p=0.005). Overall, twenty-seven complications occurred in 20 patients and 31% required reoperation other than external fixator removal. Intramedullary fixation led to a 90% rate of both infection control and radiographic union. Conclusion. Two-stage knee arthrodesis using a deliberate protocol (resection, high-dose abx spacer, targeted IV abx, and subsequent arthrodesis) ultimately achieved successful limb salvage in 95% of patients with complex infected TKA. One or more complications occurred in nearly half the patients and reoperation was required for 1-in-3. That substantial risk of complications is not surprising as this large contemporary series included complex, worst-case infected TKA in which: 2/3 had disrupted extensor mechanism, 1/3 required flap coverage, and the majority had poly-microbial or multi-drug resistant organisms. Summary. For contemporary patients with very complex, infected TKA a two-stage knee arthrodesis was reliable in achieving limb salvage (95%) at the cost of a high initial complication and reoperation rate. For figures, tables, or references, please contact authors directly

Objectives. Patient-specific (PS) implantation surgical technology has been introduced in recent years and a gradual increase in the associated number of surgical cases has been observed. PS technology uses a patient’s own geometry in designing a medical device to provide minimal bone resection with improvement in the prosthetic bone coverage. However, whether PS unicompartmental knee arthroplasty (UKA) provides a better biomechanical effect than standard off-the-shelf prostheses for UKA has not yet been determined, and still remains controversial in both biomechanical and clinical fields. Therefore, the aim of this study was to compare the biomechanical effect between PS and standard off-the-shelf prostheses for UKA. Methods. The contact stresses on the polyethylene (PE) insert, articular cartilage and lateral meniscus were evaluated in PS and standard off-the-shelf prostheses for UKA using a validated finite element model. Gait cycle loading was applied to evaluate the biomechanical effect in the PS and standard UKAs. Results. The contact stresses on the PE insert were similar for both the PS and standard UKAs. Compared with the standard UKA, the PS UKA did not show any biomechanical effect on the medial PE insert. However, the contact stresses on the articular cartilage and the meniscus in the lateral compartment following the PS UKA exhibited closer values to the healthy knee joint compared with the standard UKA. Conclusion. The PS UKA provided mechanics closer to those of the normal knee joint. The decreased contact stress on the opposite compartment may reduce the overall risk of progressive osteoarthritis. Cite this article: K-T. Kang, J. Son, D-S. Suh, S. K. Kwon, O-R. Kwon, Y-G. Koh. Patient-specific medial unicompartmental knee arthroplasty has a greater protective effect on articular cartilage in the lateral compartment: A Finite Element Analysis. Bone Joint Res 2018;7:20–27. DOI: 10.1302/2046-3758.71.BJR-2017-0115.R2

Introduction. First generation cephalosporins remain the gold standard perioperative antibiotic for total hip and knee arthroplasty (THA, TKA). However, some patients have documented or self-reported allergies to antibiotics, most commonly penicillin, that result in changes to perioperative antibiotic coverage. Furthermore, patients testing positive for methicillin resistant staphylococcus aureus (MRSA) represent another group where an alternative to cefazolin, typically vancomycin, is often chosen for perioperative prophylaxis. The aims of this study were to 1) characterize the antibiotic choices for perioperative prophylaxis at the time of primary TKA and THA, 2) assess the efficacy of a preoperative antibiotic allergy testing program, and 3) determine rates of periprosthetic joint infection (PJI) based on perioperative antibiotic regimen. Methods. We evaluated all patients undergoing primary TKA or THA at a single academic institution from January 2004-May 2017, yielding a cohort of 29,695 patients. A series of institutional databases were combined to determine which patients underwent antibiotic allergy testing prior to surgery, outcomes from the allergy consultation, perioperative antibiotic management strategy, and survivorship free of infection until final follow-up. Results. Antibiotic allergy testing was performed in 3,411 patients (11.5%) on the basis of a patient provided history of possible penicillin or cephalosporin allergy. Among those tested, 3,310 patients (97.0%) were cleared by the allergist to use cephalosporins in the perioperative period and 2,883 patients (87.1%) eventually received cefazolin. For the entire cohort, 28,174 patients (94.9%) received an operative antibiotic regimen including cefazolin and 1,521 patients (5.1%) received non-cefazolin antibiotics, most commonly vancomycin or clindamycin. Survivorship free of PJI was significantly higher among patients receiving cefazolin compared to non-cefazolin antibiotics with the most rapid divergence occurring within 2 months of surgery (p<0.001) (Figure 1). Survivorship free of PJI in the cefazolin compared to the non-cefazolin groups was 99.40% vs 99.34% at 1 month, 99.11% vs 98.55% at 2 months, 98.83% vs 98.22% at 1 year, and 98.15% vs 96.96% at 10 years (Table 1). Notably, the increased PJI rate observed in the non-cefazolin group was not attributable to high preoperative MRSA prevalence as 0 of the 38 PJIs grew MRSA on culture. The number needed to treat with cefazolin to prevent 1 PJI was 164 patients at 1-year and 84 patients at 10-years. Therefore, potentially 6,098 PJIs could be prevented by 1-year and 11,905 by 10-years in a cohort of 1,000,000 primary TKA and THA patients. Conclusions. This study demonstrates a significantly higher rate of PJI when non-cefazolin antibiotics are used for prophylaxis during primary TKA and THA, which is likely attributable to the superior spectrum of coverage for common PJI organisms compared to vancomycin or clindamycin. This is supported by the increased rate of non-MRSA PJI observed in the non-cefazolin cohort. Furthermore, cefazolin has been shown to act synergistically with vancomycin against MRSA. This work highlights the positive impact of a formal preoperative antibiotic allergy testing program to increase cefazolin usage. Also, surgeons may consider using cefazolin as a dual agent in the case of known MRSA colonization, whenever possible for PJI prophylaxis during TKA and THA. For any figures or tables, please contact authors directly

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

Aims

Unicompartmental knee arthroplasty (UKA) is the preferred treatment for anterior medial knee osteoarthritis (OA) owing to the rapid postoperative recovery. However, the risk factors for UKA failure remain controversial.

Aims

Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

Aims

The aims of this study were: 1) to describe extended restricted kinematic alignment (E-rKA), a novel alignment strategy during robotic-assisted total knee arthroplasty (RA-TKA); 2) to compare residual medial compartment tightness following virtual surgical planning during RA-TKA using mechanical alignment (MA) and E-rKA, in the same set of osteoarthritic varus knees; 3) to assess the requirement of soft-tissue releases during RA-TKA using E-rKA; and 4) to compare the accuracy of surgical plan execution between knees managed with adjustments in component positioning alone, and those which require additional soft-tissue releases.

We report the clinical outcome and findings at second-look arthroscopy of 216 patients (mean age 25 years (11 to 58)) who underwent anterior cruciate ligament (ACL) reconstruction or augmentation. There were 73 single-bundle ACL augmentations (44 female, 29 male), 82 double-bundle ACL reconstructions (35 female, 47 male), and 61 single-bundle ACL reconstructions (34 female, 27 male). In 94 of the 216 patients, proprioceptive function of the knee was evaluated before and 12 months after surgery using the threshold to detect passive motion test. Second-look arthroscopy showed significantly better synovial coverage of the graft in the augmentation group (good: 60 (82%), fair: 10 (14%), poor: 3 (4%)) than in the other groups (p = 0.039). The mean side-to-side difference measured with a KT-2000 arthrometer was 0.4 mm (-3.3 to 2.9) in the augmentation group, 0.9 mm (-3.2 to 3.5) in the double-bundle group, and 1.3 mm (-2.7 to 3.9) in the single-bundle group: the result differed significantly between the augmentation and single-bundle groups (p = 0 .013). No significant difference in the Lysholm score or pivot-shift test was seen between the three groups (p = 0.09 and 0.65, respectively). In patients with good synovial coverage, three of the four measurements used revealed significant improvement in proprioceptive function (p = 0.177, 0.020, 0.034, and 0.026). We conclude that ACL augmentation is a reasonable treatment option for patients with favourable ACL remnants. Cite this article: Bone Joint J 2014;96-B:1325–32

Introduction. Periprosthetic infection (PJI) after primary total knee arthroplasty (TKA) remains a challenging issue affecting 1–2% of cases. Locally delivered prophylactic antibiotics, including tobramycin or gentamicin mixed in polymethylmethacrylate (PMMA) bone cement and vancomycin powder, are increasingly used despite a lack of high quality evidence for either practice. In this study, we report the antibiotic susceptibility of organisms recovered in culture from patients with acute prosthetic joint infection after primary TKA to gentamicin, tobramycin and vancomycin. Methods. Using a retrospective database of all primary TKA performed at a single institution between January, 1 2014 and July 1, 2018, we identified 18 cases of acute PJI after primary TKA, as defined by the Musculoskeletal Infection Society 2011 guidelines as less than 3 months from symptoms or index surgery to presentation. The use of antibiotic bone cement during the index procedure and time to surgical management of the infection were recorded. Fluid cultures and tissue cultures were obtained intraoperatively at the time of revision. The organisms from positive cultures underwent MIC testing to gentamicin, tobramycin and vancomycin using a gradient diffusion method (ETEST). MIC breakpoints for susceptibility were based on Clinical and Laboratory Standards Institute definitions. Results. 18 cases of PJI after TKA were identified, including 4 polymicrobial infections (22.2%) (Table 1). Average time to revision for infection was 38 days (range: 6–84 days). 34.8% of bacterial isolates were resistant to gentamicin, 39.1% were resistant to tobramycin and 17.4% were resistant to vancomycin. Of the 8 bacterial isolates resistant to gentamicin, 7 (87.5%) were susceptible tobramycin. Of the 9 bacterial isolates resistant to tobramycin, (88.9%) were susceptible to vancomycin. One bacterial isolate, a Fusobacterium nucleatum from a polymicrobial infection was resistant to gentamicin, tobramycin and vancomycin. Conclusion. Over one third of bacteria causing acute PJI after primary TKA were resistant to the aminoglycosides pre-mixed in commercially available bone cements. All but one of the bacteria resistant to gentamicin and tobramycin were susceptible to vancomycin. The addition of vancomycin to bone cement or as powder in the surgical field has the potential to expand antibiotic coverage to include most organisms responsible for acute PJI after TKA. For figures, tables, or references, please contact authors directly

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

Aims

The surgical target for optimal implant positioning in robotic-assisted total knee arthroplasty remains the subject of ongoing discussion. One of the proposed targets is to recreate the knee’s functional behaviour as per its pre-diseased state. The aim of this study was to optimize implant positioning, starting from mechanical alignment (MA), toward restoring the pre-diseased status, including ligament strain and kinematic patterns, in a patient population.

Aims

The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques.

Aims

In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

Aims. The optimal method of tibial component fixation remains uncertain in total knee arthroplasty (TKA). Hydroxyapatite coatings have been applied to improve bone ingrowth in uncemented designs, but may only coat the directly accessible surface. As peri-apatite (PA) is solution deposited, this may increase the coverage of the implant surface and thereby fixation. We assessed the tibial component fixation of uncemented PA-coated TKAs versus cemented TKAs. Patients and Methods. Patients were randomised to PA-coated or cemented TKAs. In 60 patients (30 in each group), radiostereometric analysis of tibial component migration was evaluated as the primary outcome at baseline, three months post-operatively and at one, two and five years. A linear mixed-effects model was used to analyse the repeated measurements. Results. After five years of follow-up, one (cemented) component was revised due to ligament instability. Overall, uncemented PA-coated tibial components migrated significantly more (p = 0.003), with the mean maximum total point motion (MTPM) at five years being 0.62 mm (95% confidence intervals (CI) 0.49 to 0.76) for cemented tibial components and 0.97 mm (95% CI 0.81 to 1.15) for PA-coated tibial components in TKA. However, between three months and five years the cemented TKAs migrated significantly more (p = 0.02), displaying a MTPM of 0.27 mm (95% CI, 0.19 to 0.36) versus 0.13 mm (95% CI, 0.01 to 0.25) for PA-coated tibial components. One implant in each group was considered at risk for aseptic loosening due to continuous migration after five years of follow-up, albeit with different migration patterns for each group (i.e. higher initial migration but diminishing over time for the PA-coated component versus gradually increasing migration for the cemented component). Conclusion. The tibial components of PA-coated TKAs showed more overall migration compared with the tibial components of cemented TKAs. However, post hoc analysis showed that this difference was caused by higher migration of PA-coated components in the first three months, after which a stable migration pattern was observed. Clinically, there was no significant difference in outcome between the groups. Cite this article: Bone Joint J 2017;99-B:1467–76

Introduction. Employer-sponsored travel surgery programs for commonly performed procedures like total joint arthroplasty (TJA) are increasing, as employers try to more effectively manage the healthcare costs of their employees. This new approach by employers to direct their employees to designated “Centers of Excellence” (COEs) creates a need to characterize the “travel patient” population that commutes long distances to receive their surgical care and returns home for their rehab shortly after surgery. Electronic patient rehabilitation platforms (EPRA) facilitate communication, patient navigation, and care coordination across this complex episode of care and may contribute to improved outcomes after TJA. The aim of this study is to evaluate patient satisfaction, functional outcomes and engagement with the use of an EPRA among two TJA cohorts: 1) travel and 2) non-travel TJA patients. Methods. A retrospective review was performed on total knee (TKA) and total hip (THA) arthroplasty patients at a single institution during the first 6 months following implementation of an EPRA. All patients were offered internet based access to an EPRA which provided instant messaging with the care team, algorithmic navigation of the patient during the pre and post-op phases, and access to an extensive library of educational videos regarding their surgery, rehab, and FAQs. Primary outcome measures were the pre-op and 12 week post op HOOS Jr. and KOOS Jr. Patient satisfaction at 12 weeks after surgery and engagement metrics for the EPRA were also examined. Cases were separated into two groups: travel and non-travel, and the groups were compared in terms of engagement, improvement in functional outcomes, and patient satisfaction. Chi-square test and t-test statistics were used for analysis. Results. 634 TJA cases (100 travel; 534 non-travel) were included in this study. Age and BMI differed significantly between these cohorts (p<0.001). The mean age and BMI were 59.17 and 33.01, respectively for travel patients and 69.27 and 29.56, respectively for non-travel patients. 97% of the travel patients initially opted-in to use the electronic rehabilitation program compared to 87.6% of the non-travel patients. The number of travel patients logging in, watching videos, and messaging was significantly higher than that of non-travel patients (p<0.01). On average, travel patients generated double the number of sessions than non-travel patients (71.5 vs 31.5, p<0.001). Among TKA cases, travel patients reported significantly lower pre-op mean KOOS Jr. scores than non-travel patients (43.11 vs. 47.78, p< 0.01). By 12 weeks, there was no difference between the groups (67.11 vs. 70.05, p=0.15). THA cases exhibited similar increases in patient reported outcomes(PROs). Mean pre-op HOOS Jr scores for travel and non-travel patients were 42.64 and 48.16 respectively (p=0.07) and mean post-op HOOS Jr. scores at 12 weeks were 75.93 and 80.12, respectively (p=0.15). Comparing 12 week procedure satisfaction (0–5), travel THA patients reported significantly higher mean satisfaction than non-travel THA cases (4.93 vs 4.32, p<0.001). There was no difference in satisfaction between travel TKA and non-travel TKA cases (4.31 vs 4.35, p=0.85). Conclusion. This study revealed higher engagement among travel patients in comparison to non-travel patients as measured by utilization of EPRA. Patients participating in these programs are typically incentivized financially in terms of enhanced insurance coverage and elimination of out-of-pocket expenses when they obtain care at an employer designated COE which may contribute to this increased degree of engagement. Increased utilization of EPRA may have also contributed to higher 12 week patient satisfaction. Despite the logistical challenges of travel TJA surgery, the EPRA used in this study appears to facilitate effective patient navigation and care coordination in the travel patient population, resulting in patient reported outcomes and satisfaction that is comparable to our non-travel patient population. Considering the projected increased growth of these employer directed COE programs, further understanding of these travel surgery patients and the role of electronic patient engagement platforms and telehealth technologies is warranted. For figures, tables, or references, please contact authors directly