Background. Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation. Methods. We used discharge records from the Nationwide Inpatient Sample (2002–2011). Temporal trends were assessed and multivariable logistic regression modeling was used to identify factors associated with dislocation. Results. The in-hospital dislocation rate increased from 0.025% in 2002 to 0.15% in 2011, despite a downward trend in length of stay (P<0.001). Patient characteristics associated with the occurrence of dislocation were black or Hispanic race/ethnicity, lower household income, and Medicaid insurance. Comorbidities associated with dislocation included hemiparesis/hemiplegia, drug use disorder, chronic renal failure, psychosis, and obesity. Dislocations were less likely to occur at teaching hospitals and in the South. Conclusion. The in-hospital dislocation rate following elective primary THA is increasing, in spite of shorter stays and surgical advances over time. Given the sociodemographic disparities in dislocation risk documented herein, interventions to address social determinants of health might do as much or more to reduce the occurrence of dislocation than technical improvements

Background. There is growing clinical and policy emphasis on minimizing transfusion use in elective joint arthroplasty, but little is known about the degree to which transfusion rates vary across US hospitals. This study aimed to assess hospital-level variation in use of allogeneic blood transfusion in patients undergoing elective joint arthroplasty, and to characterize the extent to which variability is attributable to differences in patient and hospital characteristics. Methods. The study population included 228,316 patients undergoing total knee arthroplasty (TKA) at 922 hospitals and 88,081 patients undergoing total hip arthroplasty (THA) at 606 hospitals from January 1, 2009, to December 31, 2011, in the Nationwide Inpatient Sample database, a 20% stratified sample of US community hospitals. Results. The median hospital transfusion rates were 11.0% (interquartile range, 3.5% to 18.5%) in TKA and 15.9% (interquartile range, 5.4% to 26.2%) in THA. After fully adjusting for patient- and hospital-related factors using mixed-effects logistic regression models, the average predicted probability of blood transfusion use in TKA was 6.3%, with 95% of the hospitals having a predicted probability between 0.37% and 55%. For THA, the average predicted probability of blood transfusion use was 9.5%, with 95% of the hospitals having a predicted probability between 0.57% and 66%. Hospital transfusion rates were inversely associated with hospital procedure volume and directly associated with length of stay. Conclusions. The use of blood transfusion in elective joint arthroplasty varied widely across US hospitals, largely independent of patient case-mix and hospital characteristics

Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a Vitamin K antagonist (warfarin), low molecular weight heparin, or other oral anticoagulants for four weeks post-operatively. All patients receive sequential pneumatic compression devices post-operatively, and patients are mobilised with physical therapy on the day of surgery. Patients who have a history of peptic ulcer disease or allergy to aspirin are also considered for other types of anticoagulation following surgery. Risk Stratification Criteria. Major comorbid risk factors utilised in our risk stratification model include history of hypercoagulability or previous VTE, active cancer or history of non-cutaneous malignancy, history of stroke, and pulmonary hypertension. We consider patients with any of these risk factors at elevated risk of VTE and therefore candidates for formal anticoagulation. Other minor risk factors include older age, bilateral surgery compared with unilateral, inflammatory bowel disease, varicose veins, obstructive sleep apnea, and history of myocardial infarction, myeloproliferative disorders, and congestive heart failure. Each minor criterion is associated with a score. The cumulative score is compared with a defined threshold and the score that surpasses the threshold indicates that the patient should receive post-operative anticoagulation. To facilitate the use of this scoring system, an iOS mobile application (VTEstimator) has been developed and can be downloaded from the app store

INTRODUCTION. Shoulder arthroplasty (SA) is an effective procedure for managing patients with shoulder pain secondary to degenerative joint disease or end stage arthritis that has failed conservative treatment. Insurance status has been shown to be an indicator of patient morbidity and mortality. The objective of the current study is to evaluate the effect of patient insurance status on outcomes following shoulder replacement surgery. METHODS. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing shoulder arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical and surgical complications occurring during the same hospitalization with secondary analysis of mortality. Pearson's chi¬squared test and multivariate regression were performed. RESULTS. A data inquiry identified 103,290 patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 Other) undergoing partial, total and reverse total shoulder replacements. The total number of complications was 17,810 (17.24%), and the top three complications included acute cardiac events (8,165), urinary tract infections (3,154), and pneumonia (1,635). The highest complication rate was observed in the Medicare population (20.3%), followed by the Medicaid/uninsured (16.9%), other (11.1%), and the privately-insured cohort (10.5%). Multivariate regression analysis indicated that having Medicare insurance, white race, increasing age, higher comorbidity, and urgent or emergent admissions was associated with medical complications. Black patients, increasing age and comorbities was associated with surgical complications. Overall mortality was 0.20% and was more common in total shoulder arthroplasty and surgeries done on emergent or urgent admissions. DISCUSSION. This data reveals that patients with Medicare, Medicaid or no insurance were more likely to have medical complications, most commonly cardiac complications, UTIs and pneumonia. Primary insurance payer status can be considered as an independent risk factor during preoperative risk stratification and planning

The mean age of patients with osteonecrosis reported in series in our literature is 38 to 53. Thus, performing a total hip replacement on a patient who would need a procedure to last 40–45 years is a concern. Patients with osteonecrosis of the hip require some type of surgical treatment. Without treatment, a large majority of femoral heads in patients even with Ficat stage I osteonecrosis will collapse or become symptomatic. A common scenario is a patient who first presents to the orthopaedic surgeon with severe arthritis secondary to osteonecrosis in one hip and a normal appearing radiograph on the asymptomatic contralateral side. Performing a total hip on the severe arthritic hip is usually not debated. A MRI will commonly show Ficat stage I osteonecrosis on the asymptomatic contralateral hip. Some method of core decompression is a reasonable choice if it is non-steroid induced, small more medially positioned lesion, but not for other Ficat stage 1 lesions or those with more advanced stages. The problem is convincing the patient to have anything done when they are asymptomatic. Because results with total hip replacement for patients with osteonecrosis of the hip have significantly improved, most patients with a symptomatic hip prefer arthroplasty as treatment. Arthroplasty has become the predominant surgical treatment for osteonecrosis of the hip in the United States. 88% of procedures performed on 6,400 patients with osteonecrosis in 2008 reported in the Nationwide Inpatient Sample Database of the hip were total hip replacements. From 16 years earlier, the number of procedures performed had almost doubled and the percentage use of arthroplasty as the performed treatment had increased by 13%. I expect both numbers will continue to increase

Down syndrome (DS), is a genetic disorder caused by a third copy of the 21st chromosome (Trisomy 21), featuring typical facial characteristics, growth delays and varying degrees of intellectual disability. Some degree of immune deficiency is variably present. Multiple orthopaedic conditions are associated, including stunted growth (90%), ligamentous laxity (90%), low muscle tone (80%), hand and foot deformities (60%), hip instability (30%), and spinal abnormalities including atlanto-axial instability (20%) and scoliosis. Hip disease severity varies and follows a variable time course. Rarely a child presents with DDH, but during the first 2 years the hips are characteristically stable but hypermobile with well-formed acetabulae. Spontaneous subluxation or dislocation after 2 presents with painless clicking, limping or giving way. Acute dislocation is associated with moderate pain, increased limp and reduced activity following minor trauma. Hips are reducible under anesthesia, but recurrence is common. Eventually concentric reduction becomes rarer and radiographic dysplasia develops. Pathology includes: a thin, weak fibrous capsule, moderate to severe femoral neck anteversion and a posterior superior acetabular rim deficiency. A number of femoral and acetabular osteotomies have been reported to treat the dysplasia, with acetabular redirection appearing to be most successful. However, surgery can be associated with a relatively high infection rate (20%). Additionally, symptomatic femoral head avascular necrosis can occur as a result of slipped capital femoral epiphysis. Untreated dysplasia patients can walk with a limp and little pain into the early twenties even with fixed dislocation. Pain and decreasing hip function is commonly seen as the patient enters adult life. Occasionally the hip instability begins after skeletal maturity. Total hip arthroplasty (THA) is the standard treatment when sufficient symptoms have developed. The clinical outcomes of 42 THAs in patients with Down syndrome were all successfully treated with standard components. The use of constrained liners to treat intra-operative instability occurred in eight hips and survival rates were noted between 81% and 100% at a mean follow-up of 105 months (6 – 292 months). A more recent study of 241 patients with Down syndrome and a matched 723-patient cohort from the Nationwide Inpatient Sample compared the incidence of peri-operative medical and surgical complications in those who underwent THA. Compared to matched controls, Down syndrome patients had an increased risk of complications: peri-operative (OR, 4.33; P<.001), medical (UTI & Pneumonia OR, 4.59; P<.001) and surgical (bleeding OR, 3.51; P<.001), Mean LOS was 26% longer (P<.001). While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function. Pre-operative education of all clinical decision makers should also reinforce the increased risk of medical and surgical complications (wound hemorrhage), and lengths of stay compared to the general population

Introduction. Hip arthroplasty is one of the most common procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following hip arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing hip arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,011,184 (64.8% Medicare, 29.3% private insurance, 3.7% Medicaid or uninsured, 2.0% Other) patients fulfilled criteria for inclusion into the study. Most were primary total hip arthroplasties (64.2%) and primary hip hemiarthroplasty (29.8%), with 6% revision hip arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.8, p=<0.001) and those with Medicaid or no insurance had more medical complications (OR 1.06, p=0.005) compared to Medicare patients. Similar trends were found for surgical complications and mortality. The matched cohort showed Medicare and private insurance patients had similar complication rates. The most common complication was postoperative anemia, occurring in 22.6% of Medicare patients and 21.1% of patients with private insurance (RR=1.06, p<0.001). Discussion and. Conclusion. This data reveals that patients with Medicare, Medicaid or no insurance have higher risk of medical complications, surgical complications and mortality following hip arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications are similar and generally low with the notable exception of the most common complication, postoperative anemia, which occurs more frequently in patients with Medicare

The mean age of patients with osteonecrosis reported in series in our literature is 38 to 53. Thus, performing a total hip replacement on a patient who would need a procedure to last 40–45 years is a concern. Patients with osteonecrosis of the hip require some type of surgical treatment. Without treatment, a large majority of femoral heads in patients even with Ficat stage I osteonecrosis will collapse or become symptomatic. A common scenario is a patient who first presents to the orthopaedic surgeon with severe arthritis secondary to osteonecrosis in one hip and a normal appearing radiograph on the asymptomatic contralateral side. Performing a total hip on the severe arthritic hip is usually not debated. A MRI will commonly show Ficat stage I osteonecrosis on the asymptomatic contralateral hip. Some method of core decompression is a reasonable choice if it is non-steroid induced, small more medially positioned lesion, but not for other Ficat stage 1 lesions or those with more advanced stages. The problem is convincing the patient to have anything done when they are asymptomatic. Because results with total hip replacement for patients with osteonecrosis of the hip have significantly improved, most patients with a symptomatic hip prefer arthroplasty as treatment. Arthroplasty has become the predominant surgical treatment for osteonecrosis of the hip in the United States. Eighty-eight percent of procedures performed on 6,400 patients with osteonecrosis in 2008 reported in the Nationwide Inpatient Sample Database of the hip were total hip replacements. From 16 years earlier, the number of procedures performed had almost doubled and the percentage use of arthroplasty as the performed treatment had increased by 13%. I expect both numbers will continue to increase

Introduction. Knee arthroplasty is one of the most common inpatient surgeries procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following knee arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing knee arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,352,505 (57.8% Medicare, 35.6% private insurance, 2.6% Medicaid or uninsured, 3.3% Other) patients fulfilled criteria for inclusion into the study. Most were primary total knee arthroplasties (96.1%) with 3.9% revision knee arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.82, p=<0.001) compared to Medicare patients. Similar trends were found for surgical complications and mortality. Patients with Medicare or no insurance had more surgical complications but equivalent rates of medical complications and mortality. The matched cohort showed Medicare and private insurance patients had overall low mortality rates and complication. The most common complication was postoperative anemia, occurring in 16.2% of Medicare patients and 15.3% of patients with private insurance (RR=1.06, p<0.001). Mortality (RR 1.34), wound dehiscence (RR 1.32), CNS, GI complications, although rare, were all statistically more common in Medicare patients (p<0.05) while cardiac complications (RR 0.93, p=0.003) was more common in patients with private insurance. Discussion and Conclusion. This data reveals that patients with Medicare insurance have higher risk of medical complications, surgical complications and mortality following knee arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications were low overall (with the exception of postoperative anemia), but in general were more common in Medicare patients

Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty (TJA). Only a few studies have investigated PJI's impact on the most worrisome of all endpoints, mortality. The purpose of this study was to perform a large-scale study to determine the rates of PJI associated in-hospital mortality, and compare it to other surgical procedures. The Nationwide Inpatient Sample was queried from 2002 to 2010 to assess the risk of mortality for patients undergoing revision for PJI or aseptic failures. Elixhauser comorbidity index and ICD-9 codes were used to obtain patients’ medical conditions and identify PJI. Multiple logistic-regression analyses were used to determine the associated variables with mortality. In-hospital mortality was compared to the followings: coronary-artery bypass graft, mastectomy, prostatectomy, appendectomy, kidney transplant, carotid surgery, cholecystectomy, and coronary interventional procedures. PJI was associated with an increased risk (odds ratio 2.04) of in-hospital mortality (0.77%) compared to aseptic revisions (0.38%). The in-hospital mortality of revision THAs done for PJI (1.38%, 95%CI, 1.12–1.64%) was comparable to or higher than interventional coronary procedure (1.22%, 95%CI, 1.20–1.24%), cholecystectomy (1.13%, 95%CI, 1.11–1.15%), kidney transplantation (0.70%, 95%CI, 0.61%–0.79%) and carotid surgery (0.89%, 95%CI, 0.86%–0.93%) (Figure 1). The following comorbidities were independent risk factors for in-hospital mortality after TJA: liver disease, metastatic disease, fluid and electrolyte disorders, coagulopathy, weight loss and malnutrition, congestive heart failure, pulmonary circulation disorder, renal failure, and peripheral vascular disease. PJI is associated with a two-fold increase in mortality and have mortality rates comparable to kidney transplantation and carotid surgery. Considering the fact that patients with PJI often require multiple surgical procedures, the rate of actual in-hospital mortality for patients with PJI may be considerably higher. Surgeons should be cognizant of the potentially fatal outcome of PJI and must emphasize the importance of infection control to reduce the risk of mortality

Total hip arthroplasty (THA) performed in patients aged 60 years and younger requires several decades of implant use under increased activity demands. Implant longevity and stable fixation are necessary for 30 or more years. The search for the optimal bearing combination for use in younger, high demand patients presents a challenge for orthopaedic surgeons as they consider the pros and cons of each material and interaction. A recent U.S. study of implant utilization trends that included 174 hospitals and 105,000 THA between 2001 and 2012 found that in 2012 93% of THA were cementless and 35% of THA bearings were ceramic-on-highly crosslinked polyethylene (HXLPE). Another recent article used the Nationwide Inpatient Sample from 2009 to 2012 to study bearing usage trends in 9265 primary THA in patients 30 years old or younger. The researchers observed ceramic-on-polyethylene as the most commonly bearing surface, used in 36% of patients, and which represented an increase from an earlier study of extremely young patients undergoing primary THA between 2006 to 2009, use of so-called hard-on-hard bearings decreased. Benefits of ceramic-on-HXLPE bearings are that unlike metal-on-polyethylene and metal-on-metal combinations, taperosis and adverse reactions to metal debris are non-existent. Ceramic-on-polyethylene is forgiving, it is an extremely low wear couple, it is the current presenter's bearing of choice in high demand patients, and it is a good option in the scenario of revision of failed metal-on-metal or for taperosis. Advantages to bulk ceramics are: extremely hard and scratch resistant to third body wear, not damaged by instruments and repositioning, excellent wettability, extreme low wear against itself with no known pathogenic reaction to ceramic particles, inherently stable with no oxidation or aging effect, no corrosion, safe in terms of metal ion release, no known risk of hypersensitivity or allergy, and no concerns about biological reaction. Biolox® (Ceramtec AG; Plochingen, Germany) ceramics have been available since 1974, with fourth generation Biolox® Delta introduced in 2003. Extensive clinical experience includes over 1630 published studies with over 12 million Biolox® components implanted with almost every available hip system. Two recent meta-analyses studies of randomised controlled trials comparing ceramic-on-ceramic to ceramic-on-polyethylene found significantly higher linear wear in ceramic-on-polyethylene but higher incidences of noise and fracture in ceramic-on-ceramic THA. There were no differences in revision, function, dislocation, osteolysis or loosening. A recent meta-analysis review of randomised controlled trials reporting survivorship of ceramic-on-ceramic, ceramic-on-HXLPE, and metal-on-HXLPE found no difference among bearing surfaces in risk of revision after primary THA in patients younger than 65. Risk ratio for revision was 0.65 (p=0.50) between ceramic-on-ceramic and ceramic-on-HXLPE, and 0.40 (p=0.34) between ceramic-on-ceramic and metal-on-HXLPE. A recent study of ceramic-on-HXLPE bearings for 130 cementless THA in 119 patients younger than 50 years at mean follow-up of 8.3 years (range, 7–9) reported a mean post-operative Harris hip score of 94, UCLA activity score of 8.1, no acetabular revisions, no osteolysis, no head or liner fracture, and 0.022 ± 0.003 mean annual penetration rate of the femoral head. While longer follow-up is necessary, ceramic-on-HXLPE bearings are an attractive option in younger, high demand patients undergoing primary THA

Introduction:. Over the last several decades, life expectancy following solid organ transplant (i.e. kidney, liver, heart, lung, and pancreas) has increased significantly, largely due to improvements in surgical technique, immunosuppressive regimens, patient selection, and postoperative care. As this population ages, many of these transplant patients become candidates for total knee arthroplasty (TKA). However, these patients may be at greater risk of complications following TKA due to immunosuppression and metabolic derangements secondary to organ dysfunction. The purpose of this study was to use a large, nationally representative database to compare morbidity, mortality, length of stay (LOS), and charges for TKA patients with and without a history of solid organ transplant. Methods:. This retrospective study was a review of the Nationwide Inpatient Sample (NIS; the largest all-payer inpatient care United States database representing a 20% stratified sample) from 1998 to 2010. Patients who had a primary TKA (ICD-9-CM 81.54) were included (n = 5,706,675, weighted national frequency). A total of 763,924 cases were excluded for the following: age <18 years, pathologic fracture of lower extremity, malignant neoplasm and/or metastatic cancer, previous and/or bilateral arthroplasty, admission type other than “elective”. The remaining 4,942,751 patients were categorized as transplant (n = 5,245; included only liver, kidney, heart, lung and/or pancreas transplant) or non-transplant group (n = 4,931,017; no history of any transplant including solid organ or tissue). A multivariable regression model was used to identify any association(s) between a history of solid organ transplant and morbidity, mortality, LOS and hospital charges, while adjusting for patient and hospital characteristics. Results:. Between 1998 and 2010, the volume of TKA increased among transplant patients at a rate of 382%, which was significantly higher than that of the non-transplant group (197%; p < 0.01). Patients with a history of transplant had a significantly higher prevalence of renal failure (+69.3%), liver disease (+22.9%), uncomplicated diabetes (+9.0%), hypertension (+8.9%), deficiency anemia (+8.9%) (p < 0.001). Transplant patients suffered 1 or more complication at a rate of 7.3%, which was significantly higher than that of the non-transplant group (5.7%; p < 0.001). A 0.1% mortality rate was observed in the non-transplant group, while no deaths were reported in the transplant group. Unadjusted trends for mean LOS (Figure 1) show that transplant patients have a longer LOS (4.2 days) than non-transplant patients (3.7 days; p < 0.001), although LOS decreased for both groups. Overall mean charges per admission (USD) were significantly higher for the transplant cohort ($ 40,999) than the non-transplant group ($ 35,686; p < 0.001), and both increased over time (Figure 2). After adjusting for patient demographics, hospital characteristics, and comorbidity, transplant patients stayed 0.46 days longer in the hospital (p < 0.01) and had $ 3,480 increased charges (p < 0.01). There was no statistically significant increase in hospital complications (adjusted odds ratio = 1.20; p = 0.13). Conclusions:. While the annual number of TKAs performed in the United States on patients with a history of solid organ transplant is relatively low, the rate is increasing at nearly twice that of non-transplant patients undergoing TKA. Transplant patients have a significantly higher number of comorbidities, longer LOS, and greater charges than patients with no transplant history

Introduction:. Solid organ transplant patients are living longer than in past decades, largely due to improvements in surgical technique, immunosuppressive regimens, patient selection, and postoperative care. As these patients grow older, many of them present for total hip arthroplasty (THA). However, life-long immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk for complications following THA. The objective of this study was to use a national administrative database to compare morbidity, acute complications, in-hospital mortality, length of stay (LOS), and admission costs for THA patients with and without solid organ transplant history. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was retrospectively queried for primary THA (ICD-9-CM 81.51) patients from 1998 to 2009 (n = 2,567,930; weighted national frequency). Cases were excluded (n = 324,837) for the following: age <18 years, pathologic fracture of lower extremity, malignant neoplasm and/or metastatic cancer, primary diagnosis of femoral neck fracture, admission type other than “elective,” previous and/or bilateral arthroplasty. The remaining 2,243,093 THA patients were assigned to transplant (n = 6,319; liver, kidney, heart, lung and/or pancreas transplant history) or non-transplant groups (n = 2,231,446; no history of any transplant including solid organ or tissue). Acute complications included a variety of organ-specific and procedure-related complications (i.e. mechanical implant failure, dislocation, hematoma, infection, pulmonary embolism, venous thrombosis). Multivariable regression and general estimating equations were developed to study the effect of transplant history on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. Between 1998 and 2009, the volume of THA among patients with a history of solid organ transplant grew approximately 40% (444 to 620 cases/year), which was lower than that among non-transplant patients (+102%). Transplant THA patients were significantly sicker than their non-transplant peers, with an elevated Elixhauser comorbidity index (7.69 vs. 1.21; p < 0.001). Transplant and non-transplant patients had similar rates of 1+ inpatient complication(s) following THA (transplant 23.6% vs. non-transplant 24.3%; p = 0.60). There were no in-hospital deaths in the transplant group, while 0.1% (n = 2,855) of non-transplant patients died after THA. Unadjusted trends show that transplant patients have a longer mean LOS (4.5 days) than non-transplant patients (3.9 days; p < 0.001) after THA, although LOS decreased for both groups over time (Figure 1). Also, overall unadjusted mean costs per THA admission were significantly higher for the transplant cohort ($15,518) than the non-transplant group ($14,474; p < 0.001), and both increased over time (Figure 2). After adjusting for confounders, transplant patients had an 8% increase in LOS (0.38 days) compared to non-transplant patients (p < 0.001); however, there were no statistically significant increases in admission costs (p = 0.13) or complications (p = 0.19). Conclusions:. While the annual volume of THA performed in the United States on patients with a history of solid organ transplant is increasing, the rate is less than half that of non-transplant patients undergoing THA. Transplant patients have a significantly higher number of comorbidities and longer LOS after THA compared to non-transplant patients. Admission costs and acute complications are comparable among these populations, after adjusting for patient and hospital characteristics

Introduction:. Primary total knee arthroplasty (TKA) is associated with perioperative bleeding, and some patients will require allogenic blood transfusion during their inpatient admission. While blood safety has improved in the last several decades, blood transfusion still carries significant complications and costs. Transfusion indications and alternative methods of blood conservation are being explored. However, there is limited nationally representative data on allogenic blood product utilization among TKA patients, and its associated outcomes and financial burden. The purpose of this study was to use a national administrative database to investigate the trends in utilization and outcomes (i.e. in-hospital mortality, length of stay, admission costs, acute complications) of allogenic blood transfusion in primary TKA patients. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was utilized. Primary TKA (ICD-9-CM 81.54) cases from 2000 to 2009 were retrospectively queried (n = 4,544,999; weighted national frequency). A total of 67,841 admissions were excluded (Figure 1). The remaining 4,477,158 cases were separated into two study cohorts: (1) patients transfused with allogenic blood products (red blood cells, platelets, serum) (n = 540,270) and (2) patients not transfused (n = 3,936,888). Multivariable regression and generalized estimating equations were used to examine the effect of transfusion on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. During the study period, the overall allogenic blood transfusion rate in primary TKA patients was 12.1%. The rate increased ∼5% from 2000 to 2009, and stayed constant around 13% from 2006 to 2009. Transfusion rates were higher in older patients (80–89 yrs, 21.4%; ≥ 90 yrs, 30.7%), blacks (19.6%), females (14.0%), Medicare patients (14.6%), and Medicaid patients (14.4%). Transfused TKA patients had a greater percent of comorbidities than their non-transfused peers. The largest differences in comorbidity prevalence among transfused and non-transfused patients were: deficiency anemia (27.5% vs. 10.1%), renal failure (4.0% vs. 1.4%), chronic blood loss (3.7% vs. 1.4%), and coagulopathy (3.1% vs. 1.0%) (p < 0.001). Unadjusted trends show that from 2000 to 2009, in-hospital mortality rate decreased (Figure 2A), mean length of stay decreased (Figure 2B), and mean admission cost increased (Figure 2C) for both transfused and non-transfused patients following TKA. Adjusting for patient and hospital characteristics, transfused patients had a 22% (95% CI, 4%–43%) greater likelihood of in-hospital mortality (p = 0.013), 0.68 ± 0.02 days longer length of stay (p < 0.001), and $2,237 ± 76 increased admission costs (p < 0.001). Additionally, patients who received a transfusion had a greater adjusted risk of a postoperative infection (odds ratio, 2.35), pulmonary insufficiency (odds ratio, 1.60), and other complications (p < 0.001) (Figure 3). Conclusions:. The allogenic blood transfusion rate increased between 2000 and 2009 in the United States. Transfusion has a considerable burden on patients and healthcare institutions, increasing in-hospital mortality, length of stay, admission costs, and acute complications. Preoperative optimization strategies, transfusion criteria, and hemostatic agents for at-risk patients need to be further researched as possible ways to reduce transfusion occurrence and its effects

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.

Cite this article: Bone Joint J 2013;95-B:4–9.