Arthroplasty Practice Research Articles

Anatomic or Reverse Total Shoulder Arthroplasty? How Fellowship Training Affects Selection of Arthroplasty Type

While both anatomic (ATSA) and reverse total shoulder arthroplasty (RTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely amongst providers. While surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant. A national database was queried to identify surgeons performing anatomic and reverse total shoulder arthroplasty. For all surgeons who performed more than 10 cases between 2010-2022, fellowship data was individually collected via online search. For each fellowship group, rates of anatomic and reverse total shoulder arthroplasty were identified using International Classification of Diseases (ICD) procedural codes. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSA and RTSA by fellowship in addition to the rate of RTSA performed for a primary diagnosis of glenohumeral osteoarthritis. A total of 131,974 patients met the inclusion criteria and were retained for this study. RTSA increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary RTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose RTSA more frequently for the diagnosis of glenohumeral osteoarthritis compared to Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than RTSA in comparison to surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in percentage of all shoulder arthroplasty procedures from 2010-2022 (28.4% to 40.4%) while the Other group decreased by a comparable amount (45.9% to 32.4%) over the same period. Surgeons who have completed a Sports Medicine fellowship choose RTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and also for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSA in their arthroplasty practice. Revision anatomic and revision reverse total shoulder arthroplasty represents a larger percentage of overall case volume for Shoulder and Elbow surgeons.

Effect of body mass index on 30-day complication rate and implant survival rate after simultaneous bilateral unicompartmental knee arthroplasty: a multicentre retrospective study

ObjectiveThe practice of simultaneous bilateral unicompartmental knee arthroplasty (SBUKA) remains a topic of debate, particularly in patients with obesity. Thus, the purpose of this study was to assess the impact of body mass index (BMI) on the 30-day complication rate and the survival rate of the implant following SBUKA.MethodsWe retrospectively examined the clinical records of 245 patients (490 knees) who underwent SBUKA at the Affiliated Hospital of Qingdao University and the Third Hospital of Hebei Medical University between January 2010 and December 2020. Patients were categorised based on their BMI at the time of surgery into four groups: normal weight (BMI 18.5 to 22.9 kg/m2), overweight (BMI 23.0 to 24.9 kg/m2), obese (BMI 25.0 to 29.9 kg/m2), and severely obese (BMI ≥30 kg/m2). Variables such as length of hospital stay, duration of surgery, and costs of hospitalisation were compared across all groups. Additionally, we recorded the 30-day postoperative complication rate and the time from surgery to any required revision. The Kaplan-Meier survival analysis was employed to evaluate and compare the implant survival rates.ResultsThe follow-up period for the 245 patients ranged from 39 to 114 months, with an average of 77.05±18.71 months. The incidence of complications within 30 days post-surgery did not significantly differ across the groups (χ2 = 1.102, p = 0.777). The implant survival rates from the lowest to the highest BMI groups were 97.14%, 93.9%, 94.44%, and 96.43%, respectively. Both the rate of implant revision (χ2 =1.612, p = 0.657) and the survival curves of the implants (p = 0.639) showed no statistically significant differences among the groups.ConclusionsBMI did not influence the 30-day complication rate nor the survival rate of implants following SBUKA, suggesting that SBUKA should not be contraindicated based on BMI alone.

Starting up a Lateral Unicompartmental Knee Arthroplasty Practice – Is Outcome Affected?

BackgroundIn the past, the utilization of lateral unicompartmental knee arthroplasty (UKA) has been limited at national levels, despite the fact that an estimated 10% of patients who have an indication for arthroplasty, present with isolated lateral compartment osteoarthritis (OA). Units dedicated to UKA have reported good outcomes. Identifying patients for the procedure has been less clear, and the procedure has been perceived to be technically more demanding than medial UKA. This may result in a reluctance to start a lateral UKA practice and challenge the early phase. Therefore, this paper aimed to present the outcomes and learning curve when starting up a lateral UKA practice, as this theme remains unelucidated. MethodsThere were 85 primary fixed-bearing lateral UKAs, with a minimum of 1-year follow-up, performed between 2016 and 2022 by 2 arthroplasty surgeons with existing UKA practices. The indications were primary (n = 79) or post-traumatic (n = 6) OA. Patient-reported outcome measures (PROMs) were assessed at 3, 12, and 24 months. A cumulative sum (CUSUM) analysis was used to evaluate surgical duration and the 12-month Oxford Knee Score (OKS). ResultsMedian (interquartile range) 12-month OKS, activity and participation questionnaire, and Forgotten Joint Score (FJS) were 43 (37.5 to 46), 78 (42.5 to 98.5), and 72 (55 to 90), respectively. The OKS outcomes did not reveal adverse effects from the learning curve. A performance shift in surgical duration was observed around case 33. Kaplan-Meier implant survival reached 95.4% at 7 years for the endpoint “implant revision” and 93.5% for “implant revision or implant addition.” ConclusionsStarting up a lateral UKA practice is safe and efficient for surgeons who have prior medial UKA experience, provided strict adherence to indications. While surgical duration indicated a learning curve over approximately 33 cases, PROMs remained stable, suggesting proficient outcomes irrespective of the learning curve.

Chinese expert consensus on clinical practice of daytime hip arthroplasty

Daytime hip arthroplasty refers to a medical procedure where a patient undergoes admission, surgery, and discharge all within a single day (24 hours). The establishment of daytime hip arthroplasty centers signifies a significant paradigm shift in the development model of modern hospitals. While numerous nationally accredited large medical institutions are undertaking daytime hip arthroplasty in various forms and scales, there remains a lack of standardized system processes and criteria. In this context, the National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Bone and Joint Specialty Committee of the China Ambulatory Surgery Alliance, Joint Surgery Branch of the Chinese Orthopedic Association, and Osteoarthritis Study Group of the Chinese Association of Orthopedic Surgeons have collaboratively organized experts in the relevant field domestically. Leveraging international experiences in daytime hip arthroplasty and integrating them with the clinical practices of well-established medical institutions conducting daytime surgeries in China, they have arrived at consensus recommendations. These recommendations cover the establishment of daytime hip arthroplasty centers, policies, procedures, and perioperative management. The ultimate goal is to provide reference points and guidance for the standardized implementation of daytime hip arthroplasty.

Champions in usage of medial unicompartmental knee arthroplasty : The story behind the Danish success.

Historically, the use of medial unicompartmental knee arthroplasty (mUKA) as treatment for end-stage anteromedial osteoarthritis (AMOA) of the knee was limited by contraindications due to age, weight, and activity level; however, now evidence-based, validated, and less selective criteria are used rendering nearly 50% of end-stage OA patients eligible for mUKA. Recent studies have showcased benefits, such as shorter hospital stays, cost efficiency, and comparable functional outcomes to total knee arthroplasty (TKA). Notably, revision rates have been shown to markedly decrease with increased usage, with an ideal usage of > 30% but an acceptable usage of 20-60%. The usage of unicompartmental knee arthroplasty (UKA) varies among countries, with Denmark achieving anotably higher usage compared to Sweden, the UK, the Netherlands, the USA and Germany. This article investigates potential factors contributing to Denmark having ahigher national usage of mUKA, surpassing the recommended threshold of ausage > 20%. We explore the tradition for national alliances and streamlined surgical education as possible explanations of this development. These insights offer valuable perspectives for potentially optimizing surgical approaches and implant choices in the surgical treatment of end-stage AMOA of the knee across diverse healthcare settings, underscoring the impact of collective strategies in advancing knee arthroplasty practices, ultimately benefiting patients.

Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry

Introduction: 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. Methods: 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, body mass index (BMI) and American Society of Anesthesiologist (ASA) grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. Results: 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% 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. Conclusions: 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.

Adapting hip arthroplasty practices during the COVID-19 pandemic: Assessing the impact of outpatient care sudden increase on early complications and clinical outcomes.

The COVID-19 pandemic has significantly affected access to timely care for patients with hip osteoarthritis requiring total hip replacement (THR). This study aimed to assess the changes in surgical activity, outpatient treatment, length of stay (LOS), discharge destinations, readmission rates, clinical outcomes, and patient satisfaction before and after the pandemic at our institution. This retrospective study encompassed patients undergoing primary THR through the direct anterior approach at a single university hospital. Data on demographic characteristics, surgical technique, perioperative management, LOS, discharge destinations, complications, and clinical outcomes were collected. Furthermore, a comparative analysis between the pre-pandemic (2019) and post-pandemic (2022) periods was conducted. There was a 14% increase in surgical activity post-pandemic, with 214 patients undergoing surgery in 2019 versus 284 in 2022. The percentage of patients managed as outpatients significantly increased from 0.5% in 2019 to 29.6% in 2022 (p<0.001). LOS decreased from 2.7±1 [0-8] days to 1.4±1.1 [0-12] days (p<0.001), and the rate of discharge to rehabilitation centres declined from 21.5% to 8.8% (p<0.001). No significant increase in the readmission rates was observed (1.4% in both periods). At two months postoperatively, the mean HHS and satisfaction rates were comparable between the two groups (p=1 and p=0.73, respectively). Despite the challenges posed by the COVID-19 pandemic, surgical activity at our institution demonstrated an increase compared to the pre-pandemic levels by expanding outpatient care, reducing LOS, and increasing rates of home discharges. Importantly, these changes did not adversely affect rehospitalization rates or early clinical outcomes. IV.

Does changes in unicompartmental knee arthroplasty practice pattern influence reasons for revision?

The aim of this study was to describe the pattern of revision indications for unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) and any change to this pattern for UKA patients over the last 20 years, and to investigate potential associations to changes in surgical practice over time. All primary knee arthroplasty surgeries performed due to primary osteoarthritis and their revisions reported to the Danish Knee Arthroplasty Register from 1997 to 2017 were included. Complex surgeries were excluded. The data was linked to the National Patient Register and the Civil Registration System for comorbidity, mortality, and emigration status. TKAs were propensity score matched 4:1 to UKAs. Revision risks were compared using competing risk Cox proportional hazard regression with a shared γ frailty component. Aseptic loosening (loosening) was the most common revision indication for both UKA (26.7%) and TKA (29.5%). Pain and disease progression accounted for 54.6% of the remaining UKA revisions. Infections and instability accounted for 56.1% of the remaining TKA revision. The incidence of revision due to loosening or pain decreased over the last decade, being the second and third least common indications in 2017. There was a decrease associated with fixation method for pain (hazard ratio (HR) 0.40; 95% confidence interval (CI) 0.17 to 0.94) and loosening (HR 0.29; 95% CI 0.10 to 0.81) for cementless compared to cemented, and units UKA usage for pain (HR 0.67, 95% CI 0.50 to 0.91), and loosening (HR 0.51; 95% CI 0.37 to 0.70) for high usage. The overall revision patterns for UKA and TKA for the last 20 years are comparable to previous published patterns. We found large changes to UKA revision patterns in the last decade, and with the current surgical practice, revision due to pain or loosening are significantly less likely.

A Comparative Evaluation of Conventional Instrumentation and Accelerometer-Based Navigation in the Practice of a High-Volume Unicompartmental Knee Arthroplasty (UKA) Surgeon

BackgroundComponent malpositioning and joint malalignment following unicompartmental knee arthroplasty (UKA) increase the risk for revision. This study investigates whether accelerometer-based navigation (NAV) decreases radiographic outliers with respect to component placement and joint alignment in comparison to conventional instrumentation in UKA. MethodsA radiographic review of UKAs was performed by a single surgeon following adoption of an accelerometry-guided navigation system (OrthAlign, Aliso Viejo, CA). This cohort was then compared to previous patients undergoing UKA with conventional instrumentation. Six-week postoperative radiographs were used to compare femoral coronal and sagittal angles, tibial coronal and sagittal angles, the net coronal angle, tibial component rotation, and medial tibial overhang. Outliers in implant positioning were compared between groups. Patient variables including age, gender, body mass index, American Society of Anesthesiology, and surgical time (incision until the start of closure) were also compared between groups. ResultsEighty-eight UKA’s were reviewed (49 conventional instrumentation [CI] patients; 39 NAV patients). Using 2-sample t-tests, no significant differences were found in patient demographics, radiographic parameters, and operative times between the CI and NAV cohorts. Using chi-squared tests, no significant difference was found in the number of radiographic outliers between the CI and NAV cohorts. ConclusionsOur study found that a high-volume UKA surgeon achieved a low rate of radiographic outliers in both NAV and CI cohorts. This data suggests that NAV is no different from conventional instrumentation with respect to implant positioning, overall joint alignment, and operative time when used by a high-volume UKA surgeon.

The Impact of the COVID-19 Pandemic on the Practice of Hip and Knee Arthroplasty

» The COVID-19 global pandemic resulted in unprecedented disruptions in care including massive surgical cancelations, a shift to outpatient surgery, and novel medical risks posed by COVID-19 infection on patients undergoing joint replacement surgery.» Refined patient optimization pathways have facilitated safe, efficient outpatient total joint arthroplasty in patient populations that may not otherwise have been considered eligible.» Rapid innovations emerged to deliver care while minimizing the risk of disease transmission which included the widespread adoption of telemedicine and virtual patient engagement platforms.» The widespread adoption of virtual technology was similarly expanded to resident education and continuing medical activities, which has improved our ability to propagate knowledge and increase access to educational initiatives.» Novel challenges borne of the pandemic include profound personnel shortages and supply chain disruptions that continue to plague efficiencies and quality of care in arthroplasty and require creative, sustainable solutions.

Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons

IntroductionTotal joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes. MethodsThis cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons. ResultsMost participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors. ConclusionRobotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.

Cementing Techniques In Knee Surgery (CeTIKS).

Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA. A UK-based, three-round, online modified Delphi Expert Consensus Study was completed focusing on cementation technique in TKA. Experts were identified as having a minimum of five years' consultant experience in the NHS and fulfilling any one of the following criteria: a 'high volume' knee arthroplasty practice (> 150 TKAs per annum) as identified from the National joint Registry of England, Wales, Northern Ireland and the Isle of Man; a senior author of at least five peer reviewed articles related to TKA in the previous five years; a surgeon who is named trainer for a post-certificate of comletion of training fellowship in TKA. In total, 81 experts (round 1) and 80 experts (round 2 and 3) completed the Delphi Study. Four domains with a total of 24 statements were identified. 100% consensus was reached within the cement preparation, pressurization, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfaces. The Cementing Techniques In Knee Surgery (CeTIKS) Delphi consensus study presents comprehensive recommendations on the optimal technique for component cementing in TKA. Expert opinion has a place in the hierarchy of evidence and, until better evidence is available these recommendations should be considered when cementing a TKA.

Hip arthroplasty practice across the Organisation for Economic Co-operation and Development (OECD) over the last decade.

There are large variations in the number of hip replacements performed between countries, demonstrating large health inequalities; however, there has been limited research on this variation. The aims of this paper were to compare rates of hip replacements using Organisation for Economic Co-operation and Development (OECD) data for the period 2008-2018. The study also compared changes in the number of hip replacements in the total population and in only those aged over 65, and looked for a correlation of health expenditure and gross domestic product (GDP) with rates of hip replacements. The OECD collects annual data from all member countries on the numbers of hip replacements, healthcare expenditure and GDP. Data analysis was undertaken using STATA. Descriptive statistics and Pearson's correlation coefficient were performed. The mean number of hip replacements performed in OECD countries in 2018 was 191.5 per 100,000 population per year. The largest number was 310.6 in Germany and the lowest was 8.6 in Mexico. There has been a 21.7% increase in the mean number of hip replacements across OECD countries. There was a moderate and significant Pearson coefficient of 0.468 (p = 0.009) between the number of hip replacements performed per 100,000 population in 2018 and GDP per person, and a strong and significant correlation with health expenditure (R = 0.784, p < 0.001). There was a moderate correlation (R = 0.645, p = 0.003) between the percentage change in the number of hip replacements performed per 100,000 population and the percentage change in healthcare expenditure per person between 2008 and 2018. There is 36-fold variation in the practice of hip replacements across the OECD and the number of hip replacements has increased by more than 20% over the past decade. The number of hip replacements performed appears to be correlated with health expenditure in each country and may indicate a need that can only be met by increasing health expenditure.

Better Flexion but Unaffected Satisfaction After Treatment With Posterior Stabilized Versus Cruciate Retaining Total Knee Arthroplasty – 2-year Results of a Prospective, Randomized Trial

BackgroundBoth the cruciate-retaining (CR) and posterior-stabilized (PS) implant systems are commonplace in modern total knee arthroplasty (TKA) practice. However, there is controversy regarding functional outcomes and survivorship. The aim of the underlying study was to evaluate differences between CR and PS TKA regarding knee function, patient-reported outcome measures (PROMs) as well as complication rates. Methods140 patients with knee osteoarthritis scheduled for an unconstrained TKA were enrolled in a prospective, randomized study. Patients received either a CR or PS implant. Range of motion and PROMs (Oxford Knee Score, Knee Society Score, European Quality of Life 5 Dimensions 3 Level, University of California Los Angeles Activity scale and subjective satisfaction) were assessed prior to, 3 months, 1 and 2 years after surgery. ResultsWe found minor differences between treatment groups regarding demographic factors. Within the PS group duration of surgery was longer (mean PS 81.4 min vs CR 76.0 min, P = .006). We observed better flexion (median PS 120.0° vs CR 115°, P = .017) and an overall better range of motion (median PS 120.0° vs CR 115.0°, P = .008) for the PS group. PROMs did not differ between groups. At 2-year follow-up there were no revisions in either cohort. Five patients needed reoperations. Three patients needed manipulation under anesthesia, 2 in the CR and one in the PS group. ConclusionWhile PS TKA achieved a better flexion capability, PROMs were similar in CR and PS TKA. The CR implant design continues to be a reliable option for patients with an intact posterior cruciate ligament.

CEMENTING TECHNIQUES IN KNEE SURGERY (CETIKS): A UK EXPERT CONSENSUS STUDY

AbstractIntroductionAseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA) and this has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA.MethodologyA UK based, three round, online modified Delphi Expert Consensus Study was completed focussing on cementation technique in TKA. Experts were identified as having a minimum of 5 years Consultant experience in the NHS and fulfilling any one of the following three criteria:· A ‘high volume’ knee arthroplasty practice (&gt;150 TKA per annum) as identified from the National joint registry (NJR).· A senior author of at least 5 peer reviewed articles related to TKA in the previous 5 years· A named trainer for a post CCT fellowship in TKA.ResultsEighty-one experts (Round 1) and eighty experts (Round 2 and 3) completed the Delphi Study. Four domains with a total of twenty-four statements were identified. 100% consensus was reached within the cement preparation, pressurisation, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfacesConclusionThe CeTIKS expert consensus study presents comprehensive recommendations on the optimal technique for component cementation in TKA. Expert opinion has a place in the hierarchy of evidence and until better evidence is available these recommendations should be considered when cementing a TKA.

Volume distribution of primary shoulder arthroplasty among low- and high-volume surgeons

BackgroundCare from high-volume surgeons has been shown to improve patient outcomes and reduce revision rates, complications, and hospital stays. According to prior research, most shoulder arthroplasties are performed by lower volume surgeons. However, this research is limited as it does not account for the recent increase in case numbers and projected growth of shoulder arthroplasty, and was focused only to states with urban populations. The purpose of this study is to identify and compare contemporary shoulder arthroplasty practice patterns and volume distributions in the state of Iowa. MethodsThe Iowa Hospital Association Databank was queried using International Classification of Diseases (ICD)-10 procedure codes for primary total shoulder arthroplasty. Surgeon and hospital volume were stratified according to procedures performed yearly as: low-volume <15 arthroplasties yearly, medium-volume 15-49, and high-volume ≥50 arthroplasties yearly. The proportion of surgeon and hospital volume, and number of procedures performed by each group were assessed. Distance traveled by patients to visit high-volume vs. low-volume surgeons and hospitals was compared. ResultsIn 2019, 1847 primary shoulder arthroplasties were performed in the state of Iowa by 144 surgeons at 49 institutions. Seventy four percent (106/144) of these surgeons were considered low-volume, 20% (29/144) medium-volume, and only 6% (9/144) were high-volume. However, 43% (793/1847) of shoulder arthroplasties were performed by high-volume surgeons, and 18% (333/1847) by low-volume surgeons. Eighteen percent (9/49) of hospitals where shoulder arthroplasties were performed qualified as high-volume institutions, whereas 45% (22/49) were low-volume. Compared to previous results, 65% (1194/1847) of procedures were performed at high-volume institutions and 6% (118/1847) at low-volume institutions. There was a significant difference in median distance traveled for patients to access high vs. low-volume surgeons (34 vs. 14 miles, P < .0001), and high-volume vs. low-volume hospitals (30 vs. 14.5, P < .0001). DiscussionIn the state of Iowa, while only a small portion of surgeons are considered “high-volume”, almost half of primary shoulder arthroplasties are performed by high-volume surgeons. These findings differ from the previous literature regarding volume distribution in shoulder arthroplasty. Furthermore, the results from this study demonstrate a shift from former documented trends which in the past had indicated that most shoulder arthroplasties were performed by low-volume surgeons. Data from this current study provides a glimpse into the evolution in practice patterns for shoulder arthroplasty. As practice patterns continue to evolve, further investigation may demonstrate improved patient outcomes in patients undergoing shoulder arthroplasty at higher volume hospitals with high-volume surgeons.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020).

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

Is Outcome of Total Hip Arthroplasty for Hip Fracture Inferior to That of Arthritis in a Contemporary Arthroplasty Practice?

BackgroundOutcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. MethodsThis was a retrospective, multisurgeon study from an academic center. Of FNFs treated between 2010 and 2020, 177 received THA by an arthroplasty surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score. ResultsPostoperative mean leg-length difference was 0 mm (range, −10 to −10 mm), with a mean cup inclination and anteversion of 41 and 26°, respectively. There was no difference in radiological measurements between FNF and OA patients (P = .3). At a 5-year follow-up, mortality rate was significantly higher in the FNF-THA group compared to the OA-THA group (15.3 versus 1.1%; P < .001). There was no difference in complications (7.3 versus 4.2%; P = .098) or reoperation rates (5.1 versus 2.9%; P = .142) between the groups. Dislocation rate was 1.7%. Oxford Hip Score at the final follow-up was similar [43.7 points (range, 10 to 48) versus 43.6 points (range, 10 to 48); P = .030]. ConclusionTHA for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2 years, similar clinical and radiographic outcomes with low rates of revision can be expected compared to elective THA for OA. Level of evidenceIII, case-control study.

Consensus statement on unicompartmental knee replacement: A collaboration between BASK and EKS

BackgroundThe aim of this study was to deliver consensus recommendations for the clinical practice of unicompartmental knee arthroplasty (UKA). MethodsMembers of the British Association for Surgery of the Knee (BASK) and European Knee Society (EKS) were invited to attend a joint meeting in London, UK (December 2019). A formal consensus process was undertaken at the meeting incorporating a multiple round Delphi exercise, with group discussion of areas of agreement and disagreement between rounds. Eighty delegates attended the meeting and five consensus statements were considered and revised, with a threshold level of 80% agreement required as the definition consensus. ResultsFive consensus statements with accompanying supporting evidence and text were agreed following two rounds of the process: (1) UKA should be offered as a successful alternative to TKA in patients undergoing arthroplasty who meet agreed indications; (2) When consenting a patient for UKA, information including the benefits and risks that are specific to UKA, should be tailored to and discussed with the individual patient; (3) Evidence suggests that surgeons should avoid low-volume use of UKA to optimise outcomes for their patients; (4) Surgeons should use the contemporary evidence-based indications and contraindications for medial UKA; (5) Knee arthroplasty surgeons should have exposure to and training in UKA. ConclusionsThe agreed joint BASK-EKS consensus statements on UKA practice are recommended as the contemporary basis of optimal care for these patients and should inform future training and service developments.

TRENDS IN REVISION HIP ARTHROPLASTY SURGERY: A 21-YEAR REVIEW OF THE NEW ZEALAND JOINT REGISTRY

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&lt;0.001) and pain (8.1 – 14.9%, p&lt;0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p&lt;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&lt;0.001) and femoral fracture (4-18%, p&lt;0.001), whereas revision for dislocation decreased (59-30%, p&lt;0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p&lt;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.