Sleep disturbance is common in patients with hip and knee osteoarthritis and may worsen during the perioperative period of total joint arthroplasty. Poor sleep has been linked to higher pain, delayed functional recovery, and reduced patient satisfaction; however, most arthroplasty studies rely on subjective questionnaires, providing limited insight into the magnitude and time course of postoperative sleep disruption. A systematic literature search of PubMed, Embase, and the Cochrane Library was conducted from inception to November 17, 2025, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting objective perioperative sleep assessment using actigraphy, consumer wearables, or portable electroencephalography (EEG) in adults undergoing total hip arthroplasty or total knee arthroplasty were included. Seven studies met inclusion criteria, including observational cohorts and randomized controlled trials. Objective monitoring consistently demonstrated substantial sleep disruption in the early postoperative period, characterized by reduced nocturnal sleep duration, increased fragmentation, and decreased sleep efficiency, with gradual recovery over subsequent days to weeks. Studies using portable EEG identified marked but transient suppression of rapid eye movement (REM) sleep immediately after surgery. Longer-term wearable monitoring suggested stabilization of total sleep time, although correlations with subjective sleep quality were variable. Pharmacologic interventions showed minimal or inconsistent benefits on objective sleep duration or architecture. Objective wearable monitoring identifies reproducible sleep disruption after total hip arthroplasty and total knee arthroplasty that is incompletely captured by patient-reported measures. Standardized objective endpoints, validation of wearable devices in arthroplasty populations, and integration of sleep assessment into enhanced recovery pathways may improve postoperative care and patient-centered outcomes.
The purpose of this study was to examine how hip and knee arthroplasty surgeon Merit-based Incentive Payment System (MIPS) performance, surgeon demographics, practice characteristics, and patient population varied based on the social risk of their caseload in 2017 and 2021. Multiple databases published by the Centers for Medicare and Medicaid Services were combined and utilized to examine all US hip and knee arthroplasty surgeons. Surgeons were placed into quintiles of social risk based on the proportion of dual-eligible Medicare-Medicaid patients in their patient population. Demographics, Distressed Community Index scores, patient population information, and MIPS performance were compared between quintiles in years 2017 and 2021. In 2017, arthroplasty surgeons with the highest social risk caseloads scored lower on MIPS (70.0 vs 73.5, P = .012) and were more likely to receive a negative payment adjustment (odds ratio: 1.64; 95% confidence interval: 1.01-2.68, P = .046) compared to surgeons with the lowest social risk caseload. In 2021, arthroplasty surgeons with the highest social risk caseloads scored higher on MIPS (86.2 vs 82.4, P < .001), but remained more likely to receive a negative payment adjustment (odds ratio: 3.98; 95% confidence interval: 1.63-10.53, P = .003) compared to those with low social risk caseloads. These findings suggest that while policy adjustments have started to address inequities in performance assessments, they are not sufficient. More work needs to be done to ensure equitable reimbursements for hip and knee arthroplasty surgeons providing care to the most vulnerable patients.
Total joint arthroplasty (TJA) is one of the most frequent orthopaedic surgeries in the United States; however, disparities in utilization and outcomes based on race, sex, and socioeconomic level have been well documented. The impact of rural geographic location, a characteristic that may impact access to TJA care and postoperative outcomes, remains understudied. This systematic review investigated associations between rural location and several metrics in total hip arthroplasty and total knee arthroplasty to investigate whether disparities are present based on rural geographic location. In November 2024, PubMed, Web of Science, Scopus, EMBASE, and Cochrane Review databases were queried. Ten studies investigating TJA utilization and outcomes that included patients in a rural location were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. Ten articles were included in the final analysis. Differences in complications, readmission rates, and length of stay due to rural location of patient and/or hospital were reported. Results indicate urban TJA patients more frequently discharge to rehab. Patient-reported outcome measures following TJA do not appear different between rural and urban patient groups. Rural geographic location is associated with different TJA utilization and outcomes and may point to disparities in care. Continued efforts dedicated to eliminating inequalities in TJA care should consider the impact geographic location may have on exacerbating other forms of inequity. The reporting of urban-rural classification of patients in arthroplasty research is important for advancing this area of study. Access to care for all patients should be prioritized.
Patient characteristics may predict implant sizes in total hip arthroplasty (THA), but the clinical value and generalizability of such models remain uncertain. This study evaluated the accuracy and relevance of an artificial intelligence (AI)-driven prediction tool for THA sizing in a diverse population. We retrospectively reviewed 2410 primary THAs at 2 academic hospitals (2007-2021). Data included patient characteristics, surgical approach, surgeon fellowship training, and complications (periprosthetic femur fracture [PPF], aseptic loosening within 1 year). An AI model predicted femoral stem and acetabular cup sizes using age, sex, height, weight, and race/ethnicity, and these predictions were compared with implanted sizes. In a subset, predictions were compared to traditional radiographic templating. Multivariate analyses assessed associations between size deviation and complications. AI-predicted femoral stems and cups were within one size of implanted components in 72.0% and 77.7% of cases, and within 2 sizes in 91.2% and 94.7%, respectively. Excluding complex cases (dysplasia, avascular necrosis, head collapse, conversion THA) improved accuracy (P < .0001). In subgroup analysis, AI predictions outperformed radiographic templating for stems (mean deviation 0.731 vs 1.179; P < .0001) and cups (0.673 vs 1.071; P = .036). Arthroplasty-trained surgeons implanted components significantly closer to AI-predicted sizes (P < .001). Closer alignment with AI-predicted stem size was associated with reduced aseptic loosening and PPF (P < .0001). A free AI-assisted prediction tool (Mortho) demonstrated strong accuracy and generalizability for implant sizing in primary THA, particularly in standard cases. Predictions mirrored arthroplasty-trained surgeons' selections and outperformed radiographic templating, supporting patient characteristic-based AI as a valuable adjunct for THA planning.
Metal implant hypersensitivity remains a subject of ongoing debate in the orthopaedic community. With the global rise in total knee arthroplasty (TKA) procedures per annum and an increasing prevalence of reported metal allergies in the general population, understanding the clinical relevance of metal implant hypersensitivity in knee arthroplasty patients is essential. This systematic review evaluates the relationship between metal hypersensitivity, diagnostic testing, and postoperative outcomes following TKA. A literature search was conducted using the Ovid, MEDLINE, and Embase databases for studies published between 1990 and December 2024. Studies assessing diagnosis, management, or outcomes of metal hypersensitivity in TKA were included. Both prospective and retrospective studies were considered. The search yielded 554 records, with an additional 25 studies identified through manual reference screening. Following full-text assessment of 58 articles and application of predefined inclusion and exclusion criteria, 24 studies were included. Data extraction focused on study design, patient demographics, implicated metals, diagnostic methods, interventions, and outcomes. Patient Reporting Items for Systematic Reviews & Meta Analysis (PRISMA) guidelines were followed. A pooled cohort of 5615 knee arthroplasty cases was analyzed, with a mean patient age of 65.35 years and a female predominance (60.55%). Among these, 1165 patients had a documented history of metal hypersensitivity. Twenty studies reported follow-up durations, with a mean follow-up of 27.59 months. Patient symptoms, diagnostic test results, patient-reported outcome measures, and revision rates were evaluated. The available literature demonstrates significant heterogeneity and limited comparability across studies. Current evidence suggests that self-reported metal allergy or positive skin patch/lymphocyte transformation tests do not reliably predict poorer pain or functional outcomes following TKA. The clinical significance of metal hypersensitivity remains uncertain, highlighting the need for standardized diagnostic criteria and further high-quality research.
Rural patients in the United States often face higher tobacco use, obesity rates, and lower health literacy, impacting arthroplasty outcomes. This study investigates whether rural residency is directly associated with poorer patient-reported outcomes (PROs) following total knee (TKA) and total hip arthroplasty (THA). It also evaluates the effectiveness of web-based PRO tools across urban and rural populations. Understanding these relationships is crucial for addressing disparities in care and improving surveillance for rural populations. From May 2021 to April 2023, TKA and THA patients at our institution were categorized based on their home zip codes, using the 2020 Census Bureau binary urban-rural classification. Web-based PROs were administered via text or email and assessed using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement; Hip Injury and Osteoarthritis Outcomes Score, Joint Replacement; University of California, Los Angeles Activity Score; Patient-Reported Outcomes Measurement Information System Global Physical and Mental Health Scores; and Forgotten Joint Scores. PROs were recorded preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. Statistical analysis encompassed chi-square and independent samples t-tests. Among 781 THA and 1094 TKA cases, survey response rates (71.9%-83.8%) were consistent across urban and rural groups (all P > .05). PROs were similar across all timepoints, except rural THA patients reported lower Patient-Reported Outcomes Measurement Information System Global Physical and Mental Health scores [(Mental:Urban 54.2 ± 8.5 vs Rural 50.7 ± 10.0, P = .021); (Physical: Urban 52.2 ± 8.6 vs Rural 48.9 ± 10.0, P = .029)] at the 1-year postoperative mark. Rural patients report comparable arthroplasty-specific PROs following TKA and THA, with a similar response rate to web-based tools.
In robotic-assisted total knee arthroplasty, soft tissue tension assessment is critical during pre-resection balancing. This study compares the reliability and gap differences between the varus-valgus stress technique and the paddles technique, given the lack of comprehensive comparisons in the current literature. Prospective cohort study of 75 knees undergoing robotic-assisted total knee arthroplasty. During pre-resection balancing, joint tensioning assessments were performed by both an arthroplasty fellowship- trained surgeon and an experienced surgeon using both techniques. Four gap parameters were documented: extension medial, extension lateral, flexion medial, and flexion lateral widths. Interobserver reliability was evaluated using intraclass correlation coefficients. Incidence of >2 mm differences between assessors and mean gap differences between techniques were analyzed. Both techniques demonstrated good-to-excellent interobserver reliability (intraclass correlation coefficient >0.8), with no statistically significant differences between fellowship-trained and experienced surgeons across all gap measurements (P > .05). However, technique choice significantly impacted gap measurements. The paddles technique consistently yielded wider lateral gaps compared to the varus-valgus stress technique: extension lateral gaps were 2.5-2.7 mm wider (P < .001) and flexion lateral gaps were 1.4-1.5 mm wider (P < .001). These differences were consistent regardless of surgeon experience level. Gap measurement differences are primarily determined by the assessment technique rather than surgeon experience. The paddles technique produces systematically wider lateral gaps compared to varus-valgus stress technique. Surgeons must account for these clinically significant differences when making balancing decisions, as technique choice impacts results; more than assessor experience level. Level II.
The purpose of this study was to assess the demographic characteristics of orthopaedic surgeons in Louisiana taking care of patients with Medicaid insurance and to assess any perceived barriers to care, with a focus on total joint arthroplasty (TJA). An electronic survey was distributed to all practicing surgeon members of the Louisiana Orthopaedic Association with questions about practice type, subspecialty, demographics, estimated percentage of Medicaid patient volume, and perceived barriers to care. Responses were collected using a secure database, and statistical analysis was performed. The 114 respondents were mostly male (95.6%), white (87.7%), and in private practice (61.4%). Most respondents (73.8%) did not accept Medicaid insurance (22.8%) or took care of <25% patients with Medicaid (50.9%). Fifty-eight respondents (50.9%) reported performing TJA. The majority of surgeons performing TJA (76.6% total hip arthroplasty [THA], 93.7% total knee arthroplasty [TKA]) either did not accept Medicaid insurance (36.2% THA, 47.3% TKA) or performed less than 25% of their TJA volume on patients with Medicaid insurance (40.4% THA, 36.4% TKA). The most commonly reported perceived barriers to care were lower physician and facility reimbursement, and difficulty referring to ancillary services. Surgeons in academic practice were significantly more likely to take care of a higher percentage of patients with Medicaid insurance (P = .0001). Most orthopaedic surgeons performing TJA in Louisiana either do not accept or perform a relatively small percentage of their practice volume on patients with Medicaid insurance. Low physician and facility reimbursement rates and difficulty referring to ancillary services were perceived as the greatest barriers to caring for these patients.
Medicare is the largest payer of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in the United States, yet reimbursement has shifted substantially in the past decade. We described and compared state- and region-level trends in Medicare inpatient reimbursement for primary THA/TKA from 2013 to 2023. This study retrospectively analyzed the Medicare Inpatient Hospitals by Provider and Service database for diagnostic-related group 470 (major hip/knee replacement without major complication or comorbidity) from 2013 to 2023. Extracted fields were hospital-submitted charges and Medicare facility payments, inflation adjusted to 2023 US dollars. State means were discharge-volume-weighted to reflect the average beneficiary; states were aggregated to US Census regions (Northeast, Midwest, South, and West). Regional differences were compared, and longitudinal trends were estimated using linear mixed-effects models, including year, region, and their interaction. In total, 3,724,353 primary THA/TKA discharges were billed to Medicare. Annual inpatient volume fell 84.1% (451,603 to 71,939). Inflation-adjusted reimbursement per discharge declined from $15,808 to $13,696 (-$2113; -13.4%), whereas charges rose from $71,469 to $85,675 (+$14,206; +19.9%). No state experienced an inflation-adjusted increase. Regional declines ranged from -19.1% (Midwest) to -10.1% (West). Mixed-effects modeling showed an overall decline of approximately -$285 per discharge per year (P < .001); the South declined less steeply than the Midwest (+$36/year relative slope difference, P < .05). Inflation-adjusted Medicare inpatient reimbursement for THA/TKA decreased nationwide with consistent but heterogeneous declines across states and regions. The steepest reductions occurred in the Midwest and the smallest in the West, underscoring persistent geographic variability with implications for access to arthroplasty care and sustainable payment models.
Total joint arthroplasty has become one of the most successful surgeries in regard to quality of life and cost-effectiveness. Periprosthetic joint infections can have catastrophic effects on a patient's surgical outcome, quality of life, and function. Shared decision-making can help patients reduce their risk by changing modifiable risk factors. Logistic regression was used to construct an infection risk prediction model for primary total joint arthroplasty of hips and knees using data from the Michigan Arthroplasty Registry Collaborative Quality Initiative dataset, which included 140,884 total knee arthroplasties and 82,110 total hip arthroplasties. The resulting model was deployed using a web-based interface that allows surgeons to counsel their patients in the clinic by showing them in real time how adjusting modifiable risk factors will affect their overall risk of infection. To our knowledge, this study is novel in finding preoperative opioid use and use of assistive devices to be correlated with infection after primary total knee arthroplasties and total hip arthroplasties. Modifiable risk factors that were found to significantly affect risk included body mass index, smoking, and preop narcotic use. Nonmodifiable risk factors included sex assigned at birth, marital status, race, type of payer, preoperative use of assistive devices, and annual surgeon volume <100 cases per year. While some of these risk factors are nonmodifiable, others can be addressed and optimized prior to surgery. Surgeons must be equipped with infection risk information to accurately counsel patients preoperatively, while also using data to drive patient selection.
Heart failure is a known risk factor for complications after arthroplasty, yet few studies separate heart failure with reduced ejection fraction (HFrEF; left ventricular ejection fraction ≤40%) from heart failure with preserved ejection fraction (HFpEF; left ventricular ejection fraction ≥50%). We evaluated whether heart failure subtype influences postoperative outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Using the TriNetX Network, we conducted a retrospective cohort study of adults with HFrEF or HFpEF undergoing elective primary THA or TKA (2004-2024). Propensity score matching (1:1) balanced demographics, comorbidities, medications, and laboratory values. Seven complications were assessed at 90 days and 1 year. In the THA cohort (560 matched pairs), HFrEF was associated with higher odds of acute kidney failure (OR1year = 1.63, P < .01), myocardial infarction (OR90days = 1.66, P = .012), stroke (OR90days = 3.11, P < .01), atrial fibrillation (OR90days = 1.56, P < .01), and mortality (OR1year = 1.54, P = .044); cardiac arrest and sepsis did not differ. In the TKA cohort (950 matched pairs), HFrEF was associated with higher odds of acute kidney failure (OR1year = 1.45, P < .01), myocardial infarction (OR1year = 1.93, P < .01), atrial fibrillation (OR90days = 1.56, P < .01), mortality (OR1year = 1.85, P < .01), and cardiac arrest (OR1year = 2.37, P = .011); stroke and sepsis did not differ. HFrEF confers higher risk than HFpEF after THA and TKA, supporting the need for HFrEF-specific perioperative management to improve outcomes.
Despite similar rates of osteoarthritis, minority populations undergo fewer hip and knee arthroplasties and have more complications. More than 90% of US hospitals have certified electronic health records, yet only 40% of patients utilize electronic patient portals (EPPs), with lower rates across some demographics. Adverse quality metrics and lower patient-reported outcome survey completion rates were noted for patients with inactive portals. Activation rates for EPPs can be lower among underrepresented groups, perpetuating existing disparities in access to care. Barriers to EPP activation must be identified to design interventions that improve portal utilization and, therefore, outcomes. We designed this study as there are no published reports analyzing factors which impede EPP utilization by total joint patients. In this IRB-exempt qualitative study, sixty-six arthroplasty patients were interviewed using a questionnaire designed to reveal reasons for EPP nonusage. Demographic factors including language, age, sex, insurance type, and zip code were collected from the electronic health records. Dedoose, a qualitative research tool, was used to analyze data and abstract trends from interview notes and transcripts. We found arthroplasty patients' demographics and social drivers of health influenced utilization of EPPs. Older adults struggled with digital literacy or lack of familiarity with technology. Limited internet access was cited as an obstacle to use. Patients with language barriers reported accessibility issues. Patients additionally reported concerns regarding personal information being online and perceptions that portals would not be useful. EPPs are becoming the preferred method of patient-physician communication. Demographic and social factors impact patient willingness and ability to access EPPs. Certain patients are, therefore, at greater risk of ineffective communication with care teams, delayed follow-up appointments, or challenges with scheduling and managing rehabilitation. This may lead to suboptimal recovery and surgical outcomes. The current study investigated underlying issues impeding EPP usage to inform potential interventions.
In the early days of artificial joint replacement, the choice of bearing material was a decisive factor for the long-term success of an artificial joint. Through intensive research and development over more than three decades, the materials and their processing and sterilisation have been continuously improved. The materials used today all offer a high degree of safety and durability. As a result - In combination with the strict approval guidelines - the choice of a specific material is no longer as important as it was when artificial joint replacement was first introduced.This article focuses on the results of primary hip arthroplasty in eight established registries. In all of the registries examined, ceramic-ceramic bearings and bearings with cross-linked polyethylene cups or liners in combination with heads made of all common head materials, show very good long-term results with a low revision risk. The choice of head size varies considerably in the individual registries. In America, large (36 mm diameter) or very large ceramic heads (over 36 mm) tend to be used, even though the country's own registry warns against very large heads. In Australia, also mainly large heads are used. However, recent analyses indicate that large heads (36 mm) have a higher risk of revision in the long term. In Scandinavian countries, the Netherlands, and New Zealand, smaller heads (32 mm diameter) tend to be predominantly used. The situation in the other countries whose registries were analysed lies somewhere in between, with each country having its own special features. In England, the results of surface replacement are being closely monitored. The results are inconspicuous for the recommended patient population. The further performance of the newly introduced ceramic surface replacement is being followed with great interest. In Germany, the proportion of heads with a diameter of 36 mm is growing continuously, which should be critically questioned when considering the results from Australia. Ceramic-ceramic bearings are being used less and less frequently, even though they perform similarly well overall to hard-soft bearings and even better in some settings. Switzerland is the only country where this bearing still accounts for more than 10 % of treatments. Sweden no longer differentiates between materials in its annual report, but instead provides a ranking of the 74 Swedish clinics in terms of revision risk. In the Netherlands, the 32 mm head diameter is still the most frequently chosen. The German registry has the highest granularity of all registries. The use of dual mobility systems in primary endoprosthetics varies greatly between registries.Despite the differences in head materials and diameters, the results for hip replacements using HXLPE or ceramic cup inlays, show a comparable overall survival rate of approximately 96 % to 98 % after 5 years. What is noteworthy is the approach taken by the Swedish mother of all endoprosthesis registries, which no longer reports results for the different bearing combinations or head sizes, but instead reports the individual results for each facility. The overall good results for all currently used bearing materials in combination with appropriate patient selection make this a comprehensible step. Consequently, the respective clinical care quality is becoming increasingly important. In der Frühzeit des künstlichen Gelenkersatzes war die Wahl der Gleitpaarung ein maßgeblicher Faktor für den Langzeiterfolg eines Kunstgelenkes. Durch intensive Forschung und Entwicklung über mehr als 3 Jahrzehnte wurden die Materialien und deren Verarbeitung und Sterilisation kontinuierlich verbessert. Die heute eingesetzten Materialien weisen alle ein hohes Maß an Sicherheit und Langlebigkeit auf. In Kombination mit den harten Zulassungsrichtlinien entsteht dadurch die Situation, dass der Wahl eines spezifischen Materials nicht mehr die Bedeutung zukommt, die diese bei der Einführung des künstlichen Gelenkersatzes hatte.Der vorliegende Beitrag konzentriert sich auf die Ergebnisse der Primärendoprothetik in 8 etablierten Registern. Keramik-Keramik-Paarungen sowie Paarungen mit Pfannen aus quervernetztem Polyäthylen in Kombination mit Köpfen aus allen gebräuchlichen Kopfmaterialien zeigen in diesen Registern sehr gute Langzeitergebnisse mit niedrigem Revisionsrisiko. Die Wahl der Kopfgröße stellt sich hierbei recht unterschiedlich dar. In Amerika werden eher große (36 mm Durchmesser) oder sehr große Köpfe (über 36 mm) aus Keramik verwendet, auch wenn das eigene Register vor sehr großen Köpfen warnt. In Australien werden ebenfalls hauptsächlich große Köpfe eingesetzt. Neuere Analysen zeigen jedoch, dass große Köpfe (36 mm) im Langzeitverlauf ein höheres Revisionsrisiko aufweisen. In den skandinavischen Ländern, Holland und Neuseeland werden eher kleinere Köpfe (32 mm Durchmesser) eingesetzt. Die Situation in den anderen Ländern, deren Register analysiert wurden, liegt dazwischen, wobei jedes Land Besonderheiten aufweist. In England werden die Ergebnisse des Oberflächenersatzes aufmerksam beobachtet. Die Ergebnisse sind für das empfohlene Patientenkollektiv unauffällig. Es wird mit Spannung verfolgt, wie sich der neu eingeführte keramische Oberflächenersatz entwickelt. In Deutschland wächst der Anteil von Köpfen mit 36 mm Durchmessern kontinuierlich, was bei Betrachtung der Ergebnisse aus Australien kritisch hinterfragt werden sollte. Keramik-Keramik-Paarungen werden immer seltener eingesetzt obwohl sie insgesamt ähnlich gut wie Hart-Weich-Paarungen abschneiden, für gewisse Rahmenbedingungen sogar besser. Die Schweiz ist das einzige Land, in dem diese Paarung noch einen Anteil von über 10 % an den Versorgungen hat. Schweden differenziert die Materialien im Jahresbericht gar nicht mehr, sondern gibt ein Ranking der 74 schwedischen Kliniken in Bezug auf das Revisionsrisiko an. In Holland ist immer noch der 32-mm-Kopfdurchmesser der am häufigsten gewählte. Das deutsche Register weist die höchste Granularität aller Register auf. Die Verwendung von Dual-Mobility-Systemen in der Primärendoprothetik variiert stark zwischen den Registern.Trotz der Unterschiede bei den Kopfmaterialien und -durchmessern zeigen die Ergebnisse für den Hüftgelenkersatz bei der Verwendung von HXLPE- oder Keramikpfanneninlays nach 5 Jahren insgesamt eine vergleichbare Überlebensrate von ungefähr 96–98 %. Bemerkenswert ist das Vorgehen der schwedischen Mutter aller Endoprothesenregister, die keine Ergebnisse für die unterschiedlichen Gleitpaarungen oder Kopfgrößen mehr angeben, sondern hingegen die individuellen Ergebnisse für jede Einrichtung. Die insgesamt guten Ergebnisse für alle derzeit gebräuchlichen Gleitpaarungen bei entsprechender Patientenselektion machen dies zu einem nachvollziehbaren Schritt. Die Bedeutung der klinischen Versorgungsqualität tritt dadurch immer mehr in den Vordergrund.
Resident participation in total hip arthroplasty and total knee arthroplasty (THA/TKA) is important, but the time-driven financial impact remains unclear. We quantified the "opportunity cost" of resident involvement in THA and TKA. Primary THA and TKA cases were identified at a single academic center (2013-2017). Cases were attending-only (AO) or resident-involved (RI). Fellows excluded. RI was stratified between juniors (postgraduate year I-III) and seniors (postgraduate year IV-V). Outcomes included operative efficiency and financial productivity. Relative value units/case were fixed at 19.6 to isolate time-driven effects. A total of 3,217 AO and 1,148 RI THA cases, and 4,174 AO and 1,235 RI TKA cases were analyzed. RI increased operative time (THA +4.0 minutes, 95% CI [2.3, 5.7]; TKA +7.9 minutes, 95% CI [6.7, 9.1]; both p<0.001) but reduced set-up time (THA -1.7 minutes, 95% CI [-2.2, -1.2]; TKA -1.6 minutes, 95% CI [-2.0, -1.2]; both p<0.001), partially offsetting total operating room (OR) time (THA +2.3 minutes; TKA +6.3 minutes). Juniors concentrated these effects. Seniors approximated AO efficiency and had quicker THA total OR times. Per-case opportunity costs were small: operative-time (THA $36.81; TKA $76.51) and total OR time (THA $15.16; TKA $7.22). Seniors showed a $12.99 per-case savings on a THA total OR time basis. Resident participation in primary THA/TKA carries small, experience-dependent costs, partially offset with seniority and quicker set-up times. These findings may reflect anticipatory workflow gains and offer insights into schedule optimization.
There has been increased awareness around the interplay between patients' social and demographic background and health outcomes. The influence of social determinants of health on patients outcomes has recently been recognized in orthopaedic literature. As knee osteoarthritis (OA) is one of the leading causes of disability in the world and the procedural volume of total knee arthroplasty (TKA) is rising with increased access and an aging population, better appreciation for these factors is imperative. This review seeks to examine the effect of sociodemographic factors on OA care and disease burden; and TKA outcomes. Our goal is to provide the arthroplasty surgeon community with a better understanding of how inequities in care and research impact our patients' OA and TKA outcomes. Previously published research has focused mainly on race and ethnicity, but the literature is limited, with what is available showing that there are disparate presentations and outcomes in both OA and TKA based on different social determinants of health. There is substantial work that will be required to better understand and address nonmodifiable risk factors and optimize surgery outcomes across all demographics.
Recent evidence has shown a connection between the gut microbiome (GM) and joint health, with changes in the microbial community (dysbiosis) leading to joint degeneration, prosthesis loosening, and joint infection. A leading cause of dysbiosis is excessive antibiotic use. However, the relationship between antibiotics and post-operative joint recovery is largely unexplored. This study aims to investigate whether a history of antibiotic use is associated with a higher odds of revision following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA.). This retrospective study analyzed the records of patients who underwent a primary TKA or THA from January 2014 to January 2024 at a quaternary-care medical center. Demographic information, comorbidities, lifetime antibiotic prescriptions excluding perioperative prophylaxis, post-operative infection status, and reoperation data were collected. Controlling for age, sex, BMI, race, prior prosthetic joint infections, and Charlson Comorbidity Index, a multivariable logistic regression analysis was conducted. A total of 2457 patients were analyzed. Among patients undergoing TKA, any history of antibiotics was associated with revision (OR 2.04, 95% CI 1.19-3.58, p = 0.011). The THA cohort had similar odds of revision (OR 2.51, 95% CI 1.25-5.18, p = 0.011). In a model limited to revisions caused by infection, antibiotic use on a binary scale was not a significant predictor (OR 1.63, 95% CI 0.735-3.70 p = 0.232). However, on a continuous scale, the odds of revision increased by 1% for each additional antibiotic taken for infection-related revisions (OR 1.01, 95% CI 1.000-1.03 P = 0.046). Our study demonstrates that antibiotic use is associated with higher odds of revision following TKA and THA. These preliminary findings contextualize the gut-joint axis, adding a unique variable to this relationship. Future studies may build on this hypothesis-generating information to further understand the interplay between the GM and joint health.
With the rise of internet access and social media use, finding medical information has become easier than ever. Increasingly, medical professionals (MPs) are using video-sharing platforms such as TikTok to disseminate educational material. This study aims to assess the quality of educational content related to total knee arthroplasty (TKA) treatment on TikTok. On July 31, 2025, using the search terms "total knee arthroplasty," "knee replacement surgery," and "TKA," the first 150 videos produced by TikTok were compiled. After applying exclusion criteria, 59 videos were reviewed using the following assessments: Global Quality Score (GQS), Journal of the American Medical Association benchmark, Health on the Net Code, The Patient Education Materials Assessment Tool for Audiovisual Materials, and a modified DISCERN. The 59 videos had a cumulative total of 2,738,858 views. Videos created by MPs had higher average scores in GQS (2.29 vs 1.31; P = .00047), Journal of the American Medical Association (1.76 vs 1.31; P = .00056), Health on the Net Code (3.95 vs 2.40; P = <0.000001), The Patient Education Materials Assessment Tool for Audiovisual Materials Understandability (8.29 vs 7.20; P = .0033), and modified DISCERN (2.3 vs 1.1; P = <0.0008) when compared to videos created by non-MPs. TikTok demonstrates potential as a platform for disseminating educational content related to TKA. Although videos created by MPs scored higher across all evaluation metrics compared with those produced by non-MPs, the overall educational quality of available content remains limited. Improving video quality requires citing credible sources, providing supplementary learning materials, and disclosing potential conflicts of interest.
Diuretics are commonly prescribed for hypertension in patients undergoing total hip arthroplasty (THA). These medications can alter bone metabolism and remodeling, yet their impact on arthroplasty outcomes remains unclear. This study aimed to evaluate the effect of diuretic use on 2-year implant-related complications following THA. A retrospective analysis was performed using a national administrative claims database to identify patients undergoing primary THA. Patients prescribed loop diuretics, thiazides, or combination therapy were compared to controls not taking diuretics. Multivariable logistic regression analyses were conducted to assess the association between diuretic use and 2-year outcomes, including all-cause revision, loosening, and periprosthetic fracture (PPF)-indicated revision. Odds ratios (ORs) were then recorded. Of 225,996 THA patients, 61,202 (27.1%) were prescribed at least one diuretic before surgery. Multivariable analysis demonstrated higher odds of 2-year all-cause revision with thiazides (OR: 1.1), loop diuretics (OR: 1.5), and combination therapy (OR: 1.9). Loop diuretics and combination therapy were also associated with an increased risk of PPF-related revision (OR: 1.4 and 1.2, respectively). Additionally, loop diuretics were the only class associated with higher odds of revision due to mechanical loosening (OR: 1.2; P < .05 for all). Loop diuretic use was associated with higher odds of adverse 2-year implant-related outcomes, including PPF, mechanical loosening, and all-cause revision. Thiazide use was also associated with a modest increase in revision risk. These findings highlight a potential relationship between diuretic use and THA outcomes; however, further studies are required to clarify causality and investigate the underlying mechanisms driving these associations.
Health-related social needs (HRSNs) are the individual-level adverse social conditions that negatively impact a person's health. This study characterizes the association of HRSNs with patient-reported outcomes and adverse events following total hip (THA) and knee arthroplasty (TKA). This single-institution cross-sectional study utilized the Centers for Medicare & Medicaid Services HRSN Screening Tool. In-person interviews captured HRSNs, patient-reported outcome measures, and demographic data from postoperative THA and TKA patients in an academic arthroplasty practice. Charlson Comorbidity Index, American Society of Anesthesiologists scores, discharge data, and 90-day complications were collected via chart review. Regression analysis was used to determine associations between HRSNs and outcomes. Among 190 patients, food insecurity had a significant association with reoperation (odds ratio (OR) = 5.78, 95% confidence interval 1.44-23.2, P = .013). Patients with food and transportation HRSNs had significantly worse postoperative physical function, pain, and mobility (all P < .05). Black patients had significantly higher odds of visiting the emergency department (OR = 2.15, 95% CI 1.10-4.20, P = .025) or being readmitted (OR = 2.70, 95% confidence interval 1.11-6.58, P = .029) within 90 days postoperation compared to White patients. Food insecurity was associated with increased odds of reoperation, and food insecurity and transportation were associated with worse patient-reported outcomes following THA and TKA. Black patients had increased risks of readmission and emergency department visits. These findings highlight the critical impacts of HRSNs on THA and TKA outcomes and underscore the need for targeted interventions addressing HRSNs to improve postoperative recovery and health-care equity.
Our study evaluated 90-day outcomes of patients treated preoperatively with glucagon-like peptide-1 receptor agonists (GLP-1) or bariatric surgery compared to no weight loss intervention prior to total hip arthroplasty (THA) and total knee arthroplasty (TKA). A multicenter institutional cohort of patients undergoing primary THA (n = 5710) and TKA (n = 6770) from 2023 to 2024 was identified. Preoperative weight-loss strategies included no intervention (89%), perioperative use of GLP-1 (10%), or prior bariatric surgery (1%). Ninety-day readmissions and reoperations were compared among groups. Subanalyses were performed stratifying obesity (body mass index) classification and diabetes mellitus status vs others to contextualize these independent risk factors. Among all patients undergoing THA and TKA, those who had undergone bariatric surgery experienced significantly higher reoperation rates at 90 days compared to those without intervention and GLP-1 groups (2.2 vs 0.5 vs 0.8%, respectively; P = .014). For THA, both the no intervention and GLP-1 groups had significantly lower readmission rates compared to the bariatric surgery group (4.4 vs 6.5 vs 8.8%, respectively; P = .04) and lower reoperation rates (0.4 vs 1.4 vs 2.2%; P = .006). For TKA, there were no significant differences in readmission (P ≥ .47) or reoperation rates (P ≥ .067) among the groups or by body mass index class and diabetes mellitus status. Compared to no weight loss intervention, patients utilizing perioperative GLP-1s demonstrated similar 90-day readmission and reoperation rates after primary THA and TKA. Those with prior bariatric surgery showed the greatest risk of readmission and reoperation, particularly after THA. IV, Retrospective Review.