Ivan Z. Liu

Purpose: The purpose of this study was to evaluate changes in perioperative tranexamic acid (TXA) utilization among patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), based on patient demographics and comorbidities, including those at higher and lower risk of venous thromboembolism (VTE). Methods: Patients who underwent THA or TKA between 2012 and 2021 were identified using the TriNetX electronic health record database. Perioperative TXA use was evaluated among patients stratified according to risk of VTE. Utilization rates were analyzed using compound annual growth rates (CAGRs) and linear regression analysis. Results: From 2012 to 2021, TXA use increased by 406% (CAGR: +17.66%; P < 0.001) for THA and 459% for TKA (CAGR: +18.86%; P < 0.001). Among patients with at least 1 factor placing them at high risk of VTE, TXA use increased by 1277% for THA (CAGR: +30.0%; P < 0.001) and by 966% for TKA (CAGR: +26.7%; P < 0.001). During the final study year (2021), surgeons overall used TXA in 67.8% of THA cases and 62.5% of TKA cases. In the high-risk group, TXA use was lowest among patients with a history of myocardial infarction (THA, 48.7%; TKA, 51.4%), cerebrovascular accident (THA, 51.0% and TKA, 50.6%), bleeding or clotting disorder (THA, 57.4% and TKA, 57.1%), or previous VTE (THA, 57.3%; TKA, 53.6%). Conclusion: Despite the rapid growth in TXA utilization over the past decade in THA and TKA, patients at high risk of VTE and ischemia are still less likely to receive perioperative TXA.

The prevalence of obesity is significantly increasing in the U.S. population and is associated with both increased incidence of total hip arthroplasty (THA) and potentially worsened postoperative outcomes. Current guidelines strongly encourage exercise-based weight loss in morbidly obese THA candidates to decrease patient risk profiles, but data on the impact of receiving bariatric surgery (BS) for weight loss prior to THA are limited and controversial. The purpose of this study was to clarify the impact of BS on postoperative complications and outcomes following THA. Using Current Procedural Terminology, International Classification of Diseases (ICD)-9, and ICD-10 codes, patients undergoing primary THA from 2010 to 2018 were retrospectively collected from PearlDiver's Mariner dataset. Patients were divided into three cohorts who underwent primary THA: nonmorbidly obese patients, morbidly obese patients, and morbidly obese patients who underwent THA within 2 years of BS. Patients were subsequently matched based on age, Charlson Comorbidity Index, gender, and tobacco use. The primary outcome of this study was the frequency of 90-day and 2-year postoperative complications following primary THA. Compared with morbidly obese non-BS patients, morbidly obese patients who underwent BS prior to receiving a primary THA were less likely to have blood transfusion (4.24 vs. 7.44%, p < 0.05), cellulitis (2.92 vs. 6.11%, p < 0.05), myocardial infarction (2.39 vs. 4.91%, p < 0.05), and deep venous thrombosis (1.06 vs. 3.05%, p < 0.05) at 90-day follow-up. The remaining 90-day postoperative outcomes were not found to be statistically different between cohorts. There were no significant differences in 2-year surgical complications between the morbidly obese non-BS cohort and morbidly obese BS cohort. In this study, we found that morbidly obese patients who underwent BS prior to THA had fewer 90-day medical complications and no significant differences in 2-year surgical complications compared with those who did not undergo BS prior to THA.

Purpose Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. Methods Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. Results Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. Conclusion Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic strained the United States healthcare system, and associated policies resulted in the postponement or cancellation of many elective surgeries. While most orthopaedic surgeons are aware of how the pandemic affected their patients’ care, broader national trends in the operative treatment of orthopaedic knee pathology are poorly characterized. Therefore, the purpose of this study was to identify trends in orthopaedic knee procedures during the COVID-19 pandemic. Methods: The TriNetX database was queried for orthopaedic knee procedures performed from March 2018 to May 2021. Procedures were classified as arthroplasty (total knee arthroplasty (TKA), revision total knee arthroplasty) or non-arthroplasty (tendon or ligament repair, fracture fixation). Procedural volume per healthcare organization was determined over five seasons from March 2020 to May 2021 and compared to overlapping pre-pandemic periods from March 2018 to May 2019. Descriptive analysis was performed, and comparisons were made using a Student’s T-test. Results: Compared to the pre-pandemic period, there were significant decreases in primary TKA (p=0.016), femoral or entire tibial component revision TKA (p=0.005), and open treatment of femoral shaft fractures (p=0.007) in spring 2020. Procedural volume returned to baseline in summer 2020 through winter 2021. In spring 2021, primary TKA (p=0.017) and one component revision TKA (p=0.003) increased compared to the pre-pandemic period. Conclusion: The greatest decrease in knee procedures occurred early in the pandemic. Rates of these procedures have since rebounded, with some exceeding pre-pandemic levels. Hospitals are now better able to accommodate orthopaedic surgical volume while continuing to care for patients with COVID-19.