Medicare Advantage (MA) plans are popular among Medicare-eligible patients, but little is known about MA in lower-extremity total joint arthroplasty (TJA). The purpose of this study was to describe trends in MA utilization and analyze differences in patient characteristics and postoperative outcomes between patients undergoing primary TJA using traditional Medicare (TM) or MA plans.Patients ≥65 years of age who underwent primary total knee or total hip arthroplasty were identified using the Premier Healthcare Database. Patients were categorized into TM and MA cohorts. Data from 2004 to 2020 were used to describe trends in insurance coverage. Data from 2015 to 2020 were used to identify differences in patient characteristics and postoperative complications using ICD-10 codes. Multivariate analyses were performed using 2015 to 2020 data to account for potential confounders.From 2004 to 2020, the proportion of patients with MA increased from 7.9% to 34.4%, while those with TM decreased from 83.7% to 54.0%. Of the 697,317 patients who underwent primary elective TJA from 2015 to 2020, 471,439 (67.6%) had TM coverage and 225,878 (32.4%) had MA coverage. The cohorts were similar in terms of age and sex. However, a higher proportion of Black patients (8.29% compared with 4.62%; p < 0.001) and a lower proportion of White patients (84.0% compared with 89.2%; p < 0.001) were enrolled in MA compared with TM. After controlling for confounders, patients with MA had higher odds of surgical site infection (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.47; p = 0.031), periprosthetic joint infection (aOR: 1.10; 95% CI: 1.03 to 1.18; p = 0.006), stroke (aOR: 1.15; 95% CI: 1.02 to 1.31; p = 0.026), and acute kidney injury (aOR: 1.08; 95% CI: 1.04 to 1.11; p < 0.001), but lower odds of urinary tract infection (aOR: 0.94; 95% CI: 0.90 to 0.98; p = 0.003).From 2004 to 2020, the number of patients utilizing MA increased markedly such that 1 in 3 were covered by MA in 2020. From 2015 to 2020, patients who were non-White were more likely to have MA than TM, and the MA group had a higher rate of several postoperative complications compared with the TM group. As TM claims data inform health-care policy and clinical decisions, this change portends future challenges, including limitations in arthroplasty registry research, an increase in the administrative burden of surgeons, and a potential worsening of social disparities in health care.
Studies on diversity in orthopaedic surgery have exclusively examined challenges from a race or sex perspective. This study examines trends in the diversity of entering orthopaedic surgery residents from the intersection of race and sex.
The original review article, published in 2006, describing leg length discrepancy after total hip arthroplasty commented that "equal leg length should not be guaranteed." There has been considerable advancement in surgical technique and technology over the past decade, allowing surgeons to "hit the target" much more consistently. In this interval paper, we review leg length discrepancy and introduce some technologies designed to mitigate this complication. In addition, we present challenging clinical scenarios in which perceived leg length may differ from true leg length and how these can be addressed with proper workup and surgical execution.
Abstract Purpose The purpose of this cross-sectional, observational study was to establish the relationship between standing lumbar lordosis (LL) and lateral decubitus LL. Methods Forty-nine subjects, 24 male and 25 female, were prospectively enrolled. Patients with pre-existing spinopelvic pathology were excluded. Standing, relaxed-seated, and lateral decubitus lateral radiographs were obtained. Radiographic variables measured included LL and lordosis change at each lumbar level (e.g. L1-L2). The change in LL when going from a standing to a lateral decubitus position (ΔLL), the correlation between standing and sitting LL compared to lateral decubitus LL, and the correlation between ΔLL and standing pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, pelvic femoral angle (PFA), and sacral slope (SS) were calculated. Results Subjects had an average age of 25.7 ± 2.3 years and body mass index of 24.1 ± 3.0 kg/m 2 . On average, 11.9°±8.2° (range − 7° to 29°) of LL was lost when transitioning from a standing to the lateral decubitus position. Lateral decubitus LL had a higher correlation with standing LL ( R = 0.725, p < 0.001) than with relaxed-seated LL ( R = 0.434, p < 0.001). Standing PT and PI-LL mismatch had moderately negative correlations with ΔLL ( R =-0.58 and R =-0.59, respectively, both p < 0.05). Standing PI and standing PFA had a low negative correlation with ΔLL ( R =-0.31 and R =-0.44, respectively, both p < 0.05) Standing SS and LL had no correlation with ΔLL. Conclusions Standing LL was strongly correlated to lateral decubitus LL, although subjects lost an average of 11.9° from the standing to the lateral decubitus position. This has important implications for fusion in the lateral position.
The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype.The Premier Healthcare Database was queried to identify all patients who were diagnosed with metastatic bone disease from January 2015 to December 2020. The prevalence of all primary tumour subtypes was tabulated. Rates of long bone pathological fracture, 90-day mortality, and 360-day mortality following surgical treatment of pathological fracture were assessed for each primary tumour subtype. Patient characteristics and postoperative outcomes were analyzed based upon whether patients had impending fractures treated prophylactically versus treated completed fractures.In total, 407,893 unique patients with metastatic bone disease were identified. Of the 14 primary tumours assessed, metastatic bone disease most frequently originated from lung (24.8%), prostatic (19.4%), breast (19.3%), gastrointestinal (9.4%), and urological (6.5%) malignancies. The top five malignant tumours resulting in long bone pathological fracture were renal (5.8%), myeloma (3.4%), female reproductive (3.2%), lung (2.8%), and breast (2.7%). Following treatment of pathological fractures of long bones, 90-day mortality rates were greatest for lung (12.1%), central nervous system (10.5%), lymphoma (10.4%), gastrointestinal (10.1%), and non-renal urinary (10.0%) malignancies. Finally, our study demonstrates improved 90-day and 360-day survival in patients treated for impending pathological fracture compared to completed fracture, as well as significantly lower rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and blood transfusion.This study defines the contemporary characteristics of primary malignancies resulting in metastatic bone disease. These data should be considered by surgeons when prognosticating patient outcomes during treatment of their metastatic bone disease.
Postoperative spinopelvic changes are associated with increased dislocation risk following total hip arthroplasty (THA). The aim of this study was to identify preoperative patient and radiographic factors associated with high-risk postoperative spinopelvic parameters. A retrospective review of consecutive THA patients who received preoperative and postoperative sitting and standing lateral lumbar spine-hip radiographs with minimum radiographic and clinical follow-up of 10 months was performed. Patient demographics were recorded and preoperative standing and sitting sacral slope (SS), anteinclination, pelvic femoral angle (PFA), and combined sagittal index (CSI) were measured. High-risk patients were defined by decreased spinopelvic motion (∆SS from sitting to standing of >10°), increased hip motion (∆PFA from sitting to standing of >10°), or decreased CSI of >10° at final follow-up compared with preoperative measurements. Univariate and multivariate regression analyses were used to identify preoperative demographic and radiographic factors associated with these high-risk categories. One hundred and fifty-three patients were included with an average age of 62 years, average body mass index of 27.8 kg/m2 , and average follow-up of 16.2 months. At 1-year follow-up, 43 (28.1%) patients demonstrated a decreased ∆SS > 10° and 67 (43.7%) patients demonstrated an increased ∆PFA > 10° compared with preoperative values. Sitting CSI decreased by >10° in 17 (11.1%) patients. Preoperative increased sitting PFA (adjusted odds ratio [aOR] 1.057, p < 0.001) and decreased preoperative hip motion (∆PFA) were associated with decreased sitting CSI of >10° at 10-month follow-up. Increased spinopelvic motion (∆SS) and decreased hip motion (∆PFA) preoperatively are associated with postoperative radiographic changes that be associated with increased dislocation risk.
