Matthew R. Boylan

Atrial Septal Defect Increases the Risk for Stroke After Total Hip Arthroplasty

BACKGROUND Atrial septal defect (ASD) and patent foramen ovale (PFO) are 2 of the most common congenital heart diseases in adults and pose important risks of perioperative acute ischemic stroke (AIS) from paradoxical emboli. We evaluated the following: (1) the prevalence of ASD/PFO in the total hip arthroplasty (THA) population; (2) the rate of perioperative AIS during index admissions; and (3) the risk for perioperative AIS after THA for patients with ASD/PFO vs matched controls. METHODS We identified 393,652 patients in the Nationwide Inpatient Sample who underwent THA between January 1, 2007, and December 31, 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify patients with ASD/PFO and perioperative AIS. Propensity scores matched 252 patients with ASD/PFO to 756 controls (3:1 ratio) without ASD/PFO according to age, gender, race, Deyo comorbidity score, year of surgery, and stroke risk factors. Logistic regression models assessed risk for perioperative AIS. RESULTS The prevalence of ASD/PFO was 64 per 100,000 THA patients. The rate of perioperative AIS was 99 per 100,000 THA in the general THA population. The rate of perioperative AIS was 7.14% for ASD/PFO patients compared with 0.26% in matched controls (P < .001). Risk for perioperative AIS was 29 times greater for patients with ASD/PFO compared with matched controls (odds ratio, 29.00; 95% confidence interval, 6.68-125.89; P < .001). CONCLUSION Patients with ASD/PFO undergoing THA are at a significantly higher risk of perioperative AIS. Orthopedic surgeons should discuss this risk with patients before surgery. The efficacy of mechanical and pharmacologic thromboprophylactic measures to reduce perioperative AIS among ASD/PFO patients warrants further investigation.

Knee dislocation with popliteal artery disruption: A nationwide analysis from 2005 to 2013

Objective Few have compared short-term outcomes following knee dislocations with or without concomitant popliteal artery disruption (PAD). Methods The Nationwide Inpatient Sample was used to identify 2175 patients admitted for knee dislocation from 2005 to 2013 (concomitant PAD: n = 210/9.7%; without: n = 1965/90.3%). Results Patients with PAD were younger, more often male, Black and Hispanic, and with Medicaid (all p ≤ 0.013). PADs were associated with 11.0-times higher odds of increased LOS (95%CI, 6.6-18.4) and 2.8-times higher odds of experiencing any complication (95%CI, 2.03-3.92). Female sex was a protective factor against increased LOS, (OR = 0.65; 95%CI, 0.48-0.88). Conclusion High suspicion index should be maintained for concomitant vascular injuries following knee dislocations.

Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement

ABSTRACT The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost (

Cost-Effectiveness of Preoperative Smoking Cessation Interventions in Total Joint Arthroplasty

20,817 versus

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients

17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90‐day readmission (4.9% versus 5.8%). In multivariable‐adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p < .001), costs were 14% greater (p < .001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p < .001), with no significant difference in 90‐day readmission (p = .957). Patients undergoing TAA had different patterns of short‐term resource usage compared with patients undergoing THA and TKA, most notably higher short‐term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA. Level of Clinical Evidence: 3

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty

BACKGROUND Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear. METHODS Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis. RESULTS In our model, the average 90-day cost was

Have Periprosthetic Hip Infection Rates Plateaued

32 less for patients enrolled in a mandatory smoking cessation intervention (

Mortality Following Periprosthetic Proximal Femoral Fractures Versus Native Hip Fractures

23,457) compared with patients who were not (

Technology-Assisted Hip and Knee Arthroplasties: An Analysis of Utilization Trends

23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty

95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than