Background
Hip fracture is an international public health problem. Worldwide, approximately 1.5 million hip fractures occur per year, with roughly 340,000 in the United States in individuals older ...than 65 years. In 2050, there will be an estimated 3.9 million fractures worldwide, with more than 700,000 in the United States. However, whether there are disparities in morbidity, mortality, and function between men and women or between races/ethnicities is unclear.
Questions/purposes
The purpose of this article is to review the gender and racial/ethnicity differences in hip fracture epidemiology, mortality, and function and to ask what more information is needed and how can it be attained.
Methods
A PubMed literature review was performed and appropriate articles selected for inclusion in the review.
Where are we now?
Overall, men with hip fracture are younger, are less healthy, and have a higher postoperative mortality and morbidity. African American and Hispanics patients with hip fractures are younger than whites and have a higher incidence of fracture in men. Non-Hispanic black, Hispanic, and Asian race/ethnicity were all associated with higher odds of discharge home but a longer stay when discharged to rehabilitation.
Where do we need to go?
Expanded knowledge of the influence of gender and race/ethnicity on hip fracture epidemiology, mortality, and outcomes is necessary.
How do we get there?
Additional focused research on gender and racial/ethnic differences in patients with hip fractures is needed. Improving database capture of race/ethnicity data will aid in population studies. Finally, journal editors should require authors to include gender and race/ethnicity data or explain the absence of this information.
Combination antiretroviral therapy (ART) has significantly increased survival among HIV-positive adults in the United States (U.S.) and Canada, but gains in life expectancy for this region have not ...been well characterized. We aim to estimate temporal changes in life expectancy among HIV-positive adults on ART from 2000-2007 in the U.S. and Canada.
Participants were from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), aged ≥20 years and on ART. Mortality rates were calculated using participants' person-time from January 1, 2000 or ART initiation until death, loss to follow-up, or administrative censoring December 31, 2007. Life expectancy at age 20, defined as the average number of additional years that a person of a specific age will live, provided the current age-specific mortality rates remain constant, was estimated using abridged life tables.
The crude mortality rate was 19.8/1,000 person-years, among 22,937 individuals contributing 82,022 person-years and 1,622 deaths. Life expectancy increased from 36.1 standard error (SE) 0.5 to 51.4 SE 0.5 years from 2000-2002 to 2006-2007. Men and women had comparable life expectancies in all periods except the last (2006-2007). Life expectancy was lower for individuals with a history of injection drug use, non-whites, and in patients with baseline CD4 counts <350 cells/mm(3).
A 20-year-old HIV-positive adult on ART in the U.S. or Canada is expected to live into their early 70 s, a life expectancy approaching that of the general population. Differences by sex, race, HIV transmission risk group, and CD4 count remain.
Dialysis-dependent patients can develop osteoarthritis or osteonecrosis, warranting hip or knee arthroplasty. Their comorbidities predispose them to complications. Our goal was to determine inpatient ...outcomes of dialysis-dependent patients after primary elective total hip or knee arthroplasty.
In the National Inpatient Sample, we identified 2934 dialysis-dependent patients who had undergone total hip or knee arthroplasty from 2000 through 2009 and compared them with 6,186,475 patients who had undergone the same procedures and were not dialysis-dependent. We described demographic characteristics, comorbidities, and outcomes and assessed associations of dialysis status with inpatient mortality and complications.
In the hip arthroplasty group, dialysis-dependent patients were younger (63.2 compared with 65.2 years; p = 0.0476) and more commonly diagnosed with osteonecrosis (34.29% compared with 10.94%; p < 0.0001) than non-dialysis-dependent patients. Dialysis-dependent patients had higher inpatient mortality rates (1.88% compared with 0.13%; p < 0.0001) and greater overall complication rates (9.98% compared with 4.97%; p = 0.0001). Dialysis was an independent risk factor for mortality (odds ratio, 6.66; 95% confidence interval 95% CI, 2.66 to 16.66) and complications (odds ratio, 1.53; 95% CI, 1.01 to 2.33). In the knee arthroplasty group, dialysis-dependent patients were similar in age (66.7 compared with 66.8 years; p = 0.8085) and were more commonly diagnosed with osteonecrosis (3.32% compared with 0.74%; p < 0.0001) than non-dialysis-dependent patients. Dialysis-dependent patients had higher inpatient mortality rates (0.92% compared with 0.10%; p < 0.0001) and greater overall complication rates (12.48% compared with 5.00%; p < 0.0001). Dialysis status was an independent risk factor for mortality (odds ratio, 3.31; 95% CI, 1.04 to 10.54) and complications (odds ratio, 1.86; 95% CI, 1.34 to 2.60).
Total hip and knee arthroplasty in dialysis-dependent patients presents high risk, with inpatient mortality rates ten to twenty times greater and overall complication rates two times greater than in non-dialysis-dependent patients. Arthroplasty should be approached with caution and preferably should be delayed until after renal transplantation.
Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has ...been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors.
This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity.
The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain.
This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.
Letters of recommendation are considered one of the most important factors for whether an applicant is selected for an interview for orthopaedic surgery residency programs. Language differences in ...letters describing men versus women candidates may create differential perceptions by gender. Given the gender imbalance in orthopaedic surgery, we sought to determine whether there are differences in the language of letters of recommendation by applicant gender.
(1) Are there differences in word count and word categories in letters of recommendation describing women and men applicants, regardless of author gender? (2) Is author gender associated with word category differences in letters of recommendation? (3) Do authors of different academic rank use different words to describe women versus men applicants?
Using a linguistic analysis in a retrospective study, we analyzed all letters of recommendation (2834 letters) written for all 738 applicants with completed Electronic Residency Application Service applications submitted to the Johns Hopkins Orthopaedic Surgery Residency program during the 2018 to 2019 cycle to determine differences in word category use among applicants by gender, authors by gender, and authors by academic rank. Thirty nine validated word categories from the Linguistic Inquiry and Word Count dictionary along with seven additional word categories from previous publications were used in this analysis. The occurrence of words in each word category was divided by the number of words in the letter to obtain a word frequency for each letter. We calculated the mean word category frequency across all letters and analyzed means using non-parametric tests. For comparison of two groups, a p value threshold of 0.05 was used. For comparison of multiple groups, the Bonferroni correction was used to calculate an adjusted p value (p = 0.00058).
Letters of recommendation for women applicants were slightly longer compared with those for men applicants (366 ± 188 versus 339 ± 199 words; p = 0.003). When comparing word category differences by applicant gender, letters for women applicants had slightly more "achieve" words (0.036 ± 0.015 versus 0.035 ± 0.018; p < 0.0001). Letters for men had more use of their first name (0.016 ± 0.013 versus 0.014 ± 0.009; p < 0.0001), and more "young" words (0.001 ± 0.003 versus 0.000 ± 0.001; p < 0.0001) than letters for women applicants. These differences were very small as each 0.001 difference in mean word frequency was equivalent to one more additional word from the word category appearing when comparing three letters for women to three letters for men. For differences in letters by author gender, there were no word category differences between men and women authors. Finally, when looking at author academic rank, letters for men applicants written by professors had slightly more "research" terms (0.011 ± 0.010) than letters written by associate professors (0.010 ± 0.010) or faculty of other rank (0.009 ± 0.011; p < 0.0001), a finding not observed in letters written for women.
Although there were some minor differences favoring women, language in letters of recommendation to an academic orthopaedic surgery residency program were overall similar between men and women applicants.
Given the similarity in language between men and women applicants, increasing women applicants may be a more important factor in addressing the gender gap in orthopaedics.
Preoperative anemia is associated with adverse events following total knee arthroplasty (TKA). It remains unknown if this effect is due to comorbid conditions, adverse events associated with ...transfusions, or the anemia itself. We used propensity-score matching to isolate the effect of anemia on postoperative complications following TKA, regardless of blood transfusions.
Patients undergoing primary TKA from 2010 to 2020 without receiving a perioperative blood transfusion, were identified using a large national database. A 1:1 propensity score matching was used to create cohorts of anemic and nonanemic patients matched on Charlson Comorbidity Index (CCI), American Society of Anesthesiology (ASA) classification, age, sex, and prevalence of bleeding disorders. There were 43,370 patients were included in each group (mean age 68 range, 29 to 99; 44% male). The 1:1 matching yielded groups with similar CCI, ASA classification, age, sex, and prevalence of bleeding disorders (all, P > .9).
Anemic patients had a higher incidence of major complications (4.1 versus 2.8%; P < .001), 30-day mortality rate (0.2 versus 0.1%; P < .001), and extended lengths of stay (LOS) (8.3 versus 6.6%; P < .001). Anemic patients also had increased 30-day rates of wound infection requiring hospital admission, renal failure, reintubation, myocardial infarction, and pneumonia (all, P < .001).
In matched cohorts of anemic versus nonanemic patients undergoing TKA, all who had no postoperative blood transfusion, anemic patients had higher rates of complications, extended LOS, and mortalities. Thus, anemia should be considered an independent risk factor for complications following TKA.
Access to total joint arthroplasty can be difficult in low-resource settings. Service trips are conducted to provide arthroplasty care to populations in need around the world. This study aimed to ...compare the pain, function, surgical expectations, and coping mechanisms of patients from one such service trip to the United States.
In 2019, the Operation Walk program conducted a service trip in Guyana during which 50 patients had hip or knee arthroplasties. Patient demographics, patient-reported outcome measures, questionnaires assessing pain attitudes and coping, and pain visual analog scales were collected preoperatively and at 3 months postoperatively. These outcomes were compared with a matched cohort of elective total joint arthroplasty at a US tertiary care medical center. There were 37 patients matched between the 2 cohorts.
The mission cohort had significantly lower preoperative self-reported function scores than the US cohort (38.3 versus 47.5, P = .003), as well as a significantly larger improvement at 3 months (42.4 versus 26.4, P = .014). The mission cohort had significantly higher initial pain (8.0 versus 7.0, P = .015), but there were no differences with regard to pain at 3 months (P = .420) or change in pain (P = .175). The mission cohort had significantly greater preoperative scores in pain attitude and coping responses.
Patients in low-resource settings were more likely to have preoperative functional limitations and pain, and they coped with pain through prayer. Understanding the key differences between these 2 types of populations and how they approach pain and functional limitations may help improve care for each group.
II, prospective study.
Bacterial biofilm formation is a major complication of implantable medical devices that results in therapeutically challenging chronic infections, especially in cases involving antibiotic-resistant ...bacteria. As an approach to prevent these infections, an electrospun composite coating comprised of poly(lactic-coglycolic acid) (PLGA) nanofibers embedded in a poly(ϵ-caprolactone) (PCL) film was developed to locally codeliver combinatorial antibiotics from the implant surface. The release of each antibiotic could be adjusted by loading each drug into the different polymers or by varying PLGA:PCL polymer ratios. In a mouse model of biofilm-associated orthopedic-implant infection, three different combinations of antibiotic-loaded coatings were highly effective in preventing infection of the bone/joint tissue and implant biofilm formation and were biocompatible with enhanced osseointegration. This nanofiber composite-coating technology could be used to tailor the delivery of combinatorial antimicrobial agents from various metallic implantable devices or prostheses to effectively decrease biofilm-associated infections in patients.
A new mandatory hospital-level, risk-standardized performance measure for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on patient-reported outcomes (THA/TKA PRO-PM) ...has been implemented by the Centers for Medicare & Medicaid Services (CMS). All THA and TKA in Medicare fee-for-service beneficiaries at inpatient facilities are included. The THA/TKA PRO-PM is the proportion of risk-standardized THA or TKA patients meeting or exceeding the substantial clinical benefit threshold between preoperative and postoperative outcomes measures (Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Knee injury and Osteoarthritis Outcome Score for Joint Replacement). This binary outcome (yes/no) is then divided by all eligible patients creating a percentage of patients reaching substantial clinical benefit. The percentile score among hospitals will be reported. Following 2 voluntary reporting periods, mandatory reporting will begin in 2025. The CMS requires 50% reporting rates; failure leads to annual payment reduction in fiscal year 2028. The CMS intends the THA/TKA PRO-PM to be a patient-centered, meaningful, and relatable measure of hospital performance reported to the public. For surgeons, this is an opportunity to collaborate with hospitals for developing and implementing a THA/TKA data collection system to avoid penalties for the hospital. Further implementation for outpatient surgery and in ambulatory surgery centers has been announced by CMS. Major resources will be needed to succeed in the expected capture rates.
In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine ...duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty.
Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01.
Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges.
Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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