had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Background As primary total hip arthroplasty volume continues to increase, so will the number of revision total hip arthroplasty (rTHA) procedures. These complex cases represent a significant clinical and financial burden to the health-care system. Methods This was a retrospective review using the National Inpatient Sample. International Classification of Diseases, 9th and 10 th revision codes were used to identify patients who underwent rTHA and create cohorts based on rTHA indications from 2012 to 2018. National and regional trends for length of stay (LOS), cost, and discharge location were evaluated. Results A total of 292,250 rTHA procedures were identified. The annual number of rTHA procedures increased by 28.1% from 2012 to 2018 (37,325 to 47,810). The top 3 indications for rTHA were instability (20.4%), aseptic loosening (17.8%), and infection (11.1%). Over the study period, the proportion of patients discharged to skilled nursing facility decreased from 44.2% to 38% ( P < .001). Hospital LOS decreased on average from 4.8 to 4.4 days ( P < .001). Infections had the highest average LOS (7.3 days) followed by periprosthetic fractures (6.5 days). Hospital costs decreased over the study period, from $25,794 to $24,555 ( P < .001). The proportion of rTHA cases performed at urban academic centers increased (58.0% to 75.3%, P < .001) while the proportion performed at urban nonacademic centers decreased (35.5% to 19.4%, P < .001). Conclusion Instability was the most common indication for rTHA between 2012 and 2018. The proportion of rTHA performed in urban academic centers has increased substantially, away from urban nonacademic centers. While cost and LOS have decreased, significant geographic variability exists.

Introduction: Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures.Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications.Results: A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications.Conclusions: Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.

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Background In settings with limited access to specialist services, differentiating septic arthritis-a surgical emergency-from non-infectious atraumatic arthropathy in paediatric patients is challenging, especially in a setting with a high burden of tuberculosis (TB). We aimed to investigate the aetiologies of swollen, painful joints in an urban setting in South Africa and determine how clinical and laboratory findings varied with diagnosis. Patients and methods A retrospective review of patients aged 12 or younger presenting to a paediatric hospital in Cape Town, South Africa, with atraumatic swollen, painful joints was conducted over a two year period from 2013 to 2015. Children were excluded if they did not have tissue culture or analysis conducted at our facility. Aetiology was classified as non-infectious, TB septic arthritis, or pyogenic arthritis from other bacterial causes. Results One hundred and four children met inclusion criteria. Arthritis was classified as noninfectious in 43 (41%), TB in 15 (14%), and pyogenic in 40 (38%), with six (6%) patients never receiving a final diagnosis. Mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WCC) were all significantly higher in pyogenic infectious arthritis compared with TB and non-infectious arthritis. There were no significant differences in these parameters between non-infectious and TB arthritis. Using cut-point analysis, thresholds were identified predictive of the presence of pyogenic arthritis versus TB or non-infectious arthritis; these included the presence of fever, CRP > 50 mg/L, ESR > 65 mm/h and WCC > 12x10 9 /L. The absence of all of these criteria resulted in a negative predictive value of 100% for pyogenic infection; the presence of three to four criteria resulted in a positive predictive value of 71%. Conclusions Despite insignificant differences in their clinical presentation compared with non-infectious arthidities, 15% of children were diagnosed with tissue-confirmed TB infection. Predictive values of clinical criteria are reduced in our population due to elevated levels of inflammatory markers in all patients. Synovial biopsy to rule out TB is recommended in all patients in a high-burden setting given clinical similarity to non-infectious aetiologies.