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The optimal management of the patella during total knee arthroplasty (TKA) remains controversial and surgeons tend to approach the patella with one of three general mindsets: always resurface the patella, never resurface the patella, or selectively resurface the patella based on specific patient or patellar criteria. Studies comparing resurfacing and non-resurfacing of the patella during TKA have reported inconsistent and contradictory findings. When resurfacing the patella is chosen, there are a number of available patellar component designs, materials, and techniques for cutting and fixation. When patellar non-resurfacing is chosen, several alternatives are available, including patellar denervation, lateral retinacular release, and patelloplasty. Surgeons may choose to perform any of these alone, or together in some combination. Prospective randomized studies are needed to better understand which patellar management techniques contribute to superior postoperative outcomes. Until then, this remains a controversial topic, and options for patellar management will need to be weighed on an individual basis per patient. Cite this article: EFORT Open Rev 2021;6:861-871. DOI: 10.1302/2058-5241.6.200156

As smoking increases the risk of adverse events and leads to increased hospital costs following total joint arthroplasty (TJA), many institutions have introduced perioperative smoking cessation initiatives. Although such programs have been demonstrated to improve outcomes for smokers undergoing TJA, the optimal approach, duration, and timing of smoking cessation models have not been well-defined.Overall, initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA, although longer periods of cessation should be encouraged if feasible.Patients brought in for emergency surgical treatment who cannot participate in a preoperative intervention may still benefit from an intervention instituted in the immediate postoperative period.Cotinine testing may provide some benefit for encouraging successful smoking cessation and validating self-reported smoking status, although its utility is limited by its short half-life. Further study is needed to determine the value of other measures of cessation such as carbon monoxide breath testing.Smoking cessation programs instituted prior to TJA have been demonstrated to be cost-effective over both the short and long term.

As a result of an aging population, musculoskeletal disease is a growing source of health and economic burden in the United States. In 2019, musculoskeletal conditions affected approximately 127.4 million people (more than a third of the U.S. population); they were the top driver of health-care spending in 2016, with an estimated direct annual cost of $380.9 billion. While musculoskeletal conditions represent a substantial and growing burden in terms of prevalence, disability, and health-care costs, National Institutes of Health (NIH) research funding has remained disproportionately allocated to other disease conditions. Therefore, our purpose was to provide an assessment of the current burden of musculoskeletal disease in terms of prevalence, disability, and health-care costs, and compare the changing burden of disease to trends in NIH funding.

Comorbidity indices currently used to estimate negative postoperative outcomes in orthopaedic surgery were originally developed among non-orthopaedic patient populations. While current indices were initially intended to predict short-term mortality, they have since been used for other purposes as well. As the rate of hip and knee arthroplasty steadily rises, understanding the magnitude of the effect of comorbid disease on postoperative outcomes has become increasingly more important. Currently, the ASA classification is the most commonly used comorbidity measure and is systematically recorded by the majority of national arthroplasty registries. Consideration should be given to developing an updated, standardized approach for comorbidity assessment and reporting in orthopaedic surgery, especially within the setting of elective hip and knee arthroplasty. Cite this article: EFORT Open Rev 2021;6:629-640. DOI: 10.1302/2058-5241.6.200124

Background:The effects of comorbid disease remain an area of interest. Concurrent diagnoses not only affect clinical outcomes but also affect health-care reimbursement. As the rate of arthroplasty increases, consistent risk stratification is imperative. Therefore, our aim was to ascertain how comorbidities have been reported in the recent total hip arthroplasty (THA) and total knee arthroplasty (TKA)-related literature; we also wanted to quantify the use of comorbidity scores for the assessment of comorbid disease in arthroplasty research.Methods:A systematic review of the recent THA and TKA literature that was published between January 1, 2019, and September 21, 2020, was performed using the PubMed and MEDLINE databases. Clinical studies that provided data on comorbidities were evaluated for method of comorbidity reporting. The prevalence of comorbidity reporting was assessed, and the manner of reporting was analyzed.Results:Among 659 articles, a total of 207 studies (31.4%) reported comorbidities and met our inclusion criteria. Of the 207 studies that reported comorbidities, only 57% used a comorbidity index to report comorbid disease. Of all of the indices, the American Society of Anesthesiologists (ASA) Physical Status Classification System was the score that was most commonly used (TKA, 86.2%; THA, 83.3%). Additional scores were used at varying frequencies. For TKA, the scores included the Charlson Comorbidity Index (CCI) (15.5%); the New York Heart Association (NYHA) Functional Classification (3.4%); and the CCI-Deyo (adapted by Deyo et al.), the age-adjusted CCI, the Cumulative Illness Rating Scale (CIRS), and the Readmission Risk Assessment Tool (RRAT) (1.7% each). For THA, the scores included the CCI (16.7%), the Elixhauser Comorbidity Measure (ECM) (6.7%), and the CCI-Deyo (1.7%).Conclusions:Considering the impact of comorbid disease on outcomes, complications, and, ultimately, reimbursement, standardized risk stratification in arthroplasty is necessary. Current studies demonstrate inconsistent comorbidity reporting, making it challenging to further characterize the impact of comorbidities on outcomes. Future research should target the development of a standardized data-driven model for comorbidity assessment in the orthopaedic patient population.

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