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Journal of Orthopaedics logoLink to Journal of Orthopaedics
. 2023 Nov 20;48:77–83. doi: 10.1016/j.jor.2023.11.030

Trends in deep vein thrombosis prophylaxis after total hip arthroplasty: 2016 to 2021

Mallory C Moore 1, Jeremy A Dubin 1, Sandeep S Bains 1, Daniel Hameed 1, James Nace 1, Ronald E Delanois 1,∗
PMCID: PMC10696429  PMID: 38059214

Abstract

Introduction

Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin.

Methods

A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion.

Results

From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05).

Conclusion

Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients.

Keywords: Aspirin, VTE prophylaxis, Hip arthroplasty, Trends, Anticoagulation

1. Introduction

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs.1 Historically, PE stood as the leading cause of mortality following total hip arthroplasty (THA).2,3 However, the introduction of routine VTE prophylaxis (VTEp) combined with advances in perioperative protocols,4 has reduced VTE incidence, with current estimates ranging from 0.24 % to 1.60 %.5, 6, 7, 8, 9

Potent anticoagulants such as warfarin, heparins, low molecular weight heparin (LMWH), were traditionally the mainstay of VTE chemoprophylaxis following THA. However, concerns regarding higher rates of bleeding10, and wound complications11,12 led to calls for a more optimal agent—one that strikes a balance between VTE prevention and the risk of bleeding.

Aspirin has garnered significant attention as VTEp due to its affordability, wide availability, well-established safety profile, no required monitoring, and the growing body of evidence supporting its efficacy as a VTE prophylactic.13 In 2022, a remarkable 93 % of members of the American Association of Hip and Knee Surgeons (AAHKS) reported the use of aspirin in combination with mechanical measures for VTE prophylaxis,14 marking a substantial increase from the 20 % reported in 2012. There is evidence demonstrating a similar or slightly improved efficacy and safety profile of aspirin compared to commonly used anticoagulants,15,16 with significantly lower odds of major bleeding events,17 decrease rates of heterotopic ossification,18 knee manipulation for stiffness, prosthetic joint infections,10 mortality,15 and reduced overall costs.19 Patients considered high risk for VTE often receive more potent anticoagulants, such as low molecular weight heparin (LMWH), factor Xa inhibitors, and warfarin, however, some suggest aspirin to be more, or comparatively, effective, and safe even in patients considered high-risk.10,16,20

Despite the current prevalent use of aspirin for VTE prophylaxis, conflicting literature combined with the current rare occurrence of VTE after THA, creates a challenge for definitively determining the optimal agent for VTEP. While awaiting the results of large, high quality, randomized controlled trials, such as the PEPPER Trial,21 the large cohorts afforded by retrospective observational database analyses are a practical approach gain useful insights in the trends in VTEp utilization and current rates of VTE, as well as monitor the efficacy and safety of current measures. As such, this study aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin.

2. Methods

2.1. Database

PearlDiver Mariner Patient Claims Database (PearlDiver Technologies, Colorado Springs, CO, USA) is a national, all-payer database containing over 120 million Health Insurance Portability and Accountability Act (HIPPA) compliant records from across the United States and includes commercial, Medicare, Medicaid, government, and cash payers. The database is queried using International Classification of Diseases (ICD)-10 and Current Procedural Terminology (CPT) codes were utilized to identify the patient cohorts. This study was exempt from Institutional Review Board approval due to the use of deidentified patient information. Annual audits for validity and reliability of the data were required for providers supplying the claims information by an independent third-party. There was no funding for this study.

2.2. Patients

All patients who underwent primary THA between January 1, 2016 and December 31, 2022 were identified using ICD-10 and CPT codes. Patients undergoing THA who also had a pre-existing coagulopathy, cancer, or were prescribed an anticoagulant or antithrombotic within the year prior to undergoing THA were excluded. Revision THA and THA indicated due to trauma were also excluded.

Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed for years 2016 through 2021. Patient demographic and baseline characteristics were collected, including age, sex, Elixhauser Comorbidity Index (ECI),22 alcohol abuse, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, hypertension, hypothyroidism, rheumatoid arthritis, obesity, tobacco use, coronary artery disease (CAD), renal disease, renal failure, and depression. Patients receiving dabigatran were oldest, with an average age of 67.19 (SD = 10.31) and had the highest percentage of patients with an ECI >3 (64 %). Those receiving aspirin were the youngest, with average age of 61.58 (SD = 10.77) and had the lowest percent of patients with an ECI >3 (47 %). See Table 1 for full baseline demographic and patient characteristic data.

Table 1.

Demographics and baseline patient characteristics.

Dabigatran n = 13,065 (%) Rivaroxaban n = 11,790 (%) Enoxaparin n = 11,380 (%) Warfarin n = 6326 (%) Aspirin n = 36,346 (%) p-value
Average Age (SD) 67.19 (10.31) 64.11 (10.38) 62.51 (10.95) 65.34 (10.32) 61.58 (10.77)
Sex <0.0001
 Female 7661 (59) 7170 (61) 6827 (60) 3869 (61) 20,799 (57)
 Male 5404 (41) 4620 (39) 4553 (40) 2457 (39) 15,547 (43)
ECI >3 8421 (64) 6057 (51) 5895 (52) 3249 (51) 17,262 (47) <0.0001
Alcohol Abuse 883 (7) 843 (7) 1017 (9) 435 (7) 3356 (9) <0.0001
CKD 2694 (21) 1733 (15) 1766 (16) 1049 (17) 4236 (12) <0.0001
COPD 4190 (32) 3404 (29) 3387 (30) 1923 (30) 9357 (26) <0.0001
CHF 891 (7) 573 (5) 526 (5) 340 (5) 1165 (3) <0.0001
Diabetes 5042 (39) 4174 (35) 4113 (36) 2348 (37) 11,398 (31) <0.0001
HTN 11,023 (84) 9261 (79) 8852 (78) 5070 (80) 26,049 (72) <0.0001
Hypothyroidism 3838 (29) 3235 (27) 3073 (27) 1720 (27) 8999 (25) <0.0001
RA 747 (6) 633 (5) 684 (6) 344 (5) 1756 (5) <0.0001
Obesity 6515 (50) 5803 (49) 5467 (48) 3048 (48) 17,424 (48) 0.00124
Tobacco Use 5575 (43) 5036 (43) 5018 (44) 2566 (41) 15,827 (44) <0.0001
CAD 4363 (33) 2876 (24) 2747 (24) 1631 (26) 6959 (19) <0.0001
Renal Disease 2776 (21) 1797 (15) 1826 (16) 1092 (17) 4365 (12) <0.0001
Depression 4952 (38) 4662 (40) 4738 (42) 2490 (39) 14,205 (39) <0.0001
Renal Failure 911 (7) 625 (5) 655 (6) 433 (7) 1368 (4) <0.0001
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SD: Standard Deviation; ECI: Elixhauser Comorbidity Index; CKD: Chronic Kidney Disease; COPD: Chronic Obstructive Pulmonary Disease; CHF: Congestive Heart Failure; HTN: Hypertension; RA: Rheumatoid Arthritis; CAD: Coronary Artery Disease.

2.3. Outcomes

Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion. A multivariable regression was performed to determine independent risk factors for 90-day VTE and transfusion following THA, as compared to aspirin, controlling for gender, age, ECI >3, alcohol abuse, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart Failure (CHF), diabetes, hypertension (HTN), hypothyroidism, obesity, tobacco use, and chronic steroid use.

2.4. Data analysis

Continuous variables such as age were compared using student's t-tests. Categorical variables, including demographics, comorbidities, and complications utilized Chi-square tests in bivariate analyses. Multivariable analyses were performed to determine independent risk factors for 90-day transfusion and VTE following THA. All analyses were performed using R Studio (Statistics Department of the University of Auckland, New Zealand) with significance regarded as p < 0.05.

3. Results

3.1. Patients

From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326), respectively. Aspirin saw the greatest increase in use (33–58 %), while the use of warfarin had the greatest decrease (16–2 %) over this time. In 2016, dabigatran was the least used agent (10 %), however by 2021 it was the second most used agent (22 %) for VTEp. Rivaroxaban and enoxaparin both decreased in use, 21 %–10 % and 21 %–8 %, respectively (Table 2, Fig. 1).

Table 2.

Thromboprophylaxis use trends by year from 2016 to 2021.

Yearly Total Dabigatran
 Rivaroxaban
 Enoxaparin
 Aspirin
 Warfarin
Number Percent Number Percent Number Percent Number Percent Number Percent
2016 15,434 1563 10.13 % 3249 21.05 % 3177 20.58 % 5039 32.65 % 2406 15.59 %
2017 13,739 1875 13.65 % 2351 17.11 % 2446 17.80 % 5512 40.12 % 1555 11.32 %
2018 13,992 2332 16.67 % 2071 14.80 % 2123 15.17 % 6488 46.37 % 978 6.99 %
2019 15,273 2994 19.60 % 1988 13.02 % 1738 11.38 % 7682 50.30 % 871 5.70 %
2020 15,514 3224 20.78 % 1633 10.53 % 1493 9.62 % 8746 56.37 % 418 2.69 %
2021 4955 1077 21.74 % 498 10.05 % 403 8.13 % 2879 58.10 % 98 1.98 %
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Fig. 1.

Fig. 1

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Trends in VTE prophylaxis use from 2016 to 2021.

3.2. Outcomes

The cohort who received dabigatran had the highest incidence of 90-day postoperative VTE (3.9 %), followed second by rivaroxaban (2.5 %). The cohort who received aspirin had the lowest incidence of 90-day postoperative VTE (0.4 %), as well as the lowest incidence of requiring transfusion (1.1 %). Enoxaparin use had the highest incidence of transfusion (1.9 %) (Table 3).

Table 3.

Incidence of postoperative VTE and transfusion within 90 Days of THA.

Dabigatran Rivaroxaban Enoxaparin Aspirin Warfarin p-value
n = 13,065 (%) n = 11,790 (%) n = 11,380 (%) n = 36,346 (%) n = 6326 (%)
90-Day Complications
 VTE 512 (3.9) 290 (2.5) 132 (1.2) 153 (0.4) 138 (2.2) <0.0001
 Transfusion 182 (1.4) 170 (1.4) 215 (1.9) 394 (1.1) 103 (1.6) <0.0001
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TKA: Total Knee Arthroplasty; VTE: Venous Thromboembolism.

Compared to aspirin, dabigatran, rivaroxaban, enoxaparin, and warfarin all demonstrated greater odds of VTE when compared to aspirin (all p-value <0.0001). Dabigatran use was associated with nearly 10-fold greater odds of VTE in the 90 days following THA relative to aspirin (OR 9.65, 95 % CI 8.05 to 11.57, p < 0.0001). Enoxaparin was associated with the greatest odds of requiring transfusion (OR 1.76, 95 % CI 1.49 to 2.08, p < 0.0001) (Table 4).

Table 4.

Odds of VTE and transfusion within 90 Days of THAa.

 Dabigatran
 Rivaroxaban
 Enoxaparin
 Warfarin
OR (95 % CI) p-value OR (95 % CI) p-value OR (95 % CI) p-value OR (95 % CI) p-value
90-Day Complications
 VTE 9.65 (8.05–11.57) <0.0001 5.97 (4.90–7.26) <0.0001 2.78 (2.20–3.51) <0.0001 5.28 (4.18–6.65) <0.0001
 Transfusion 1.29 (1.08–1.54) 0.0049 1.33 (1.11–1.60) 0.0018 1.76 (1.49–2.08) <0.0001 1.51 (1.21–1.88) 0.0002
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a

Odds ratio calculated with Aspirin as comparative group. TKA: Total Knee Arthroplasty; OR: Odds Ratio; CI: Confidence Interval; VTE: Venous Thromboembolism.

Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05) (Table 5). Independent risk factors for 90-day transfusion included CKD, HTN, tobacco use, rivaroxaban, and warfarin (all p < 0.05). Male sex and obesity were independently associated with a decreased risk of requiring transfusion (Table 6).

Table 5.

Independent risk factors for 90-day VTEa.

OR 95 % CI p-value
Age 1.00 0.99–1.01 0.9894
Male Sex 1.09 0.95–1.25 0.2144
ECI 1.00 0.97–1.03 0.9508
Alcohol Abuse 1.08 0.83–1.38 0.5441
CKD 1.21 1.01–1.44 0.0376
COPD 1.47 1.28–1.70 < 0.0001
CHF 0.71 0.52–0.97 0.0356
Diabetes 1.16 0.91–1.47 0.2145
HTN 0.99 0.82–1.21 0.9361
Hypothyroidism 0.95 0.81–1.10 0.4840
Obesity 1.37 1.19–1.58 < 0.0001
Tobacco Use 0.90 0.78–1.03 0.1396
Dabigatran 24.59 18.72–32.95 < 0.0001
Enoxaparin 18.42 12.18–27.64 < 0.0001
Rivaroxaban 14.51 10.93–19.61 < 0.0001
Warfarin 7.52 5.24–10.82 < 0.0001
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OR: Odds Ratio; CI: Confidence Interval; VTE: Venous Thromboembolism.

a

Controlled for gender, age, ECI >3, Alcohol Abuse, Chronic Kidney Disease, Chronic Pulmonary Disease, Congestive Heart Failure, Diabetes, Hypertension, Hypothyroidism, Obesity, Tobacco Use, Chronic Steroid Use.

Table 6.

Independent risk factors for 90-day transfusiona.

OR 95 % CI p-value
Age 0.99 0.99–1.00 0.04984
Male Sex 0.50 0.42–0.59 < 0.0001
ECI 1.15 1.11–1.18 < 0.0001
Alcohol Abuse 0.93 0.72–1.19 0.57617
CKD 1.33 1.10–1.60 0.00249
COPD 0.98 0.84–1.15 0.83382
CHF 1.08 0.81–1.41 0.59010
Diabetes 0.94 0.71–1.22 0.63664
HTN 1.30 1.05–1.62 0.01688
Hypothyroidism 0.87 0.74–1.02 0.09511
Obesity 0.85 0.73–0.99 0.03238
Tobacco Use 1.20 1.03–1.39 0.01635
Dabigatran 1.13 0.94–1.36 0.19413
Enoxaparin 1.20 0.72–1.88 0.45687
Rivaroxaban 1.32 1.09–1.58 0.00418
Warfarin 1.44 1.12–1.83 0.00312
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OR: Odds Ratio; CI: Confidence Interval; ECI: Elixhauser Comorbidity Index; CKD: Chronic Kidney Disease; COPD: Chronic Obstructive Pulmonary Disease; CHF: Congestive Heart Failure; HTN: Hypertension; RA: Rheumatoid Arthritis; CAD: Coronary Artery Disease.

a

Controlled for gender, age, ECI >3, Alcohol Abuse, Chronic Kidney Disease, Chronic Pulmonary Disease, Congestive Heart Failure, Diabetes, Hypertension, Hypothyroidism, Obesity, Tobacco Use, Chronic Steroid Use.

4. Discussion

Efforts to identify an optimal VTE chemoprophylactic agent that balances the reduction in clot formation with the risk of postoperative bleeding-related complications has been underway for nearly 2 decades. While a consensus on the best approach remains elusive, aspirin has garnered immense attention due to the mounting evidence supporting its efficacy and safety. Nonetheless, the search for an ideal agent continues, as high-quality evidence comparing its efficacy and safety with common anticoagulants remains inconclusive. Observational studies, like the present one, play a crucial role in monitoring prophylaxis trends and associated outcomes. Our study, spanning from 2016 to 2021, revealed a rising trend in aspirin use, correlating with the lowest rates of VTE and transfusions.

This observational study presents several limitations that warrant attention. First, given its observational nature, it carries an inherent risk of selection bias. The rationale behind a surgeons' selection of VTE prophylaxis agents for individual patients is not known from the available data, therefore it cannot be ruled out that those patients receiving aspirin for VTEp already had a lower baseline risk than those receiving more potent, anticoagulants, introducing the potential to skew results. To mitigate this risk, a multivariable analysis was performed to control for baseline patient characteristics. Furthermore, neither the specific dosage nor the frequency of administration for each prophylactic agent, nor the extent of patient adherence to the prescribed protocols, could be ascertained. Similarly, perioperative protocols, such as anesthesia type, TXA use, time to ambulation, for example, were unknown. Additionally, the study was constrained by its reliance on prescribed medications within the database, limiting inclusion to patients specifically prescribed aspirin. This precluded the use of a control group as it would present the risk of erroneously including individuals who may have utilized over-the-counter aspirin. Moreover, it is important to acknowledge the susceptibility to coding inaccuracies in databases. To address this issue, regular third-party performance audits are conducted with the aim of minimizing coding errors, with a reported 1 % coding error rate.23 Finally, it is crucial to note that the findings of this study may not be readily applicable to individuals with known hypercoagulability, cancer diagnoses, or those who had received anticoagulants or antithrombotic drugs in the year preceding THA, as these patient groups were intentionally excluded from the analysis.

Arthroplasty surgeons’ use of aspirin VTEp has seen a substantial increase in popularity over the last decade.14,24 Notably, a recent study by Agarwal et al. reported a 27.01 % positive annual growth rate in the use of prescribed aspirin following THA from 2011 to 2019. During this period, they also observed a significant reduction VTE rates, decreasing from 1.96 % in 2011 to 1.25 % in 2019.25 The authors largely attributed the decreasing VTE rates during this period to be due to improvements in perioperative protocols4,26,27 and pre-operative medical optimization.28 This shift in clinical practice towards increased aspirin utilization can likely additionally be explained by low cost,19 lack of routine monitoring requirements, and the convenience of oral administration, the latter two which contribute positively to patient compliance.29

The efficacy of aspirin in preventing venous thromboembolism (VTE) following total hip arthroplasty (THA) has been extensively studied. Sidhu et al. compared 90-day VTE rates in elective primary THA and TKA, evaluating aspirin, LMWH, LMWH with aspirin, and direct oral anticoagulants (DOAC). They found aspirin to be associated with low rates of symptomatic VTE, although no significant association between VTE and prophylaxis type was observed after adjusting for confounders.30 Additionally, another study investigated 90-day VTE rates following THA or TKA, comparing aspirin with non-aspirin anticoagulants, including factor Xa inhibitors (e.g., rivaroxaban), LMWH (enoxaparin), and warfarin. Their findings suggested that aspirin was non-inferior to LMWH and warfarin for VTE prevention but not when compared to factor Xa inhibitors.10 While practice generally favors the use of one of the more potent anticoagulants for those considered to be high-risk for VTE, several studies have revealed that aspirin may still be sufficient in high-risk patients. For example, Ludwick et al. reported an incidence of 0.4 % for symptomatic VTE with aspirin in patients undergoing primary TKA or THA, with no increased risk of VTE even after controlling for comorbidities (p = 0.024).31 This finding is particularly noteworthy as they focused on patients with a history of VTE, a group at high risk for VTE following THA. A similar result was observed by Tan et al. which indicated that aspirin was as effective as LMWH (enoxaparin) and warfarin, in primary and revision THA and TKA patients deemed high-risk for VTE16 as determined by an existing VTE risk stratification tool.32 These studies collectively contribute to the growing body of evidence supporting aspirin as an effective VTE chemoprophylactic agent.

An integral aspect of research endeavors aimed at determining the most suitable chemoprophylactic agent involves the identification of risk factors that may significantly elevate a patient's susceptibility to VTE or the need for transfusion. In our study, we identified chronic obstructive pulmonary disease (COPD) and obesity as independent risk factors for VTE, findings largely consistent with existing literature.33, 34, 35, 36, 37 While both are commonly associated with a higher comorbidity burden, heightening the risk of surgical complications overall, the literature on VTE risk in COPD and obesity has regularly highlighted the presence of chronic low-level systemic inflammation38, 39, 40, 41 as contributing to an elevated baseline VTE risk by way of enhanced coagulation and impeded fibrinolysis.38,42, 43, 44 Assessing VTE risk in obesity, Yuan et al. demonstrated waist circumference, serving as a proxy for abdominal obesity, was a better predictor of VTE risk than overall obesity, as measured by body mass index (BMI),45 possibly due to the distinct impact of visceral adiposity on systemic inflammation41 and thus VTE risk.46 This may explain inconsistencies in the literature with regards to obesity's effect on VTE risk and VTEp effectiveness following THA,47 as BMI is overwhelming used for this purpose. The anti-inflammatory properties of aspirin may be a possible explanation for the non-inferior effectiveness of aspirin even in some higher risk populations, relative to anticoagulants.47,48

In our study, several risk factors for transfusion following THA were identified. The relationship between elevated transfusion risk and CKD has been extensively delineated in the literature.49 In fact, risk of transfusion has been found to be positively correlated with disease severity, as determined by eGFR-based staging,50,51 with increased transfusion risk even seen in those with mild to moderate CKD (stages 3 b and 4).51 Many have underscored the need to optimize hemoglobin (Hgb) preoperatively, not only in those with CKD, but all patients undergoing THA,52,53 due to preoperative anemia predicting postoperative transfusion necessity.54 The relationship between transfusion and obesity is one of debate however, the present study supports obesity being independently associated with a lower risk of transfusion.55, 56, 57 This may be a factor of the larger total blood volume with increasing body weights,57,58 or the increased propensity toward a hypercoagulable state in the obese population.59 The elevated risk of transfusion with warfarin and rivaroxaban corroborates that of many reports.60, 61, 62

In conclusion, from 2016 to 2021, aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin VTEp has been accomplished in appropriately selected patients.

Funding

None.

Data availability

Available in a respository upon request.

Patient consent

No patient consent needed due to retrospective nature and public database.

Ethical approval

IRB exemption due to retrospective nature and public database.

CRediT authorship contribution statement

Mallory C. Moore: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Jeremy A. Dubin: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Sandeep S. Bains: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Daniel Hameed: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. James Nace: Conceptualization, Formal analysis, Writing – review & editing. Ronald E. Delanois: Conceptualization, Formal Analaysis, Project, Writing – review & editing.

Declaration of AI and AI-assisted technologies in the writing process

No use of AI tool.

Declaration of competing interest

JD- None.

DH-None.

JN- Arthritis Foundation: Board or committee member, Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic, Knowledge Online: Editorial or governing board, Journal of Knee Surgery: Editorial or governing board, Knee: Editorial or governing board, Microport: Paid consultant; Paid presenter or speaker; Research support, Stryker: Research support United: Research support

RD- Baltimore City Medical Society.: Board or committee member, Biocomposites, Inc.: Research support, CyMedica Orthopedics: Research support, DePuy Synthes, Product, Inc.: Research support, Flexion Therapeutics: Research support, Microport Orthopedics, Inc.: Research support, Orthofix, Inc.: Research support, Patient-Centered Outcomes Research Institute (PCORI): Research support, Smith & Nephew: Research support, Stryker: Research support, Tissue Gene: Research support, United Orthopedic Corporation: Research support

MM - None.

SB - None.

Acknowledgements

None.

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