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Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H803).

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H191 ).

Background: Renal transplants are the most commonly performed solid-organ transplants worldwide. It is unclear whether a kidney transplant is associated with reduced postoperative complications in comparison with patients on dialysis for end-stage renal disease (ESRD). The purpose of this study was to utilize a national database to compare readmissions, complications, and costs associated with primary total hip arthroplasty (THA) between matched renal transplant recipients (RTRs) and patients on dialysis for ESRD., Methods: Patients with a renal transplant (N = 1,401) and those on dialysis for ESRD (without a transplant) (N = 1,463) prior to being treated with a THA from 2010 to 2019 were identified within the PearlDiver database. RTRs and patients on renal dialysis were frequency-matched 1:1 on the basis of 9 patient characteristics, resulting in 582 patients in each group. Length of hospital stay, readmissions, complication rates up to 2 years, and total costs up to 1 year were compared between the groups using chi-square and multivariable logistic regression analyses to calculate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: Patients on renal dialysis had an increased mean length of stay (6.3 days) compared with RTRs (4.6 days, p < 0.01). After adjusting for age, tobacco use, and diabetes, patients on renal dialysis were more likely to be readmitted by 90 days (OR = 1.59; CI = 1.11 to 2.29, p < 0.01) and have mechanical complications (OR = 2.13; CI = 1.08 to 4.45, p = 0.03) and revisions (OR = 2.14; CI = 1.14 to 4.01, p = 0.01) by 2 years. Patients on renal dialysis were also more likely to have periprosthetic joint infections at 1 year (OR = 1.91; CI = 1.02 to 3.71, p = 0.04). Patients on dialysis incurred 14% higher costs at 1 year (p = 0.11)., Conclusions: Patients on renal dialysis had more readmissions, complications, and costs after THA when compared with RTRs. Specifically, patients on renal dialysis were more likely to have longer index lengths of stay, more readmissions by 90 days, and more mechanical complications and revision surgery by 2 years. Patients on dialysis also incurred higher costs and had greater odds of PJI. These results suggest that joint surgeons may consider delaying THA in suitable patients until after renal transplantation to reduce postoperative complications and costs., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G648)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Manipulation under anesthesia has been reported to improve range of motion when other rehabilitative efforts fail to obtain adequate motion after total knee arthroplasty. The purpose of this study was to evaluate the effects of the timing of the manipulation on knee range of motion and clinical outcomes., Methods: All 2128 total knee arthroplasties performed at our institution from 2005 to 2011 were reviewed to determine the number of patients who had undergone manipulation under anesthesia. A total of 144 manipulations in eighty-eight women and forty-five men were reviewed. Manipulations under anesthesia that were performed within the first twelve weeks after total knee arthroplasty were considered early and those after that period were considered late. Patients were further substratified according to the timing of the manipulation: Group I included those who had the manipulation within six weeks; Group II, at seven to twelve weeks; Group III, at thirteen to twenty-six weeks; and Group IV, after twenty-six weeks. Outcomes evaluated included gains in flexion and final range of motion, and Knee Society objective and function scores between early and late manipulation, using various adjusted multivariable regression models and at a mean follow-up of fifty-one months (range, twelve to eighty-one months). Mediation analysis was used to investigate whether gains in range of motion from the manipulations under anesthesia alone had mediated the effect between the timing of the manipulation and the clinical outcomes., Results: Patients who underwent early manipulation had a significantly higher mean gain in flexion (36.5° versus 17°), higher final range of motion (119° versus 95°), and higher Knee Society objective (89 versus 84 points) and function scores (88 versus 83 points) than those who had late manipulation under anesthesia. There were no significant differences in the outcomes of Groups I and II. Manipulations after twenty-six weeks resulted in unsatisfactory clinical outcomes. Multivariable regression analyses confirmed significantly better clinical outcomes with early manipulation. Mediation analysis showed that the timing of manipulation independently had significantly contributed to the outcomes., Conclusions: Orthopaedic surgeons should have a low threshold for performing early manipulations with the patient under anesthesia within twelve weeks after an arthroplasty, to achieve higher knee range of motion and improved clinical outcomes., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Symptomatic osteonecrosis of the joint is a frequent debilitating complication in patients who have been infected with the human immunodeficiency virus (HIV). In earlier reports, outcomes of primary total joint arthroplasty in such patients have been poor due to early failures, high infection rates, and increased complication rates. We report on the clinical and radiographic outcomes of primary total hip arthroplasty (THA) in nonhemophilic, HIV-infected patients as compared with the outcomes in a cohort of osteonecrosis patients who did not have this disease., Methods: Thirty-four HIV-infected patients (forty-four hips) who underwent primary THA for the treatment of osteonecrosis during the period of 2001 through 2008 were compared with a control cohort of seventy patients (seventy-eight hips) who also underwent THA for the treatment of osteonecrosis but did not have HIV or other high-risk factors for revision. The patients in the HIV study group (eleven women and twenty-three men) had a mean age of forty-eight years (range, thirty-four to eighty years) and were followed for a mean of seven years (range, four to eleven years). Evaluated outcomes included implant survivorship, Harris hip score, infection rate, activity score, postoperative Short-Form 36 (SF-36) health survey score, and radiographic outcome., Results: Kaplan-Meier survival analysis demonstrated no significant difference in aseptic implant survivorship between the HIV and comparison cohorts at the five-year (100% vs. 98%, respectively) and ten-year (95% vs. 96.5%, respectively) follow-up times. In addition, at the time of final follow-up, the mean postoperative Harris hip scores (85 points in the HIV group vs. 87 points in the comparison group), activity scores (5.7 points in the HIV group vs. 6.1 points in the comparison group), and SF-36 physical (43 points in the HIV group versus 46 points in the comparison group) and mental component summary scores (54 points in the HIV group versus 57 points in the comparison group) were statistically similar between the two cohorts. There were two late infections in the HIV cohort as compared with none in the comparison cohort., Conclusions: Our results demonstrated excellent implant survivorship, clinical and radiographic outcomes, and minimal complications at the time of midterm follow-up in the HIV-infected patient group. We believe that the outcomes associated with primary THA are improving in this patient population as a result of better medical management; however, late infections are potential complications.

Background: An asymptomatic hip with osteonecrosis is typically discovered as the contralateral hip of a patient with one symptomatic joint. Treatment of the asymptomatic hip is controversial. While some authors claim a benign natural history, others have reported a rate of femoral head collapse exceeding 50%. The purpose of this report was to systematically review the published literature regarding asymptomatic osteonecrosis of the femoral head to evaluate the overall prevalence of progression to symptomatic disease and/or femoral head collapse as well as to determine whether various radiographic and demographic factors influence progression of the disorder., Methods: A comprehensive literature search was performed to identify prognostic studies evaluating asymptomatic hip osteonecrosis. Demographic, radiographic, and outcome data were extracted from all relevant studies. The prevalence of progression to symptomatic disease and/or femoral head collapse was determined. Next, outcomes were stratified by lesion size, lesion location, radiographic stage, associated risk factors and/or disease, and the level of evidence of the study., Results: Sixteen studies that included a total of 664 hips were available for an analysis of outcomes. Overall, 394 hips (59%) had progression to symptoms or collapse. Differences in outcomes based on lesion size, lesion location, and radiographic stage at the time of diagnosis were seen. Small, medially located lesions had the best prognosis, with a prevalence of collapse of <10%. Patients with sickle cell disease had the highest frequency of progression, and those with a history of systemic lupus erythematosus had the most benign course., Conclusions: Data extracted from previously published studies suggest that asymptomatic osteonecrosis has a high prevalence of progression to symptomatic disease and femoral head collapse. While small, medially located lesions have a low rate of progression, the natural history of asymptomatic medium-sized, and especially large, osteonecrotic lesions is progression in a substantial number of patients. For this reason, it may be beneficial to consider joint-preserving surgical treatment in asymptomatic patients with a medium-sized or large, and/or laterally located, lesion.

Resurfacing is a type of shoulder arthroplasty that involves replacing the humeral joint surface with a metal covering, or cap, thus preserving the bone of the proximal part of the humerus. If the glenoid is also replaced, a current conventional polyethylene glenoid replacement prosthesis or an interposed soft-tissue graft is used. The potential advantages of humeral resurfacing, as compared with conventional shoulder arthroplasty, are: (1) no osteotomy is performed (and thus the head-shaft angle does not have to be addressed); (2) minimal bone resection; (3) a short operative time; (4) a low prevalence of humeral periprosthetic fractures; and (5) ease of revision to a conventional total shoulder replacement, if needed. Outcomes of surface replacement arthroplasty have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies. Future studies are required to assess the long-term outcomes of humeral resurfacing and to evaluate alternative surface bearing materials, especially on the glenoid side. Resurfacing appears to be a viable option for shoulder replacement, especially in young patients.

Background: Hip resurfacing has been proposed as an alternative to total hip replacement in patients who have proximal femoral deformities or retained hardware in the proximal aspect of the femur. In these situations, placement of a conventional stemmed hip prosthesis would be difficult or impossible, possibly necessitating a complex osteotomy or a custom prosthesis. The purpose of this study was to evaluate a series of patients who had extra-articular deformities of the proximal aspect of the femur and/or retained hardware and who were managed with a resurfacing hip prosthesis., Methods: Fifteen patients (seventeen hips) who underwent metal-on-metal resurfacing hip replacements were studied. Ten patients (twelve hips) had bowing or other deformities of the femur secondary to trauma, multiple epiphyseal dysplasia, renal osteodystrophy, or proximal femoral focal deficiency. Five patients (five hips) had retained hardware. Twelve of the patients (thirteen hips) had previously been told by orthopaedic surgeons that, due to the deformity or retained hardware, they could not undergo conventional total hip arthroplasty without also undergoing ancillary surgical procedures. We evaluated perioperative factors (operative time and estimated blood loss), Harris hip scores, complications, and failure rates., Results: At a mean follow-up time of three years (range, two to five years), fourteen patients (sixteen hips) were doing well clinically and radiographically. Assessment of the intraoperative records revealed minimal difficulty, with a mean operative time of 104 minutes and a mean blood loss of 621 mL. The mean Harris hip score was 92 points. One patient, a fifty-nine-year-old woman, underwent two subsequent revisions-one for the treatment of a femoral neck fracture, and one for the treatment of acetabular component loosening., Conclusions: Resurfacing hip arthroplasty offers an option for patients when placement of a conventional total hip prosthesis is difficult or impossible because of the presence of proximal femoral deformities or retained hardware in or on the proximal aspect of the femur.

Background: Recently, with the advent of improved metal-on-metal prostheses, total hip resurfacing has emerged as a viable arthroplasty option. However, it remains controversial whether this procedure should be used in patients with osteonecrosis when the femoral resurfacing component is cemented onto dead bone. The purpose of this study was to analyze the clinical and radiographic outcomes of metal-on-metal total hip resurfacing arthroplasty in patients with osteonecrosis of the femoral head. In addition, this group was compared with a matched group of patients who were diagnosed as having osteoarthritis., Methods: Forty-two osteonecrotic hips that were treated with a metal-on-metal total hip resurfacing arthroplasty were studied. They were matched by gender, age, prosthesis, surgeon, and surgical approach to forty-two osteoarthritic hips that were treated with the same metal-on-metal prosthesis. In the osteonecrosis group, there were twenty-five men and eleven women, and in the osteoarthritis group, there were twenty-eight men and thirteen women. The mean age at the time of surgery was forty-two years. Patients were followed both clinically and radiographically for a mean of forty-one months., Results: The clinical outcomes were similar for both groups, with a good or excellent outcome in thirty-nine hips (93%) with osteonecrosis and a good or excellent outcome in forty-one hips (98%) with osteoarthritis. In each of the two groups, there were two failures that required conversion to a standard total hip arthroplasty. Survivorship curves were similar for the two patient groups., Conclusions: The short-term results for metal-on-metal total hip resurfacing for this challenging patient population with osteonecrosis were excellent and comparable with those seen in patients with osteoarthritis. We await long-term results to see if these early results are maintained., Level of Evidence: Prognostic Level II. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Background: The outcome of uncemented total hip arthroplasty in patients with osteonecrosis of the femoral head in general, and in young adults in particular, remains largely unknown. This study evaluated the clinical and radiographic results of uncemented total hip arthroplasty in young adults with osteonecrosis of the femoral head and compared these results to those seen in young adults with osteoarthritis., Methods: Forty-one consecutive patients with osteonecrosis of the femoral head (fifty-two hips) and forty patients with osteoarthritis (fifty-two hips) were treated with an uncemented total hip arthroplasty at our institution. The mean age for the osteonecrosis group was thirty-eight years, and, for the osteoarthritis group, forty-two years. Clinical and radiographic outcomes at a minimum of two years were assessed., Results: At a mean duration of follow-up of three years, the functional improvement was significant in both groups (p < 0.05). The outcome was good to excellent for 94% (forty-nine hips) in the osteonecrosis group and 96% (fifty hips) in the osteoarthritis group. There were two revisions in the osteonecrosis group and one revision in the osteoarthritis group. Survivorship free of revision at the time of the latest follow-up was 96.1% for the osteonecrosis group and 98% for the osteoarthritis group., Conclusions: The short-term results of cementless total hip arthroplasty in patients with osteonecrosis of the femoral head were encouraging and comparable with the results of a matched group of patients with osteoarthritis. We await further follow-up to see if these promising results hold true., Level of Evidence: Therapeutic Level III. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Background: Osteonecrosis of the knee after various arthroscopic procedures associated with the use of laser or radiofrequency devices has been described in a few case reports. The purpose of this study was to report on a series of nineteen patients with osteonecrosis of the knee after arthroscopic procedures. A literature search was done to compare this series of patients to previously reported cases. In addition, we analyzed the outcome after treatment with minimally invasive knee arthroplasty., Methods: We studied patients who had development of osteonecrosis of the knee after a routine arthroscopic procedure. Preoperative and postoperative clinical notes, radiographs, and magnetic resonance images of patients were analyzed. Only those patients with no evidence of osteonecrosis on preoperative magnetic resonance imaging who later had development of osteonecrosis and subsequently required a knee arthroplasty were included. We conducted a search of the current literature to compare the results seen in our patient population with those seen in other patients with this entity. Patients were followed both clinically and radiographically for a mean of sixty-two months., Results: A total of nineteen patients met the inclusion criteria. There were fourteen women and five men with a mean age of sixty-nine years. Six patients underwent an arthroscopy with associated holmium or yttrium-aluminum-garnet laser treatment, ten patients had associated radiofrequency treatment, and three patients had microfracture surgery. Subsequent arthroplasty procedures included four unicompartmental knee arthroplasties and fifteen tricompartmental knee arthroplasties. At the time of final follow-up, the mean Knee Society objective score was 95 points., Conclusions: Arthroscopic procedures may play a role in the development of osteonecrosis of the knee. To our knowledge, this is the largest series of patients to have development of this condition after arthroscopy with associated laser, radiofrequency, or microfracture surgery. The midterm results of knee arthroplasty in this unique patient population are comparable with those of patients undergoing knee arthroplasty for osteoarthritis of the knee., Level of Evidence: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Background: Various clinical situations may make polyethylene liner exchange desirable in the setting of a well-fixed metal shell. Options have included a simple polyethylene liner exchange or revision of the entire acetabular shell. A recently introduced technique involves cementation of a new liner into a well-fixed metal shell. The purposes of this study were to quantify the mechanical integrity of this method of liner fixation, to evaluate the factors that may influence immediate liner fixation, and to compare this construct with a standard locking mechanism., Methods: One modular acetabular cup design was evaluated. Variables that may contribute to the mechanical integrity of the construct were evaluated via lever-out and multiaxis dislocation testing methods. The variables included the size of the liner (undersized versus oversized), type of liner (all-polyethylene versus modular design), modification of the modular liner (unmodified versus grooved), and groove configuration (cruciform versus circumferential). Metal shells with and without screw-holes were also tested. The modular locking mechanism was used as the control., Results: None of the constructs failed at the cement-metal interface. All undersized liners required significantly higher loads to failure than either the controls (p < 0.001) or the oversized liners (p < 0.001). Oversized unmodified liners failed at significantly lower loads than the controls did (p < 0.01). The creation of circumferential grooves in the oversized liners significantly improved the strength of the constructs (p < 0.01), making them comparable with the controls. No significant differences were found among the four undersized groups (p > 0.3). The standard locking construct (control) and the oversized unmodified construct failed at a force of 2000 N in the multiaxis dislocation test. No other construct failed with use of this test mode., Conclusions: Cementation of a polyethylene liner into a metal shell can be stronger than a conventional locking mechanism if the liner is undersized. Cementation of an oversized liner into a shell should be performed with caution. The long-term durability of this fixation remains unknown.

Thirty-seven ankles in twenty-four patients were treated at our institution between July 1, 1974, and December 31, 1996, for atraumatic osteonecrosis of the talus. This group represents 2 per cent of the 1056 patients who were managed for osteonecrosis during this period. There were twenty-one women and three men, and their mean age was forty years (range, twenty-six to sixty-two years) at the time of the diagnosis. Thirteen (54 per cent) of the twenty-four patients had bilateral involvement. Sixteen patients (67 per cent) had a disease that affects the immune system, including systemic lupus erythematosus (thirteen patients), scleroderma (one), insulin-dependent diabetes mellitus (one), and multiple sclerosis (one). Four patients had a history of regular alcohol use, and four patients had a history of moderate smoking. One patient had a protein-S deficiency, one patient had had a renal transplant, and one patient had a history of asthma. Two patients had no identifiable risk factors for osteonecrosis [corrected]. Fifteen patients (63 per cent) had involvement of other large joints. The mean duration of symptoms before the patients were seen was 5.4 months (range, two months to two years). The mean ankle score at the time of presentation was 34 points (range, 2 to 75 points), according to the system of Mazur et al. A radiographic review revealed that, according to the system of Ficat and Arlet, eight ankles had stage-III or IV disease of the talus at presentation. The remaining twenty-nine ankles had stage-II disease. The osteonecrosis was seen in the posterolateral aspect of the talar dome (zones III and IV on the sagittal images and zones II, III, and IV on the coronal images) in twenty-two of the twenty-three ankles for which magnetic resonance images were available. The osteonecrosis was seen in the anteromedial aspect of the talar dome (zones I and II on the sagittal images and zone I on the coronal images) in the remaining ankle. Bone scans, which were available for eleven ankles, revealed increased uptake in the talus. All patients were initially managed non-operatively with restricted weight-bearing, an ankle-foot orthosis, and use of analgesics; two ankles responded to this regimen. Thirty-two ankles that remained severely symptomatic were treated with core decompression, which was useful in the treatment of precollapse (stage-II) disease. Twenty-nine of these ankles had a fair-to-excellent clinical outcome a mean of seven years (range, two to fifteen years) postoperatively; the remaining three ankles had an arthrodesis after the core decompression failed. Three ankles were treated initially with an arthrodesis for postcollapse (stage-III or IV) disease. All six of the ankles that had an arthrodesis fused, at a mean of seven months (range, five to nine months) postoperatively. When patients who have a history of osteonecrosis are seen because of pain in the ankle, the diagnosis of osteonecrosis of the talus should be considered. Early detection may allow the ankle to be treated non-operatively or with core decompression and thus reduce the need for arthrodesis. We also believe that when a patient has osteonecrosis of the talus, the hips should be screened with use of standard radiography or magnetic resonance imaging, or both.