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Background: Studies comparing the outcomes of bariatric surgery followed by total knee arthroplasty (TKA) versus TKA alone in obese patients have disparate results. This systematic review and meta-analysis sought to compare TKA with and without prior bariatric surgery in obese patients., Methods: MEDLINE, PubMed, and Embase were searched from inception to April 9, 2023. There were twelve included studies that yielded 2,876,547 patients, of whom 62,818 and 2,813,729 underwent TKA with and without prior bariatric surgery, respectively. Primary outcomes were medical complications (ie, urinary tract infection, pneumonia, renal failure, respiratory failure, venous thromboembolism [VTE], arrhythmia, myocardial infarction, and stroke); surgical complications (ie, wound complications [eg, infection, hematoma, dehiscence, delayed wound healing, and seroma], periprosthetic joint infection, mechanical complications, periprosthetic fracture, knee stiffness, and failed hardware); revision, and mortality. Secondary outcomes were blood transfusion, length of stay (day), and readmission., Results: The odds ratios (OR) of 90-day VTE (OR = 0.75 [0.66, 0.85], P < .00001), 90-day stroke (OR = 0.58 [0.41, 0.81], P = .002), and 1-year periprosthetic fracture (OR = 0.74 [0.55, 0.99], P = .04) were lower in those who underwent bariatric surgery before TKA. Although the mean difference in hospital stays (-0.19 days [-0.23, -0.15], P < .00001) was statistically less in those who underwent bariatric surgery before TKA, it was not clinically relevant. The other outcomes were similar between the groups., Conclusions: Bariatric surgery before TKA is beneficial in terms of a lower risk of VTE, stroke, and periprosthetic fracture. This analysis suggests surgeons consider discussing bariatric surgery before TKA in obese patients, especially those who are at risk of VTE and stroke., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications., Methods: A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients., Results: The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455)., Conclusion: Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: No consensus exists regarding the appropriate timing of bariatric surgery (BS) or the complication profiles between Roux-en-Y Gastric Bypass (RYGB) and sleeve gastrectomy (SG) prior to total knee arthroplasty (TKA). We sought to compare 90-day medical and up to two-year surgical complications and revisions among (1) BS performed 6 months and 1 year prior to TKA; (2) between BS types (RYGB and SG) prior to TKA; and (3) with comparison to 2 non-BS cohorts of morbidly and nonmorbidly obese patients., Methods: We queried a national database to identify patients undergoing BS (RYGB and SG) prior to TKA from 2010 to 2020. Timing (six-month and one-year intervals) and type of BS (RYGB and SG) were identified. Cohorts without prior BS served as comparators: BMI, kg/m 2 > 40 and 20-35. Ninety-day to two-year medical/surgical complications and revisions were assessed. Multivariate regression analyses examined the risk factors for prosthetic joint infections (PJIs) and revisions., Results: The timing of BS (6 months and 1 year) had similar incidences of medical/surgical complications and revisions, with both lower than the BMI > 40 cohort (P < .001). Differences between types of BS were also lower than the BMI > 40 cohort (P < .001). The BMI 20-35 had lower complications and revisions among all cohorts. No differences were observed between BS timing or type as risk-factors for PJIs and revisions., Conclusion: Timing (6 months or 1 year prior to TKA) and type of BS shared similar complication profiles, lower than BMI > 40 and higher than BMI 20-35. These findings support a surgeon's decision to proceed with TKA at six months post-BS if indicated., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Varus-valgus constrained (VVC) implants are used for compromised ligamentous stability in revision total knee arthroplasties (TKAs). Mobile-bearing VVC implants may reduce rotational forces; yet, limited clinical data exist. The purpose of this study is to report mid-term risk of re-revision, complications, and clinical outcomes with a mobile-bearing VVC implant., Methods: Three hundred thirty-seven patients (367 TKAs) who underwent revision TKA with a mobile-bearing VVC implant between 1999 and 2013 at a single institution were reviewed. Mean age at revision was 67 years. Mean follow-up was 4 years. The main indications for revision were aseptic loosening in 158 cases (43%), reimplantation after 2-stage exchange arthroplasty in 120 (33%), instability in 61 (17%), and other in 28 (7%). Clinical outcomes were assessed by Knee Society Scores, and survivorship was analyzed with death as the competing risk., Results: The 5-year cumulative incidences of any re-revision or re-revision for aseptic loosening were 9% and 3%, respectively. Twenty-six knees (7%) were re-revised: 15 for infection, 6 for aseptic loosening, and 5 for other causes. There were 17 cases of irrigation and debridement, 10 cases of manipulations under anesthesia, and 9 cases of periprosthetic fractures. There were no bearing "spin-outs." The mean Knee Society Scores improved from 45 preoperatively to 77 at most recent follow-up (P < .001)., Conclusion: The functional improvement and 5-year cumulative incidence of revision of a mobile-bearing VVC implant demonstrated acceptable outcomes with no unique complications related to the mobile-bearing construct. Additional follow-up will be needed to determine long-term implant survivorship., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Quadriceps snips (QSs) are commonly used to gain enhanced exposure during revision total knee arthroplasties (TKAs). The goals of this study were to evaluate the longer-term clinical outcomes and complications in a contemporary cohort of patients treated with QS and to compare them to a matched cohort treated with standard exposure during revision TKAs., Methods: We retrospectively identified 3107 revision TKAs performed at our institution between 2002 and 2012. QS was performed in 321 of these knees. Each QS revision TKA was 1:1 matched to a control (standard exposure) based on age, gender, body mass index, surgery date, and reason for revision. Clinical outcomes studied included Knee Society Score, range of motion, and extensor lag. Other outcomes assessed were complications (especially extensor mechanism disruption) and survivorship. Mean follow-up was 5 years., Results: The mean Knee Society Score improvement was not significantly different between groups (P = .9). At latest follow-up, the mean range of motion was 93° in the QS group and was slightly higher at 100° in the control group (P = .002). Postoperative extensor lag of 10 degrees or more was present in 21 (6.7%) QS knees versus 19 (6.8%) control knees (P = .95). Complication rates were similar in both groups with extensor mechanism disruption occurring in 3 in the QS group (0.7% at 10 years) versus 4 in the control group (0.8% at 10 years; P = .91). Kaplan-Meier survivorships free of revision for aseptic loosening, free of any revision, and free of any reoperation were similar at 10 years (85%, 71%, and 61%, respectively, in the QS group vs 89%, 70% and 60%, respectively, in the control group)., Conclusion: This matched cohort study is the largest to report the results of QS and also the largest to report results compared with patients treated with standard exposure. Building on the results of smaller historical series, this study demonstrates QS was a facile technique in complex revision TKAs allowing for safe exposure with few complications., Level of Evidence: III (case-control study)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Proper component positioning in total hip arthroplasty (THA) is crucial for implant fixation and hip stability. The purpose of this study is to assess if neutral coronal stem alignment (0° ± 3°) improved long-term survivorship in uncemented femoral components., Methods: Between 2005 and 2010, 1028 primary THAs were performed with 2 contemporary dual-tapered, proximally coated uncemented stem types. Alignment was measured immediately postoperatively and at most recent follow-up. In total, 978 femoral stems (95%) were within 0° ± 3° of the neutral anatomic coronal axis, and the 50 stems (5%) outside that range were considered outliers (3.1° of valgus to 4.8° of varus). Outcomes analyzed included implant survivorship, Harris Hip Scores, and incidence of dislocation. Mean follow-up was 5 years., Results: Survivorship free of aseptic femoral component loosening was 99.3% and 98.2% at 5 and 8 years in the neutral group vs 100% at 5 and 8 years in the outlier group (P = .98). Survivorship free of femoral component revision for any reason was 99.1% and 97.3% at 5 and 8 years vs 100% at 5 and 8 years, respectively (P = .80). Harris Hip Scores were similar (89 in both groups; P = .84) at most recent follow-up. The incidence of mild to moderate thigh pain was also similar in both groups (6.1% vs 6%, P = .85). The incidence of dislocation was 1.5% at 8 years, and similar between both groups (P = .77)., Conclusion: Slight malalignment of contemporary dual-tapered uncemented THA femoral components does not appear to negatively impact survivorship or clinical outcomes, which is in contrast to cemented femoral components., Level of Evidence Iii: Case-control study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The diagnosis of a periprosthetic joint infection (PJI) remains a clinical challenge, as there is no uniformly accepted gold standard. In 2011, the Musculoskeletal Infection Society (MSIS) convened a work group to create a standardized definition for a PJI that could be universally adopted. Based on the MSIS criteria, the diagnosis of a PJI can be made with 1 of the 2 major criteria, or 3 of the 5 minor criteria. The purpose of this study was to determine the likelihood of having a PJI based on the number of positive minor criteria and thereby develop a prediction algorithm for differentiating between a chronic PJI and a non-PJI based on the number of positive MSIS minor criteria., Methods: We retrospectively reviewed 297 patients who presented to a tertiary care center between 2004 and 2014 with a failed total joint arthroplasty and subsequently underwent a PJI workup to exclude chronic PJI. Patients were divided into 2 groups: (1) PJI group and (2) non-PJI group. Patients who had a positive PJI workup and subsequently underwent a 2-stage revision for infection were included in the PJI group. Patients who had a negative clinical and diagnostic workup were included in the non-PJI group. One hundred eighty-two patients met the criteria for inclusion in the study, 91 in each group. Univariate and multiple logistic regression analyses were used to evaluate 21 independent variables in each of the 2 groups. A prediction algorithm for differentiating between a chronic PJI and a non-PJI based on independent multivariate variables was created., Results: Patients who had a PJI differed significantly (P < .05) from those who did not have a PJI with regard to 10 independent variables, which included all the MSIS minor criteria we evaluated. Five independent multivariate variables were identified to differentiate between the 2 groups: positive cultures, elevated synovial white blood cell count, elevated synovial polymorphonuclear neutrophil percentage, elevated erythrocyte sedimentation rate, and elevated C-reactive protein. The predictive probability of a PJI for all 32 combinations of these 5 variables was: 3.6% for 1 positive variable, 19.3% for 2, 58.7% for 3, 83.8% for 4, and 97.8% for 5. The chi-squared test for trend and the area under the receiver-operating characteristic curve (0.977) suggest that the model is highly predictive, with an excellent diagnostic performance in identifying a PJI., Conclusions: Diagnosing a PJI remains a clinical challenge as there is no gold standard for diagnosis. The development of the MSIS criteria, which is based on a consensus of over 400 of the world's experts in musculoskeletal infection, was a major step forward in defining the diagnosis of a PJI. However, to our knowledge, the likelihood of having a PJI based on the number of positive minor criteria has yet to be validated or quantified. Of the 20 independent variables that were evaluated, 10 were found to be significantly associated with a PJI, including all the MSIS minor criteria evaluated. In addition, a diagnostic prediction algorithm was constructed to determine the likelihood of a PJI based on 5 binary independent multivariate variables. The relationship was also examined with a receiver-operating characteristic curve analysis. The area under the curve was 0.98, indicating excellent diagnostic performance for the MSIS minor criteria in identifying a PJI., Level of Evidence: III., (Copyright © 2018 Elsevier Inc. All rights reserved.)