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AimsThe purpose of this study was to assess mid-term survivorship following primary total knee arthroplasty (TKA) with Optetrak Logic components and identify the most common revision indications at a single institution.MethodsWe identified a retrospective cohort of 7,941 Optetrak primary TKAs performed from January 2010 to December 2018. We reviewed the intraoperative findings of 369 TKAs that required revision TKA from January 2010 to December 2021 and the details of the revision implants used. Kaplan-Meier analysis was used to determine survivorship. Cox regression analysis was used to examine the impact of patient variables and year of implantation on survival time.ResultsThe estimated survivorship free of all-cause revision was 98% (95% confidence interval (CI) 97% to 98%), 95% (95% CI 95% to 96%), and 86% (95% CI 83% to 88%) at two, five, and ten years, respectively. In 209/369 revisions there was a consistent constellation of findings with varying severity that included polyethylene wear and associated synovitis, osteolysis, and component loosening. This failure mode, which we refer to as aseptic mechanical failure, was the most common revision indication. The mean time from primary TKA to revision for aseptic mechanical failure was five years (5 months to 11 years).ConclusionIn this series of nearly 8,000 primary TKAs performed with a specific implant, we identified a lower-than-expected mid-term survivorship and a high number of revisions with a unique presentation. This study, along with the recent recall of the implant, confirms the need for frequent monitoring of patients with Optetrak TKAs given the incidence of polyethylene failure, osteolysis, and component loosening.Cite this article: Bone Joint J 2023;105-B(3):277–283.

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR.The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA.We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P0.001), specifically low-molecular-weight heparin (OR: 2.651; P0.001), warfarin (OR: 1.529; P0.001), and direct factor Xa inhibitors (OR: 1.957; P0.001).In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

Background: While database studies have become more prevalent in the literature, there is concern over their value. In addition, the questions they are suitable to answer are limited. Questions/Purposes: We sought to determine the incidence of database studies in the orthopedic literature and in each subspecialty. In addition, we wanted to assess the impact of database studies on the literature by determining whether citations and Altmetric Attention Scores (AAS) varied by study type (studies using internal or external databases and those not using databases). Methods: We searched PubMed for articles published in impactful orthopedic surgery journals in the year 2018. All articles were discoverable on the Altmetric explorer portal database. Impact was determined by journal impact factor. Study design, subspecialty, number of citations, and AAS were obtained. Univariable analyses were conducted between study type, demographic variables, and the outcome of either citation count or AAS. Multivariable analyses were performed to identify independent predictors of the primary outcomes. Subgroup analyses were performed to differentiate the impact of external and internal database studies compared with non-database studies. Results: A total of 2684 total articles were eligible for inclusion. Of these, 366 studies (13.6%) were database studies. Hip and knee articles had the greatest incidence of database studies. Database studies had significantly more citations (5.9 vs 4.0) and significantly higher AAS (12.8 vs 11.3) compared with non-database studies. External database studies had significantly more citations (6.7 vs 4.8) and significantly higher AAS (14.0 vs 10.7) than internal database studies. Internal database studies had higher traditional citation counts but similar AAS to non-database studies. Conclusions: In 2018, database studies in well-reputed orthopedic journals had a greater number of citations but similar AAS compared with non-database studies. Further studies are warranted.

In TKA, soft tissue balancing is assessed through manual intraoperative trialing. This assessment is a physical examination via manually applied forces at the ankle, generating varus and valgus moments at the knee while the surgeon visualizes the lateral and medial gaps at the joint line. Based on this examination, important surgical decisions are made that influence knee stability, such as choosing the polyethylene insert thickness. Yet, the applied forces and the assessed gaps in this examination represent a qualitative art that relies on each surgeon's intuition, experience, and training. Therefore, the extent of variation among surgeons in conducting this exam, in terms of applied loads and assessed gaps, is unknown. Moreover, whether variability in the applied loads yields different surgical decisions, such as choice of insert thickness, is also unclear. Thus, surgeons and developers have no basis for deciding to what extent the applied loads need to be standardized and controlled during a knee balance exam in TKA.(1) Do the applied moments in soft tissue assessment differ among surgeons? (2) Do the assessed gaps in soft tissue assessment differ among surgeons? (3) Is the choice of insert thickness associated with the applied moments?Seven independent human cadaveric nonarthritic lower extremities from pelvis to toe were acquired (including five females and two males with a mean age of 73 ± 7 years and a mean BMI of 25.8 ± 3.8 kg/m 2 ). Posterior cruciate ligament substituting (posterior stabilized) TKA was performed only on the right knees. Five fellowship-trained knee surgeons (with 24, 15, 15, 7, and 6 years of clinical experience) and one chief orthopaedic resident independently examined soft tissue balance in each knee in extension (0° of flexion), midflexion (30° of flexion), and flexion (90° of flexion) and selected a polyethylene insert based on their assessment. Pliable force sensors were wrapped around the leg to measure the loads applied by each surgeon. A three-dimensional (3D) motion capture system was used to measure knee kinematics and a dynamic analysis software was used to estimate the medial and lateral gaps. We assessed (1) whether surgeons applied different moments by comparing the mean applied moment by surgeons in extension, midflexion, and flexion using repeated measures (RM)-ANOVA (p0.05 was assumed significantly different); (2) whether surgeons assessed different gaps by comparing the mean medial and lateral gaps in extension, midflexion, and flexion using RM-ANOVA (p0.05 was assumed significantly different); and (3) whether the applied moments in extension, midflexion, and flexion were associated with the insert thickness choice using a generalized estimating equation (p0.05 was assumed a significant association).The applied moments differed among surgeons, with the largest mean differences occurring in varus in midflexion (16.5 Nm; p = 0.02) and flexion (7.9 Nm; p0.001). The measured gaps differed among surgeons at all flexion angles, with the largest mean difference occurring in flexion (1.1 ± 0.4 mm; p0.001). In all knees except one, the choice of insert thickness varied by l mm among surgeons. The choice of insert thickness was weakly associated with the applied moments in varus (β = -0.06 ± 0.02 [95% confidence interval -0.11 to -0.01]; p = 0.03) and valgus (β = -0.09 ± 0.03 [95% CI -0.18 to -0.01]; p= 0.03) in extension and in varus in flexion (β = -0.11 ± 0.04 [95% CI -0.22 to 0.00]; p = 0.04). To put our findings in context, the greatest regression coefficient (β = -0.11) indicates that for every 9-Nm increase in the applied varus moment (that is, 22 N of force applied to the foot assuming a shank length of 0.4 m), the choice of insert thickness decreased by 1 mm.In TKA soft tissue assessment in a human cadaver model, five surgeons and one chief resident applied different moments in midflexion and flexion and targeted different gaps in extension, midflexion, and flexion. A weak association between the applied moments in extension and flexion and the insert choice was observed. Our results indicate that in the manual assessment of soft tissue, changes in the applied moments of 9 and 11 Nm (22 to 27 N on the surgeons' hands) in flexion and extension, respectively, yielded at least a 1-mm change in choice of insert thickness. The choice of insert thickness may be more sensitive to the applied moments in in vivo surgery because the surgeon is allowed a greater array of choices beyond insert thickness.Among five arthroplasty surgeons with different levels of experience and a chief resident, subjective soft tissue assessment yielded 1 to 2 mm of variation in their choice of insert thickness. Therefore, developers of tools to standardize soft tissue assessment in TKA should consider controlling the force applied by the surgeon to better control for variations in insert selection.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are cost-effective procedures that decrease pain and improve health-related quality of life for patients with advanced symptomatic arthritis, including rheumatoid arthritis (RA). Patients with RA have a longer length of stay (LOS) after THA or TKA than patients with osteoarthritis, yet the factors contributing to LOS have not been investigated. Purpose: We sought to identify the factors contributing to LOS for patients with RA undergoing THA and TKA at a single tertiary care orthopedic specialty hospital. Methods: We retrospectively reviewed data from a prospectively collected cohort of 252 RA patients undergoing either THA or TKA. Demographics, RA characteristics, medications, serologies, and disease activity were collected preoperatively. Linear regression was performed to explore the relationship between LOS (log-transformed) and possible predictors. A multivariate model was constructed through backward selection using significant predictors from a univariate analysis. Results: Of the 252 patients with RA, 83% were women; they had a median disease duration of 14 years and moderate disease activity at the time of arthroplasty. We had LOS data on 240 (95%) of the cases. The mean LOS was 3.4 ± 1.5 days. The multivariate analysis revealed a longer LOS for RA patients who underwent TKA versus THA, were women versus men, required a blood transfusion, and took preoperative opioids. Conclusion: Our retrospective study found that increased postoperative LOS in RA patients undergoing THA or TKA was associated with factors both non-modifiable (type of surgery, sex) and modifiable (postoperative blood transfusion, preoperative opioid use). These findings suggest that preoperative optimization of the patient with RA might focus on improving anemia and reducing opioid use in efforts to shorten LOS. More rigorous study is warranted.

Background Instability constitutes over 20% of revisions after total hip arthroplasty (THA). Dual mobility (DM) designs were introduced as a solution to this problem. However, the few publications that have reported promising results for monobloc DM constructs have been limited by sample size or length of follow-up. The purpose of this study is to evaluate mid-term outcomes (minimum 5-year follow-up) of a single-surgeon series utilizing a monobloc DM acetabular component in patients with high risk for dislocation. Methods This is a single-surgeon consecutive series of 207 primary THAs implanted with a monobloc DM component in patients who were considered at high risk for dislocation. Patient demographics and case-specific data were collected retrospectively. All patients had a minimum of 5-year follow-up. The Mann-Whitney U test was used to assess continuous variables, whereas categorical variables were analyzed using the chi-square test. Survival probability was calculated using the Kaplan-Meier method. Results Radiographic analysis did not reveal acetabular radiolucency in any patients, and there were no revisions for aseptic loosening. In addition, there were no dislocations. Seven of 205 patients (3.4%) were revised, 5 on the femoral side due to periprosthetic fracture and the remaining two for infection. Survivorship of the acetabular component from revision was 99%. The mean Veteran RAND (VR-12) physical score improved from 7 (standard deviation [SD]: 13.7) preoperatively to 9.5 (SD: 17.6) at the final follow-up. Similarly, the hip disability osteoarthritis score improved from 8 (SD: 17.9) preoperatively to 21.2 (SD: 37). Conclusion Monobloc DM components reliably prevent dislocation after primary THA in high-risk patients. At mid-term follow-up, this DM monobloc component demonstrates excellent implant survivorship, radiographic fixation, and improved functional outcomes.

Background Questions exist about the release of cobalt and chromium ions from dual mobility (DM) cups. Modular implants, with potential backside wear between the cobalt-chromium liner and titanium cup, are of particular concern. This study compares the metal ion profile of patients with contemporary monoblock and modular DM articulations from two commonly used designs. Methods Cobalt and chromium serum levels were measured one year after surgery in a prospective cohort of patients undergoing total hip arthroplasty with a DM construct. Ion levels were detected above 1 μg/L. Clinical and surgical data were correlated with the ion levels for analysis. Results Overall, 29% of the patients had levels above 1 μg/L of either ion. More patients with modular cups had detectable ions than patients with monoblock cups (39% vs 20%, P = .05). Cobalt was more commonly detected in the monoblock group, and chromium was more commonly detected in the modular group (P = .05). There were no differences in the actual ion levels between the groups (1.35 μg/L vs 1.64 μg/L, P = .44, for cobalt and 1.35 μg/L vs 1.31 μg/L, P = .77, for chromium). No patient underwent revision during the follow-up period. Conclusions We found similar cobalt and chromium levels in patients with monoblock and modular DM cups. More patients in the modular group had detectable ions. Cobalt was more frequently detected in the monoblock group. These results suggest that both implants are performing well in the short term, but further follow-up is needed to determine whether the differences found are of clinical significance.

Although various papers have reported on the clinical performance of cup retention with cementation of a new liner and bone grafting in the management of well-fixed cups with polyethylene wear and periacetabular osteolysis after total hip arthroplasty (THA), no systematic review of this topic has been published to date. Medline, EMBASE and Cochrane Library were searched for articles published from January 1999 to January 2019 using “osteolysis” AND “well-fixed”, “osteolysis” AND “retro-acetabular”, “bone graft” AND (“retention” OR “retained” OR “stable”) AND “cup”, and “cemented liner” AND “well-fixed”. Nine articles were selected for review (186 cases, 76.1 months mean follow-up). The overall revision rate was 11.3% (21 hips) most commonly due to aseptic loosening (9/186 hips), dislocation (8/186 hips), and liner wear progression (2/186 cases). The reported square size of osteolytic lesions ranged from a mean of 465.84 mm2 to a max of 4,770 mm2. Almost all reported lesions treated with bone grafts resolved or did not progress 97% (72/74). All studies indicated improved pain and functional scores at follow-up. Cementation of a new liner with periacetabular bone grafting provides an alternative option to isolated liner exchange and cup revision for the management of periacetabular osteolysis in well-fixed cups with a disrupted locking mechanism or unavailable exchange liner. Further higher quality studies are required in order to examine if the use of highly cross-linked polyethylene, highly porous-coated cups, hydroxyapatite-coated cups, and small-diameter cups influence the clinical outcome of liner cementation in well-fixed cups with periacetabular osteolysis.

BACKGROUND Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described. QUESTIONS/PURPOSES (1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA? METHODS Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups. RESULTS Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04). CONCLUSION Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted. LEVEL OF EVIDENCE Level III, therapeutic study.

Aims Although CT is considered the benchmark to measure femoral version, 3D biplanar radiography (hipEOS) has recently emerged as a possible alternative with reduced exposure to ionizing radiation and shorter examination time. The aim of our study was to evaluate femoral stem version in postoperative total hip arthroplasty (THA) patients and compare the accuracy of hipEOS to CT. We hypothesize that there will be no significant difference in calculated femoral stem version measurements between the two imaging methods. Methods In this study, 45 patients who underwent THA between February 2016 and February 2020 and had both a postoperative CT and EOS scan were included for evaluation. A fellowship-trained musculoskeletal radiologist and radiological technician measured femoral version for CT and 3D EOS, respectively. Comparison of values for each imaging modality were assessed for statistical significance. Results Comparison of the mean postoperative femoral stem version measurements between CT and 3D hipEOS showed no significant difference (p = 0.862). In addition, the two version measurements were strongly correlated ( r = 0.95; p < 0.001), and the mean paired difference in postoperative femoral version for CT scan and 3D biplanar radiography was -0.09° (95% confidence interval -1.09 to 0.91). Only three stem measurements (6.7%) were considered outliers with a > 5° difference. Conclusion Our study supports the use of low-dose biplanar radiography for the postoperative assessment of femoral stem version after THA, demonstrating high correlation with CT. We found no significant difference for postoperative femoral version when comparing CT to 3D EOS. We believe 3D EOS is a reliable option to measure postoperative femoral version given its advantages of lower radiation dosage and shorter examination time. Cite this article: Bone Joint J 2022;104-B(11):1196–1201.

BackgroundPatients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied.MethodsThis cohort study extracted claims data on patients with an obesity diagnosis that received both bariatric surgery and TKA/THA surgery within 5 years of each other (Premier Healthcare database 2006–2019). Overall, 1894 patients received bariatric surgery before TKA or THA, while 1000 patients underwent TKA or THA before bariatric surgery. Main outcomes and measures include major complications (acute renal failure, acute myocardial infarction, other cardiovascular complications, sepsis/septic shock, pulmonary complications, pulmonary embolism, pneumonia, and central nervous system-related adverse events), postoperative intensive care unit utilization, ventilator utilization, 30-day readmission, 90-day readmission, 180-day readmission and total hospital length of stay after the second surgery. Regression models measured the association between the complications and sequence of TKA/THA and bariatric surgery.ResultsUndergoing TKA/THA before bariatric surgery (compared with the reverse) was associated with higher odds of major complications (7.0% vs 1.9%; adjusted OR 4.8, 95% CI 3.1, 7.6, pConclusionsPatients who require both bariatric surgery and TKA/THA should consider bariatric surgery before TKA/THA as it is associated with improved outcomes. Procedures should be staged beyond 6 months.

Accurate acetabular component placement may reduce the risk of complication after total hip arthroplasty (THA). While surgeon experience and volume may reduce outliers, little is known how cup positioning accuracy and consistency relates to level of training (resident, fellow, attending) and whether trainee level impacts the magnitude and direction of cup placement errors. Ninety patients undergoing posterolateral computer-assisted navigation THA were included for analysis. All surgery was performed by two fellowship-trained orthopaedic surgeons and assisted by a trainee (orthopedic resident (PGY 1–5) or fellow in adult reconstruction). In order to determine accuracy of cup placement in trainees and attendings, we used computer navigation to determine freehand cup placement by the trainee, then by the attending surgeon. Final cup inclination and version were determined and recorded by computer-assisted surgical navigation. Comparison of consistency in cup inclination and anteversion was made on values obtained by residents, fellows, and attendings and final values provided by the navigation system. In addition, to assess the role of training and repetition, acetabular cup inclination and version were compared between fellows during the first half and the second half of their training year. All comparisons were performed with the Student t-test except for comparison of rate of deviation from the safe zone, which were performed with the chi-square test. The level of significance was defined as p values ≤ 0.05 with 95% confidence interval, and trend toward significance was defined as p values ≤ 0.1. Inclination deviation from the final position and cup version deviation from the final position were statistically significant between resident vs attendings (p

To examine postoperative complications associated with rotator cuff repair (RCR) in HIV-positive patients ages 65 and older. Data were collected from the Medicare Standardized Analytic Files between 2005 and 2015 using the PearlDiver Patient Records Database. Subjects were selected using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Demographics including age, sex, medical comorbidities, and smoking status were collected. Complications were examined at 7-day, 30-day, and 90-day postoperative time points. Data were examined with univariate and multivariate analyses. The study included 152,114 patients who underwent RCR, with 24,486 (16.1%) patients who were HIV-positive. Following univariate analysis, patients with HIV were observed to be more likely to develop 7-day, 30-day, and 90-day postoperative complications. However, the absolute risk of each complication was quite low for HIV-positive patients. Univariate and multivariate analysis showed that within 7 days following surgery, patients with HIV were more likely to develop myocardial infarction (OR 2.5, AR 0.1%) and sepsis (OR 2.5, AR 0.04%). Within 30 days, HIV-positive patients were at increased risk for postoperative anemia (OR 2.8, AR 0.1%), blood transfusion (OR 3.3, AR 0.1%), heart failure (OR 2.3, AR 0.8%), and sepsis (OR 2.7, AR 0.1%). Within 90 days, mechanical complications (OR 2.1, AR 0.1%) were increased in the HIV-positive group. Postoperative complications of RCR occurred at increased rates in the HIV-positive group compared to the HIV-negative group in patients ages 65 and older. In particular, increased risk for myocardial infarction, sepsis, heart failure, anemia, and mechanical complications was noted in HIV-positive patients. However, the actual percentage of patients who experienced each complication was low, indicating RCR is likely safe to perform even in older HIV-positive patients. As more older adults living with HIV present for elective orthopedic procedures, the results of the present study may reassure physicians who are considering RCR as an option for patients in this particular population, while also informing providers about potential complications. III.

Background Recent data suggest that a modified, more lenient set of precautions after total hip arthroplasty (THA) performed through the posterolateral approach may safely allow more patient movement and exercise in the immediate postoperative period. We hypothesize that 1) patients undergoing THA given modified precautions will demonstrate a fast-track return to functional activity and 2) wrist-based activity trackers will provide valuable information on postoperative activity levels. Methods We prospectively enrolled patients undergoing THA. Patients were given a wrist-based, commercially available activity tracker to wear 1 week preoperatively and 6 weeks postoperatively. Postoperative hip precautions included only the avoidance of the “leg-shaving” position of combined hip flexion, adduction, and internal rotation. Linear mixed models were used to analyze the change in steps and Hip Disability and Osteoarthritis Outcome Score-Junior (HOOS)-JR data. Pearson correlation coefficients were used to describe the relationship between average steps and HOOS-JR scores over time. Results Eighty-two patients were enrolled. Seventy-four percent returned to work by week 4. Seventy-six percent of left THA patients returned to driving by week 4. At 6 weeks, 23% of survey respondents were taking pain medication and 26% were using assistive devices. Average daily steps were 1098 at week 1, 2491 at week 2, 4130 at week 3, 4850 at week 4, 5712 at week 5, and 6069 at week 6. A significant correlation (R: −0.981) was found between increased weekly steps and improved HOOS-JR scores after THA (P Conclusion Defining expected recovery timelines for patients undergoing THA helps surgeons counsel their patients preoperatively. Our study demonstrates an expected pathway for recovery after THA by using modified precautions that will be more clearly outlined with ongoing clinical data analysis.

Background Several studies have evaluated the survivorship and clinical outcomes of constrained acetabular liners (CALs) in complex primary and revision total hip arthroplasty with hip instability; however, there remains no consensus on the overall performance of this constrained implant. We therefore performed a systematic review of the literature to examine survivorship and complication rate of CAL usage. Methods A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords. Results In all, 37 articles met the inclusion criteria. A total of 4152 CALs were implanted. The all-cause reoperation-free survivorship was 79.9%. The overall complication rate was 22.2%. Dislocation was the most common complications observed and the most frequent reason for reoperation with an incidence of 9.4% and 9.2%, respectively. Infection after CAL placement had an incidence of 4.6%. The reoperation rate for aseptic acetabular component loosening was 2.9%. Overall, patients had improved outcomes as documented by postoperative hip scores. Conclusion CALs usage have a relatively high complication rate, particularly when compared with current bearing alternatives (dual mobility cups and large diameter femoral heads), however, it remains a valuable salvage procedure in complex patients affected by recurrent dislocation and implant instability. Newer designs have shown reduced impingement and higher survivorship free from dislocation. However, CALs should only be used when the reasons of instability have been correctly recognized and optimized.

Aims This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA). Methods Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay. Results The predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis. Conclusion Both ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols. Cite this article: Bone Joint J 2021;103-B(8):1358–1366.

Background Over 1 million Americans undergo joint replacement each year, and approximately 1 in 75 will incur a periprosthetic joint infection. Effective treatment necessitates pathogen identification, yet standard-of-care cultures fail to detect organisms in 10% to 20% of cases and require invasive sampling. We hypothesized that cell-free DNA (cfDNA) fragments from microorganisms in a periprosthetic joint infection can be found in the bloodstream and utilized to accurately identify pathogens via next-generation sequencing. Methods In this prospective observational study performed at a musculoskeletal specialty hospital in the U.S., we enrolled 53 adults with validated hip or knee periprosthetic joint infections. Participants had peripheral blood drawn immediately prior to surgical treatment. Microbial cfDNA from plasma was sequenced and aligned to a genome database with >1,000 microbial species. Intraoperative tissue and synovial fluid cultures were performed per the standard of care. The primary outcome was accuracy in organism identification with use of blood cfDNA sequencing, as measured by agreement with tissue-culture results. Results Intraoperative and preoperative joint cultures identified an organism in 46 (87%) of 53 patients. Microbial cfDNA sequencing identified the joint pathogen in 35 cases, including 4 of 7 culture-negative cases (57%). Thus, as an adjunct to cultures, cfDNA sequencing increased pathogen detection from 87% to 94%. The median time to species identification for cases with genus-only culture results was 3 days less than standard-of-care methods. Circulating cfDNA sequencing in 14 cases detected additional microorganisms not grown in cultures. At postoperative encounters, cfDNA sequencing demonstrated no detection or reduced levels of the infectious pathogen. Conclusions Microbial cfDNA from pathogens causing local periprosthetic joint infections can be detected in peripheral blood. These circulating biomarkers can be sequenced from noninvasive venipuncture, providing a novel source for joint pathogen identification. Further development as an adjunct to tissue cultures holds promise to increase the number of cases with accurate pathogen identification and improve time-to-speciation. This test may also offer a novel method to monitor infection clearance during the treatment period. Level of evidence Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background There is a paucity of data on the outcomes of distal femoral replacements (DFRs) in patients with total knee arthroplasty (TKA) periprosthetic fractures. We sought to characterize these patients’ survivorship free from rerevision. Methods We retrospectively identified 49 patients, including 34 after primary TKA (primary cohort), 9 after revision TKA, and 6 conversions for failed open reduction and internal fixation (revision cohort) that underwent DFR for a periprosthetic femur fracture. The mean age was 76 years, and 40 patients (82%) were female. The mean follow-up was 4 years. Femoral fixation included 44 cemented stems (90%) and 5 cementless stems (10%). Survivorship free from rerevision was characterized by the Kaplan–Meier method; cox proportional regression was used to analyze the risk factors for rerevision. Results Survivorship free from any rerevision at 5 years in the primary and revision cohort was 93% and 18%, respectively. The revision cohort had a 5.3× higher risk of re-revision (P = .008). Survivorship free from re-revision for aseptic loosening at 5 years in the primary and revision cohort was 93% and 53%, respectively. Two of the 3 patients with cementless stems in the primary cohort underwent early rerevision for aseptic loosening, but patients with prior primary TKAs treated with cemented femoral fixation (n = 31) had a 97% 5-year survivorship free from re-revision. Conclusion Patients with periprosthetic fractures around prior primary TKAs treated with DFRs with cemented femoral fixation had a 97% 5-year survivorship free from any re-revision. DFRs for periprosthetic femur fractures around revision TKAs or conversions of failed open reduction and internal fixations have a 5× increased risk of rerevision.

AimsSurgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture, which leads to femoral joint line elevation. There is a paucity of data describing the effect of joint line elevation on mid-flexion stability and knee kinematics. Thus, the goal of this study was to quantify the effect of joint line elevation on mid-flexion laxity.MethodsSix computational knee models with cadaver-specific capsular and collateral ligament properties were implanted with a posterior-stabilized (PS) TKA. A 10° flexion contracture was created in each model to simulate a capsular contracture. Distal femoral resections of + 2 mm and + 4 mm were then simulated for each knee. The knee models were then extended under a standard moment. Subsequently, varus and valgus moments of 10 Nm were applied as the knee was flexed from 0° to 90° at baseline and repeated after each of the two distal resections. Coronal laxity (the sum of varus and valgus angulation with respective maximum moments) was measured throughout flexion.ResultsWith + 2 mm resection at 30° and 45° of flexion, mean coronal laxity increased by a mean of 3.1° (SD 0.18°) (p < 0.001) and 2.7° (SD 0.30°) (p < 0.001), respectively. With + 4 mm resection at 30° and 45° of flexion, mean coronal laxity increased by 6.5° (SD 0.56°) (p < 0.001) and 5.5° (SD 0.72°) (p < 0.001), respectively. Maximum increased coronal laxity for a + 4 mm resection occurred at a mean 15.7° (11° to 33°) of flexion with a mean increase of 7.8° (SD 0.2°) from baseline.ConclusionWith joint line elevation in primary PS TKA, coronal laxity peaks early (about 16°) with a maximum laxity of 8°. Surgeons should restore the joint line if possible; however, if joint line elevation is necessary, we recommend assessment of coronal laxity at 15° to 30° of knee flexion to assess for mid-flexion instability. Further in vivo studies are warranted to understand if this mid-flexion coronal laxity has negative clinical implications. Cite this article: Bone Joint J 2021;103-B(6 Supple A):87–93.

Aims Many patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA. Methods The prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA. Results We identified 152 employed patients who had undergone simultaneous bilateral TKA and 61 who had undergone staged bilateral TKA, and had completed the registry’s return to work questionnaire. The simultaneous group missed a mean of 46.2 days (SD 29.1) compared with the staged group who missed a mean total of 68.0 days of work (SD 46.1) when combining both operations. This difference was statistically significant (p < 0.001). In multivariate mixed regression analysis adjusted for age, sex, BMI, American Society of Anesthesiologists status, and type of work, the simultaneous group missed a mean of 16.9 (SD 5.7) fewer days of work compared with the staged group (95% confidence interval 5.8 to 28.1; p = 0.003). Conclusion Employed patients undergoing simultaneous bilateral TKA missed a mean of 17 fewer days of work as a result of their surgical treatment and rehabilitation compared with those undergoing staged bilateral TKA. This information may be useful to surgeons counselling employed patients with bilateral OA of the knee who are considering surgical treatment. Cite this article: Bone Joint J 2021;103-B(6 Supple A):108–112.

Instability remains one of the most frequent complications requiring revision surgery after primary total hip arthroplasty (THA). Elevated liners are often utilized to reduce the risk of dislocation; however, the literature is inconclusive, with no systematic reviews summarizing the data. Thus, this systematic review aimed to establish a consensus for the efficacy of elevated liners in primary THA by determining rates of overall revision and revision specifically for recurrent dislocation. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies reporting on the use of elevated liners in primary total hip arthroplasty were identified through May 2020. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. Eight studies met inclusion criteria, and overall, 26,507 patients undergoing primary THA with use of an elevated liner were included. In aggregate, the most common cause of revision was recurrent hip dislocation (1.3%, N = 82/6,267) followed by joint infection (1.2%, N = 45/3,772) and acetabular loosening (0.3%, N = 10/3,772). Notably, elevated liners were associated with a lower risk of revision for recurrent dislocation compared to neutral liners (HR: 0.74; 95% CI: 0.55–1.00; p = 0.048). This review found that after primary THA with the use of elevated liners, hip dislocation and prosthetic joint infection continued to be the most frequent reasons for revision surgery. However, elevated liners had a lower risk of revision for recurrent dislocation compared to neutral liners.

Lymphocyte transformation testing (LTT) is often used in the workup for possible metal allergy after total knee arthroplasty (TKA) but the correlation of this test with other diagnostic metal-allergy findings in patients undergoing revision TKA for suspected metal allergy has not been established. A single-center, single-surgeon cohort of 19 TKAs in which both components were revised for presumed implant-related metal allergy based on history, physical, and LTT testing, to nonnickel-containing implants were retrospectively identified. Histopathologic samples obtained intraoperatively were semiquantitatively analyzed using both the Hospital for Special Surgery (HSS) synovial pathology score and the Campbell aseptic lymphocyte-dominant vasculitis-associated lesion (ALVAL) score. As histopathology control group, we included in the study an additional cohort of 17 patients who received aseptic revision TKA and had no history of reported or tested metal sensitivity. All preoperative LTT results were highly reactive to nickel. However, this did not correlate with local periarticular tissue response in 18 of 19 cases which demonstrated a low HSS synovial score (mean: 3.8 ± 2.8, of a maximum score of 28) and the low Campbell ALVAL scores (mean: 2.5/10 ± 1.3, of a maximum score of 10). There were not any significant differences between the study group (suspected implant-related metal allergy) and the control group (nonsuspected implant-related metal allergy) in regard to (1) the Campbell score and (2) the HSS synovial inflammatory score. Knee Society Clinical Rating System (KSCRS) function score improved significantly after revision (mean postoperative increase: 34.0 ± 17. 2; p

The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA. The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “cross-linked”, “polyethylene”, “HXLPE”, “conventional”, “total knee arthroplasty”, “TKA”, “total knee replacement” and “TKR” combined with Boolean operators AND and OR. Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39–1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20–1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31–0.39; I2: 0.0%). The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/mOne hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb12.5 (OR = 3.99, P.0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P.001).Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.

Background Metaphyseal cones provide durable fixation in revision total knee arthroplasty (TKA). However, there is a paucity of data on the outcomes of a new porous cone design. As such, the goal of this study was to analyze the early survivorship in patients undergoing revision TKA with this cone. Methods We retrospectively reviewed 163 revision TKAs with a newly designed porous tibial cone from 2016 to 2018. Mean age was 67 years, and mean body mass index was 33 kg/m2. Minimum follow-up duration was 2 years. Most patients were revised for aseptic loosening (46%), 2-stage periprosthetic joint infection (PJI) reimplantation (28%), or instability (15%). Most were varus-valgus constrained (65%) or hinged (32%) constructs. The majority had hybrid tibial stem fixation (74%). A multivariate Cox regression analysis was used to identify risk factors for reoperation. Results Survivorship free from re-revision for aseptic loosening, any nonmodular revision, and any reoperation was 100%, 96%, and 86% at 2 years, respectively. No patients were revised for aseptic loosening. Six (4%) tibial cones were removed for PJI, one of which was loose. There were 23 reoperations (14%), most commonly for PJI (10%). Multivariate analysis identified PJI reimplantation (hazard ratios [HR] = 4.2, P = .002), males (HR = 2.9, P = .02), and hinged constructs (HR = 2.7, P = .02) as significant risk factors for reoperation. Conclusions In a complex revision TKA cohort with a new highly porous tibial cone, in which most patients received hybrid stem fixation and nonlinked and linked constraint, there was 100% survival free from re-revision for aseptic loosening at 2 years. Longer term follow-up is required.

Background Little is known about the relationship between infection and the risk of risk of venous thromboembolism (VTE) following orthopaedic surgery. We assessed the 90-day risk of VTE following revision total knee replacement to measure the association between periprosthetic joint infection and the risk of postoperative VTE. Methods We used New York Statewide Planning and Research Cooperative System data to identify all New York State residents undergoing revision total knee replacement from 1998 to 2014. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes were used to identify comorbidities and to classify the indication for revision total knee replacement as aseptic, infection, or fracture. The primary outcome was any diagnosis code for VTE recorded for the revision surgery and/or subsequent admissions within 90 days. A multivariable logistic regression model that included demographic characteristics and comorbidities was used to estimate the risk of VTE after revision for infection or fracture, with aseptic revision as the reference group. Results The present study included 25,441 patients who were managed with revision total knee replacement; the indication for revision was aseptic for 17,563 patients (69%), infection for 7,075 (28%), and fracture for 803 (3%). The mean age (and standard deviation) was 66 ± 12 years, 15,592 (61%) of the patients were female, 3,198 (13%) were Black, 1,192 (5%) were smokers, and 4,222 (17%) were obese. Seven hundred and nineteen patients (2.8%) had VTE within the 90 days after revision total knee replacement, including 387 (1.5%) during the admission for the revision procedure. The 90-day incidence of VTE was 2.1% after aseptic revision, 4.3% after revision for infection, and 5.9% after revision for fracture. The adjusted odds ratio (aOR) for VTE relative to aseptic revision was 2.01 (95% confidence interval [CI], 1.72 to 2.35) for septic revision total knee replacement and 2.62 (95% CI, 1.91 to 3.6) for fracture. A history of VTE was also a strong risk factor for VTE following revision total knee replacement (aOR, 2.01; 95% CI, 1.48 to 2.71). Conclusions We found that the odds of VTE after revision total knee replacement for infection were double those after aseptic revision total knee replacement. Although fracture accounts for a small percentage of revision total knee replacements, the risk of VTE was 2.6-fold higher after these procedures. The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bilateral knee osteoarthritis requiring total knee arthroplasty (TKA) can be addressed simultaneously in one surgical setting, staggered a few days apart during a single hospitalization, or staged several weeks to months apart. Several studies have reported on the complications and clinical outcomes of staggered bilateral TKA (BTKA) in a single hospitalization. However, there is no consensus regarding the safety and efficacy of this practice. We performed a systematic review of the literature, utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and identifying articles that reported the clinical outcomes and postoperative complications following staggered BTKA. Overall, six articles were included for analysis, including 43,892 patients in total. Females (n = 25,931; 59% of all patients) outnumbered males (n = 17,961; 40.1% of all patients), and most patients were middle-aged or elderly (mean age: 68.0 years). The majority of studies (83%) used a 1-week interval as the maximum time for single-hospitalization staggered BTKA. Five studies (83%) reported no difference in mortality rates between staggered, simultaneous, or staged BTKA. Compared to staged BTKA, staggered BTKA conferred an increased rate of blood transfusions. There was no consensus that staggered BTKA led to reduced complications rates, compared to simultaneous or staged BTKA. Single-hospitalization staggered BTKA does not appear to be safer than the well-established simultaneous or staged procedures. Overall, the data suggest that staggered BTKA will continue to decline in utilization, as staggered BTKA does not appear to yield clinical advantage over simultaneous BTKA in a medically appropriate patient. systematic review (lowest level of studies included)

Purpose Knee instability is considered one of the most frequent cause of failure after primary total knee arthroplasty (TKA). In order to address intraoperative instability, varus-valgus constrained knee implants (VVC) are increasingly utilized in primary TKA. Despite an increased risk of mechanical failure, short to mid-term results seem to be encouraging, but long-term results are still lacking. Methods A systematic review of prospective and retrospective studies that reported clinical outcomes of patients with VVC systems in primary TKAs between 1990 and 2020 was performed. Results In all, 28 articles met our inclusion criteria. A total of 2798 VVC implants were used in primary TKA. The all-cause revision-free survivorship was 95.2% at a mean follow-up of 7 years. Infection and aseptic loosening were the most common reasons for reoperation with an incidence of 1.8% and 1.7%, respectively. Overall complication rate was 9.6%, the most common complications were knee stiffness and infection with an incidence of 2.8% and 2.5%, respectively. Conclusions VVC implants in primary TKA are associated with improved functional outcomes and good mid-term survivorship, comparable to lower level of constraint implants. Non-modular stemless seem to be reliable implants at mid-term follow-up. However, given the lack data coming from long-term studies, VVC implants should be used cautiously in primary TKA.

Introduction Medial Pivot Total Knee Arthroplasty was introduced in clinical practice in 1990s to reproduce the in vivo-natural knee kinematics. This design is characterized by an asymmetric constraint profile, with aa highly congruent medial compartment, and a less congruent lateral compartment. Short-term outcomes of the medial pivot systems in primary knee arthroplasty have been widely reported in the current literature, however, only few studies have described results beyond 5-year follow-up. Objectives The primary objectives of this systematic review of the literature is to analyze the mid-term studies on medial pivot total knee arthroplasty focusing on the reoperation rate, survivorship and clinical outcome scores. Methods The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to December 2019 utilizing the following keywords: “medial pivot”, “medial stabilized”, “medial rotating”, “medial congruent”, medial ball and socket”, “arthroplasty”, “TKA”, “TKR”, and “knee surgery”. Results 18 articles met the inclusion criteria for the present study. The average quality was 11.4 for non-comparative studies and 21.7 for comparative studies based on MINORS criteria. A total 2832 knee arthroplasties were included for the final analysis with an average age of 69 years, and an average follow-up of 8.1 years (minimum 5 years). The overall reoperation rate was 2.4%, with periprosthetic joint infection as the leading cause of revision in 0.9% of cases, followed by aseptic loosening in 0.4% of cases. The average Knee Society Score improved to a mean preoperative score of 40.1 to a mean postoperative score of 89.2. The functional knee society score improved from a mean preoperative score of 44.8 to an average postoperative score of 82.9. The global range of motion improved from 104.8° preoperatively to 115.6° postoperatively. Conclusion We found that medial pivot system in primary total knee arthroplasty provide overall mid-term survivorship comparable to other standard implasnts. In addition, medial pivot system is associated with better high-end function compared to standard implants.

Periprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).Using the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.At two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P.001), blood transfusion (P.001), and urinary tract infection (UTI; P.001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P.001), blood transfusion (P.001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P.001) relative to matched controls.In primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.

Background: Little is known about patients’ postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

Background: The optimal route and dosing regimen of tranexamic acid (TXA) in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unclear. As such, we sought to analyze if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and transfusions. Methods: We retrospectively analyzed 6720 primary TKAs and 6559 THAs performed from February 1, 2016 to December 31, 2019 at a single institution in patients who received a double IV dose (6159 TKAs and 6276 THAs) compared with a combined single IV and topical dose (561 TKAs and 283 THAs) of TXA. Multivariate logistic regression models, adjusting for age, body mass index, American Society of Anesthesiologists class, preoperative hemoglobin, and TXA administration, were performed for significant variables from a univariate analysis. Results: In the TKA cohort, the mean total blood loss was statistically similar for double IV (305 mL, 95% confidence interval [CI] = 301-310 mL) TXA compared with combined TXA (310 mL, 95% CI = 299-321 mL) (P = .43). Furthermore, there was no difference in the rate of transfusion (odds ratio = 1.23, 95% CI = 0.57-2.67, P = .598). In the THA cohort, there was statistically higher blood loss with double IV (328 mL, 95% CI = 323-333 mL) TXA than in the combined group (295 mL, 95% CI = 280-310 mL) (P < .001). The rate of transfusion was statistically similar at ~2% (P = .970). Conclusions: A double IV TXA dose and a combined single IV and topical TXA dose were equally effective in minimizing blood transfusions (~2%) at primary TKA and THA. We did not find a synergistic effect when combining a systemic IV TXA with a topical TXA. Level of Evidence: Level III.

Early periprosthetic fractures after total knee arthroplasty are rare but devastating complications which require revision surgery and lead to poor patient satisfaction. We present 2 siblings who underwent primary total knee arthroplasty on the same day and then both presented 2 weeks after surgery with atraumatic periprosthetic femur fractures. The first patient underwent revision for a cemented distal femoral replacement with stemmed tibial fixation. The second patient underwent an isolated femoral component revision with a stemmed femoral component and distal augment. Histological evaluation identified significant peri-implant osteoporosis. The variation in complexity associated with early periprosthetic femoral insufficiency fractures is highlighted by these 2 cases. Surgeons may consider using stemmed femoral components in similar patients if poor distal femoral bone stock is encountered intraoperatively.

BACKGROUND Knee arthroscopy may be performed prior to total knee arthroplasty (TKA) in patients with symptomatic degenerative knee changes that do not yet warrant TKA. The purpose of this study was to determine whether the time interval between knee arthroscopy and subsequent primary TKA is associated with increased rates of revision and certain complications following TKA. METHODS Data from 2006 to 2017 were collected from a national insurance database. Patients who underwent knee arthroscopy within 1 year prior to primary TKA were identified and stratified into the following cohorts based on stratum-specific likelihood ratio (SSLR) analysis: 0 to 15, 16 to 35, 36 to 43, and 44 to 52 weeks from the time of knee arthroscopy to TKA. Univariate and multivariable analyses were conducted to determine the association between these specific time intervals and rates of revision surgery, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia. RESULTS In total, 130,128 patients were included in this study; 6,105 (4.7%) of those patients underwent knee arthroscopy within 1 year prior to TKA and 124,023 (95.3%) underwent TKA without any prior knee surgery, including arthroscopy (the control group). Relative to the control group, the likelihood of undergoing revision surgery was significantly greater in patients who underwent knee arthroscopy ≤15 weeks (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.43 to 2.22; p < 0.001) or 16 to 35 weeks (OR: 1.20; 95% CI: 1.01 to 1.42; p = 0.035) prior to TKA. Patients were at significantly increased risk for PJI if knee arthroscopy was done ≤35 weeks prior to TKA, and all 4 time groups that underwent knee arthroscopy within 1 year before TKA were at increased risk for manipulation under anesthesia. CONCLUSIONS We found a time-dependent relationship between the timing of knee arthroscopy and complications following TKA, with the prevalence of revision surgery and PJI increasing as knee arthroscopy was performed closer to the time of TKA. This study suggests that an interval of at least 36 weeks should be maintained between the 2 procedures to minimize risks of PJI and revision surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: In conjunction with impaction bone grafting (IBG), metal meshes have been proposed to minimise defects of the medial and superolateral walls in order to convert combined complex uncontained segmental defects into contained cavitary defects to facilitate IBG. Methods: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to March 2019 utilising keywords pertinent to total hip arthroplasty (THA), acetabular impaction bone grafting, clinical or functional outcomes, revision THA, or postoperative complications. Results: 7 articles were found to be suitable for inclusion in the present study. The mean modified Coleman methodology score for methodological deficiencies of the studies was 45.3 (range 38–59). Severe acetabular bone loss was present in 56% of cases having moderate bone loss in 18%, and mild in 26%. The all-cause reoperation rate was 7.4%, while the all-cause revision rate of the acetabular component was 6.2%. Conclusions: IBG with mesh is effective for selected patients with acetabular bone defects. Most patients with moderate bone loss as well as selected patients with large superolateral defects can be successfully treated with IBG combined with mesh. There is limited data to show that IBG with mesh might be associated with decreased survival rates in patients with severe lateral defects (Paprosky IIIA) combined with ischial or medial wall osteolysis who require combined medial and lateral meshes. In addition, patients with severe superomedial migration of the cup (Paprosky IIIB) should not be treated with IBG and mesh.

The relationship between cervical degenerative pathology and total knee arthroplasty (TKA) revision rates is not well understood. The aim of the study was to determine whether cervical spine degenerative diseases have a role in complications following TKA within 2 years. Data were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007–2017. Patients who had a primary TKA were identified using Current Procedural Terminology (CPT) code 27,447, and patients with degenerative cervical disease were identified using CPT and International Classification of Diseases (ICD) codes. Data on patients’ demographics, comorbidities and postoperative complications were recorded and analyzed with univariate and multivariate analysis with significance set at p

Background: Changes in acetabular or hip center of rotation (HCOR) commonly occur during acetabular component preparation during total hip arthroplasty (THA). HCOR displacement in mediolateral or superoinferior directions is known to influence offset and leg length, but the incidence and range of HCOR change in the anteroposterior direction is less understood as the sagittal plane cannot be measured on standard anteroposterior radiographs. This study assessed the 3-dimensional displacement of HCOR after cup implantation and evaluated for potential factors associated with increased acetabular component translations. Methods: A total of 894 THAs were performed using a posterior, lateral, or direct anterior approach. Only intraoperative data from the navigation device were included in the analysis. All THAs performed between September 2015 and October 2017 were included. Paired t-tests were used to compare native HCOR and new HCOR values. Results: The mean HCOR displacement in 3 directions was 4.97mm medially (P < .001), 0.83mm superiorly (P < .001), and 0.64mm posteriorly (P < .001). Subgroup analysis revealed greater posterior HCOR displacement with the anterior approach than the lateral/posterior approach (2.32mm vs 0.44mm; P < .001). Increasing medial HCOR displacement also resulted in increased superior and posterior HCOR displacement across surgical cases (P < .001). Conclusions: HCOR displacement is commonly observed in medial, superior, and posterior directions. HCOR changes are influenced by surgical approach, potentially secondary to patient positioning, with greater posterior HCOR displacement observed in anterior cases. Surgeons should be aware of these factors, particularly in cases with deficient or reduced posterior column bone stock.

Revision total hip arthroplasty (rTHA) is increasingly performed but may carry a high rate of complication. This aim of the study was to determine if a decreased eGFR increases risks of postoperative complications following rTHA. A retrospective cohort study using the American College of Surgeons National Quality Improvement Program Database was conducted. Patients undergoing rTHA between 2007 and 2014 were identified and stratified by glomerular filtration rates (eGFR): eGFR > 125 mL/min, eGFR 90–125 mL/min, eGFR 60–90 mL/min, eGFR 30–60 mL/min, and eGFR 7 days, and unplanned return to the operating room, was assessed. The complication rates following rTHA were assessed with univariate and multivariate analysis with a significance set at p

Introduction: Revision total hip arthroplasty (rTHA) is becoming a more common procedure due to the increasing volume of primary total hip arthroplasty. Diabetes mellitus (DM) is currently projected to affect 4.4% of the global population by 2030. Diabetes has been associated with poor outcomes for a variety of surgical interventions. However, the impact of insulin dependence has yet to be fully understood. The aim of this study was to determine the impact of insulin dependence on acute postoperative complications following rTHA. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. All patients who underwent rTHA between 2006 and 2016 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM) or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after rTHA. Results: A total of 7685 patients were evaluated (No DM = 6651, NIDDM = 700, IDDM = 334). Univariate analysis revealed that all patients with DM had significantly higher incidences of postoperative complications (NIDDM: p Conclusions: Insulin dependence is an independent risk factor for numerous short-term postoperative complications following rTHA. When assessing risk and planning perioperative management, surgeons should consider insulin-dependent diabetics as a sub-cohort within the diabetic population.

BACKGROUND: A variety of classification systems have been developed to help surgeons treat patients with acetabular or femoral bone loss in total hip arthroplasty, yet no “gold standard” for classification has been agreed upon. Furthermore, the reliability and validity of the available classification systems remain unknown. QUESTIONS/PURPOSE: The aims of our study were to determine the reliability and validity of the three most common acetabular and femoral bone loss classification systems (Paprosky, American Academy of Orthopaedic Surgeons [AAOS], and Saleh and Gross). METHODS: A systematic review of the literature was performed to identify studies that reported on the reliability or validity (or both) of the acetabular and femoral components of the three bone loss classification systems. RESULTS: In all, seven articles met our inclusion criteria. Six studies reported on the reliability (all six studies) or validity (three studies) of acetabular bone loss rating systems (286 acetabula), and five analyzed reliability (all five studies) or validity (three studies) of femoral bone loss classification systems (364 femurs). In studies in which either the Paprosky or AAOS acetabular bone loss classifications were used, the classification systems were considered unreliable in 75% and 100% of them, respectively. On the femoral side, the Paprosky classification demonstrated moderate interobserver and good intraobserver reliability. The AAOS femoral bone classification was found to have good intraobserver reliability but poor interobserver reliability. The Saleh and Gross acetabular and femoral bone loss classification systems yielded mixed results, but each was considered reliable in one of the studies looking at these aspects of the systems. CONCLUSION: Although surgical techniques, treatment options, and advanced imaging available to the surgeon have evolved over the past few decades, the acetabular and femoral bone loss classification systems, first developed in the 1990s, have remained largely unchanged. Our results indicate that improvements to these systems are necessary in order for them to be as useful as possible in planning the surgical course.

Stiffness after total knee arthroplasty (TKA) remains a clinical challenge for health care professionals. Historically, arthroscopic arthrolysis is a treatment modality that has been reserved for patients that have failed other conservative modalities, including manipulation under anesthesia. However, a systematic review of the literature evaluating the clinical efficacy and complications of arthroscopic arthrolysis for stiffness after TKA has not been performed. A systematic review of medical databases (PubMed, EMBASE, Cochrane Library) was undertaken for articles published from January 1980 to October 2018. A descriptive and critical analysis of the results was performed. From 1,326 studies, 7 studies met the inclusion criteria for this study. A total of 160 patients who underwent arthroscopic arthrolysis for arthrofibrosis following TKA were included for analysis. The quality of the evidence for the included studies ranged between moderate and high. Overall, patients had significant increased range of motion and flexion by 32.5 and 26.7 degrees, respectively following arthroscopic arthrolysis. Functional outcome scores also significantly improved for patients who underwent arthroscopic arthrolysis after TKA. Arthroscopic arthrolysis is an efficacious modality for treatment of stiffness following TKA. The greatest benefit is seen among patients that present with significant loss of flexion. Arthroscopic arthrolysis should be reserved for patients that have previously failed more conservative modalities.

Aims The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Results Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Conclusion Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485–494.

Background: It has not been determined yet whether hip arthroscopy (HA) leads to adverse outcomes after total hip arthroplasty (THA). The purpose of this study was to (1) determine 2-year conversion rate of HA done for osteoarthritis (OA) to THA and (2) explore the relationship between HA performed in patients with hip osteoarthritis and the risk of revision THA within 2 years of index arthroplasty. Methods: Data was collected from the Medicare Standardized Analytic Files insurance database using the PearlDiver Patient Records Database from 2005–2016. Patients were stratified into 2 groups based upon a history of hip arthroscopy prior to THA. Results: The 2-year conversion to THA rate for hip arthroscopy in patients with OA was 68.4% (95% CI, 66.2–70.6%). Multivariate analysis demonstrated that OA patients who underwent HA prior to THA were at an increased risk of revision surgery (OR 3.72; 95% CI, 3.15–4.57; p = 0.012), periprosthetic joint infection (OR 1.86; 95% CI, 1.26–2.77, p = 0.010) and aseptic loosening (OR 2.81; 95% CI, 1.66–4.76; p Conclusions: Analysis of a large insurance database found the conversion rate from HA performed in Medicare OA patients to THA within 2 years is unacceptably high. Hip arthroscopy prior to THA also significantly increased the risk of THA revision within 2 years after index THA. These results suggest that arthroscopic hip surgery should not be performed in patients with a diagnosis of OA as conversion rates are high and revision rates post THA are significantly increased.

Background Considerable practice variability exists among orthopedic surgeons performing total knee arthroplasty (TKA). The purpose of this study is to understand what TKA surgical and perioperative techniques are standard among high-volume academic knee arthroplasty surgeons. Methods A written survey with 59 questions regarding management preferences in TKA was distributed by the 2018 John N. Insall Traveling Fellows to all arthroplasty-trained attending physicians at 13 medical centers, with 45 responses recorded. Results Surveyed surgeons performed unicompartmental knee arthroplasty (88%) and bilateral TKA (87%). Most surveyed surgeons rarely or never performed outpatient primary TKA (71%). Conventional alignment guides and cemented implants were used by 80% of respondents. Most surgeons used posterior-stabilized implants (67%), followed by cruciate-retaining (20%), ultracongruent (20%), and medial congruent or medial pivot designs (17.8%). Surveyed surgeons frequently or always resurfaced the patella (73%), used a tourniquet for the entire case (73%), and used tranexamic acid for all TKAs (91%). The most common locations for intra-articular anesthetic injection were the arthrotomy (91%), the periosteum (84%), and the medial posterior capsule (82%). Saline (62%) and dilute iodine (47%) were the most common irrigation fluids. The arthrotomy was most commonly closed with running barbed suture (60%) followed by interrupted vicryl (40%). Skin closure was predominantly with running monocryl (60%) followed by staples (29%). Anticoagulation for TKA was primarily aspirin 81 mg BID (60%). Conclusion There was considerable variability among surgeons polled although a strong preference for more conventional and less developmental techniques prevailed.

Several clinical trials have retrospectively evaluated the role of extended trochanteric osteotomy in two-stage total hip arthroplasty (THA) revision for the management of periprosthetic joint infection of the hip. However, no systematic review of the literature has been published to date to evaluate the clinical, functional, and radiographic outcomes of extended trochanteric osteotomy (ETOs) performed as part of implant removal during a two-stage revision for the management of periprosthetic joint infection (PJI). The US National Library of Medicine (PubMed/MEDLINE), and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to April 2019 using the following keywords: “extended” AND “trochanteric” AND “osteotomy.” Six studies included in this systematic review assessed 305 cases (281 patients) of PJI treated surgically with two-stage revision combined with ETO at the first stage. The mean overall union rate of the ETO was 97%, while the overall rate of radiographic femoral stem subsidence >5 mm was 5%. In addition, the overall mean infection-free rate of two-stage revision combined with ETO was 94% (288 out of 305 operated hips), while the overall complication rate requiring reoperation was 8% (26 out of 305 operated hips). Finally, there was some evidence to show that two-stage revision with ETO was associated with improved infection-free rates compared with two-stage revision without ETO. ETO seems safe and effective in patients with well-fixed femoral stems who require two-stage THA revision for the management of chronic PJI. Two-stage revision with ETO might result in improved infection-free rates compared with two-stage revision without ETO.

Recently, a variety of studies have analyzed the potential correlation between lumbar degenerative disease (LDD) and inferior clinical outcomes after total hip arthroplasty. However, there has been limited data concerning the role of LDD as a risk factor for failure after total knee arthroplasty (TKA). The aim of our study was to determine: (1) what is the association of LDDs with TKA failure (all-cause revision) within 2 years of index arthroplasty and (2) if patients with LDD and lumbar fusion are at increased risk of TKA revision within 2 years compared with LDD patients without fusion. Data were collected from the Humana insurance database using the PearlDiver database from 2007 to 2017. To assess aim 1, patients were stratified into two groups based on a prior history of LDD (International Classification of Diseases [ICD]-9 or -10 diagnostic codes). To analyze aim 2, patients within the LDD cohort were stratified based on the presence of lumbar fusion (lumbar fusion Current Procedural Terminology code). All-cause revision rate was 3.4% among LDD patients versus 2.4% of patients with non-LDD (p

The objective was to evaluate if the use of CA-THA was associated with lower complications in the first 90 days following THA compared with conventional THA. The Nationwide Readmission Database (NRD) was queried to identify patients who underwent THA between 2012 and 2014. The primary outcome was arthroplasty-related complications within the first 90 days following THA. Multivariate models predicting the risk of complications, readmission, and revision-related readmission within 90 days of discharge were created. A total of 309,252 patients with a minimum 90-day follow-up following elective primary THA were identified. After controlling for age, sex, comorbidities, indication, income, and type of insurance, the use of CA during THA resulted in a 12% reduced odds of 90-day complications (OR 0.88, 95% CI 0.77–0.99, p = 0.04). The use of CA-THA resulted in lower 90-day complication rates and readmission rates compared with traditional THA after controlling for confounding variables. There was no significant difference in the rates of revision surgery between the groups within the first 90 days.