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Background: Modular fluted tapered (MFT) femoral components are frequently utilized in aseptic revision total hip arthroplasties (THAs). However, long-term follow-up has been limited. The purpose of this study was to update our prior series at long-term follow-up, with specific emphasis on implant survivorship, radiographic results, and complications in a large cohort of aseptic revision THAs using MFT stems. Methods: We retrospectively identified 515 aseptic femoral revisions performed with 2 MFT stem designs in the total joint registry of a single tertiary care academic institution from 1999 to 2013. Serial radiographs were reviewed for subsidence of >5 mm. The mean follow-up (and standard deviation) was 10 ± 5 years (range, 2 to 21 years). A competing risk model accounting for death was utilized. Results: The 15-year cumulative incidence of any revision was 12%. There were 57 revisions, 27 of which involved revision of the fluted tapered component (FTC). Dislocation (n = 19), periprosthetic joint infection (n = 15), and aseptic loosening of the FTC (n = 11) were the most common reasons for revision. The 15-year cumulative incidence of any reoperation was 16%. The 15-year cumulative incidences were 6% for any FTC revision and 2% for FTC revision for aseptic loosening. Stem subsidence of >5 mm occurred in 2% of unrevised cases, and all but 1 stem was stable at the most recent follow-up. Conclusions: This large series of MFT stems used in aseptic revision THAs had a 2% incidence of subsequent revision of the FTC for aseptic loosening at 15 years. Dislocation and infection were the most common reasons for any revision. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Many risk factors have been described for dislocation following total hip arthroplasty (THA), yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to develop a high-dimensional, patient-specific risk-stratification nomogram that allows dynamic risk modification based on operative decisions.Methods: In this study, 29,349 THAs, including 21,978 primary and 7371 revision cases, performed between 1998 and 2018 were evaluated. During a mean 6-year follow-up, 1521 THAs were followed by a dislocation. Patients were characterized, through individual-chart review, according to non-modifiable factors (demographics, indication for THA, spine disease, prior spine surgery, and neurologic disease) and modifiable operative decisions (operative approach, femoral head diameter, and type of acetabular liner [standard, elevated, constrained, or dual-mobility]). Multivariable regression models and nomograms were developed with dislocation as a binary outcome at 1 year and 5 years postoperatively.Results: Dislocation risk, based on patient-specific comorbidities and operative decisions, was wide-ranging-from 0.3% to 13% at 1 year and from 0.4% to 19% at 5 years after primary THA, and from 2% to 32% at 1 year and from 3% to 42% at 5 years after revision THA. In the primary-THA group, the direct anterior approach (hazard ratio [HR] = 0.27) and lateral approach (HR = 0.58) decreased the dislocation risk compared with the posterior approach. After adjusting for the approach in that group, the combination of a ≥36-mm-diameter femoral head and an elevated liner yielded the largest decrease in dislocation risk (HR = 0.28), followed by dual-mobility constructs (HR = 0.48). In the patients who underwent revision THA, the adjusted risk of dislocation was most markedly decreased by the use of a dual-mobility construct (HR = 0.40), followed by a ≥36-mm femoral head and an elevated liner (HR = 0.88). The adjusted risk of dislocation after revision THA was decreased by acetabular revision (HR = 0.58), irrespective of whether other components were revised.Conclusions: Our patient-specific dislocation risk calculator, which was strengthened by our use of a robust multivariable model that accounted for comorbidities associated with instability, demonstrated wide-ranging patient-specific risks based on comorbidity profiles. The resultant nomograms can be used as a screening tool to identify patients at high risk for dislocation following THA and to individualize operative decisions for evidence-based risk mitigation.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia provides several benefits for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), but historically comes at the cost of slow and unpredictable return of lower-extremity motor function related to the use of long-acting local anesthetics. In this prospective, double-blinded, randomized clinical trial we sought to determine if an alternative local anesthetic, mepivacaine, would allow more consistent return of motor function compared with low-dose bupivacaine spinal anesthesia during primary THA and TKA.Methods: This trial was conducted at a single academic institution. Prior to trial initiation an internal pilot study determined that 154 patients were required to achieve 80% power. Patients were randomized in a 1:1 fashion with use of advanced computerized stratification based on procedure, age group, sex, and body mass index. Following the surgical procedure, motor function was assessed every 15 minutes in the nonoperative lower extremity according to the Bromage scale and discontinued once Bromage 0 was achieved (spontaneous movement at hip, knee, and ankle).Results: Return of lower-extremity function was more predictable in patients who received mepivacaine than in those who received low-dose bupivacaine. Among patients who received mepivacaine, 1% achieved motor function return beyond 5 hours compared with 11% of patients who received bupivacaine (p = 0.013). The mean time to return of lower-extremity motor function was 26 minutes quicker in patients who received mepivacaine (185 minutes; 95% confidence interval, 174 to 196 minutes) compared with low-dose bupivacaine (210 minutes; 95% confidence interval, 193 to 228 minutes) (p = 0.016). There were no significant differences in safety outcomes including pain scores, time to participation in physical therapy, incidence of orthostatic hypotension, urinary retention, or transient neurologic symptoms in patients receiving mepivacaine compared with low-dose bupivacaine.Conclusions: In patients undergoing primary THA and TKA, spinal anesthesia with mepivacaine allowed more consistent return of lower-extremity motor function compared with low-dose bupivacaine, without a concomitant increase in complications potentially associated with spinal anesthetics. This is particularly of value in an era of short-stay and outpatient surgical procedures.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Long-term mortality after primary THA is lower than in the general population, but it is unknown whether this is also true after revision THA.Questions/purposes: We examined (1) long-term mortality according to reasons for revision after revision THA, and (2) relative mortality trends by age at surgery, years since surgery, and calendar year of surgery.Methods: This retrospective study included 5417 revision THAs performed in 4532 patients at a tertiary center between 1969 and 2011. Revision THAs were grouped by surgical indication in three categories: periprosthetic joint infections (938; 17%); fractures (646; 12%); and loosening, bearing wear, or dislocation (3833; 71%). Patients were followed up until death or December 31, 2016. The observed number of deaths in the revision THA cohort was compared with the expected number of deaths using standardized mortality ratios (SMRs) and Poisson regression models. The expected number of deaths was calculated assuming that the study cohort had the same calendar year, age, and sex-specific mortality rates as the United States general population.Results: The overall age- and sex-adjusted mortality was slightly higher than the general population mortality (SMR, 1.09; 95% CI, 1.05-1.13; p < 0.001). There were significant differences across the three surgical indication subgroups. Compared with the general population mortality, patients who underwent revision THA for infection (SMR, 1.35; 95% CI, 1.24-1.48; p < 0.001) and fractures (SMR, 1.23; 95% CI, 1.11-1.37; p < 0.001) had significantly increased risk of death. Patients who underwent revision THA for aseptic loosening, wear, or dislocation had a mortality risk similar to that of the general population (SMR, 1.01; 95% CI, 0.96-1.06; p = 0.647). The relative mortality risk was highest in younger patients and declined with increasing age at surgery. Although the relative mortality risk among patients with aseptic indications was lower than that of the general population during the first year of surgery, the risk increased with time and got worse than that of the general population after approximately 8 to 10 years after surgery. Relative mortality risk improved with time after revision THA for aseptic loosening, wear, or dislocation.Conclusions: Shifting mortality patterns several years after surgery and the excess mortality after revision THA for periprosthetic joint infections and fractures reinforce the need for long-term followup, not only for implant survival but overall health of patients having THA.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Modular fluted tapered stems have become the most commonly employed category of femoral component in revision hip arthroplasty in North America as a result of favorable early results and simplicity of use. Despite wide adoption, the majority of published data are limited to relatively small series with modest follow-up. The goal of the current study was to determine the success rate and factors associated with success, failure, and complications of the use of modular fluted tapered stems in aseptic revision total hip arthroplasties (THAs) in a large patient cohort.Methods: We identified 519 aseptic femoral revisions during which a modular fluted tapered stem was utilized. Clinical outcomes, Kaplan-Meier survivorship, radiographic outcomes, and complications were assessed. The mean age at revision arthroplasty was 70 years, the mean body mass index (BMI) was 29 kg/m, and the mean duration of follow-up was 4.5 years (range, 2 to 14 years).Results: The mean Harris hip score (HHS) improved significantly from 51 points preoperatively to 76 points at 2 years (p < 0.001). This improvement was maintained at the last follow-up evaluation (mean HHS = 75 points). At the time of the most recent follow-up, 16 femoral revisions had been performed: 6 because of aseptic loosening, 4 because of infection, 3 because of instability, 2 because of periprosthetic fracture, and 1 because of stem fracture. The 10-year survivorship was 96% with revision for any reason as the end point and 90% with any reoperation as the end point. Of the patients who were alive and had not undergone revision at the time of final follow-up, 12 had stem subsidence but all but 1 of these stems had stabilized after subsiding. Postoperative complications were noted in 12% of the cases. Repeat revision due to femoral component loosening was not correlated with the preoperative bone-loss category or patient demographic factors.Conclusions: In this large series, femoral revision with a modular fluted tapered stem provided a high rate of osseointegration and sustained improvement in clinical scores at the time of the last follow-up. There was also a high rate of successful implant fixation across all categories of preoperative bone loss and an acceptable rate of complications.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Despite the large increase in total hip arthroplasties and total knee arthroplasties, the incidence and prevalence of additional contralateral or ipsilateral joint arthroplasty are poorly understood. The purpose of this study was to determine the rate of additional joint arthroplasty after a primary total hip arthroplasty or total knee arthroplasty.Methods: This historical cohort study identified population-based cohorts of patients who underwent primary total hip arthroplasty (n = 1,933) or total knee arthroplasty (n = 2,139) between 1969 and 2008. Patients underwent passive follow-up through their medical records beginning with the primary total hip arthroplasty or total knee arthroplasty. We assessed the likelihood of undergoing a subsequent total joint arthroplasty, including simultaneous and staged bilateral procedures. Age, sex, and calendar year were evaluated as potential predictors of subsequent arthroplasty.Results: During a mean follow-up of 12 years after an initial total hip arthroplasty, we observed 422 contralateral total hip arthroplasties (29% at 20 years), 76 contralateral total knee arthroplasties (6% at 10 years), and 32 ipsilateral total knee arthroplasties (2% at 20 years). Younger age was a significant predictor of contralateral total hip arthroplasty (p < 0.0001), but not a predictor of the subsequent risk of total knee arthroplasty. During a mean follow-up of 11 years after an initial total knee arthroplasty, we observed 809 contralateral total knee arthroplasties (45% at 20 years), 31 contralateral total hip arthroplasties (3% at 20 years), and 29 ipsilateral total hip arthroplasties (2% at 20 years). Older age was a significant predictor of ipsilateral or contralateral total hip arthroplasty (p < 0.001).Conclusions: Patients undergoing total hip arthroplasty or total knee arthroplasty can be informed of a 30% to 45% chance of a surgical procedure in a contralateral cognate joint and about a 5% chance of a surgical procedure in noncognate joints within 20 years of initial arthroplasty. Increased risk of contralateral total knee arthroplasty following an initial total hip arthroplasty may be due to gait changes prior to and/or following total hip arthroplasty. The higher prevalence of bilateral total hip arthroplasty in younger patients may result from bilateral disease processes that selectively affect the young hip, such as osteonecrosis, or structural hip problems, such as acetabular dysplasia or femoroacetabular impingement.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Maintaining robust perfusion is an important physiologic parameter in wound healing. The effect of different closure techniques on wound perfusion after total knee arthroplasty (TKA) has not been established previously and may have implications for wound healing.Questions/purposes: We asked whether a running subcuticular, vertical mattress, or skin staple closure technique enables the most robust wound perfusion after TKA as measured by laser-assisted indocyanine green angiography (LA-ICGA) in patients without specific risk factors for wound healing complications.Methods: Forty-five patients undergoing primary TKA without comorbidities known to impact wound healing and perfusion were prospectively randomized to receive superficial skin closure with one of the following techniques: (1) running subcuticular (3-0 monofilament); (2) vertical mattress (2-0 nylon); or (3) skin staples. Twenty procedures were performed by RTT, 15 by RJS, and 10 by FHS. All surgeons used an anterior skin incision over the medial third of the patella in combination with a median parapatellar arthrotomy. Perfusion was assessed with a LA-ICGA device and software system immediately after closure to quantify fluorescence. Twenty-seven points were assessed immediately after closure in the operating room in each patient (nine along the incision and nine pairs medial and lateral to the incision). Mean incision perfusion was determined from the nine points along the incision with higher values indicating greater blood flow. Mean perfusion impairment was determined by calculating the difference between the nine pairs of surrounding skin and the nine points along the incision with smaller values indicating less perfusion impairment. These parameters were compared with analysis of variance (ANOVA) and subsequent pairwise comparisons with an unadjusted analysis as well as a multivariate analysis that adjusted for age, sex, and body mass index. Patients were followed for a mean of 7 months after surgery (range, 3-12 months) for possible incision-related complications. No patents were lost to followup.Results: Running subcuticular closure demonstrated the best overall perfusion. Mean incision perfusion in fluorescent units with SD was as follows: running subcuticular, 64 (16); vertical mattress, 32 (18); and staples, 19 (7) (ANOVA p < 0.001). The running subcuticular closure demonstrated the least impairment of perfusion among the closures compared. Mean perfusion impairment was as follows: running subcuticular, 21 (12); vertical mattress, 37 (24); and staples, 69 (27) (ANOVA p < 0.001). All Tukey-adjusted pairwise comparisons from both metrics likewise favored the subcuticular closure (p < 0.001) both before and after adjusting for age, sex, and body mass index. One patient in the vertical mattress cohort experienced a surgical site infection; no other wound-related complications were observed in this study.Conclusions: The method of closure can influence skin and soft tissue perfusion after TKA. Running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing. However, the clinical importance of these findings remains uncertain, because patients in this study were selected because they lacked risk factors for wound healing complications. Studies with this modality in specific patient populations at higher risk for wound complications will be necessary to quantify the clinical advantage of using running subcuticular closure.Level Of Evidence: Level I, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Descriptive epidemiology of total joint replacement procedures is limited to annual procedure volumes (incidence). The prevalence of the growing number of individuals living with a total hip or total knee replacement is currently unknown. Our objective was to estimate the prevalence of total hip and total knee replacement in the United States. Methods: Prevalence was estimated using the counting method by combining historical incidence data from the National Hospital Discharge Survey and the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases from 1969 to 2010 with general population census and mortality counts. We accounted for relative differences in mortality rates between those who have had total hip or knee replacement and the general population. Results: The 2010 prevalence of total hip and total knee replacement in the total U.S. population was 0.83% and 1.52%, respectively. Prevalence was higher among women than among men and increased with age, reaching 5.26% for total hip replacement and 10.38% for total knee replacement at eighty years. These estimates corresponded to 2.5 million individuals (1.4 million women and 1.1 million men) with total hip replacement and 4.7 million individuals (3.0 million women and 1.7 million men) with total knee replacement in 2010. Secular trends indicated a substantial rise in prevalence over time and a shift to younger ages. Conclusions: Around 7 million Americans are living with a hip or knee replacement, and consequently, in most cases, are mobile, despite advanced arthritis. These numbers underscore the substantial public health impact of total hip and knee arthroplasties. [ABSTRACT FROM AUTHOR]