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Background: The American Academy of Orthopaedic Surgeons defined the acceptable threshold for elective safe surgery as a body mass index (BMI) under 40 due to the increased risk of complications. A consequence of this recommendation has been a hard cutoff based on BMI, which restricts access to care for an increasingly large and diverse population. There is an improved understanding that excess adipose tissue confers additional risk for postoperative complications, including infection, through mechanical and physiologic mechanisms. But, it is unclear if BMI is an accurate indicator of adiposity in total joint arthroplasty (TJA) patients and, thus, whether BMI is capturing clinically relevant information in obese patients. Our objective was to determine the relationship between peri-incisional adiposity (PIA) and BMI in a consecutive series of diverse primary TJA patients., Methods: A consecutive series of patients indicated for primary TJA were preoperatively evaluated. For each patient, the following variables were collected: BMI and measures of PIA on radiographs and ultrasounds., Results: In THA patients (N = 99), Pearson's correlation coefficient (r) = 0.436, which indicates a moderate correlation between BMI and adiposity. In total knee arthroplasty patients (N = 271), r = 0.395 for femoral PIA (FPIA) and r = 0.249 for tibial PIA, which indicates a weak correlation between BMI and adiposity measured on radiography. In total knee arthroplasty patients, r = 0.560 for femoral PIA and r = 0.544 for tibial PIA, which indicates a moderate correlation between BMI and adiposity measured on ultrasound., Conclusions: Quantification of obesity has become a common practice in the preoperative evaluation of primary TJA patients. The intent is to determine the magnitude of adipose tissue, which is one of the main drivers of postoperative complications in obesity. The BMI is ubiquitously used as a proxy for obesity due to its simplicity of attainment and calculation. We report that BMI has a weak-to-moderate association with PIA in this population. These findings indicate that BMI may not accurately represent the condition of peri-incisional adipose tissue and, thus, is not capturing the relevant obesity data for preoperative risk stratification in primary TJA patients., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Leg length discrepancy (LLD) following total knee arthroplasty (TKA) is a common complaint, leading to decreased patient satisfaction. However, the effect of LLD diagnosis prior to TKA on outcomes and complications is not well defined. Thus, this study aimed to assess the effects that LLD has on rates of falls and implant complications, length of stay and readmissions, and implant survivorship following TKA., Methods: A retrospective review of a private insurance claims database was conducted from 2010 to 2021. All cases of TKA and those with a diagnosis of leg length discrepancy were identified. Patients undergoing TKA with a diagnosis of LLD were matched to control patients 1:5 based on demographic and comorbidity profiles. Two-year fall rates and implant complications, lengths of stay, 90-day readmissions, and time to revision were compared between cohorts., Results: A total of 1,378 LLD patients were matched to 6,889 control patients. The LLD group had significantly higher rates of falls, dislocation, mechanical loosening, periprosthetic fracture, and fibrosis when compared to the control group (all P < 0.01). Additionally, mean length of stay was significantly greater in the LLD group (4.9 days vs. 3.0 days, P < 0.001). There was no significant difference in 90-day readmission rates between groups (P = 0.178). Time to revision was significantly shorter in the LLD group (392 days vs. 928 days, P < 0.001)., Conclusions: Leg length discrepancy in patients undergoing TKA was associated with significantly increased fall risk, rates of implant complications, length of stay, and faster time to revision. The findings of this study may allow orthopedic surgeons to identify those patients at risk and allow for more educated patient counseling and operative planning., Level of Evidence: III, retrospective case-control study., (© 2024. The Author(s).)

Background: Dual-mobility (DM) total hip arthroplasty (THA) combines the stabilization advantage provided by large head articulation with the low friction advantage provided by small head articulation. There is momentum for DM to be used in a wider selection of patients, with some advocating for DM to be the routine primary total hip construct. Further investigation is needed to determine whether the use of DM in younger adults is validated by aggregate data. Our objective was to review the literature for the clinical performance of DM THA in patients aged 55 years and younger., Methods: A systematic review of the literature was performed according to the guidelines of Preferred Reporting in Systematic Reviews and Meta-Analyses. Inclusion in the review required clinical outcome reporting for DM primary THA in ambulatory patients aged 55 years or younger. The risk of bias was appraised using the Cochrane risk of bias in nonrandomized studies of interventions and the quality of the evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation framework., Results: Across a sample of 1048 cases, the frequency weighted term of follow-up was 87.7 months. The pooled rate of revision was 9.5%. The Harris Hip Score significantly improved from 49.1 preoperatively to 93 postoperatively. The Postel-Merle d'Aubigné score significantly improved from 10.5 preoperatively to 17.1 postoperatively., Conclusions: The literature demonstrates satisfactory short-term outcomes with a mitigated risk of dislocation for DM used as primary THA in patients aged 55 years and younger. The current findings suggest that third-generation designs provide reduced rates of intraprosthetic dislocation and improved survivorship., (© 2023 The Authors.)

Purpose: Improved understanding of the factors that predispose TKA patients to infection has considerable economic and medical impact. BMI is commonly used as a proxy for obesity to determine the risk of postoperative infection. However, this metric appears to be fraught with inconsistency in this application. BMI is a simple calculation which provides general insight into body habitus. But it fails to account for anatomic distribution of adipose tissue and the proportion of the mass that is skeletal muscle. Our objective was to review the literature to determine if local adiposity was more predictive than BMI for infection following TKA., Methods: A database search was performed for the following PICO (Population, Intervention, Comparison, and Outcome) characteristics: local measurements of adiposity (defined as soft tissue thickness or fat thickness or soft tissue envelope at the knee) in patients over 18 years of age treated with total knee arthroplasty used to determine the relationship between local adiposity and the risk of infection (defined as prosthetic joint infection or wound complication or surgical site infection). Quality was assessed using the GRADE framework and bias was assessed using ROBINS-I ., Results: Six articles (N=7081) met the inclusion criteria. Four of the six articles determined that adiposity was more associated with or was a better predictor for infection risk than BMI. One of the six articles concluded that increased adiposity was protective for short term infection and that BMI was not associated with the outcome of interest. One of the six articles determined that BMI was more strongly associated with PJI risk than soft tissue thickness., Conclusion: The use of adiposity as a proxy for obesity in preoperative evaluation of TKA patients is an emerging concept. Although limited by heterogeneity, the current literature suggests that local adiposity may be a more reliable predictor for infection than BMI following primary TKA., Level of Evidence: IV systematic review., (© 2023. The Author(s).)

Irreparable rotator cuff tears in young patients can be challenging for the patient and orthopaedic surgeon. Interposition rotator cuff reconstruction has gained popularity in patients with retracted tears and a viable rotator cuff muscle belly. Superior capsular reconstruction is an emerging treatment option that was developed to restore native glenohumeral joint mechanics by creating a superior constraint, which provides a stable glenohumeral fulcrum. Reconstructing both the superior capsule and rotator cuff tendon in the setting of an irreparable tear may improve clinical results in younger patients with viable rotator cuff muscle belly and a maintained acceptable acromiohumeral distance., (© 2023 The Authors.)

Introduction: Preoperative optimization of obese patients is a critical component of risk stratification in primary total hip arthroplasty (THA). Body mass index is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. The use of adiposity as a proxy for obesity is an emerging concept. Local adiposity provides insight into the magnitude of peri-incisional tissue and has demonstrated an association with postoperative complications. Our objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty., Methods: In keeping with the PRISMA guidelines, a database search of PubMed was conducted for articles which reported on the relationship between quantified measures of adiposity at the hip and rates of complication following primary THA. Methodological quality was assessed using GRADE and risk of bias using ROBINS-I., Results: A total of six articles (N = 2931) met the inclusion criteria. Local adiposity at the hip was measured on anteroposterior radiograph in four articles and was measured intraoperatively in two. Across four of the six articles, adiposity was significantly associated with postoperative complications including prosthesis failure and infection., Conclusion: The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in preoperative THA risk stratification. The current findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA., Competing Interests: The authors declare no potential conflicts of interests with respect to the research, authorship, and/or publication of this article., (©2023ProfessorPKSurendranMemorialEducationFoundation.PublishedbyElsevierB.V.)