Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Marfan Syndrome.

BACKGROUND: Outcomes of Marfan syndrome (MFS) patients after total knee arthroplasty (TKA) are poorly documented in the literature. The purpose of this study was to evaluate MFS as a potential risk factor for complications after TKA. METHODS: Using a national private payer insurance database from 2010 to 2022, MFS patients undergoing primary TKA were identified and compared to 10:1 matched controls based on age, sex, obesity, diabetes mellitus, and a comorbidity index. A total of 4,092 patients undergoing primary TKA were analyzed, of which 372 had MFS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department-visits and inpatient readmissions were also documented. RESULTS: Compared to the matched controls, patients who have MFS displayed elevated rates of surgical complications, including prosthetic instability (1-year, odds ratio (OR) 3.88, 95% confidence interval (CI) [1.58 to 8.66]; 2-year, OR 4.39, 95% CI [2.16 to 8.44]), and revision surgery (2 year, OR 1.79, 95% CI [1.05 to 2.91]). Additionally, patients who have MFS demonstrated significant higher rates of medical complications, including aortic dissection (2.15 versus 0%) and transfusion (OR 2.63, 95% CI [1.31 to 4.90]). CONCLUSIONS: Patients who have MFS are at higher risks of postoperative complications after TKA, encompassing both medical and surgical complications. Specifically, patients who have MFS have a significantly higher likelihood of experiencing prosthetic instability and requiring revision surgery. Given these results, it is crucial for orthopedic surgeons and patients alike to consider these risks when determining a course of TKA for patients who have MFS.

Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty.

BACKGROUND: New technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors' COI and industry funding would be associated with conclusions favorable to a new technology. METHODS: Economic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher's exact test was utilized to determine the relationship between the presence of COI and an article's conclusions. RESULTS: Of 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher's exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author's COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003). CONCLUSIONS: Financial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.

Risks Following Total Knee Arthroplasty in Patients Who Have Antiphospholipid Syndrome.

BACKGROUND: Antiphospholipid syndrome (APS) is recognized as a thrombophilic autoimmune condition characterized by a tendency to develop venous thromboembolism. Total knee arthroplasty (TKA) is a prevalent procedure in patients who have advanced knee arthritis. Notably, TKA is unequivocally considered a thrombotic risk factor. However, outcomes of APS patients after TKA are still poorly documented in literature. The purpose of this study was to evaluate APS as a potential risk factor for complications after TKA. METHODS: Using the PearlDiver Mariner database from 2010 to 2022, APS patients undergoing primary TKA were identified and compared to 10:1 matched control based on age, sex, and relevant comorbidities. A total of 7,478 patients undergoing primary TKA were analyzed, of which 683 had APS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications including revision up to 2 years. Ninety-day emergency department visit and inpatient readmission were also documented. RESULTS: Within 90 days after TKA, patients who have APS exhibited higher rates of cerebrovascular accident (adjusted odds ratio 2.04, 95% confidence interval 1.12 to 3.57; P = .014) and deep vein thrombosis (adjusted odds ratio 2.87, 95% confidence interval 1.99 to 4.06; P < .001) as compared to matched controls. No difference in surgical or nonthrombotic medical complications was observed between 2 cohorts. CONCLUSIONS: There were significantly higher rates of stroke and deep vein thrombosis in APS patients. Our study did not find statistical differences in other surgical complications or readmissions between the 2 groups. Orthopaedic surgeons should consider appropriate prophylaxis of thrombosis in this patient population undergoing TKA perioperatively.

The Impact of Robotic-Assisted Total Knee Arthroplasty on Resident Training.

BACKGROUND: As robotic-assisted total knee replacement (rTKA) continues to gain popularity, the impact of this technology on resident education remains unknown. The purpose of this study was to describe trainee experience and perceptions of rTKA and its effect on surgical training. METHODS: Two hundred and twenty two senior orthopaedic residents attending a national board review course completed a 17-question survey regarding their experience and perceptions regarding rTKA. Mean and standard deviations were calculated for Likert scale questions, and bivariate analyses were utilized to compare answer groups. RESULTS: Seventy percent of respondents reported exposure to rTKA during their training. Of those with robotic exposure, 20% reported that greater than half of their TKA experience involved robotics. Only 29% percent agreed that robotics improved outcomes, whereas 21% disagreed and the remainder were unsure. Over half of respondents agreed that robotics are used primarily for marketing purposes. Of those who trained with rTKA, 45% percent believed that robotics improved their understanding of the surgical procedure; however, 25% felt robotics negatively compromised their training with traditional instrumentation. Higher robotic case exposure (P = .001) and attending an industry-sponsored course (P = .02) was associated with the belief that robotics improved outcomes. Robotic case volume and percentage was associated with the belief that robotics improved understanding of the surgical procedure, however, it also was associated with reduced comfort performing traditional knee arthroplasty (P = .001). CONCLUSION: Current resident training experience varies greatly within the United States with regards to rTKA. While exposure to rTKA may be beneficial for a well-rounded surgical education, over-exposure likely results in decreased comfort with traditional instrumentation.

The impact of Behcet syndrome on total knee arthroplasty outcomes: a retrospective matched cohort study.

PURPOSE: Articu lar involvement is a common manifestation of Behcet syndrome (BS), which can eventually result in significant arthralgia and necessitate total knee arthroplasty (TKA). However, outcomes of BS patients after TKA are still poorly documented in the literature. The purpose of this study was to evaluate BS as a potential risk factor for complications after TKA. METHODS: BS patients undergoing primary TKA were identified from the PearlDiver Mariner database from 2010 to 2021 and compared to 10:1 matched controls. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. Ninety-day emergency department (ED) visit and inpatient readmission were also documented. RESULTS: A total of 4286 patients undergoing primary TKA were queried, of which 390 had BS. Patients with BS demonstrated significantly higher rates of medical complications, including deep venous thrombosis. The rates of surgical complications were similar between the two groups with the exception of periprosthetic instability, aseptic loosening, and wound complications in BS patients. Additionally, a significantly higher rate of ED visits but markedly lower rates of 90-day readmissions were noted in patients with BS. CONCLUSION: Patients with BS undergoing TKA are at higher risks of medical and surgical complications. Special considerations for a unique postoperative course with the higher complications should be made. It is crucial for orthopedic surgeons and patients alike to consider these risks when determining the expected course after TKA for patients with BS.

Are We Training Surgeons to Cement a Femoral Component in Hip Arthroplasty? The Trainees' Perspective.

BACKGROUND: The importance of surgical technique is widely recognized when cementing a femoral component in hip arthroplasty. Concern exists that surgeon trainees in the United States are not being adequately trained in cement technique. The purpose of this study is to describe recent trainees' perceived experience with their training in this skill. METHODS: Orthopedic graduate candidates attending a national board review course were polled with an anonymous 15-question survey regarding their experiences during training with cemented femoral components. Means and standard deviations were calculated for Likert scale questions, and univariate statistics were used to compare answers for select questions. RESULTS: A total of 152 surveys were completed. Ninety percent of respondents anticipated that they would be performing hemiarthroplasty for fracture in their future practice, 99% of whom anticipated using cement for stem fixation in at least some of these cases. Only a minority of respondents planned further training in an adult reconstruction fellowship (21%). Only 37% of residents perceived their training in cement technique to be comprehensive or very comprehensive, with 17% reporting that their training was inadequate or nonexistent. Forty percent reported being less than satisfied with their training. Although 96% of residents felt prepared to implant a cementless femoral component, only 82% felt adequately trained to properly cement a femoral implant. Feeling prepared to perform a well done cemented femoral stem correlated with higher percentage of cemented stems in training and higher satisfaction with training (both P = .001). CONCLUSION: Although most trainees feel prepared to cement a femoral component, many young surgeons do not perceive that they are receiving adequate training in femoral cement technique.

Clinical Outcomes After Stage-One Antibiotic Coated Molded Hip Spacer.

BACKGROUND: Two-stage exchange remains the gold standard for managing periprosthetic joint infection (PJI). We evaluated the outcomes of patients treated with a specific molded articulating antibiotic hip spacer for PJI at a tertiary referral center. METHODS: An institutional database was retrospectively queried for patients who underwent implantation of spacer between 2009-2019. Patient demographics and clinical outcomes were collected. RESULTS: We identified 88 patients at an average age of 60.4 years who received a spacer implant, with an average of 4.2 years follow-up (standard deviation [SD] 2.5 years). A total of 34 patients (38.6%) had a "clean" two-stage course with successful reimplantation and no evidence of infection at 1-year follow-up. The remaining patients (61.4%) required 3.67 (±0.52) additional surgeries. Overall reimplantation rate was 72%. Causative bacterial agents included MSSA (n = 22), MRSA (n = 16), coagulase-negative Staphylococcus (n = 14), and polymicrobial (n = 12). Regarding complications, there were 13 (15%) dislocations, 16 (18%) periprosthetic fractures, 8 (9%) bent/fractured stems, and 16 (18%) patients had clinically significant subsidence. Patients with previous extended trochanteric osteotomy (ETO) experienced higher rates of bent/broken spacer stems (25% vs 3.1%; P = .006) periprosthetic fractures (37.5% vs 10.9%; P = .010), and dislocations (37.5% vs 6.2%; P = .001). The rate of infection clearance was lower in the prior ETO cohort (26.6% vs 54.2%; P = .029). CONCLUSION: We report outcomes in patients who underwent implantation of a specific molded articulating hip spacer at our institution. Infection eradication was roughly in line with published series of hip PJI treatment. There was a high rate of mechanical complications, especially in those patients who required an ETO.

Open reconstruction with autologous spongiosa grafts and matrix-induced chondrogenesis for osteochondral lesions of the talus can be performed without medial malleolar osteotomy.

PURPOSE: To evaluate complication rates and postoperative outcomes in patients with osteochondral lesions of the talus who underwent an autologous matrix-induced chondrogenesis (AMIC) procedure with autologous spongiosa grafting without malleolar osteotomy. METHODS: A total of 23 patients with a mean age of 35.6 ± 13.9 years were included in this study. The mean follow-up was 33.5 ± 10.4 months (range 24-52.9 months). The clinical outcomes were evaluated using the visual analog scale (VAS) and the Foot Function Index (FFI). Postoperatively, lesion healing was assessed using the magnetic resonance observation of cartilage repair tissue (MOCART) protocol. RESULTS: There were no intraoperative or perioperative complications. In one patient, arthroscopic arthrolysis was performed due to painful arthrofibrosis. The mean VAS significantly decreased from 7.6 ± 1.1 (range 4.2-9.3) to 1.4 ± 2.2 (range 0-7.4) (P < 0.001). The mean FFI significantly improved from 46.8 ± 14.3 (range 24.3-80.8) to 15.9 ± 11.4 (range 10.0-51.7) (P < 0.001). The mean MOCART score at 1-year follow-up was 74.1 ± 12.4 (range 50-95). Both preoperative and postoperative pains were significantly higher for smokers when compared to non-smokers. CONCLUSIONS: The results of the present study study indicate that AMIC procedure can be performed through the anterolateral and anteromedial arthrotomy without malleolar osteotomy. Thus, the possible complications associated with malleolar osteotomy can be avoided. The AMIC procedure without a malleolar osteotomy can be considered a safe and reliable procedure in patients with osteochondral lesions localized anterior to the midline in the sagittal plane. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Fracture of a 40-mm BIOLOX Delta Femoral Head.

Ceramic bearing surfaces have gained popularity in total hip arthroplasty as a result of the favorable mechanical properties and low wear rates. Despite the recognition as an attractive articulation, problems such as ceramic head fracture persist. Smaller heads and higher body mass indices are touted as risk factors for ceramic head fracture and are often associated with antecedent trauma. We present a case report of an 83-year-old male with a body mass index of 26.7 kg/m2 who suffered a fracture of a 40-mm ceramic femoral head. This occurred atraumatically 5 years from his index surgery. This patient underwent revision total hip arthroplasty which included debridement of ceramic debris and alteration of the bearing surface with femoral head and polyethylene liner exchange.

Arthroscopic Femoral Osteochondroplasty for Cam-type Femoroacetabular Impingement: Cortical-Cancellous Sclerotic Boundary Guides Resection Depth.

Hip arthroscopy and femoral osteochondroplasty are commonly used in the treatment of femoroacetabular impingement (FAI). Determining the correct resection depth of the femoral head-neck cam lesion intraoperatively can be challenging. Both inadequate resection and over-resection may result in complications, underlying the importance of using a consistent and accurate technique when resecting and reshaping the proximal femur. Osseous resection to a depth of the subchondral cortical-cancellous bone margin in individuals with FAI has been shown to restore proximal femoral anatomy to within submillimeter differences when compared with control subjects without FAI. This bony boundary may be used as an intraoperative guide to consistently achieve appropriate resection depth. The sclerotic margin indicating the extent of the cam-type deformity can be evaluated with preoperative radiographs and recreated fluoroscopically, giving the surgeon a reliable intraoperative template. In addition, changes in clinical appearance during arthroscopy, particularly identification of the underlying trabecular structure at the cortical-cancellous border during resection, provides a visible, reliable intraoperative guide to resection depth.

Disassociation of a Cold-Welded Bimodular Titanium Femoral Stem by Intraoperative Ice Cooling.

Modularity in total hip arthroplasty allows a surgeon to have intraoperative versatility, allowing for fine adjustments of the femoral offset, leg length, and version. However, modularity can be a source of multiple complications. This case report describes a novel intraoperative solution for the problem of cold welding of a neck-stem junction using sterile ice to cryogenically disengage the modular components.

Higher incidence of manipulation under anesthesia following TKA associated with the periarticular infiltration of a liposomal bupivacaine cocktail compared to a modified Ranawat cocktail.

BACKGROUND: The purpose of this study was to compare the frequency of postoperative stiffness requiring manipulation under anesthesia (MUA) before and after switching from the intraoperative use of liposomal bupivacaine (LB). METHODS: This was an institutional review board (IRB)-exempt retrospective cohort study (IRB#71733) on all patients who underwent primary total knee arthroplasty (TKA) by a single surgeon between April 2016 and December 2017. We compared 169 knees that received LB group to 167 knees that received a modified Ranawat cocktail (MR group). Perioperative care pathways remained consistent during the study period, as were requirements for MUA which included flexion range of motion below approximately 90 at 6-12 weeks. To compare the incidence of MUA between the groups, a population-averaged Poisson regression analysis was used. RESULTS: The two groups were similar, with mean age of 63 (range 31-91) in the LB group and 64 (range 42-84) in the MR group, a preponderance of females in both groups (p = 0.866), similar preoperative knee flexion between groups (p = 0.162), and similar Patient-Reported Outcomes Measurement Information System scores. The frequency of MUA, however, was significantly lower in the MR group (LB: 7.7% [95% CI 3.7-12%] vs. MR: 2.4% [95% CI <1-4.7%] [IRR 3.2, 95% CI 1.08-9.76, p . 0.037]). CONCLUSIONS: In summary, this is a novel report of a potentially previously unrecognized increased incidence of MUA associated with the use of LB compared with a MR cocktail. Given no other notable changes to the perioperative care or MUA thresholds following TKA, the reasons for these findings are unclear but deserve additional investigation.

Revisiting the role of isolated polyethylene exchange for aseptic failures in total knee arthroplasty.

BACKGROUND: Controversy continues to exist regarding the advisability of isolated polyethylene exchange (IPE) following total knee arthroplasty (TKA) for aseptic indications. We sought to compare the difference in the cumulative incidence of reoperation after IPE specifically for aseptic failure and to evaluate risk factors for failure. METHODS: We performed a retrospective cohort study of 122 knees revised for aseptic failure. Reasons for IPE in aseptic knees included: instability, polyethylene wear, arthrofibrosis, patella fracture, patellar resurfacing, patellar maltracking, extensor mechanism failure, patellectomy, and a custom polyethylene for correction of valgus deformity. The relatively high rate of mortality warranted a competing risk model to evaluate the cumulative incidence reoperation. Follow-up time was defined by years from IPE to date of reoperation or last follow-up. Generalized estimating equations were used for comparisons. RESULTS: Our analysis demonstrated an 87% (95% CI, 78-92%) survivorship free of reoperation at five years. Re-revision was secondary to aseptic failure, infection, and patellar malalignment. IPE for polyethylene wear was found to be protective and less likely to require reoperation (SHR 0.121 95% CI: 0.016-0.896, p = 0.039). CONCLUSIONS: The current study suggests that when done for carefully selected indications, IPE may be an acceptable procedure and helpful alternative for aseptic TKA revisions, particularly when the pre-operative diagnosis is polyethylene wear. This is in contrast to prior reports and may represent a need to re-visit the role of isolated polyethylene exchange.

Patients with Type-1 Diabetes Are at Greater Risk of Periprosthetic Joint Infection: A Population-Based, Retrospective, Cohort Study.

BACKGROUND: The effect of diabetes type on the risk of periprosthetic joint infection is not well documented. We hypothesized that patients with diabetes mellitus type 1 would be at greater risk for periprosthetic joint infection than those with diabetes mellitus type 2 and that a history of diabetic complications would be associated with an increased risk of periprosthetic joint infection. METHODS: We performed a retrospective cohort study, within a statewide database, on all adult patients who underwent hip or knee arthroplasty, with follow-up of ≥2 years, from 1996 to 2013. Of the 75,478 patients included, 1,668 had type-1 diabetes and 18,186 had type-2 diabetes. Risk factors were calculated using Cox regression, adjusting for siblings and stratified by age. Logistic regression was used to analyze the effect of diabetic complications on the risk of periprosthetic joint infection, controlling for other known risks for periprosthetic joint infection. RESULTS: There was no difference in age or sex between groups (p > 0.05). The frequency of periprosthetic joint infection in patients without diabetes was 2.6% compared with 4.3% in all patients with diabetes (relative risk, 1.47; p < 0.001). Patients with type-1 diabetes were at a 1.8 times greater risk for periprosthetic joint infection than patients with type-2 diabetes (7% compared with 4%; p < 0.001). The following diabetic complications increased the risk of periprosthetic joint infection: peripheral circulatory disorders (odds ratio [OR], 2.59 [95% confidence interval (CI), 1.70 to 3.94]), ketoacidosis (OR, 2.52 [95% CI, 1.51 to 4.19]), neurological manifestations (OR, 2.33 [95% CI, 1.96 to 2.78]), renal manifestations (OR, 2.15 [95% CI, 1.66 to 2.79]), and ophthalmic manifestations (OR, 1.76 [95% CI, 1.24 to 2.51]). The odds of periprosthetic joint infection increased with each added complication and patients with ≥4 complications were 9 times more likely to have a periprosthetic joint infection than patients with uncomplicated diabetes (OR, 9.47 [95% CI, 4.97 to 18.03]). Overweight and obese patients with type-2 diabetes and underweight patients with type-1 diabetes were at greater risk for periprosthetic joint infection compared with the general population (all p < 0.05). CONCLUSIONS: Our data showed an increased risk of periprosthetic joint infection in patients with type-1 diabetes compared with those with type-2 diabetes, along with an increasing risk associated with additional diabetic complications. These findings emphasize the need to better understand the medical history of patients with diabetes for more appropriate risk management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.