Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study.

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Femoral Head Penetration Rates and Oxidation of Highly Cross-Linked Polyethylene Hip Liners Implanted More Than 10 Years.

BACKGROUND: Highly cross-linked polyethylene (HXLPE) was introduced to improve wear in total hip arthroplasty, with manufacturers implementing different thermal treatments to reduce oxidation. It is important to understand how long-term time in vivo affects the wear of these materials. The purpose of this study was to investigate the wear and oxidative performance of first-generation HXLPE hip inserts implanted for greater than 10 years and compare annealed and remelted HXLPE formulations. METHODS: There were 49 total hip arthroplasty liners retrieved during routine revision surgery as part of an institutional review board-approved implant retrieval program. Penetration rates for the liners were calculated as the difference between the thickness of the unloaded and loaded regions divided by implantation time. Oxidation indices for the rim, locking mechanism, articulating surface, and backside regions were measured using Fourier-transform infrared spectroscopy according to American Society for Testing and Materials 2102. Mann-Whitney U tests were used to determine the statistical difference between annealed and remelted components. RESULTS: The cohort had an average implantation time of 13.1 ± 2.6 years for annealed and 12.1 ± 1.7 years for remelted components. The components were revised most often for polyethylene wear, instability, and loosening. The penetration rate averaged 0.0177 ± 0.014 mm/year for annealed components and 0.015 ± 0.022 mm/year for remelted components. Penetration rates did not differ between the remelted and annealed cohorts (P = .28). Oxidation indices were found to be significantly higher in the annealed cohort for all regions of interest (P < .001). CONCLUSIONS: Oxidation was found to be higher in the annealed HXLPE; however, this does not seem to be associated with greater wear as we found the average penetration rates for the cohorts were low, and the penetration rates were similar between the annealed and remelted cohorts.

Oxidation and Damage Mechanisms of 2nd Generation Highly Cross-Linked Polyethylene Tibial Inserts.

INTRODUCTION: After clinical introduction in 2005, sequentially annealed, highly crosslinked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices (OI) of SA HXLPE and conventional gamma-inert sterilized (Gamma Inert) ultra-high molecular weight polyethylene tibial inserts implanted for > 5 years. METHODS: There were 74 total knee arthroplasty (TKA) tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for > 5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semi-quantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials (ASTM) 2102. Differences between cohorts were assessed with Mann-Whitney U-Tests. RESULTS: Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = 0.022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = 0.002) and anterior-posterior (AP) faces (P = 0.023). No difference was observed at the backside surface (P = 0.060). CONCLUSIONS: Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years.

Results of Primary Total Knee Arthroplasty in Patients on Chronic Psychotropic Medications.

BACKGROUND: Psychotropic medications are commonly used to treat several mental health conditions. The aim of this study was to determine the impact of psychotropic medications in patients undergoing primary total knee arthroplasty (TKA) with respect to postoperative opioid use, complications, patient-reported outcome measures, and satisfaction. METHODS: This is a retrospective cohort study of 514 consecutive patients undergoing primary TKA. There were 120 patients (23.3%) who were excluded due to preoperative opioid usage. The remaining 394 patients had a minimum 1-year follow-up. Of those, 133 (34%) were on psychotropic medications preoperatively and were compared to the remaining 261 (66%) patients who were not on psychotropics. Clinical data, satisfaction, Knee Society (KS) scores, Western Ontario McMaster Universities Arthritis Index, Patient-Reported Outcomes Measurement Index Score, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, postoperative opioid medication usage, and complications were compared. RESULTS: The study cohort (psychotropic medications) had significantly lower postoperative KS Function, KS Knee, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario McMaster Universities Arthritis Index, and Patient-Reported Outcomes Measurement Index Score compared to the control group. The study group had a lower overall satisfaction score (Likert scale 1 to 5) and a lower percentage of patients either satisfied or very satisfied (4.55 versus 4.79, P < .001; 92.0 versus 97.24%, P = .03, respectively). Postoperative opioid usage was significantly greater in the study group at both 6.4 weeks (range, 4 to 8) and 12-month follow-up (52.76 versus 13.33%, P < .001; 5.51 versus 0.39%, P = .002, respectively). There were no differences in complications and revisions between the groups. CONCLUSIONS: Patients on psychotropic medications should be educated on the risk of increased opioid consumption, diminished satisfaction, and patient-reported outcome measures following primary TKA. Given the large number of patients on psychotropic medications undergoing TKA, additional studies are needed to further improve clinical outcomes in this group.

Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?

BACKGROUND: Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients. METHODS: This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed. RESULTS: Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients. CONCLUSIONS: Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation.

Modular Revision System for Complex Hip Revisions: A Case Series.

Revision total hip arthroplasty (THA) is a procedure with many challenges, especially when patients exhibit femoral bone defects. The causes of these defects vary, ranging from removal of prior implants to aseptic loosening. As surgeons navigate these challenges, a reliable surgical system is important. One modular fluted tapered system provides surgeons with tools to address complex hip revision cases. Introduced in 2003, this system has been utilized in over 180,000 procedures, demonstrating its reliability and effectiveness. Previously, the body stem came in sizes 155mm to 235mm. In the discussed case series, we present six distinct patient cases that highlight the advantages and efficacy of a newly introduced modification of the system; that is the use of smaller stemmed components (now 115mm). With each patient presenting unique challenges, we have demonstrated the use of this new short-stem version for multiple applications for various revision scenarios.

Neutral Mechanical Alignment Alters the Native Distal Femoral Joint Line: A Virtual Three-Dimensional Planning Total Knee Arthroplasty Study.

BACKGROUND: Alternative alignment concepts have garnered great interest in an effort to improve patient satisfaction following primary total knee arthroplasty (TKA). The purpose of this study is to determine variation or deviation from an individual's native joint line in primary TKA using neutral mechanical versus a restricted kinematic technique. METHODS: An institutional review board-approved prospective cohort study was performed evaluating the effect of neutral mechanical alignment (nMA) versus a restricted kinematic alignment (rKA) on the native joint line in 100 consecutive patients undergoing primary TKA. Using preoperative computed tomography and intraoperative 3-dimensional software, 2 virtual preoperative plans were created: nMA and rKA. Templated bone resections were recorded. Change in joint line was calculated using known implant planar thickness and planned bone resection. RESULTS: nMA yielded significantly greater deviation from the patient's native joint line along the lateral compartment of the knee (lateral distal femoral condyle, lateral posterior femoral condyle, lateral tibial resection). With nMA, the lateral distal femoral joint line was distalized by a mean 4.3 versus 2.6 mm using rKA technique (P < .001). In rKA, >60% of knees had <3 mm of deviation from the native lateral posterior femoral offset, whereas in nMA, >95% of knees had ≥3 mm change in the lateral posterior femoral condylar offset. CONCLUSION: nMA-TKA resulted in statistically larger joint line deviations compared to rKA-TKA, most notably along the lateral distal femoral condyle joint line. Further analysis is needed to determine the clinical consequences of joint line deviation from the native anatomy using nMA as the target for primary TKA.

Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision.

BACKGROUND: Stiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA. METHODS: We reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses. RESULTS: The incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001. CONCLUSION: The incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.

Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population.

BACKGROUND: Instability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA, including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships. METHODS: Using the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk of instability. RESULTS: Instability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by periprosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High-risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders. CONCLUSION: Instability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability, including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.

Cementless Metal-Backed Patellar Components in Primary Total Knee Arthroplasty: An Average 10-Year Follow-Up.

BACKGROUND: Historically, 1st generation metal-backed cementless patellar implants demonstrated high failure rates due to multiple factors. The 2nd generation cementless implants were developed with purported improvements in component design and polyethylene wear characteristics. This study evaluated clinical results of a current generation cementless metal-backed patellar implant with a minimum 5-year follow-up. METHODS: One hundred and thirty-six primary total knee arthroplasties (TKAs) with metal-backed cementless patellae were compared to 183 cemented patellae with the same implant design. The cementless group mean age was 61 years (range, 40 to 81), mean body mass index (BMI) of 34.9 (range, 22.6 to 64.5), and mean follow-up of 10 years (range, 5 to 13). The cemented group mean age was 65 years (range, 32 to 89), mean BMI of 32.5 (range, 18.2 to 56.6), and mean follow-up of 10 years (range, 5 to 12). Significant demographic differences of age (P < .001), BMI (P < .01), and sex (P < .001) were found, with cementless patients being younger, heavier, and with more men. RESULTS: There were no statistical differences in non-revision procedures (P = .214), TKA revisions (P = .639), patellar revisions (P = .151), and patellar aseptic loosening (P = .737). The 10-year survivorship of the cementless metal-backed patella was 95.9% with all-cause failure as the endpoint. The 10-year survivorship of the cemented patellar component was 98.9%. CONCLUSION: This study demonstrated noninferiority of a 2nd generation HA-coated cementless metal-backed patellar implant in primary TKA compared to cemented patellae with 10-year survivorship of 95.9%. Advances in implant design and polyethylene wear properties have led to improved clinical results with metal-backed patellar components in primary TKA.

Primary THA Using Thin Polyethylene Liners and Large Femoral Heads: A Minimum 5-Year Follow-Up.

BACKGROUND: Large femoral head sizes are commonly used in total hip arthroplasty (THA) to minimize the risk of instability. With small acetabular cup-size, large femoral head diameter often results in the use of thin polyethylene liners. The purpose of this study was to evaluate clinical and radiographic results of large femoral heads against thin polyethylene liners with minimum 5-year follow-up. METHODS: This was a retrospective review identifying 58 primary THAs utilizing thin polyethylene inserts from one manufacturer (X3 polyethylene, Stryker, Mahwah, NJ) and large femoral heads (36 mm or greater) with minimum 5-year follow-up. A total of 3 patients were deceased and 11 lost to follow-up, leaving 44 patients for review. All patients were female with mean age 65.7 (range 26-85) and mean body mass index (BMI) 29.9 (range 19.6-45.4). Average length of follow-up was 8.5 years (range 5.1-11.3). Outcome measures included survivorship, complications, PROMs and radiographic analysis. RESULTS: There were four revisions: two aseptic loosening, one prosthetic joint infection, and one recurrent dislocation. Average HOOS-Jr, FJS-12, and patient satisfaction using Likert score was 94.3/100, 92.9/100, and 4.69/5.00, respectively, with 94% of patients reporting being satisfied or very satisfied. Radiographic analysis at average of 8.5 years demonstrated well-fixed implants without evidence of progressive radiolucent lines, osteolysis, or failure of the polyethylene liner. Survivorship using failure of the thin polyethylene liner as the endpoint was 100% at an average of 8.5 years. CONCLUSION: Thin polyethylene liners used with large femoral head sizes in small acetabular cups demonstrated excellent results at average 8.5-year follow-up with no cases of liner fracture or osteolysis.

Early Experience With New Femoral and Tibial Cones in Revision Total Knee Arthroplasty: A Case Series.

Highly porous metaphyseal cones have proven useful in revision total knee arthroplasty in providing surgeons with improved metaphyseal fixation when large contained and uncontained bony defects are encountered. In this case series, we demonstrate three patients who received the latest generation of metaphyseal cones. Specifically, these cases will highlight this new system description and its operative techniques as well as the indications for metaphyseal cone use with various real-world applications. These newer-generation porous-coated cones are excellent options for large bone defects in the absence of infection, providing adequate metaphyseal fixation without constraining final implant positioning.

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Tourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes. METHODS: Patients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected. RESULTS: Visual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent. CONCLUSION: This study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.

Independent Risk Factors for Transfusion in Contemporary Revision Total Hip Arthroplasty.

BACKGROUND: The incidence of transfusion in contemporary revision total hip arthroplasty (THA) remains high despite recent advances in blood management, including the use of tranexamic acid. The purpose of this prospective investigation was to determine independent risk factors for transfusion in revision THA. METHODS: Six centers prospectively collected data on 175 revision THAs. A multivariable logistic analysis was performed to determine independent risk factors for transfusion. Revisions were categorized into subgroups for analysis, including femur-only, acetabulum-only, both-component, explantation with spacer, and second-stage reimplantation. Patients undergoing an isolated modular exchange were excluded. RESULTS: Twenty-nine patients required at least one unit of blood (16.6%). In the logistic model, significant risk factors for transfusion were lower preoperative hemoglobin, higher preoperative international normalized ratio (INR), and longer operative time (P < .01, P = .04, P = .05, respectively). For each preoperative 1g/dL decrease in hemoglobin, the chance of transfusion increased by 79%. For each 0.1-unit increase in the preoperative INR, transfusion chance increased by 158%. For each additional operative hour, the chance of transfusion increased by 74%. There were no differences in transfusion rates among categories of revision hip surgery (P = .23). No differences in demographic or surgical variables were found between revision types. CONCLUSION: Despite the use of tranexamic acid, transfusions are commonly required in revision THA. Preoperative hemoglobin and INR optimization are recommended when medically feasible. Efforts should also be made to decrease operative time when technically possible.

Point/Counterpoint: Static vs Articulating Spacers-Static Spacers for Resection Arthroplasty of the Knee.

Antibiotic spacers play a significant role in the treatment of periprosthetic joint infections. They help maintain soft-tissue tension and provide delivery of high dose of antibiotics to the local tissue. The use of static or dynamic spacers is based on multiple factors including the extent of soft-tissue, ligamentous and bone compromise, overall patient function, comorbid conditions, and virulence of the organism. There is no difference in reinfection incidence between static vs dynamic spacers following two-stage reimplantation. Static spacers can be customized to treat all cases of periprosthetic total knee infections and offer intraoperative flexibility to vary the cement quantity and amount of antibiotics in the spacer to provide high-dose local delivery of antibiotics to address the dead space, bone loss, and soft-tissue compromise. Static spacers are especially advantageous in cases of extensor mechanism and ligamentous compromise where articulating spacers may not be able to provide adequate stability.

Corrosion Concerns? Trends in Metal-on-Polyethylene Total Hip Arthroplasty Revision Rates and Comparisons Against Ceramic-on-Polyethylene up to 10 Years of Follow-Up.

BACKGROUND: We compared the revision risk between metal-on-polyethylene (MOP) and ceramic-on-polyethylene (COP) total hip arthroplasty patients and evaluated temporal changes in short-term revision risks for MOP patients. METHODS: Primary MOP (n = 9480) and COP (n = 3620) total hip arthroplasties were evaluated from the Medicare data set (October 2005 to December 2015) for revision risk, with up to 10 years of follow-up using multivariate analysis. Temporal change in the short-term revision risk for MOP was evaluated (log-rank and Wilcoxon tests). RESULTS: Revision incidence was 3.8% for COP and 4.3% for MOP. MOP short-term revision risk did not change over time (P ≥ .844 at 1 year and .627 at 2 years). Dislocation was the most common reason for revision (MOP: 23.5%; COP: 24.8%). Overall adjusted revision risks were not different between MOP and COP up to 10 years of follow-up (P ≥ .181). CONCLUSIONS: Concerns with corrosion for metal heads do not appear to result in significantly elevated revision risk for MOP at up to 10 years. Corrosion does not appear as a primary reason for revision compared to other mechanisms.

Results of Cemented Posterior-Stabilized Total Knee Arthroplasty in Obese Patients With an Average 10-Year Follow-Up.

BACKGROUND: Obese and morbidly obese patients undergoing primary total knee arthroplasty (TKA) place significant stress at the bone-cement-implant interface over the life of the patient. The purpose of this study is to evaluate results of cemented, posterior-stabilized TKA in obese and morbidly obese patients at an average follow-up of 10 years. METHODS: Retrospective study of 181 patients who had a cemented, posterior-stabilized TKA between 2000 and 2013 with body mass index >35 at the time of surgery was conducted. Clinical data and radiographs were evaluated along with survivorship, complications, and revisions. Minimum follow-up was 5 years with an average follow-up of 10 years. RESULTS: There were 135 women and 46 men in the study, with mean age of 60.2 years (range 43-80), mean body mass index of 42.0 (range 35.1-66.1), and an average follow-up of 10 years (range 5-18). There were a total of 39 failures (22%) that underwent revision TKA surgery with mean time to revision of 8 years. Failures included 25 (14%) cases of aseptic loosening; 9 (5%) polyethylene wear; 2 (1%) prosthetic joint infection; and 3 additional revisions for instability, pain, and stiffness. There were a total of 11 cases of isolated tibial component loosening and 13 for both tibial and femoral loosening. Survivorship at 15 years with aseptic loosening as the endpoint was 86.7%, and for all causes 79.6% at 15 years. CONCLUSION: Aseptic loosening is the leading cause of failure following TKA in obese and morbidly obese patients with decreasing survivorship from 96.1% to 91.2% and 86.7% at 5, 10, and 15 years, respectively.

Isolated Patellofemoral Joint Arthroplasty: Can Preoperative Bone Scans Predict Survivorship?

BACKGROUND: Isolated patellofemoral joint arthritis has been identified in 10% of the population presenting with symptomatic knee osteoarthritis. Patient selection is important in order to improve survivorship following PF arthroplasty. The purpose of this study is to compare the use of a preoperative bone scan vs a magnetic resonance imaging (MRI) to identify the patient with isolated PF arthritis. METHODS: This is a retrospective review of 32 patients undergoing isolated PF arthroplasty for PF arthritis using the same implant design. Sixteen consecutive patients received a preoperative bone scan to confirm isolated PF arthritis. These patients were matched by age and gender to patients where an MRI was used to determine isolated PF arthritis. The bone scan cohort contained 13 females and three males with an average age of 48 years and average follow-up of 52 months. There was no significant difference in age, body mass index, follow-up, or preoperative range of motion between the groups. The MRI and bone scan results were reported by a radiologist specializing in orthopedic radiology. RESULTS: Survivorship was 100% in the PF arthroplasty group selected using a preoperative bone scan. Revision surgery with conversion to TKA was required in 5 of 16 patients (31%) when an MRI was used to identify isolated PF arthritis. Revision in all patients in the MRI group was due to progression of knee arthritis in the tibial-femoral joint. There were no cases of implant-related failures. CONCLUSION: Patellofemoral arthroplasty using a modern design implant demonstrated 100% survivorship when a preoperative bone scan was used for patient selection to confirm isolated PF arthritis. In the group where only an MRI was used, there was a 31% failure due to progression of the disease. Based on this study, we would recommend the use of a bone scan as a tool in the selection criteria for patients undergoing PF arthroplasty.

Mid-Term Follow Up of Newer-Generation Morphometric Wedge Stems for Total Hip Arthroplasty (THA).

INTRODUCTION: Proximally coated, morphometric wedge femoral stems illustrated excellent survivorship and clinical outcomes at a minimum five-year postoperative follow up. MATERIALS AND METHODS: We completed a retrospective review of 186 THA patients from three high-volume surgeons to assess clinical- and patient-reported outcomes five years after implantation with a cementless, proximally coated morphometric wedge femoral stem. We reviewed Gruen zones on early postoperative and mid-term radiographs for signs of osteolysis, loosening, and wear. Clinical- and patient-reported outcomes were compared with previously published two-year outcomes for these femoral stems. RESULTS: No progression of radiolucencies or loosening was observed radiographically when comparing minimum one-year and five-year follow up. Reactive radiodense lines were observed in 23 cases (12.64%), and 13 cases (7.14%) exhibited true radiolucencies of 1-3mm, and all remained unchanged between follow ups or were no longer present on the five-year film. Cortical hypertrophy was noted in Gruen zones 3 and/or 5 in 11 cases (6.04%). No stems were revised for mechanical loosening or for periprosthetic fracture. Nine (9) patients (4.87%) underwent revisions during the follow-up period for periprosthetic infection, femoral head and/or acetabular component revisions, and impingement requiring release and femoral head change. Average Harris Hip Scores were excellent at five years and improved slightly when compared to a two-year follow up; however, this change was not statistically significant. Health-related quality of life mental component and physical component scores were a mean of 48.45 and 43.10 at 5 years, respectively. All cause Kaplan-Meier survivorship of the femoral stem was calculated at 98.4% at an average 65.7 months post implantation. Additionally, this cohort exhibited 100% aseptic survivorship during the follow-up period. CONCLUSION: Newer-generation morphometric wedge femoral stems for THA exhibit excellent radiographic stability, patient satisfaction, and clinical outcomes five years post implantation.

New Technology for Total Knee Arthroplasty Provides Excellent Patient-Reported Outcomes: A Minimum Two-Year Analysis.

INTRODUCTION: Robotic-assisted total knee arthroplasty has been demonstrated to help increase various patient-reported, clinical, and surgical outcome metrics (PROMs). However, the current literature is limited regarding PROMs data for longer follow-up periods beyond one year. Therefore, the purpose of this study was to 1) report multicenter patient-reported outcomes with multiple metrics, as well as 2) postoperative surgeon-specific outcomes at a minimum two-year follow-up. MATERIALS AND METHODS: Five fellowship-trained, high-volume surgeons performed a total of 188 total knee arthroplasty surgeries using the enhanced preoperative planning and real-time intraoperative feedback of a robotic-assisted device. Patients from all surgeons followed similar postoperative rehabilitation beginning on postoperative day one. Patients were evaluated based on the Short Form-12 Questionnaire (SF-12), the Forgotten Joint Score (FJS), and Knee Society total and subscores (KSS). The SF-12 was subdivided into two components: mental composite score (MCS) and physical composite score (PCS). The KSS was subdivided into functional and knee scores. Additionally, surgical outcomes from the latest follow-up visit were evaluated. All patients were evaluated at a minimum of two years follow-up time. RESULTS: All patients reported excellent postoperative outcomes for all three PROMs. The mean postoperative SF-12 MCS and PCS scores were both 57 points, with 50 as the threshold for norm-based scoring (MCS range: 42 to 69 points; PCS range: 41 to 68 points). The mean FJS was 75 points (range: 14 to 100 points). The mean KSS functional score was 84 points (range: 20 to 100) while the mean Knee Score was 92 points (range: 40 to 100). Similarly, we found that the aseptic revision rates were low (n=2, 1.06%, one for unexplained pain, and another for a post-traumatic tibial fracture) with few other postoperative complications (n=7 patients [3.7%]) in our cohort. CONCLUSION: Our analysis found that patients had excellent outcomes across multiple PROM metrics. Future work can build on these results with large patient populations over longer follow-up intervals. Nevertheless, these results provide the foundation and evidence to support the continued use of this innovative technology for total knee arthroplasties.