Time to Achieve the Minimal Clinically Important Difference in Primary Total Hip Arthroplasty: Comparison of Anterior and Posterior Surgical Approaches.

BACKGROUND: Controversy remains over outcomes between total hip arthroplasty approaches. This study aimed to compare the time to achieve the minimal clinically important difference (MCID) for the Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-Physical for patients who underwent anterior and posterior surgical approaches in primary total hip arthroplasty. METHODS: Patients from 2018 to 2021 with preoperative and postoperative HOOS-PS or PROMIS Global-Physical questionnaires were grouped by approach. Demographic and MCID achievement rates were compared, and survival curves with and without interval-censoring were used to assess the time to achieve the MCID by approach. Log-rank and weighted log-rank tests were used to compare groups, and Weibull regression analyses were performed to assess potential covariates. RESULTS: A total of 2,725 patients (1,054 anterior and 1,671 posterior) were analyzed. There were no significant differences in median MCID achievement times for either the HOOS-PS (anterior: 5.9 months, 95% confidence interval [CI]: 4.6 to 6.4; posterior: 4.4 months, 95% CI: 4.1 to 5.1, P = .65) or the PROMIS Global-Physical (anterior: 4.2 months, 95% CI: 3.5 to 5.3; posterior: 3.5 months, 95% CI: 3.4 to 3.8, P = .08) between approaches. Interval-censoring revealed earlier times of achieving the MCID for both the HOOS-PS (anterior: 1.509 to 1.511 months; posterior: 1.7 to 2.3 months, P = .87) and the PROMIS Global-Physical (anterior: 3.0 to 3.1 weeks; posterior: 2.7 to 3.3 weeks, P = .18) for both surgical approaches. CONCLUSIONS: The time to achieve the MCID did not differ by surgical approach. Most patients will achieve clinically meaningful improvements in physical function much earlier than previously believed. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Deep-Learning Automation of Preoperative Radiographic Parameters Associated With Early Periprosthetic Femur Fracture After Total Hip Arthroplasty.

BACKGROUND: The radiographic assessment of bone morphology impacts implant selection and fixation type in total hip arthroplasty (THA) and is important to minimize the risk of periprosthetic femur fracture (PFF). We utilized a deep-learning algorithm to automate femoral radiographic parameters and determined which automated parameters were associated with early PFF. METHODS: Radiographs from a publicly available database and from patients undergoing primary cementless THA at a high-volume institution (2016 to 2020) were obtained. A U-Net algorithm was trained to segment femoral landmarks for bone morphology parameter automation. Automated parameters were compared against that of a fellowship-trained surgeon and compared in an independent cohort of 100 patients who underwent THA (50 with early PFF and 50 controls matched by femoral component, age, sex, body mass index, and surgical approach). RESULTS: On the independent cohort, the algorithm generated 1,710 unique measurements for 95 images (5% lesser trochanter identification failure) in 22 minutes. Medullary canal width, femoral cortex width, canal flare index, morphological cortical index, canal bone ratio, and canal calcar ratio had good-to-excellent correlation with surgeon measurements (Pearson's correlation coefficient: 0.76 to 0.96). Canal calcar ratios (0.43 ± 0.08 versus 0.40 ± 0.07) and canal bone ratios (0.39 ± 0.06 versus 0.36 ± 0.06) were higher (P < .05) in the PFF cohort when comparing the automated parameters. CONCLUSIONS: Deep-learning automated parameters demonstrated differences in patients who had and did not have early PFF after cementless primary THA. This algorithm has the potential to complement and improve patient-specific PFF risk-prediction tools.

Intersurgeon Variability of Minimal Clinically Important Difference for Worsening Achievement Rates After Total Joint Arthroplasty.

BACKGROUND: Using the Patient-Reported Outcome Measurement Information System, we sought to evaluate surgeon performance variability via minimal clinically important difference for worsening (MCID-W) achievement rates in primary and revision total knee and hip arthroplasty. METHODS: This retrospective study analyzed 3,496 primary total hip arthroplasty (THA), 4,622 primary total knee arthroplasty (TKA), 592 revision THA, and 569 revision TKA patients. Patient factors collected included demographics, comorbidities, and Patient-Reported Outcome Measurement Information System physical function short form 10a scores. Surgeon factors collected included caseload, years of experience, and fellowship training. The MCID-W rate was calculated as the percent of patients in each surgeon's cohort who achieved MCID-W. Distribution was presented via a histogram with associated average, standard deviation, range, and interquartile range (IQR). Linear regressions were performed to evaluate the potential correlation between surgeon- and patient-level factors with MCID-W rate. RESULTS: The average MCID-W rates of the surgeons represented in the primary THA and TKA cohorts were 12.7 ± 9.2% (range, 0 to 35.3%; IQR, 6.7 to 15.5%) and 18.0 ± 8.2% (range, 0 to 36%; IQR, 14.3 to 22.0%). The average MCID-W rates among the revision THA and TKA surgeons were 36.0 ± 22.2% (range, 9.1 to 90%; IQR, 25.0 to 41.4%) and 21.2 ± 7.7% (range, 8.1 to 37.0%; IQR, 16.6 to 25.4%). Strong correlations were not found between patient- or surgeon-level factors and MCID-W rate of the surgeon. CONCLUSION: We demonstrated variance in MCID-W achievement rates across surgeons in both primary and revision joint arthroplasty, independent of patient- or surgeon-level factors.

Rates and Outcomes of Periprosthetic Joint Infection in Persons Who Inject Drugs.

BACKGROUND: The risk of periprosthetic joint infection (PJI) is higher in persons who inject drugs (PWID) after total joint arthroplasty (TJA), though reported rates vary widely. This study was designed to assess outcomes of TJA in PWID and to describe factors associated with improved PJI outcomes among PWID. METHODS: A retrospective matched cohort study was performed using a 1:4 match among those with and those without a history of injection drug use (IDU) undergoing TJA. Demographic, surgical, and outcome variables were compared in multivariate logistic regressions to determine PJI predictors. Kaplan-Meier analyses were constructed to characterize the difference in survival of patients who did not have PJI or undergo joint explantation between PWID and the matching cohort. RESULTS: PWID had a 9-fold increased risk of PJI compared to the matched cohort (odds ratio 9.605, 95% CI 2.781-33.175, P < .001). Ten of 17 PWID whose last use was within 6 months (active use) of primary TJA had a PJI, while 7 of 41 PWID who did not have active use developed a PJI. Of PWID with PJI, treatment failure was seen in 15 of 17, while in patients who did not have an IDU history, 5 of 8 with PJI had treatment failure. CONCLUSION: IDU is a significant risk factor for PJI following TJA. Future work investigating the effect of a multidisciplinary support team to assist in cessation of IDU and to provide social support may improve outcomes and reduce morbidity in this vulnerable population.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA. METHODS: A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions. RESULTS: Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively. CONCLUSION: While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Identifying Aseptic Revision Total Knee Arthroplasty Diagnoses That Achieve Minimal Clinically Important Difference and Patient Acceptable Symptom State.

BACKGROUND: Minimal clinically important difference (MCID) defines a meaningful clinical change in patient-reported outcome measures. Patient acceptable symptom state (PASS) provides a patient-reported outcome measures threshold value to indicate a satisfactory clinical state. MCID and PASS for revision total knee arthroplasty (rTKA) are ill-defined. Moreover, it is unknown whether diagnosis influences the likelihood of achieving MCID or PASS. The purpose of this study was to calculate MCID for aseptic rTKA and compare the percentage of patients achieving MCID and PASS per diagnosis. METHODS: An institutional registry of rTKA was used. First-time aseptic rTKA were included. Demographics, revision diagnosis, preoperative Knee Injury and Osteoarthritis Outcome Score, Jr (KOOS Jr), and 1-year postoperative KOOS Jr were recorded. The 1-year postoperative KOOS Jr PASS score was available. MCID was calculated using distribution-based methods. Three hundred fifty eight first-time aseptic rTKAs were analyzed. The 3 most common diagnoses were aseptic loosening (n = 156), instability (n = 109), and stiffness (n = 37). RESULTS: The mean KOOS Jr 1-year postoperative MCID for rTKA was 10.3. Overall, 75.4% achieved MCID and 56.9% achieved PASS. The percentage of patients per diagnosis achieving MCID and PASS, respectively, were periprosthetic fracture (100, 44), aseptic loosening (94, 60), implant fracture (88, 63), stiffness (60, 38), instability (59, 61), polyethylene wear/osteolysis (57, 57), and metal allergy (44, 33). CONCLUSION: Aseptic rTKA MCID is 10.3 for KOOS Jr at 1 year postoperatively. rTKA outcomes vary depending on preoperative diagnosis. Even in diagnoses with a high proportion of MCID achieved, less than 2/3 of patients achieved PASS, suggesting rTKA provides noticeable improvement but may not return patients to a satisfactory state.

Postoperative Outcomes in Total Hip and Total Knee Arthroplasty for Patients Who Have Multiple Myeloma.

BACKGROUND: Advancements in oncologic care have increased the longevity of patients who have multiple myeloma, although outcomes beyond the early postoperative period following total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. This study investigated the influence of preoperative factors on implant survivorship following THA and TKA after a minimum 1-year interval for multiple myeloma patients. METHODS: Using our institutional database, we identified 104 patients (78 THAs, 26 TKAs) from 2000 to 2021 diagnosed with multiple myeloma before their index arthroplasty by International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes 203.0× and C90.0× and corresponding Current Procedural Terminology (CPT) codes. Demographic data, oncologic treatments, and operative variables were collected. Multivariate logistic regressions assessed variables of interest, and Kaplan-Meier curves were used to estimate implant survival. RESULTS: There were 9 (11.5%) patients who underwent revision THA after an average time of 1,312 days (range, 14 to 5,763), with infection (33.3%), periprosthetic fracture (22.2%), and instability (22.2%) being the most common indications. Of these patients, 3 (33.3%) underwent multiple revision surgeries. There was 1 (3.8%) patient who underwent revision TKA at 74 days postoperatively for infection. Patients treated with radiotherapy were more likely to require revision THA (odds Rratio (OR): 6.551, 95% confidence interval (CI): 1.148-53.365, P = .045), but no predictors of failure were identified for TKA patients. CONCLUSION: Orthopaedic surgeons should know that multiple myeloma patients have a relatively high risk of revision, particularly following THA. Accordingly, patients who have risk factors for failure should be identified preoperatively to avoid poor outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Can machine learning models predict failure of revision total hip arthroplasty?

INTRODUCTION: Revision total hip arthroplasty (THA) represents a technically demanding surgical procedure which is associated with significant morbidity and mortality. Understanding risk factors for failure of revision THA is of clinical importance to identify at-risk patients. This study aimed to develop and validate novel machine learning algorithms for the prediction of re-revision surgery for patients following revision total hip arthroplasty. METHODS: A total of 2588 consecutive patients that underwent revision THA was evaluated, including 408 patients (15.7%) with confirmed re-revision THA. Electronic patient records were manually reviewed to identify patient demographics, implant characteristics and surgical variables that may be associated with re-revision THA. Machine learning algorithms were developed to predict re-revision THA and these models were assessed by discrimination, calibration and decision curve analysis. RESULTS: The strongest predictors for re-revision THA as predicted by the four validated machine learning models were the American Society of Anaesthesiology score, obesity (> 35 kg/m2) and indication for revision THA. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.80), calibration and decision curve analysis. Higher net benefits for all machine learning models were demonstrated, when compared to the default strategies of changing management for all patients or no patients. CONCLUSION: This study developed four machine learning models for the prediction of re-revision surgery for patients following revision total hip arthroplasty. The study findings show excellent model performance, highlighting the potential of these computational models to assist in preoperative patient optimization and counselling to improve revision THA patient outcomes. LEVEL OF EVIDENCE: Level III, case-control retrospective analysis.

Minimal Clinically Important Difference (MCID) at One Year Postoperatively in Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: Outcomes after aseptic revision total hip arthroplasty (THA) are variable, and it is unknown whether the indication for aseptic revision THA influences postoperative clinical improvement. The minimal clinically important difference (MCID) assesses if changes in patient-reported outcome measure result in meaningful clinical benefit to patients. The purpose of this study was to quantify the 1-year postoperative MCID for aseptic revision THA and to assess the percentage of patients achieving the MCID for each revision diagnosis. METHODS: A prospective, single-institution registry of revision total joint arthroplasties was used. Retrospective review of 413 first-time aseptic revision THAs was performed. Demographics, revision diagnosis, preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS Jr.), and 1-year postoperative HOOS Jr. were recorded. The MCID for the HOOS Jr. at one year postoperatively was calculated for each revision diagnosis using a distribution-based method. The percentage of patients exceeding the MCID with each diagnosis was determined. RESULTS: There were 9 aseptic revision diagnoses, all with n ≥ 5. The 3 most common revision diagnosis were aseptic loosening (n = 114), dislocation or instability (n = 103), and polyethylene wear or osteolysis (n = 73). The MCID for all the aseptic revision THAs was 10.9. Seven of the nine revision diagnoses achieved the MCID. The highest percentage of patients achieving the MCID was for aseptic loosening (84.2%) and implant fracture (81.3%), whereas lowest was for adverse local tissue reaction (35.3%) and implant recall (20.0%). CONCLUSION: The one-year revision THA MCID is 10.9 for the HOOS Jr. There is variability in the percentage of patients achieving the MCID based on diagnosis. Our data can be used to counsel patients undergoing revision THA for noninfectious etiologies.

Femoral Component Undersizing and Alignment are Risk Factors for Early Periprosthetic Femur Fracture.

BACKGROUND: Known risk factors for early periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) include poor bone quality and the use of cementless implants. The association between femoral component size and alignment and the risk of early PFF is not well described. We evaluated radiographic parameters of femoral component sizing and alignment as risk factors for early PFF. METHODS: From 16,065 primary cementless THAs, we identified 66 cases (0.41%) of early PFFs (<90 days from index THA) at a single institution between 2016 and 2020. Sixty early PFFs were (1:2) matched to 120 controls based on the femoral component model, offset, surgical approach, age, body mass index (BMI), and gender. Radiographic assessment of preoperative bone morphology and postoperative femoral component orientation included stem alignment, metaphyseal fill, and implant congruence with medial cortical bone. A multivariable logistic regression was built to identify radiographic risk factors associated with early PFF. RESULTS: Markers of preoperative bone quality including canal calcar ratio (P = .003), canal flare index (P < .001), anteroposterior canal bone ratio (CBR) (P < .001), and lateral CBR (P < .001) were statistically associated with PFF. Distance between the medial cortical bone and implant was greater in cases of PFF (2.5 mm vs 1.4 mm) (P < .001). A multivariate analysis demonstrated that a larger lateral metaphyseal CBR (Odds Ratio [OR] 5), valgus implant alignment (OR 5), and medial implant-bone incongruity (OR 2) increased the risk of early PFF. CONCLUSION: A larger lateral metaphyseal CBR, valgus component alignment, and implant incongruity with medial cortical bone posed the greatest radiographic risk for early PFF following cementless THA.

Immersive technologies for total knee arthroplasty surgical education.

The need to adapt surgical curricula to meet the demands of an increasingly restrictive training environment is rising. Modern constraints of surgical trainees including work-hour restrictions and concerns surrounding patient safety have created an opportunity to supplement traditional teaching methods with developing immersive technologies including virtual and augmented reality. Virtual reality (VR) and augmented reality (AR) have been preliminarily investigated as it relates to total joint arthroplasty. The purpose of this article is to discuss VR and AR as it applies to modern total knee replacement (TKR) surgical education.

Endoscopic Repair of Full-Thickness Gluteus Medius and Minimus Tears-Prospective Study With a Minimum 2-Year Follow-Up.

PURPOSE: To evaluate the short-term outcomes of endoscopic repair of full-thickness gluteus medius and minimus tendon tears with a minimum of 2-year follow-up and add to the paucity of literature on abductor tendon tears. METHODS: All patients who underwent endoscopic abductor tendon repair between December 2013 and August 2017 were prospectively evaluated. The inclusion criteria for this study were primary full-thickness gluteal tendon tears and at least 2-years of follow-up. Clinical outcome data consisted of visual analog scale (VAS) pain score, hip abduction strength, Trendelenburg sign, complications, and patient-reported outcome measures (PROMs): modified Harris Hip Score, Hip Outcome Score, Non-arthritic Hip Scale, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. RESULTS: A total of 15 hips, all full-thickness tears, met inclusion criteria with an average follow-up of 31.2 months, with no patients being excluded. On physical examination, there was a significant improvement in VAS pain score from 5.36 to 2.43 (P = .0243), hip abduction strength with 8 (53.3%) hips improving by at least 1 point (P = .02056), and resolution of Trendelenburg sign in all 15 hips at 2-years (P = .0019). The mean difference for all 6 PROMs was statistically significant, even after Bonferroni adjustment, with the majority of patient improvement exceeding the minimal clinically important difference (MCID) thresholds: modified Harris Hip Score: 86.67%, Hip Outcome Score-ADL: 86.67%, Hip Outcome Score-SSS: 66.67%, Non-arthritic Hip Scale: 93.33%, and International Hip Outcome Tool-33: 80%. Greater Goutallier grade was associated with a greater VAS pain score. There were no complications, including no retears. CONCLUSIONS: In this study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average of 31.2 months follow-up, while offering the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair. LEVEL OF EVIDENCE: Level 4, Case Series.

The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears.

BACKGROUND: Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology. METHODS: We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports. RESULTS: Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying," or tearing). CONCLUSION: DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.

A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management.

BACKGROUND: Magnetic resonance imaging (MRI) is often used to evaluate the integrity of the rotator cuff in patients with suspected full-thickness rotator cuff tears or other cuff tendinopathies. The value of advanced imaging value comes into question when it is used as the initial musculoskeletal imaging test before a trial of conservative therapy in patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy. METHODS: A prospective study of a group of patients suspected to have cuff tendinopathy based on clinical findings was performed. Every patient underwent MRI and was offered an initial trial of conservative management. Patients had an average follow-up of 28.3 ± 5.3 months after imaging to determine whether surgery was performed. RESULTS: A total of 51 patients were included in this study. Of this cohort, 46 (90.2%) patients did not go on to surgical intervention, whereas 5 (9.8%) patients did at an average 68.3 days after imaging. These results suggest that over 90.2% of patients (46 of 51) had premature MRI, posing an unnecessary economic burden of $181,619 in advanced imaging charges. CONCLUSIONS: The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level.

Outcomes after primary open or endoscopic abductor tendon repair in the hip: a systematic review of the literature.

PURPOSE: The purpose of this study was to systematically appraise the evidence on primary open and endoscopic abductor tendon repair. METHODS: A systematic review of the literature was performed to (1) identify the demographic undergoing abductor tendon repair, (2) summarize the overall outcomes after primary surgical abductor tendon repair, (3) identify the type of tear most commonly encountered intraoperatively, (4) summarize the repair methods used, and (5) identify the published complication and tendon retear rates. RESULTS: A total of 8 articles were identified as eligible for inclusion. All studies were Level IV Evidence. Of the patients undergoing surgical repair, 90% were women. As assessed by a variety of outcome measures, most patients reported good to excellent functional outcomes and pain reduction after open or endoscopic repair. Intraoperatively, tears of the gluteus medius and partial-thickness tears were encountered most often. Tears involving both the gluteus medius and minimus occurred 29% of the time. Complication rates were low for both the open and endoscopic approaches. No tendon retears were documented after endoscopic repair, whereas the retear rate after open repair was 9%. CONCLUSIONS: Patients undergoing surgical repair for partial- and full-thickness tears are mostly women. Intraoperatively, tears almost always include the gluteus medius, with concomitant tearing of the gluteus minimus in approximately one-third of cases. Both open and endoscopic techniques are viable surgical approaches to repairing abductor tendon tears in the hip that produce good to excellent functional results and reduce pain; however, endoscopic repair appears to result in fewer postoperative complications including tendon retear. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Diagnostic Test Performances for Identifying Periprosthetic Joint Infection in Hip Hemiarthroplasty.

INTRODUCTION: Periprosthetic joint infection (PJI) is a devastating complication of hip hemiarthroplasty (HHA) that is not well-represented in the literature. Therefore, this study aimed to evaluate diagnostic markers for identifying PJI in patients after HHA and compare them with the most recent 2018 International Consensus Meeting on Musculoskeletal Infection criteria. METHODS: A total of 98 patients (64 PJIs, 65.3%) were analyzed. Patients were identified by relevant Current Procedural Terminology and International Classification of Diseases-9/10 codes from 2000 to 2021 across a single healthcare system. Preoperative or intraoperative synovial fluid nucleated cell (NC) count, synovial polymorphonuclear (PMN) percentage, serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and serum white blood cell count were compared with Student t -test between aseptic and septic cohorts. Diagnostic utility and laboratory cutoff values were determined using receiver-operating characteristic curves and Youden index, respectively. RESULTS: Mean values were significantly higher in the septic cohort for synovial NC count (120,992.2 versus 1,498.0 cells/µL, P < 0.001), synovial PMN percentage (91.3% versus 56.2%, P < 0.001), serum ESR (75.6 versus 36.3 mm/hr, P < 0.001), serum CRP (20.2 versus 125.8 mg/L, P < 0.001), and serum white blood cell count (8.5 versus 11.5 cells/µL, P < 0.001). Synovial NC count, synovial PMN percentage, and serum CRP had excellent PJI discriminatory ability with an area under the curve of 0.99, 0.90, and 0.93, respectively. Optimal cutoffs were 2,700 cells/µL for synovial NC count (100% sensitivity and 94% specificity), 81.0% for synovial PMN percentage (96% sensitivity and 89% specificity), 52.0 mm/hr for serum ESR (75% sensitivity and 80% specificity), and 40.0 mg/L for serum CRP (85% sensitivity and 92% specificity). CONCLUSION: Our findings support the continued use of routine serum and synovial fluid tests for diagnosing PJI in HHA patients. Optimal cutoff values for both synovial fluid biomarkers were very close in alignment with the 2018 International Consensus Meeting criteria. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Mental Health Effects on the Minimal Clinically Important Difference in Total Joint Arthroplasty.

INTRODUCTION: The effect of mental health on patient-reported outcome measures is not fully understood in total joint arthroplasty (TJA). Thus, we investigated the relationship between mental health diagnoses (MHDs) and the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in primary TJA and revision TJA (rTJA). METHODS: Retrospective data were collected using relevant Current Procedural Terminology and MHDs International Classification of Diseases, 10th Revision, codes with completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form, Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, Patient-reported Outcomes Measurement Information System (PROMIS)-Physical Function Short Form 10a, PROMIS Global-Mental, or PROMIS Global-Physical questionnaires. Logistic regressions and statistical analyses were used to determine the effect of a MHD on MCID-I/MCID-W rates. RESULTS: Data included 4,562 patients (4,190 primary TJAs/372 rTJAs). In primary total hip arthroplasty (pTHA), MHD-affected outcomes for Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (MCID-I: 81% versus 86%, P = 0.007; MCID-W: 6.0% versus 3.2%, P = 0.008), Physical Function Short Form 10a (MCID-I: 68% versus 77%, P < 0.001), PROMIS Global-Mental (MCID-I: 38% versus 44%, P = 0.009), and PROMIS Global-Physical (MCID-I: 61% versus 73%, P < 0.001; MCID-W: 14% versus 7.9%, P < 0.001) versus pTHA patients without MHD. A MHD led to lower rates of MCID-I for PROMIS Global-Physical (MCID-I: 56% versus 63%, P = 0.003) in primary total knee arthroplasty patients. No effects from a MHD were observed in rTJA patients. DISCUSSION: The presence of a MHD had a prominent negative influence on pTHA patients. Patients who underwent rTJA had lower MCID-I rates, higher MCID-W rates, and lower patient-reported outcome measure scores despite less influence from a MHD. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of radiofrequency use on hip arthroscopy irrigation fluid temperature.

PURPOSE: The purpose of this study was to determine operating parameters for joint fluid lavage using radiofrequency (RF) in maintaining intra-articular temperatures ≤50°C in the hip joint and to then quantify the influence of flow rate on maintaining safe intra-articular temperatures. METHODS: Fiberoptic intra-articular thermometers at radial distance intervals of 1, 2, 5, and 10 mm, spanning cross-sectional areas of 3.14, 12.56, 78.5, and 314.1 mm(2), respectively, from the RF probe were used in 3 human hip cadaveric specimens at room temperature, with 9 trials per variable, using a 3-portal technique with a capsule release. Using a new Dyonics RF System continuously at the superior capsulolabral junction for 90 seconds, continuous temperatures were recorded at 50 mm Hg inflow and variable outflow intervals: no flow and 5, 15, and 30 seconds. Lavages were 1 second in duration on suction. Statistical comparison was through multivariate regression analysis and a logistic model. RESULTS: Temperatures reached ≥50°C at 5-mm radial distance from the probe in all but the 5-second pulse lavage group. Elevated temperatures were reached within 1 to 2 seconds locally (1- to 2-mm radial distance) and at a radial distance of 5 mm in the 15-, 30-, and 0-second lavage groups. Logistic regression revealed a reduction in the odds that temperatures ≥50°C will occur as flow frequency increases every 30 (odds ratio = 0.68, P = .086); 15 (odds ratio = -1.22, P = .0067); and 5 (odds ratio = -4.26, P < .0001) seconds. CONCLUSIONS: Increasing-interval pulsed irrigation is effective in maintaining intra-articular temperature profiles below 50°C during use of continuous RF ablation. Five-second-interval pulsed lavage is the longest flow interval identified during which fluid 5 mm radially from the RF device never reached temperatures >50°C. CLINICAL RELEVANCE: Clinical guidelines for using the RF ablation include: meticulous technique, intermittent use, good inflow and outflow, and pulsed lavage at frequent intervals.

Endoscopic repair of full-thickness abductor tendon tears: surgical technique and outcome at minimum of 1-year follow-up.

PURPOSE: The purpose of this study was to assess the surgical outcomes of endoscopically repaired full-thickness abductor tendon tears using validated outcome measures. METHODS: After institutional review board approval was obtained, clinical outcome data were retrospectively collected from patients who underwent endoscopic gluteus medius and/or minimus repair by a single surgeon between August 2009 and September 2011. With a minimum follow-up of 1 year, patients were evaluated using the modified Harris Hip Score and the validated Hip Outcome Score (HOS). The HOS questionnaire included 2 subsections: HOS-Activities of Daily Living and HOS-Sports. Physical examination data were gathered during routine clinic visits, 1 year postoperatively. Statistical analysis was descriptive. The change in strength testing postoperatively was assessed with the Wilcoxon signed rank test, with significance set at P ≤ .05. RESULTS: Twelve patients were identified, 1 of whom was excluded; 10 of 11 patients (91%) completed the study requirements. The mean patient age was 65.9 years (range, 60 to 74 years), 70% were women, and the mean follow-up period was 23 months (range, 13 to 38 months). The mean postoperative scores were 84.7 (SD, 14.5) for the modified Harris Hip Score and 89.1 (SD, 11.3) for the HOS-Activities of Daily Living, with 90% patient satisfaction. All patients had clinically and statistically improved abductor tendon strength (P = .004). Patients with good to excellent outcomes were younger (P < .001). There were no complications identified. CONCLUSIONS: In our small series, endoscopic abductor tendon repair was an effective surgical intervention after failed conservative management at short-term follow-up. Patients had reliably good to excellent outcomes with improved strength during hip abduction, were at low risk of complications, and were satisfied with the outcome. In addition, younger patients achieved better outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Sarcopenia is an independent risk factor for failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA.

BACKGROUND: Sarcopenia, which is a progressive and multifactorial condition of decreased muscle strength, has been identified as an independent predictor for falls, revision, infection, and readmissions following total knee arthroplasty (TKA), but its association to patient reported outcomes (PROMs) is less studied. The aim of this study is to determine if sarcopenia and other measures of body composition are correlated with ability to achieve the 1-year minimal clinically important difference (MCID) of the KOOS JR and PROMIS-PF-SF10a following primary TKA. METHODS: A multicenter retrospective case-control study was performed. Inclusion criteria consisted of patients over the age of 18 undergoing primary TKA, body composition metrics determined by computed tomography (CT), and available pre- and post-operative PROM scores. Predictors of achievement of the 1-year MCID of the KOOS JR and PROMIS PF-SF-10a were determined through a multivariate linear regression. RESULTS: 140 primary TKAs met inclusion criteria. 74 (52.85%) patients achieved the 1-year KOOS, JR MCID and 108 (77.41%) patients achieved the 1-year MCID for the PROMIS PF-SF10a. Sarcopenia was independently associated with decreased odds of achieving the MCID of both the KOOS, JR (OR 0.31, 95%CI 0.10-0.97, p = 0.04) and the PROMIS-PF-SF10a (OR 0.32, 95%CI 0.12-0.85, p = 0.02) CONCLUSIONS: In our study, sarcopenia was independently associated with increased odds of failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA. Early identification of sarcopenic patients may be beneficial for arthroplasty surgeons so that targeted nutritional counseling and exercises can be recommended prior to TKA.