A balance focused biometric does not predict rehabilitation needs and outcomes following total knee arthroplasty.

BACKGROUND: Both length of hospital stay and discharge to a skilled nursing facility are key drivers of total knee arthroplasty (TKA)-associated spending. Identifying patients who require increased postoperative care may improve expectation setting, discharge planning, and cost reduction. Balance deficits affect patients undergoing TKA and are critical to recovery. We aimed to assess whether a device that measures preoperative balance predicts patients' rehabilitation needs and outcomes after TKA. METHODS: 40 patients indicated for primary TKA were prospectively enrolled and followed for 12 months. Demographics, KOOS-JR, and PROMIS data were collected at baseline, 3-months, and 12-months. Single-leg balance and sway velocity were assessed preoperatively with a force plate (Sparta Science, Menlo Park, CA). The primary outcome was patients' discharge facility (home versus skilled nursing facility). Secondary outcomes included length of hospital stay, KOOS-JR scores, and PROMIS scores. RESULTS: The mean preoperative sway velocity for the operative leg was 5.7 ± 2.7 cm/s, which did not differ from that of the non-operative leg (5.7 ± 2.6 cm/s, p = 1.00). Five patients (13%) were discharged to a skilled nursing facility and the mean length of hospital stay was 2.8 ± 1.5 days. Sway velocity was not associated with discharge to a skilled nursing facility (odds ratio, OR = 0.82, 95% CI = 0.27-2.11, p = 0.690) or longer length of hospital stay (b = -0.03, SE = 0.10, p = 0.738). An increased sway velocity was associated with change in PROMIS items from baseline to 3 months for global07 ("How would you rate your pain on average?" b = 1.17, SE = 0.46, p = 0.015) and pain21 ("What is your level of pain right now?" b = 0.39, SE = 0.17, p = 0.025) at 3-months. CONCLUSION: Preoperative balance deficits were associated with postoperative improvements in pain and function after TKA, but a balance focused biometric that measured single-leg sway preoperatively did not predict discharge to a skilled nursing facility or length of hospital stay after TKA making their routine measurement cost-ineffective.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND: Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. METHODS: Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. RESULTS: Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). CONCLUSIONS: Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

The Influence of an Unexpected Symbolic Gift on Postoperative Arthroplasty Patients' Press Ganey Scores.

BACKGROUND: Hospitals use Press Ganey surveys to evaluate patient satisfaction. The goal of our study was to evaluate whether surgeon-driven gifting to patients postoperatively affects Press Ganey Survey responses. METHODS: There were 1,468 patients undergoing arthroplasty at our institution who were randomized to receive a thank-you gift, a small bouquet of flowers, and a note from their provider after surgery, or nothing for completing their preoperative arthroplasty registry questionnaire. Press Ganey surveys were sent to patients who received and did not receive flowers immediately after their hospital stay and after the patients' first postoperative visit. Scores were reported as the mean score and the fraction of responses with a top-box rating. One-sided student t-tests and Fisher's exact tests were used to assess statistical significance. RESULTS: Hospital Discharge: Patients who received flowers had higher Press Ganey survey scores than patients who did not receive flowers. For example, for "physician's concerns for questions," they had higher scores (mean difference: 3.7 ± 1.6 points, P = .012) and a 9% higher top-box rating (P = .032). For "staff attitude toward visitors," they also had higher scores (mean difference: 2.8 ± 1.3 points, P = .019) and a 7% higher top-box rating (P = .049). First Follow-up: Patients who received flowers had a higher top-box rating for "concern provider showed for questions" and "amount of time provider spent with you" by 6% (P = .046) and 11% (P = .009), respectively. They also had higher scores for "information provider gave about medications" (mean difference: 4.0 ± 1.6 points, P = .009) and 11% higher top-box rating (P = .006). CONCLUSIONS: Press Ganey Surveys were higher in orthopaedic patients who received bouquets of flowers from their arthroplasty surgeons compared to patients who did not. At follow-up, improved Press Ganey scores persisted if the patient received flowers. The gift of flowers generates patient loyalty to their surgeon.

Objective Activity Parameters Track Patient-specific Physical Recovery Trajectories After Surgery and Link With Individual Preoperative Immune States.

OBJECTIVE: The longitudinal assessment of physical function with high temporal resolution at a scalable and objective level in patients recovering from surgery is highly desirable to understand the biological and clinical factors that drive the clinical outcome. However, physical recovery from surgery itself remains poorly defined and the utility of wearable technologies to study recovery after surgery has not been established. BACKGROUND: Prolonged postoperative recovery is often associated with long-lasting impairment of physical, mental, and social functions. Although phenotypical and clinical patient characteristics account for some variation of individual recovery trajectories, biological differences likely play a major role. Specifically, patient-specific immune states have been linked to prolonged physical impairment after surgery. However, current methods of quantifying physical recovery lack patient specificity and objectivity. METHODS: Here, a combined high-fidelity accelerometry and state-of-the-art deep immune profiling approach was studied in patients undergoing major joint replacement surgery. The aim was to determine whether objective physical parameters derived from accelerometry data can accurately track patient-specific physical recovery profiles (suggestive of a 'clock of postoperative recovery'), compare the performance of derived parameters with benchmark metrics including step count, and link individual recovery profiles with patients' preoperative immune state. RESULTS: The results of our models indicate that patient-specific temporal patterns of physical function can be derived with a precision superior to benchmark metrics. Notably, 6 distinct domains of physical function and sleep are identified to represent the objective temporal patterns: ''activity capacity'' and ''moderate and overall activity (declined immediately after surgery); ''sleep disruption and sedentary activity (increased after surgery); ''overall sleep'', ''sleep onset'', and ''light activity'' (no clear changes were observed after surgery). These patterns can be linked to individual patients preopera-tive immune state using cross-validated canonical-correlation analysis. Importantly, the pSTAT3 signal activity in monocytic myeloid-derived suppressor cells predicted a slower recovery. CONCLUSIONS: Accelerometry-based recovery trajectories are scalable and objective outcomes to study patient-specific factors that drive physical recovery.

Is Operative Time Associated With Obesity-related Outcomes in TKA?

BACKGROUND: Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA. QUESTIONS/PURPOSES: We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes? METHODS: In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m2, < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m2, 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m2, 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m2, 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m2, 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m2, 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted. RESULTS: After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration. CONCLUSION: We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does Operative Time Modify Obesity-related Outcomes in THA?

BACKGROUND: Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. QUESTIONS/PURPOSES: We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? METHODS: This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. RESULTS: A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. CONCLUSION: Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. LEVEL OF EVIDENCE: Level III, therapeutic study.

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty.

BACKGROUND: The COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes. METHODS: This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. RESULTS: SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission. CONCLUSION: SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection.

BACKGROUND: An extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a periprosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection. METHODS: Our institutional database included 76 ETOs for revision hip arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second-stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated. RESULTS: Forty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (P = .082), postoperative complications (P = .258), or rate of repeat revision surgery (P = .322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (P = .758), blood loss (P = .498), rate of repeat revision surgery (P = .302), or postoperative complications (P = .253) including infection (P = .639). CONCLUSION: An ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.

Revision Hip Arthroplasty Using a Modular, Cementless Femoral Stem: Long-Term Follow-Up.

BACKGROUND: As the number of primary total hip arthroplasty (THA) cases increase, so does the demand for revision operations. However, long-term follow-up data for revision THA is lacking. METHODS: A retrospective review was completed of patients who underwent revision THA at a single institution between January 2002 and October 2007 using a cementless modular stem. Patient demographic, clinical, and radiographic data was collected. Preoperative and postoperative patient-reported outcome scores were compared at a minimum of fourteen-year follow-up. RESULTS: Eighty-four patients (89 hips) with a median age of 69 years (range, 28 to 88) at operation were included. Indications for revision included aseptic loosening (84.2%), infection (12.4%), and periprosthetic fracture (3.4%). Twenty-two hips sustained at least 1 complication: intraoperative fracture (7.9%), dislocation (6.7%), prosthetic joint infection (4.5%), deep venous thrombosis (3.4%), and late periprosthetic fracture (2.2%). There were no modular junction complications. Eight patients underwent reoperations; only three involved the stem. Thirty-eight patients (45%) were deceased prior to final follow-up without known reoperations. Twenty-seven patients (32%) were lost to follow-up. Twenty-one patients (23%) were alive at minimum fourteen-year follow-up. Complete patient-reported outcomes were available for nineteen patients (range, 14 to 18.5 years of follow-up). Significant improvement was seen in UCLA activity, VR-12 physical, hip disability and osteoarthritis outcome score, joint replacement., and Harris Hip score pain and function scores. CONCLUSION: Challenges of long-term follow-up include patient migration, an unwillingness to travel for re-examination, medical comorbidities, advanced age, and death. The cementless modular revision stem demonstrated long-term clinical success and remains a safe and reliable option for complex revision operations.

Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties.

BACKGROUND: The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI. METHODS: We identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria. RESULTS: There were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041). CONCLUSION: Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI. LEVEL OF EVIDENCE: Prognostic Level IV.

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware.

BACKGROUND: End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial. METHODS: Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes. RESULTS: The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware. CONCLUSIONS: TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes. LEVEL OF EVIDENCE: IV, cohort without control.

Isolated Versus Full Component Revision in Total Knee Arthroplasty for Aseptic Loosening.

BACKGROUND: Revision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear. METHODS: Between January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental). RESULTS: A total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P < .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (-30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (-4.2, P = .050) scores, respectively. CONCLUSION: Isolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement. LEVEL OF EVIDENCE: III, cohort with control.

An External Acetabular Alignment Guide Decreases Positional Variance.

INTRODUCTION: Certain patient and operative factors limit accurate estimation of acetabular component positioning during total hip arthroplasty (THA). This study aimed to determine whether an intraoperative external alignment guide decreases variance in acetabular component positioning. MATERIALS AND METHODS: Adult patients who underwent primary THA from 2014-2018 were reviewed. Exclusion criteria were navigation, robot-assisted surgery, and inflammatory, post-traumatic, or avascular arthritis. One surgeon used an external guide while the second surgeon resected osteophytes and utilized available anatomical landmarks for positioning. Anteversion and inclination, variance, "safe zone" positioning, operative time, and hip instability were assessed. Multivariable regression models were used to examine effects on primary and secondary outcomes. RESULTS: 409 patients were included, of which 182 underwent component placement with landmarks only. Patients undergoing component placement with landmarks only were younger (p=0.002) and more often smokers (p=0.016). After multivariable risk adjustment, use of the external alignment guide was independently associated with 2.7° higher anteversion (CI: 1.6° to 3.8°) and smaller anteversion variance (-0.3, CI: -0.6 to 0.1) compared to landmarks only. It was independently associated with 3.2° higher inclination (CI: 2.0° to 4.4°), but there was no difference in inclination variance (-0.1, CI: -0.3 to 0.2). The external alignment guide was independently associated with a 14-minute shorter operative time (CI: 9.6 to 18.7) and smaller operative time variance (-0.9, CI: -1.2 to 0.6). DISCUSSION: Use of anatomical landmarks alone was associated with increased likelihood of safe zone positioning but lower precision and longer operative time. While this study was limited by lack of randomization and its retrospective nature, an acetabular positioner may be preferable to palpable or visible anatomy alone for acetabular component placement.

Outcome of the Wagner Cone femoral component for difficult anatomical conditions during total hip arthroplasty.

PURPOSE: Total hip arthroplasty (THA) in patients with small or unusual proximal femoral anatomy is challenging due to sizing issues, control of version, and implant fixation. The Wagner Cone is a monoblock, fluted, tapered stem with successful outcomes for these patients; however, there is limited information on subsidence, a common finding with cementless stems. METHODS: We retrospectively reviewed our cases using the modified Wagner Cone (Zimmer, Warsaw, IN) implanted over a 13-year period (2006-2019) in patients with small or abnormal proximal femoral anatomy. We performed 144 primary THAs in 114 patients using this prosthesis. Mean follow-up was 4.5 ± 3.4 years (range, 1-13 years). Common reasons for implantation were hip dysplasia (52%) and osteoarthritis in patients with small femoral proportions (22%). Analysis of outcomes included assessment of stem subsidence and stability. RESULTS: Survival was 98.6% in aseptic cases; revision-free survival was 97.9%. Femoral subsidence occurred in 84 cases (58%). No subsidence progressed after 3 months. Of those that subsided, the mean distance was 2.8 ± 2.0 mm. There was less subsidence in stems that stabilized prior to six weeks (2.2 ± 1.4 mm) compared to those that continued until 12 weeks (3.9 ± 1.6, p = 0.02). Harris Hip, UCLA, and WOMAC scores significantly improved from pre-operative evaluation (p < 0.001*, p < 0.003*, p ≪ 0.001*); there was no difference in outcome between patients with and without subsidence (p = 0.430, p = 0.228, p = 0.147). CONCLUSION: The modified Wagner Cone demonstrates excellent clinical outcomes in patients with challenging proximal femoral anatomy. Subsidence is minor, stops by 3 months, and does not compromise clinical outcome.

Pes Planovalgus Is Associated with Increased Comorbidities and Poor Outcomes After Total Knee Arthroplasty.

Pes planovalgus affects knee biomechanics but there are no studies describing its impact on total knee arthroplasty (TKA). We aim to characterize the demographics, medical, and surgical complications of patients with pes planovalgus undergoing TKA. A Medicare database was queried using ICD-9 codes to identify 5,750 patients with and 23,000 patients without pes planovalgus who underwent TKA from 2005 to 2014. Standard descriptive statistics were used to compare medical and surgical complications at 90 days and 2 years, with alpha < 0.003 after a Bonferroni Correction. Patients with pes planovalgus had an elevated incidence of hypertension (80%, p < 0.001), pulmonary disease (31%, p < 0.001), hypothyroidism (28%, p < 0.001), diabetes (30%, p < 0.001), vascular disease (20%, p < 0.001), obesity (26%, p < 0.001), and depression (23%, p < 0.001). They also had increased odds of deep vein thrombosis (DVT) (odds ratio [OR] 1.3, p < 0.001), stiffness (OR 1.3, p < 0.003) and revision (OR 1.59, p < 0.003) at 90 days. At 2 years, odds of stiffness had increased (OR 1.34, p < 0.001) with similar rates of revision and medical complications. Pes planovaglus is associated with increased medical comorbidities and this patient population may be at an increased risk for postoperative stiffness, early revisions, and DVT after TKA. Arthroplasty surgeons should be conscious of these risks when considering TKA in a patient with pes planovalgus and counsel them appropriately. (Journal of Surgical Orthopaedic Advances 32(3):202-206, 2023).

A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs.

PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians. METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted. RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and (3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care. CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

Staging Bilateral Total Knee Arthroplasties Reduces Alignment Outliers.

BACKGROUND: Patients frequently present with bilateral symptomatic knee osteoarthritis and request simultaneous total knee arthroplasties (TKAs). Technical differences between simultaneous and staged TKAs could affect clinical and radiographic outcomes. We hypothesized that staged TKAs would have fewer mechanical alignment outliers than simultaneous TKAs. METHODS: We reviewed 87 simultaneous and 72 staged TKAs with at least 2 years of follow-up. Radiographic assessment was done using standing long leg and lateral radiographs of the knee. Coronal and sagittal measurements were performed by 4 blinded observers on 2 separate occasions with an intraobserver agreement of 0.95 and interobserver of 0.92. RESULTS: The first simultaneous knee had no difference in the probability of establishing the mechanical axis outside 3° of neutral (45%) compared to the first staged knee (54%, P = .337). However, the second simultaneous knee (49%) was more likely to establish the axis outside mechanical neutral compared to the second staged knee (28%; odds ratio 2.54, confidence interval 1.31-4.94, P = .006). There was an increased risk of deep venous thrombosis with staged TKA (odds ratio 2.96, confidence interval 1.28-6.84, P = .011), but other perioperative complication rates were not significantly different. There were no clinically significant differences in range of motion or Knee Society Score. CONCLUSION: There is a significantly increased risk of establishing the second knee outside mechanical neutral during a simultaneous TKA compared to staged bilateral TKAs, possibly related to a number of surgeon-related and system-related factors. The impact on clinical outcomes and radiographic loosening may become significant in long-term follow-up.

Tolerant Small-colony Variants Form Prior to Resistance Within a Staphylococcus aureus Biofilm Based on Antibiotic Selective Pressure.

BACKGROUND: The treatment of periprosthetic joint infection (PJI) is focused on the surgical or chemical removal of biofilm. Antibiotics in isolation are typically ineffective against PJI. Bacteria survive after antibiotic administration because of antibiotic tolerance, resistance, and persistence that arise in the resident bacteria of a biofilm. Small-colony variants are typically slow-growing bacterial subpopulations that arise after antibiotic exposure and are associated with persistent and chronic infections such as PJI. The role of biofilm-mediated antibiotic tolerance in the emergence of antibiotic resistance remains poorly defined experimentally. QUESTIONS/PURPOSES: We asked: (1) Does prior antibiotic exposure affect how Staphylococcus aureus survives within a developing biofilm when exposed to an antibiotic that penetrates biofilm, like rifampicin? (2) Does exposure to an antibiotic with poor biofilm penetration, such as vancomycin, affect how S. aureus survives within a developing biofilm? (3) Do small-colony variants emerge from antibiotic-tolerant or -resistant bacteria in a S. aureus biofilm? METHODS: We used a porous membrane as an in vitro implant model to grow luminescent S. aureus biofilms and simultaneously track microcolony expansion. We evaluated the impact of tolerance on the development of resistance by comparing rifampicin (an antibiotic that penetrates S. aureus biofilm) with vancomycin (an antibiotic that penetrates biofilm poorly). We performed viability counting after membrane dissociation to discriminate among tolerant, resistant, and persistent bacteria. Biofilm quantification and small-colony morphologies were confirmed using scanning electron microscopy. Because of experimental variability induced by the starting bacterial inoculum, relative changes were compared since absolute values may not have been statistically comparable. RESULTS: Antibiotic-naïve S. aureus placed under the selective pressure of rifampicin initially survived within an emerging biofilm by using tolerance given that biofilm resident cell viability revealed 1.0 x 108 CFU, of which 7.5 x 106 CFU were attributed to the emergence of resistance and 9.3 x 107 CFU of which were attributed to the development of tolerance. Previous exposure of S. aureus to rifampicin obviated tolerance-mediate survival when rifampicin resistance was present, since the number of viable biofilm resident cells (9.5 x 109 CFU) nearly equaled the number of rifampicin-resistant bacteria (1.1 x 1010 CFU). Bacteria exposed to an antibiotic with poor biofilm penetration, like vancomycin, survive within an emerging biofilm by using tolerance as well because the biofilm resident cell viability for vancomycin-naïve (1.6 x 1010 CFU) and vancomycin-resistant (1.0 x 1010 CFU) S. aureus could not be accounted for by emergence of resistance. Adding rifampicin to vancomycin resulted in a nearly 500-fold reduction in vancomycin-tolerant bacteria from 1.5 x 1010 CFU to 3.3 x 107 CFU. Small-colony variant S. aureus emerged within the tolerant bacterial population within 24 hours of biofilm-penetrating antibiotic administration. Scanning electron microscopy before membrane dissociation confirmed the presence of small, uniform cells with biofilm-related microstructures when unexposed to rifampicin as well as large, misshapen, lysed cells with a small-colony variant morphology [29, 41, 42, 63] and a lack of biofilm-related microstructures when exposed to rifampicin. This visually confirmed the rapid emergence of small-colony variants within the sessile niche of a developing biofilm when exposed to an antibiotic that exerted selective pressure. CONCLUSION: Tolerance explains why surgical and nonsurgical modalities that rely on antibiotics to "treat" residual microscopic biofilm may fail over time. The differential emergence of resistance based on biofilm penetration may explain why some suppressive antibiotic therapies that do not penetrate biofilm well may rely on bacterial control while limiting the emergence of resistance. However, this strategy fails to address the tolerant bacterial niche that harbors persistent bacteria with a small-colony variant morphology. CLINICAL RELEVANCE: Our work establishes biofilm-mediated antibiotic tolerance as a neglected feature of bacterial communities that prevents the effective treatment of PJI.

Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial.

BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs. QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions? METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement. RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71. CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL. LEVEL OF EVIDENCE: Level II, therapeutic study.

Google Trends Analysis Shows Increasing Public Interest in Platelet-Rich Plasma Injections for Hip and Knee Osteoarthritis.

BACKGROUND: Osteoarthritis is a chronic musculoskeletal condition that frequently affects the hip and knee joints. Given the burden associated with surgical intervention for hip and knee osteoarthritis, patients continue to search for potential nonoperative treatments. One biologic therapy with mixed clinical and basic science evidence for treating osteoarthritis is platelet-rich plasma injections into the affected joint. We used the Google Trends tool to provide a quantitative analysis of national interest in platelet-rich plasma injections for hip and knee osteoarthritis. METHODS: Google Trends parameters were selected to obtain search data from January 2009 to December 2019. Various combinations of "arthritis," "osteoarthritis," "PRP," "platelet-rich plasma," "knee," and "hip" were entered into the Google Trends tool and trend analyses were performed. RESULTS: Three linear models were generated to display search volume trends in the United States for platelet-rich plasma and osteoarthritis, hip osteoarthritis, and knee osteoarthritis, respectively. All models showed increased Google queries as time progressed (P < .001), with R2 ranging from 0.837 to 0.940. Seasonal, income-related, and geographic variations in public interest in platelet-rich plasma for osteoarthritis were noted. CONCLUSION: Our results demonstrate a significant rise in Google queries related to platelet-rich plasma injections for osteoarthritis of the hip and knee since 2009. Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data. Trends in public interest may inform patient counseling, shared decision-making, and directions for future clinical research.