Innovative Hip Distraction Approaches for Total Hip Arthroplasty in Crowe IV Developmental Dysplasia or Similar High-Riding Patients.

BACKGROUND: Total hip arthroplasty (THA) for dislocated hips (Crowe IV dysplasia) presents unique challenges. Conventional approaches involve subtrochanteric osteotomies, but are complex with additional fixation and potentially lead to limb length discrepancies, nerve palsies, and other complications. An alternative strategy is a staged approach, where the femoral head (or remnant) is gradually lowered (distraction technique) to align with the true acetabulum over a period of time, followed by a second-stage anatomically acetabular-positioned THA. External fixation distraction and telescoping internal lengthening devices have been utilized to achieve preoperative alignment. We evaluated these techniques, including the types, time, and amount of distraction needed, as well as outcomes and complication rates. METHODS: In this retrospective case series, 14 patients (9 women, 5 men), who had a mean age of 32 years (range, 16 to 67), underwent staged surgical interventions using hip distraction using external fixators or internal lengthening devices for hip dysplasia and other pathologies (Perthes disease, osteonecrosis) in preparation for a second-stage anatomically placed THA. The mean follow-up duration for external-fixation patients was 10 years (range, 6.5 to 13.4). RESULTS: Staged treatment involved external fixators (n = 8) or internal lengthening devices (n = 6) with a device placement mean of 48 days (range, 42 to 71). The amount of distraction ranged from 6 to 12 cm. There were 2 patients who required uncomplicated revision of the internal lengthening devices, and another patient had a temporary peroneal nerve palsy. There was 1 patient who underwent an acetabular revision at 7 years. CONCLUSIONS: We focused on a challenging patient cohort that emphasizes the efficacy of staged interventions in managing Crowe Type IV dysplasia and similar cases. Favorable outcomes were found with the immediate transition to THA after device removal that effectively addressed soft-tissue contractures and femoral migration. Despite the need for further validation via larger, prospective studies, this innovative approach may pave the way toward optimizing this strategy for these difficult hip pathologies.

Cemented is not superior to cementless total knee arthroplasty for complications: a propensity score matched analysis.

INTRODUCTION: There is continued debate regarding the survivorship and revision rate of cementless versus cemented total knee arthroplasty (TKA) prostheses. This includes the assessment of early revision surgery due to aseptic loosenings and periprosthetic joint infections (PJIs). Studies have not always taken into account the impact of comorbidities, such as diabetes, obesity, and tobacco. Therefore, we compared revisions in a large population of patients undergoing cemented or cementless TKAs at 90 days, 1 year, and 2 years. METHODS: A review of an administrative claims database was used to identify patients undergoing primary TKA, either cementless (n = 8,890) or cemented (n = 215,460), from October 1, 2015 to October 31, 2020. Revision surgery for PJI and aseptic loosening were identified with diagnosis and associated procedural codes at 90 days, 1 year, and 2 years and then compared between groups. A propensity matched-analysis was performed for age, sex, Charles Comorbidity Index (CCI) > 3, alcohol abuse, tobacco use, obesity, and diabetes. Chi square tests assessed statistical significance of differences in the matched cohorts using odds ratios (ORs) with 95% confidence intervals (CIs). A P < 0.05 was defined as statistically significant. RESULTS: Cementless TKA was associated with similar revisions rates due to PJIs at 90 days (OR, 1.04, 95% CI 0.79-1.38, p = 0.83), 1 year (OR, 0.93, 95% CI 0.75-1.14, p = 0.53, and 2 years (OR, 0.87, 95% CI 0.73-1.05, p = 0.17) in comparison to the cemented TKA cohort. The odds ratio of revision due to aseptic loosening was similar as well at 90 days (OR, 0.67, 95% CI 0.34-1.31, 0.31), 1 year (OR, 1.09, 95% CI 0.73-1.61, p = 0.76), and 2 years (OR, 1.00, 95% CI 0.73-1.61, p = 0.99). CONCLUSIONS: This study found a comparable risk of PJI and aseptic loosening in cementless and cemented TKA when controlling for several comorbidities, such as tobacco, diabetes, and alcohol. Therefore, with proper patient selection, cementless TKAs can be performed with expectation of low risks of infections and aseptic loosenings.

Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021.

BACKGROUND: In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin. METHODS: Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA. RESULTS: From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days. CONCLUSIONS: An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.

Risk Factors Portending a Total Hip Arthroplasty for Patients Who Have Osteonecrosis of the Femoral Head.

INTRODUCTION: Osteonecrosis of the femoral head (ONFH) poses a substantial burden to orthopaedic surgeons. However, the exact risk attributed by each specific patient factor for those who end up receiving a total hip arthroplasty (THA) are not well known. We assessed: (1) patient demographics (age and sex); (2) blood cell dyscrasias (sickle-cell disease and hypercoagulable states); and (3) substance use (oral corticosteroid use, tobacco use, and alcohol abuse). MATERIALS AND METHODS: A retrospective search examined all patients who had a primary THA (n=715,100) between January 1, 2010 and April 30, 2020 using a national, all-payer database. Risk factors studied included age, sex, sickle-cell, hypercoagulable state, oral corticosteroid use, tobacco use, and alcohol abuse. RESULTS: Several risk factors were found to be significantly predictive for ONFH requiring THA: age <55 years (odds ratio [OR] 1.02, 95% confidence interval [CI] of 1.01 to 1.02, p<0.001), men (OR 1.07, 95% CI of 1.04 to 1.10, p<0.001), oral corticosteroid use (OR 1.21, 95% CI of 1.17 to 1.25, p<0.001), tobacco use (OR 1.15, 95% CI of 1.11 to 1.18, p<0.001), and alcohol abuse (OR 1.05, 95% CI of 1.01 to 1.08, p=0.009). CONCLUSIONS: Based on the results of this study, young age, men, oral corticosteroid use, tobacco use, and alcohol abuse are risk factors for patients who have ONFH and had a THA. The degree of risk from greatest to least were: oral corticosteroid use, tobacco use, men, alcohol abuse, and age <55 years old.

Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications.

Background: Distal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Methods: All patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Results: Revision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1-57.8). Conclusion: The use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

Elevated risk of prosthetic infections in cannabis users after shoulder arthroplasty.

INTRODUCTION: An increasing number of states are beginning to legalize recreational cannabis use, and as such, more patients using cannabis are undergoing shoulder arthroplasty procedures. The present study sought to examine the impact of cannabis use on post-operative outcomes. The primary outcomes of interest were postoperative complications, which included infection, periprosthetic fractures, periprosthetic joint infections (PJI), dislocations, and aseptic loosening as well as medical complications. Secondary outcomes were risk factors for PJI and aseptic loosening at two-years. METHODS: A private, nationwide, all-payer database (Pearldiver Technologies) was queried to identify shoulder arthroplasty patients from 2010 to 2020. Those not using tobacco or cannabis ("control", n = 10,000), tobacco users (n = 10,000), cannabis users (n = 155), and concurrent tobacco and cannabis users (n = 9,842) were identified. Risk factors for PJI and aseptic loosening at two-years were further quantified utilizing multivariable logistic regression analysis. RESULTS: Compared to non-users, cannabis users experienced the highest odds for PJI and aseptic revisions, which were followed by concurrent cannabis and tobacco users and tobacco-only users. Concurrent users, as well as tobacco users were at higher risk for dislocation. Cannabis use was the most significant risk factor for PJI, followed by concurrent use and male sex. CONCLUSIONS: Our study found cannabis use to cause greater risk for superficial and deep infection. More research involving randomized trials are needed to fully elucidate the impact of cannabis use on shoulder arthroplasty procedures. Clinically, these findings can appropriately guide surgeons and patients alike regarding expectations prior to undergoing TSA.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Osteoarthritis.

BACKGROUND: The mode of femoral fixation for primary total hip arthroplasty (THA) is undetermined, with reported outcomes favoring different fixation methods. This study aimed to compare postoperative complications between cemented and cementless fixation at 90 days, 1 year, and 2 years in patients aged 65 years of age and older undergoing THA for osteoarthritis. METHODS: Using an all-payer, national database, patients 65 years and older undergoing primary THA, either with cementless (n = 56,701) or cemented (n = 6,283) femoral fixation for osteoarthritis were identified. A 1:1 propensity-matched analysis for age, sex, comorbidity index, alcohol abuse, tobacco use, obesity, and diabetes was performed, resulting in n = 6,283 patients in each cohort. Postoperative outcomes, including postoperative periprosthetic joint infection, aseptic revision, surgical site infection, pulmonary embolism, venous thromboembolism, wound complications, dislocation, periprosthetic fracture, and aseptic loosening were assessed. RESULTS: The cemented cohort had higher rates of infection (4.5 versus 0.8%, odds ratio [OR] 5.9, 95% confidence interval [CI] 4.33 to 7.93, P < .001), aseptic revision (2.9 versus 2.0%, OR 1.47, 95% CI 1.17 to 1.85, P = .001), venous thromboembolism (1.8 versus 1.3%, OR 1.40, 95% CI 1.05 to 1.87, P < .001), and aseptic loosening (1.5 versus 0.7%, OR 2.31, 95% CI 1.60 to 3.32, P < .001) at 90-days. At 1 and 2 years, the cemented cohort had higher rates of infection, aseptic revision, and aseptic loosening (all P < .001). Rates of periprosthetic fracture were similar at all time points (all P < .001). CONCLUSIONS: Cemented fixation had higher rates of infection, aseptic loosening, and aseptic revision. This finding supports the current use of cementless fixation, but the ultimate decision regarding fixation type should be based on the proper optimization of the patient's comorbidities and bone quality.

Polyethylene exchange versus full component revision for arthrofibrosis following total knee arthroplasty: A retrospective cohort analysis.

Introduction: Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA. Methods: A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA. Results: The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64-1.06], p = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07-2.17], p = 0.022 and OR 1.44 CI [1.06-1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety. Conclusions: Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications.

Introduction: An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database. Methods: Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities. Results: Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA. Conclusion: Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.