High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES: (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS: A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS: The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION: Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE: Level III, prognostic study.

What's New in Periprosthetic Femur Fractures?

BACKGROUND: Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty. METHODS/RESULTS: This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons 2023 annual meeting, including an overview of the Vancouver classification and its implications on treatment and subsequent complications, an updated approach to the management of intraoperative fractures, and finally, contemporary strategies for both osteosynthesis as well as revision arthroplasty for PFFs. CONCLUSION: As the incidence of PPF continues to increase, arthroplasty and trauma surgeons must be prepared to address this challenging complication with a contemporary understanding of the treatment options and their outcomes.

How Much Protection Does a Collar Provide? Assessing Risk of Early Periprosthetic Femur Fractures Following Total Hip Arthroplasty in Elderly Patients.

BACKGROUND: Periprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients. METHODS: A consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period. RESULTS: Non-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001). CONCLUSIONS: In this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems.

Should We Wait for Bone-on-Bone Arthritis? Equivalent Clinical Outcomes in Patients Requiring Advanced Imaging Before Primary Total Hip Arthroplasty.

BACKGROUND: Plain radiographs remain the standard for diagnosing osteoarthritis (OA). Total hip arthroplasty (THA) is generally offered only for advanced OA by plain radiographs. Advanced imaging is used as an adjunct to assess OA severity in cases of progressive symptoms with less advanced OA by plain radiographs. The objective of this study was to compare outcomes following THA in patients who have advanced OA visualized by plain radiographs to patients who have less severe OA visualized by plain radiographs. METHODS: From February 2016 to February 2020, 93 patients who had Kellgren-Lawrence (KL) grade 0 to 2 OA and underwent THA were identified. The median age was 65 years, and 55% were women. They were matched 1:3 to patients who underwent THA for KL 4 OA based on age, sex, body mass index, and Charlson Comorbidity Index. The primary outcome was achievement of the Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference, substantial clinical benefit, and patient-acceptable symptom state at 1 year postoperatively. RESULTS: There was no difference between the KL 0 to 2 and KL 4 cohorts in the achievement of HOOS JR minimum clinically important difference (86 versus 85.6%, P = .922), substantial clinical benefit (81.7 versus 80.2%, P = .751), or patient-acceptable symptom state (89.2 versus 85.6%, P = .374). The KL 0 to 2 cohort had a similar improvement in their 2-year HOOS JR (42.5 versus 38.6, P = .019). CONCLUSIONS: In this series, there was no difference in outcomes following primary THA between patients who have severe OA on plain radiographs (KL 4) compared to those who have less severe OA (KL 0 to 2). In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation.

BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Does Approach Matter in Robotic-Assisted Total Hip Arthroplasty? A Comparison of Early Reoperations Between Direct Anterior and Postero-Lateral Approach.

BACKGROUND: There is no consensus on whether direct anterior approach (DAA) or postero-lateral approach (PLA) total hip arthroplasty (THA) confers a lower risk of postoperative complications. Robotic assistance in THA results in a more consistently accurate component position compared to manual THA. The objective of this study was to compare rates of dislocation, reoperation, revision, and patient-reported outcome measures between patients undergoing DAA and PLA robotic-assisted primary THA. METHODS: We identified 2,040 consecutive robotic-assisted primary THAs performed for primary osteoarthritis, using DAA (n = 497) or PLA (n = 1,542) between 2017 and 2020. The mean follow-up was 18 months. Kaplan-Meier analysis estimated survivorship free of dislocation, reoperation, and revision. Achievement of patient acceptable symptom state and minimum clinically important difference were used to compare changes in the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Visual Analog Scale. RESULTS: Dislocation was rare in this series (14 in 2,040, 0.7%), including 1 of 497 (0.2%) in the DAA cohort and 13 of 1,542 (0.8%) in the PLA cohort (P = .210). There was no difference in 2-year reoperation-free survivorship (97.8 versus 98.6%, P = .59) or revision-free survivorship (98.8 versus 99.0%, P = .87) at any time point. After controlling for age, sex, and body mass index, there was no difference in dislocation, reoperation, or revision. At 6-week follow-up, after controlling for age, sex, and body mass index, patients in the DAA cohort had higher odds of achieving HOOS JR minimum clinically important difference (odds ratio = 2.01, P = .012) and HOOS JR patient acceptable symptom state (odds ratio = 1.72, P = .028). There were no differences in patient-reported outcome measures by 3 months. CONCLUSIONS: For robotic-assisted primary THA, DAA may confer enhanced early (<6 weeks) functional recovery compared to the PLA, but there was no significant difference in postoperative dislocation, reoperation, or revision rates.

Femoral Component Debonding Frequently Missed on Advanced Imaging Prior to Revision of a Recalled Total Knee Arthroplasty.

BACKGROUND: Identification of femoral component debonding in the work-up of painful total knee arthroplasty (TKA) often poses a diagnostic challenge. The purpose of this study was to compare the sensitivity and specificity of radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) for identifying femoral component loosening with debonding at the time of revision of a primary TKA with a recalled polyethylene insert. METHODS: Using an institutional database, we identified all cases of revision TKA performed for this specific implant recall following a primary TKA between 2014 and 2022. Patients who had a preoperative radiograph, CT, and MRI were included (n = 77). Sensitivity, specificity, and positive and negative likelihood ratio (LR) for predicting loosening were compared among the imaging modalities, using the intraoperative evidence of implant loosening as the gold standard. RESULTS: At the time of revision surgery, the femoral component was noted to have aseptic loosening with debonding in 46 of the 77 (60%) of the TKAs. There were no significant differences in demographics in the cohort with femoral debonding compared to those with well-fixed implants. The CT demonstrated a sensitivity of 28% and a specificity of 97%, while the MRI demonstrated a sensitivity of 37% and a specificity of 94% for detecting femoral loosening due to debonding. Both CT and MRI demonstrated poor negative LRs for femoral loosening (LR 0.7). CONCLUSIONS: In this series of revision TKAs for a specific recalled component, neither CT nor MRI accurately diagnosed femoral component debonding. For patients who have this implant, it is imperative to interrogate the implant-cement interface intraoperatively and prepare for full revision surgery as well as marked bone loss secondary to osteolysis.

A Consecutive Series of Vancouver B2 Periprosthetic Femur Fractures Treated With Contemporary Monoblock Versus Modular Revision Stems: Clinical and Radiographic Outcomes.

BACKGROUND: Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs. METHODS: A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation. RESULTS: There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort. CONCLUSIONS: No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.

High Rate of Unplanned Reoperation for Interprosthetic Femur Fractures After Total Hip and Knee Arthroplasty.

BACKGROUND: Interprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. METHODS: We retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement and 1 total femur replacement. Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (n = 9), and in 1 case, total femur replacement (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). RESULTS: The 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for refracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral total knee arthroplasty component was associated with increased risk for reoperation (P = .007) and PJI (P = .044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = .72). CONCLUSIONS: An IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between 2 stemmed components were at the highest risk for reoperation.

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.

The John N. Insall Award: Does Melatonin Improve Subjective Sleep Quality After Total Knee Arthroplasty? A Randomized, Placebo-Controlled Trial.

BACKGROUND: Sleep disturbance is a common problem following total knee arthroplasty (TKA). The objective of this study was to determine if exogenous melatonin improves sleep quality following primary TKA. METHODS: A randomized, double-blind, placebo-controlled trial was conducted. A total of 172 patients undergoing unilateral TKA for primary knee osteoarthritis were randomized to receive either 5 mg melatonin (n = 86) or 125 mg vitamin C placebo (n = 86) nightly for 6 weeks. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) at 6 weeks and 90 days postoperatively. Secondary outcomes included 6-week and 90-day patient-reported outcome measures (PROMs), morphine milligram equivalents prescribed, medication compliance, adverse events, and 90-day readmissions. RESULTS: Mean PSQI scores worsened at 6 weeks before returning to the preoperative baseline at 90 days in both groups. There were no differences in PSQI scores between melatonin and placebo groups at 6 weeks (10.2 ± 4.2 versus 10.5 ± 4.4, P = .66) or 90 days (8.1 ± 4.1 versus 7.5 ± 4.0, P = .43). Melatonin did not improve the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, Visual Analog Scale for pain, or Veterans Rand 12 Physical Component Score or Mental Component Score at 6 weeks or 90 days. Poor sleep quality was associated with worse PROMs at 6 weeks and 90 days on univariate and multivariable analyses, but melatonin did not modify these associations. There were no differences in morphine milligram equivalents prescribed, medication compliances, adverse events, or 90-day readmissions between both groups. CONCLUSIONS: Exogenous melatonin did not improve subjective sleep quality or PROMs at 6 weeks or 90 days following TKA. Poor sleep quality was associated with worse patient-reported function and pain. Our results do not support the routine use of melatonin after TKA.

Contemporary Use of Trochanteric Plates in Periprosthetic Femur Fractures: A Displaced Trochanter Will Not Be Tamed.

BACKGROUND: The objective of this study was to evaluate the reoperation and complication rate following trochanteric plate fixation of greater trochanter (GT) periprosthetic femur fractures associated with total hip arthroplasty and to identify risk factors for subsequent reoperation, nonunion, and hardware failure (plate/cable breakage or migration). METHODS: Between 2010 and 2020, 44 patients who had 44 periprosthetic greater trochanter fractures at mean follow up of 2 years were retrospectively reviewed. Initial injury radiographs as well as immediate and final follow-up radiographs were evaluated. Subsequent reoperations, nonunion, and cases of hardware failure were identified. There were 22 (50%) Vancouver B2 fractures and 22 (50%) Vancouver A fractures. RESULTS: The 2-year cumulative probability of any subsequent reoperation was 20%. There were 9 total subsequent reoperations. The trochanteric fracture went on to nonunion in 14 patients (39%), and hardware failure occurred in 10 (28%) patients. A trochanteric bolt was used in addition to the trochanteric plate in 6 patients (14%), of which 4 (67%) patients had trochanteric plate displacement and 3 (50%) patients had trochanteric nonunion. Displacement of the greater trochanter prior to fixation was a predictor of subsequent nonunion (77% versus 23%, P = .02). CONCLUSION: In this large contemporary series, there was a high incidence of reoperation (20%) with in the first 2-years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%), and hardware failure (28%). Displacement of the GT prior to plating predicted nonunion. LEVEL OF EVIDENCE: Level IV, retrospective observational study.

Metrics of Clinically Important Changes in Total Hip Arthroplasty: A Systematic Review.

BACKGROUND: Although patient-reported outcome measures (PROMs) have become a regularly used metric, there is little consensus on the methodology used to determine clinically relevant postoperative outcomes. We systematically reviewed the literature for studies that have identified metrics of clinical efficacy after total hip arthroplasty (THA) including minimal clinically important difference (MCID), patient acceptable symptom state (PASS), minimal detectable change (MDC), and substantial clinical benefit (SCB). METHODS: A systematic review examining quantitative metrics for assessing clinical improvement with PROMs following THA was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the MEDLINE database from 2008 to 2020. Inclusion criteria included full texts, English language, primary THA with minimum 1-year follow-up, use of metrics for assessing clinical outcomes with PROMs, and primary derivations of those metrics. Sixteen studies (24,487 THA patients) met inclusion criteria and 11 different PROMs were reported. RESULTS: MCIDs were calculated using distribution methods in 7 studies (44%), anchor methods in 2 studies (13%), and both methods in 2 studies (13%). MDC was calculated in 2 studies, PASS was reported in 1 study using anchor-based method, and SCB was calculated in 1 study using anchor-based method. CONCLUSION: There is a lack of consistency in the literature regarding the use and interpretation of PROMs to assess patient satisfaction. MCID was the most frequently reported measure, while MDC, SCB, and PASS were used relatively infrequently. Method of derivation varied based on the PROM used; distribution method was more frequently used for MCID.

Outcomes After Revision Total Knee Arthroplasty From a Specific, Now-Recalled Implant System.

BACKGROUND: A specific total knee arthroplasty (TKA) implant system was recently recalled for high incidence of early polymeric wear and osteolysis. We analyzed the early outcomes of aseptic revision with these implants. METHODS: We identified 202 aseptic revision TKAs of this implant system performed at a single institution between 2010 and 2020. Revision indications included aseptic loosening (n = 120), instability (n = 55), and polymeric wear/osteolysis (n = 27). Components were revised in 145 cases (72%) and isolated polyethylene insert exchange occurred in 57 cases (28%). Kaplan-Meier and Cox proportional hazards analyses were used to determine survivorship free from all-cause rerevision and rerevision risk factors. RESULTS: At 2 and 5 years, survivorship free from all-cause rerevision was 89 and 76% in the polyethylene exchange cohort versus 92 and 84% in the component revision cohort (P = .5). At 2 and 5 years, survivorship in revision with components from the same manufacturer was 89 and 80% compared to 95 and 86% in revision with components from a different manufacturer (P = .2). Among re-revisions (n = 30), cones (37%), sleeves (7%), hinge/distal femoral replacement implants were frequently used (13%). Men had increased risk for rerevision (hazard ratio = 2.3, P = .04). CONCLUSION: In this series of aseptic revision TKAs performed on a now-recalled implant system, survivorship free from rerevision was lower than expected when components from the same manufacturer were utilized, but comparable to contemporary reports when both the components were revised with an alternative implant system. Metaphyseal fixation with cones and sleeves as well as highly constrained implants was frequently utilized at time of rerevision TKA. LEVEL OF EVIDENCE: Level IV.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Posterior Tibial Slope in Computer-Navigated Total Knee Arthroplasty: The Transmalleolar Sagittal Axis Underestimates Slope Compared to Traditional Intramedullary Axis.

BACKGROUND: Tibial slope in total knee arthroplasty (TKA) impacts knee flexion, balance, and ligament strain. Implants were initially designed with tibial slope recommendations based on the intramedullary axis. However, technology-assisted TKA, such as robotics or navigation, determines slope from the ankle-knee axis connecting the center of the transmalleolar line to the proximal exit point of the tibial shaft axis. We sought to quantify the difference in tibial slope between the traditional intramedullary and transmalleolar sagittal tibial axes. METHODS: We retrospectively identified 40 TKAs with preoperative computed tomography scans. We reconstructed the 3-dimensional geometry of the tibia and fibula and determined the intramedullary axis as the best fit cylinder to the tibial shaft. We defined the transmalleolar axis according to accepted industry standards. We measured the angular difference between both axes in the sagittal plane. RESULTS: The transmalleolar axis was radiographically posterior to the intramedullary axis in 39 knees. Utilizing the transmalleolar axis to set posterior tibial slope would reduce the posterior tibial slope by a mean of 1.9° ± 1.3° compared to the intramedullary axis. Furthermore, the posterior slope would be reduced between 0° and 2° in 24 knees (60%), between 2° and 4° in 10 knees (25%), and more than 4° in 5 knees (13%). CONCLUSION: Tibial components implanted with technology assistance referencing the transmalleolar axis to set posterior slope will show an average of 1.9° less posterior slope when measured in sagittal plain radiographs, potentially concerning for knee kinematics.

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.

The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

Surgical outcomes of dual-plate fixation for periprosthetic femur fractures around a stable hip arthroplasty stem.

INTRODUCTION: The incidence of periprosthetic femur fractures is increasing. Multiple treatment methods exist to treat fractures surrounding stable hip arthroplasty implants including locking plate fixation, cable fixation, allograft augmentation, and revision arthroplasty. No consensus regarding optimal treatment has been reached, and significant complications remain. Recently, biomechanical studies have demonstrated the benefits of orthogonal dual-plate fixation, but little clinical data exist. The purpose of the current study was to investigate the clinical and radiographic outcomes of dual-plated periprosthetic femur fractures around stable hip stems. MATERIALS AND METHODS: Patients with periprosthetic femur fractures following hip arthroplasty with a stable femoral stem treated with dual-plate fixation were identified through chart review at a single institution. Fracture classification, fixation characteristics, radiographic outcomes, clinical outcomes and complications including re-operation were recorded. RESULTS: Over a 12-year period, 31 patients (mean age 77 years at surgery, range 48-94) underwent dual plating by three traumatologists for implant-stable periprosthetic femur fractures surrounding a hip arthroplasty stem. There were 27 Vancouver B1-type and 9 inter-prosthetic fractures. Average follow-up was 2 years. Of the 26 patients with minimum 6-month follow-up, 24 (92%) united after index surgery (mean time to union 6.0 months, range 1.5-14.0). Mean time to full weight-bearing post-operatively was 2.6 months (range 1.5-4.0 months). Two patients required secondary surgery to address nonunion. CONCLUSIONS: Dual-plating achieved high union rates with an acceptable complication profile for the treatment of periprosthetic femur fractures surrounding a stable hip arthroplasty stem. Our preferred fixation construct involves a lateral plate spanning the entire femur secured with non-locking bicortical screws supplemented with an anteriorly based reconstruction plate. Additional prospective research is required to confirm the results of this study.

Total Hip Arthroplasty for Femoral Neck Fracture: What Are the Contemporary Reasons for Failure?

BACKGROUND: Total hip arthroplasty (THA) for femoral neck fracture (FNF) appears to provide superior functional outcomes compared to hemiarthroplasty in selected active, elderly patients; however, the historical tradeoff has been higher risk of complications including dislocation. We aimed to describe implant survivorship and reasons for failure after THA for FNFs. METHODS: We identified 217 FNFs treated with THA from 2000 to 2017 from our institutional total joint registry (during the same time period 2039 FNFs were treated with hemiarthroplasty). Mean age was 70 years, and 65% were female. Cemented femoral components were utilized in 41%. Approach was anterolateral in 71%, posterior in 21%, and direct anterior in 8%. Dual-mobility constructs were utilized in 3%. A competing risk model accounting for death was used to analyze revisions and complications. Mean follow-up was 6 years. RESULTS: The 5-year cumulative incidence of any revision was 8%. Nineteen hips were revised for the following indications: postoperative periprosthetic femur fracture (6: 3 uncemented stems and 3 cemented), infection (5), aseptic loosening of the femoral component (3: 2 cemented and 1 uncemented), dislocation (3), iliopsoas impingement (1), and liner dissociation (1). The 5-year cumulative incidence of periprosthetic femur fractures was 7%, including 7 intraoperative fractures and 11 postoperative fractures. The 5-year cumulative incidence of dislocation was 1.4%. CONCLUSION: The 5-year cumulative incidence of any revision after THA for FNFs was 8%, mostly attributed to periprosthetic fracture and infection. Hip instability was not as common after FNF with contemporary patient selection, techniques, and implants compared to previous series. LEVEL OF EVIDENCE: Prognostic, level III.