Diversity of Backgrounds and Academic Accomplishments for Presidents Elected to Hip and Knee Arthroplasty Societies in the United States.

BACKGROUND: Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons. METHODS: This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022). RESULTS: There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05). CONCLUSIONS: Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty.

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty.

BACKGROUND: Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA. METHODS: There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations. RESULTS: Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002). CONCLUSIONS: Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty.

BACKGROUND: Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. METHODS: We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05. RESULTS: The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). CONCLUSIONS: Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

Dysplastic Hips That Are Too Late for Periacetabular Osteotomy Are Not Too Early for Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is often performed in symptomatic patients who have hip dysplasia and do not qualify for periacetabular osteotomy. The impact of osteoarthritis (OA) severity on postoperative outcomes in dysplasia patients who undergo THA is not well described. We hypothesized that dysplasia patients who have mild OA have slower initial recovery postoperatively but similar one-year patient-reported outcome measures (PROMs) compared to dysplasia patients who have severe OA. METHODS: We performed a retrospective review at a single academic institution over a 6-year period of patients who have dysplasia who underwent THA compared to patients who have primary OA who underwent THA. There were 263 patients who had dysplasia, compared to 1,225 THA patients who did not have dysplasia. Within the dysplasia cohort, we compared PROMs stratified by dysplasia and OA severity. The diagnosis of dysplasia was verified using the radiographic lateral center edge angle. A minimum one-year follow-up was required. The PROMs were collected through one year postoperatively. Logistic and linear regression models were used, adjusting for age, sex, body mass index, and Charlson comorbidity index. RESULTS: No significant differences were found in postoperative PROMs or revision rates (P = .58). When stratified by dysplasia severity, patients who had lower lateral center edge angle had more improvement in physical function scores from preoperative to 2 weeks (P < .01) and higher physical function scores at 2 weeks (P = .03). When stratified by OA severity, patients who had a worse Tönnis score had more improvement in physical function scores from preoperative to 2 weeks (P < .01). Recovery curves in dysplasia patients based on dysplasia and OA severity were not significantly different at 6 weeks, 1 year, and 2 years postoperative. CONCLUSIONS: Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. We believe that THA is a reasonable surgical intervention for symptomatic dysplasia patients who have mild arthritis and do not qualify for periacetabular osteotomy.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees.

BACKGROUND: Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. METHODS: All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). RESULTS: There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. CONCLUSIONS: The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial.

BACKGROUND: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. CONCLUSIONS: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. LEVEL OF EVIDENCE: Level 1, RCT.

The Biomarker Toolkit - an evidence-based guideline to predict cancer biomarker success and guide development.

BACKGROUND: An increased number of resources are allocated on cancer biomarker discovery, but very few of these biomarkers are clinically adopted. To bridge the gap between Biomarker discovery and clinical use, we aim to generate the Biomarker Toolkit, a tool designed to identify clinically promising biomarkers and promote successful biomarker translation. METHODS: All features associated with a clinically useful biomarker were identified using mixed-methodology, including systematic literature search, semi-structured interviews, and an online two-stage Delphi-Survey. Validation of the checklist was achieved by independent systematic literature searches using keywords/subheadings related to clinically and non-clinically utilised breast and colorectal cancer biomarkers. Composite aggregated scores were generated for each selected publication based on the presence/absence of an attribute listed in the Biomarker Toolkit checklist. RESULTS: Systematic literature search identified 129 attributes associated with a clinically useful biomarker. These were grouped in four main categories including: rationale, clinical utility, analytical validity, and clinical validity. This checklist was subsequently developed using semi-structured interviews with biomarker experts (n=34); and 88.23% agreement was achieved regarding the identified attributes, via the Delphi survey (consensus level:75%, n=51). Quantitative validation was completed using clinically and non-clinically implemented breast and colorectal cancer biomarkers. Cox-regression analysis suggested that total score is a significant driver of biomarker success in both cancer types (BC: p>0.0001, 95.0% CI: 0.869-0.935, CRC: p>0.0001, 95.0% CI: 0.918-0.954). CONCLUSIONS: This novel study generated a validated checklist with literature-reported attributes linked with successful biomarker implementation. Ultimately, the application of this toolkit can be used to detect biomarkers with the highest clinical potential and shape how biomarker studies are designed/performed.

John Charnley Award: A Quantitative Fluoroscopic Tool Improves Acetabular Fragment Positioning in Periacetabular Osteotomy.

BACKGROUND: Radiographic assessment of acetabular fragment positioning during periacetabular osteotomy (PAO) has been linked to hip survivorship. Intraoperative plain radiographs are time and resource intensive, while fluoroscopy can introduce image distortion affecting measurement accuracy. Our purpose was to determine whether intraoperative fluoroscopy-based measurements with a distortion correcting fluoroscopic tool improved PAO measurement targets. METHODS: We retrospectively reviewed 570 PAOs; 136 PAOs utilized a distortion correcting fluoroscopic tool, and 434 PAOs performed with routine fluoroscopy, prior to this technology. Lateral center-edge angle (LCEA), acetabular index (AI), posterior wall sign (PWS), and anterior center-edge angle (ACEA) were measured on preoperative standing radiographs, intraoperative fluoroscopic images, and postoperative standing radiographs. Defined target zones of correction were AI: 0-10°, ACEA: 25-40°, LCEA: 25-40°, PWS: negative. Postoperative correction in zones and patient-reported outcomes were compared using chi-square tests and paired t-tests, respectively. RESULTS: The average difference between postcorrection fluoroscopic measurements and 6-week postoperative radiographs was 0.21° for LCEA, 0.01° for ACEA, and -0.07° for AI (all P < .01). The PWS agreement was 92%. The percentages of hips meeting target goals overall improved with the new fluoroscopic tool: 74%-92% for LCEA (P < .01), 72%-85% for ACEA (P < .01), and 69 versus 74% for AI (P = .25), though there was no improvement in PWS (85 versus 85%, P = .92). All patient-reported outcomes except PROMIS Mental Health were significantly improved at most recent follow-up. CONCLUSIONS: Our study demonstrated improved PAO measurements and target goals with the use of a distortion correcting quantitative fluoroscopic real-time measuring device. This value-additive tool gives reliable quantitative measurements of correction without interfering with surgical workflow.

Classifying Bone Loss in Failed Stemmed Total Knee Arthroplasty: Determining Reliability.

BACKGROUND: Failed stemmed total knee arthroplasty (TKA) components present with varying degrees of bone loss and technical challenges. A classification system has been proposed based upon metaphyseal bone loss and diaphyseal cortical integrity. A validation study was performed to determine interobserver and intraobserver reliability at multiple institutions and with different levels of training. METHODS: An online survey with digital anteroposterior and lateral radiographs was sent to 5 arthroplasty surgeons and 5 adult reconstruction fellows. The survey included 62 cases with stemmed femoral and tibial components, considered failures and pending revision, and scored by each reviewer independently using the classification system. Each case was scored in 2 separate sessions. Interobserver and intraobserver reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Interobserver grading for both the femur (0.69) and tibia (0.72) showed strong reliability among the attendings and fellows, with slightly stronger reliability in tibia cases. The intraclass correlation coefficient (ICC) for attendings and fellows was similar overall, demonstrating consistency of the grading regardless of training level. Intraobserver comparisons showed a strong ICC for attendings and fellows in femoral cases, while fellows had near-perfect ICC in tibia cases. Across all reviewers there was on average 93% agreement within 1 grade per case with the majority of the discrepancy occurring at the metaphyseal-diaphyseal junction. CONCLUSION: This classification demonstrated overall strong interobserver and intraobserver reliability, with 93% agreement within 1 grade of bone loss. With further education, this classification system can ultimately be used to standardize the degree of bone loss in failed stemmed components and help with preoperative planning.

Recovery Curve for Patient Reported Outcomes and Objective Physical Activity After Primary Total Knee Arthroplasty-A Multicenter Study Using Wearable Technology.

BACKGROUND: This study aimed to describe the trajectory of recovery based on patient-reported outcomes (PROs) and objective metrics of physical activity measures over the first 12 months post-total knee arthroplasty (TKA). METHODS: In total, 1,005 participants who underwent a primary unilateral TKA surgery between November 2018 and September 2021 from a multisite prospective study were analyzed. Generalized estimating equations were used to evaluate PROs and objective physical activity measures over time. RESULTS: All Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), EuroQol-5D (EQ-5D), and steps per day scores were greater than preoperative scores (P < .05). The flights of stairs per day, gait speed, and walking asymmetry all declined at 1 month (all, P < .001). However, all subsequent scores improved by 6 months (all, P < .01). The greatest clinically important differences from previous visit in KOOS JR (ß = 18.1; 95% Confidence Interval (CI) = 17.2, 19.0), EQ-5D (ß = 0.11; 95% CI = 0.10, 0.12), steps per day (ß = 1,169.3; 95% CI = 1,012.7, 1,325.9), gait speed (ß = -0.05; 95% CI = -0.06, -0.03), and walking asymmetry (ß = 0.00; 95% CI = -0.03, 0.03) were observed at 3 months. CONCLUSION: The KOOS JR, EQ-5D, and steps per day measures showed earlier improvements than other physical activity metrics, with the greatest magnitude of improvement within the first 3 months post-TKA. The greatest magnitude of improvement in walking asymmetry was not observed until 6 months, while gait speed and flights of stairs per day were not observed until 12 months. This data may further help provide expectation setting information to patients before surgery, and may aid in identifying outliers to the normal recovery curve who may benefit from targeted interventions.

Recovery Curves for Patient Reported Outcomes and Physical Function After Total Hip Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are frequently used for evaluating patient satisfaction and function following total hip arthroplasty (THA). Functional measures along with chronologic modeling may help set expectations perioperatively. Our goal was to define the trajectory of recovery and function in the first year following THA. METHODS: Prospective data from 1,898 patients in a multicenter study was analyzed. The PROMs included the Hip disability and Osteoarthritis Score for Joint Replacement and EuroQol-5 dimension. Physical activity was recorded on a wearable technology. Data was collected preoperatively and at 1, 3, 6, and 12 months postoperatively. Generalized estimating equations were used to evaluate outcomes over time. RESULTS: Significant improvement occurred between preoperative and postoperative time points for all PROMs. The PROMs showed the greatest proportional recovery within the first month postoperatively, each improving by at least 1 minimal clinically important difference (MCID). Daily steps and flights of stairs took longer to reach at least 1 MCID (3 months and 1 year, respectively). Gait speed and walking asymmetry returned to baseline by 3 months, but did not reach a MCID of improvement by 1 year. CONCLUSION: Patients can be counseled that the greatest proportional improvement in PROMs is within 1 month after THA, while function surpasses preoperative baselines by 3 months, and gait quality may not improve until after 1 year. This can help set realistic expectations and target interventions toward patients deviating from the norm.

Accelerometer-Based Navigation in Primary Total Knee Arthroplasty Leads to Improved Alignment but No Change in Patient-Reported Outcomes.

BACKGROUND: Computer and accelerometer-based navigation (ABN) tools have demonstrated improved mechanical alignment in primary total knee arthroplasty (TKA). ABN, in particular, is attractive due to avoidance of pins and trackers. Prior literature has yet to demonstrate an associated improvement in functional outcomes using ABN compared to conventional instrumentation (CONV). The purpose of this study was to compare alignment and functional outcomes between CONV and ABN in primary TKA in a large patient series. METHODS: A retrospective study of 1,925 TKAs performed by a single surgeon sequentially was performed. There were 1,223 TKAs performed with CONV and measured resection technique. There were 702 TKAs performed with distal femoral ABN and restricted kinematic alignment goals. We compared radiographic alignment, Patient-Reported Outcomes Measurement Information System scores, rates of manipulation under anesthesia, and needs for aseptic revisions between cohorts. Chi-squared, Fisher's exact, and t-tests were used to compare demographics and outcomes. RESULTS: The ABN cohort had higher rates of neutral alignment postoperatively than the CONV cohort (ABN 74% versus CONV 56%, P < .001). Rates of manipulation under anesthesia (ABN 2.8% versus CONV 3.4%, P = .382) and aseptic revision (ABN 0.9% versus CONV 1.6%, P = .189) were similar. The Patient-Reported Outcomes Measurement Information System physical function (ABN 42.6 versus CONV 42.9, P = .4554), physical health (ABN 63.4 versus CONV 63.3, P = .944), mental health (ABN 51.4 versus CONV 52.7, P = .4349), and pain (ABN 32.7 versus CONV 30.9, P = .256) scores were similar. CONCLUSION: ABN is valuable in its ability to improve postoperative alignment but does not improve complication rates or patient-reported functional outcomes.

Extensor Mechanism Disruption Remains a Challenging Problem.

BACKGROUND: Extensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking. METHODS: Patients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan-Meier curves, and factors for success were determined with logistic regressions. RESULTS: Of fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion. CONCLUSIONS: This multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.

Systematic review and validation of clinical models predicting survival after oesophagectomy for adenocarcinoma.

BACKGROUND: Oesophageal adenocarcinoma poses a significant global health burden, yet the staging used to predict survival has limited ability to stratify patients by outcome. This study aimed to identify published clinical models that predict survival in oesophageal adenocarcinoma and to evaluate them using an independent international multicentre dataset. METHODS: A systematic literature search (title and abstract) using the Ovid Embase and MEDLINE databases (from 1947 to 11 July 2020) was performed. Inclusion criteria were studies that developed or validated a clinical prognostication model to predict either overall or disease-specific survival in patients with oesophageal adenocarcinoma undergoing surgical treatment with curative intent. Published models were validated using an independent dataset of 2450 patients who underwent oesophagectomy for oesophageal adenocarcinoma with curative intent. RESULTS: Seventeen articles were eligible for inclusion in the study. Eleven models were suitable for testing in the independent validation dataset and nine of these were able to stratify patients successfully into groups with significantly different survival outcomes. Area under the receiver operating characteristic curves for individual survival prediction models ranged from 0.658 to 0.705, suggesting poor-to-fair accuracy. CONCLUSION: This study highlights the need to concentrate on robust methodologies and improved, independent, validation, to increase the likelihood of clinical adoption of survival predictions models.

Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data.

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.

Anterior-Based Approaches to Total Hip Arthroplasty: Beyond the Learning Curve.

BACKGROUND: Anterior-based approaches for total hip arthroplasty (THA) have gained popularity over the last decade. At our institution, anterior-based approaches are preferentially utilized, including both anterior-based muscle-sparing (ABMS) and direct anterior (DA) for primary THA. As there are higher complication rates during the transition to an anterior approach, we compared the outcomes and complications between ABMS and DA approaches beyond the learning curve. METHODS: A retrospective study of all ABMS and DA primary THA patients performed at a single institution was performed, excluding the first 100 anterior cases done by any surgeon. In total, 813 DA and 378 ABMS THA cases were included. Demographics, complications, and patient-reported outcomes (PROMIS and HOOS) were obtained for each patient. RESULTS: There was a 4.5% overall complication rate (4.1% in DA and 5.6% in ABMS, P = .248), with the most common complication being infection at 1.7% (1.5% vs 2.1%, P = .423). A revision was performed in 3.4% of cases overall (1.8% aseptic, 1.6% septic). There was no difference in complication rates between approaches. Length of surgery was shorter for ABMS (94.5 vs 116.0 minutes, P < .001). Both DA and ABMS had significant improvements in PROMIS and HOOS Jr. scores, without any significant difference between the groups. CONCLUSIONS: Anterior-based approaches for primary THA demonstrated excellent clinical results and low complication rates overall. Beyond the learning curve, excellent results can be obtained with either ABMS or DA approach for primary THA.

Neocortex Formation in a Tapered Wedge Stem is Not Indicative of Complications or Worse Outcomes.

BACKGROUND: The formation of sclerotic bone, a neocortex, distally surrounding total hip arthroplasty (THA) stems may commonly be seen on radiographs around proximally porous coated stems but can be confused with loosening. The goal of this study was to determine the prevalence of the neocortex finding and whether it associated with worse outcomes after THA. METHODS: A retrospective review of 825 patients with a single tapered wedge stem was performed. Radiographs at 1-year, as well as final follow-up were reviewed for evidence of sclerotic bone (neocortex) surrounding the stem in all 14 Gruen zones. The final attending radiology read of lucency was also recorded. Patients were grouped by the presence of the neocortex. PROMIS Physical Function scores and complications were compared between neocortex groups. RESULTS: The neocortex group had 558 (68%) patients compared to 267 (32%) in the no neocortex group. The most common Gruen zones for evidence of neocortex were 10 (55%), 11 (52%), and 12 (51%). Seven percent of patients had a finding of lucency on radiology read. There was no difference between groups in terms of dislocations (P = .61), infection (P = .79), fracture rates (P = .54), revision surgery (P = .73), and reoperation for any cause (P = .62). PROMIS PF scores were significantly higher in the neocortex group (P < .0001). CONCLUSION: The presence of a distal neocortex is a common finding on radiographs after THA with this proximally porous-coated tapered wedge stem and does not portend worse outcomes, nor is it a sign of aseptic loosening, increased revision rates, infection, dislocation, or periprosthetic fracture risk.

Can I Ski Doc?: Return to Skiing Following Total Joint Arthroplasty.

BACKGROUND: Currently, there are little data on performance, safety, or return to downhill skiing after total joint arthroplasty (TJA). This leaves surgeons with little information for patient counseling regarding skiing. METHODS: An online survey was sent to 4360 patients who had undergone at least 1 primary TJA at a single academic center over the past 10 years (4 surgeons). The survey asked patients about their prior and current skiing activity including ability level, limitations, and reoperations. Demographics, patient-reported outcomes, and reoperations were also captured through chart review. Chi-squared, analysis of variance, and t-tests were used to compare demographics and outcomes. Paired t-tests were used to compare preoperative and postoperative skiing levels. RESULTS: Of the 763 survey respondents, the average follow-up was 4.4 years (range 0.5-10.3). In total, 35.6% had never skied, 26.5% had not skied in the 5 years prior to surgery (remote), and 37.9% had skied in the 5 years prior to surgery (recent). Seventy percent of recent skiers returned to skiing after surgery, compared to 11.9% of remote skiers. The majority of skiers, mostly advanced, returned to their prior level. There was no difference in return rates in those with a single total hip arthroplasty vs total knee arthroplasty vs multiple TJAs. Rates of reoperation were not significantly different between patients who did and did not return to skiing. CONCLUSION: The majority of recent skiers were able to return to skiing after TJA at their same level without an increase in reoperation rate. Further studies are needed to determine long-term consequences of skiing after TJA.

High Survivorship of a Modular Titanium Baseplate Independent of Body Mass Index and Malalignment.

BACKGROUND: Tibial component aseptic loosening remains problematic in primary total knee arthroplasty (TKA). Influential factors include component design, metallurgy, and cement technique. Additionally, reports advocate for longer tibial stem fixation in high body mass index (BMI) patients. We have utilized a single stem length modular titanium baseplate in patients regardless of BMI, bone quality, or malalignment. We report the survivorship of this implant with focus on the impact of elevated BMI and postoperative malalignment. METHODS: We retrospectively reviewed patients who underwent TKA with a single modular titanium baseplate with a cruciate-shaped keel between 2004 and 2018. In total, 2,949 TKAs with a minimum of 1-year follow-up were included. The mean follow-up was 7 years. The primary outcome was component failure stratified by BMI and postoperative malalignment. High viscosity cement was utilized in all cases. Chi-squared and t-tests were used to compare outcome variables across groups. RESULTS: Eighty-five implants (2.8%) were revised with 46 (1.6%) for aseptic loosening. Failure was not associated with BMI, gender, American Society of Anesthesiologists class, or Charlson Comorbidity Index. There was no difference in failure rate by BMI (P = .26) or by malalignment (outside of 3° from neutral mechanical axis) (P = .67). Age was associated with failure as patients with failed TKAs were younger (61 vs 65, P < .01). CONCLUSION: This design of a specific modular titanium base plate with a cruciate-shaped keel and grit blast surface demonstrated 99% survivorship regardless of patient BMI or malalignment over 7-year follow-up period. Consistent cement technique with high viscosity cement indicates that component design remains an important variable impacting survivorship in TKA.

Systemic administration of a ß2-adrenergic receptor agonist reduces mechanical allodynia and suppresses the immune response to surgery in a rat model of persistent post-incisional hypersensitivity.

Beta 2 adrenergic receptor (ß2 AR) activation in the central and peripheral nervous system has been implicated in nociceptive processing in acute and chronic pain settings with anti-inflammatory and anti-allodynic effects of ß2-AR mimetics reported in several pain states. In the current study, we examined the therapeutic efficacy of the ß2-AR agonist clenbuterol in a rat model of persistent postsurgical hypersensitivity induced by disruption of descending noradrenergic signaling in rats with plantar incision. We used growth curve modeling of ipsilateral mechanical paw withdrawal thresholds following incision to examine effects of treatment on postoperative trajectories. Depletion of spinal noradrenergic neurons delayed recovery of hypersensitivity following incision evident as a flattened slope compared to non-depleted rats (-1.8 g/day with 95% CI -2.4 to -1.085, p < 0.0001). Chronic administration of clenbuterol reduced mechanical hypersensitivity evident as a greater initial intercept in noradrenergic depleted (6.2 g with 95% CI 1.6 to 10.8, p = 0.013) and non-depleted rats (5.4 g with 95% CI 1.2 to 9.6, p = 0.018) with plantar incision compared to vehicle treated rats. Despite a persistent reduction in mechanical hypersensitivity, clenbuterol did not alter the slope of recovery when modeled over several days (p = 0.053) or five weeks in depleted rats (p = 0.64). Systemic clenbuterol suppressed the enhanced microglial activation in depleted rats and reduced the density of macrophage at the site of incision. Direct spinal infusion of clenbuterol failed to reduce mechanical hypersensitivity in depleted rats with incision suggesting that beneficial effects of ß2-AR stimulation in this model are largely peripherally mediated. Lastly, we examined ß2-AR distribution in the spinal cord and skin using in-situ hybridization and IHC. These data add to our understanding of the role of ß2-ARs in the nervous system on hypersensitivity after surgical incision and extend previously observed anti-inflammatory actions of ß2-AR agonists to models of surgical injury.