Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty.

BACKGROUND: New technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors' COI and industry funding would be associated with conclusions favorable to a new technology. METHODS: Economic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher's exact test was utilized to determine the relationship between the presence of COI and an article's conclusions. RESULTS: Of 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher's exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author's COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003). CONCLUSIONS: Financial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.

The Impact of Robotic-Assisted Total Knee Arthroplasty on Resident Training.

BACKGROUND: As robotic-assisted total knee replacement (rTKA) continues to gain popularity, the impact of this technology on resident education remains unknown. The purpose of this study was to describe trainee experience and perceptions of rTKA and its effect on surgical training. METHODS: Two hundred and twenty two senior orthopaedic residents attending a national board review course completed a 17-question survey regarding their experience and perceptions regarding rTKA. Mean and standard deviations were calculated for Likert scale questions, and bivariate analyses were utilized to compare answer groups. RESULTS: Seventy percent of respondents reported exposure to rTKA during their training. Of those with robotic exposure, 20% reported that greater than half of their TKA experience involved robotics. Only 29% percent agreed that robotics improved outcomes, whereas 21% disagreed and the remainder were unsure. Over half of respondents agreed that robotics are used primarily for marketing purposes. Of those who trained with rTKA, 45% percent believed that robotics improved their understanding of the surgical procedure; however, 25% felt robotics negatively compromised their training with traditional instrumentation. Higher robotic case exposure (P = .001) and attending an industry-sponsored course (P = .02) was associated with the belief that robotics improved outcomes. Robotic case volume and percentage was associated with the belief that robotics improved understanding of the surgical procedure, however, it also was associated with reduced comfort performing traditional knee arthroplasty (P = .001). CONCLUSION: Current resident training experience varies greatly within the United States with regards to rTKA. While exposure to rTKA may be beneficial for a well-rounded surgical education, over-exposure likely results in decreased comfort with traditional instrumentation.

Are We Training Surgeons to Cement a Femoral Component in Hip Arthroplasty? The Trainees' Perspective.

BACKGROUND: The importance of surgical technique is widely recognized when cementing a femoral component in hip arthroplasty. Concern exists that surgeon trainees in the United States are not being adequately trained in cement technique. The purpose of this study is to describe recent trainees' perceived experience with their training in this skill. METHODS: Orthopedic graduate candidates attending a national board review course were polled with an anonymous 15-question survey regarding their experiences during training with cemented femoral components. Means and standard deviations were calculated for Likert scale questions, and univariate statistics were used to compare answers for select questions. RESULTS: A total of 152 surveys were completed. Ninety percent of respondents anticipated that they would be performing hemiarthroplasty for fracture in their future practice, 99% of whom anticipated using cement for stem fixation in at least some of these cases. Only a minority of respondents planned further training in an adult reconstruction fellowship (21%). Only 37% of residents perceived their training in cement technique to be comprehensive or very comprehensive, with 17% reporting that their training was inadequate or nonexistent. Forty percent reported being less than satisfied with their training. Although 96% of residents felt prepared to implant a cementless femoral component, only 82% felt adequately trained to properly cement a femoral implant. Feeling prepared to perform a well done cemented femoral stem correlated with higher percentage of cemented stems in training and higher satisfaction with training (both P = .001). CONCLUSION: Although most trainees feel prepared to cement a femoral component, many young surgeons do not perceive that they are receiving adequate training in femoral cement technique.

Clinical Outcomes After Stage-One Antibiotic Coated Molded Hip Spacer.

BACKGROUND: Two-stage exchange remains the gold standard for managing periprosthetic joint infection (PJI). We evaluated the outcomes of patients treated with a specific molded articulating antibiotic hip spacer for PJI at a tertiary referral center. METHODS: An institutional database was retrospectively queried for patients who underwent implantation of spacer between 2009-2019. Patient demographics and clinical outcomes were collected. RESULTS: We identified 88 patients at an average age of 60.4 years who received a spacer implant, with an average of 4.2 years follow-up (standard deviation [SD] 2.5 years). A total of 34 patients (38.6%) had a "clean" two-stage course with successful reimplantation and no evidence of infection at 1-year follow-up. The remaining patients (61.4%) required 3.67 (±0.52) additional surgeries. Overall reimplantation rate was 72%. Causative bacterial agents included MSSA (n = 22), MRSA (n = 16), coagulase-negative Staphylococcus (n = 14), and polymicrobial (n = 12). Regarding complications, there were 13 (15%) dislocations, 16 (18%) periprosthetic fractures, 8 (9%) bent/fractured stems, and 16 (18%) patients had clinically significant subsidence. Patients with previous extended trochanteric osteotomy (ETO) experienced higher rates of bent/broken spacer stems (25% vs 3.1%; P = .006) periprosthetic fractures (37.5% vs 10.9%; P = .010), and dislocations (37.5% vs 6.2%; P = .001). The rate of infection clearance was lower in the prior ETO cohort (26.6% vs 54.2%; P = .029). CONCLUSION: We report outcomes in patients who underwent implantation of a specific molded articulating hip spacer at our institution. Infection eradication was roughly in line with published series of hip PJI treatment. There was a high rate of mechanical complications, especially in those patients who required an ETO.

Fracture of a 40-mm BIOLOX Delta Femoral Head.

Ceramic bearing surfaces have gained popularity in total hip arthroplasty as a result of the favorable mechanical properties and low wear rates. Despite the recognition as an attractive articulation, problems such as ceramic head fracture persist. Smaller heads and higher body mass indices are touted as risk factors for ceramic head fracture and are often associated with antecedent trauma. We present a case report of an 83-year-old male with a body mass index of 26.7 kg/m2 who suffered a fracture of a 40-mm ceramic femoral head. This occurred atraumatically 5 years from his index surgery. This patient underwent revision total hip arthroplasty which included debridement of ceramic debris and alteration of the bearing surface with femoral head and polyethylene liner exchange.