Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

BACKGROUND: Registry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty. Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach triple-tapered uncemented stem designs may provide comparable results to cemented stems. METHODS: From 2000 to 2018, 5,809 primary total hip arthroplasties were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75 years of age. Statistical weighting accounted for baseline cohort differences. RESULTS: At 10 years, there was a trend toward higher all-cause revision (hazards ratio (HR) 1.6, P = .053) and higher all-cause reoperation (HR 1.6, P = .02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P < .001) but no difference in postoperative fractures (HR 0.99, P = .96). The same was true in patients ≥75 years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years. CONCLUSION: Compared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75 years, was associated with more intraoperative fractures but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

Comparative Survival of Contemporary Cementless Acetabular Components Following Revision Total Hip Arthroplasty.

BACKGROUND: The advent of highly porous ingrowth surfaces and highly crosslinked polyethylene has been expected to improve implant survivorship in revision total hip arthroplasty. Therefore, we sought to evaluate the survival of several contemporary acetabular designs following revision total hip arthroplasty. METHODS: Acetabular revisions performed from 2000 to 2019 were identified from our institutional total joint registry. We studied 3,348 revision hips, implanted with 1 of 7 cementless acetabular designs. These were paired with highly crosslinked polyethylene or dual-mobility liners. A historical series of 258 Harris-Galante-1 components, paired with conventional polyethylene, was used as reference. Survivorship analyses were performed. For the 2,976 hips with minimum 2-year follow-up, the median follow-up was 8 years (range, 2 to 35 years). RESULTS: Contemporary components with adequate follow-up had survivorship free of acetabular rerevision of ≥95% at 10-year follow-up. Relative to Harris-Galante-1 components, 10-year survivorship free of all-cause acetabular cup rerevision was significantly higher in Zimmer Trabecular Metarevision (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.2-0.45), Zimmer Trabecular MetaModular (HR 0.34, 95% CI 0.13-0.89), Zimmer Trilogy (HR 0.4, 95% CI 0.24-0.69), DePuy Pinnacle Porocoat (HR 0.24, 95% CI 0.11-0.51), and Stryker Tritanium revision (HR 0.46, 95% CI 0.24-0.91) shells. Among contemporary components, there were only 23 rerevisions for acetabular aseptic loosening and no rerevisions for polyethylene wear. CONCLUSION: Contemporary acetabular ingrowth and bearing surfaces were associated with no rerevisions for wear and aseptic loosening was uncommon, particularly with highly porous designs. Therefore, it appears that contemporary revision acetabular components have dramatically improved upon historical results at available follow-up.

Collarless Taper Slip and Collared Composite Beam Stems Differ in Failure Modes and Reoperation Rates.

BACKGROUND: Cemented femoral components are used in older patients based on lower risk of periprosthetic fracture and implant loosening. This study reports the survivorship free of periprosthetic femoral fracture (PPFX), femoral loosening, all-cause revision, and reoperation between 2 philosophies of cemented stems. METHODS: In total, 1,306 primary hybrid total hip arthroplasties were performed for osteoarthritis between 2000 and 2018 in a retrospective single center study. Cemented stems included 798 EON composite beam (CB) and 508 Exeter collarless taper slip (CTS) stems. Mean age was 77 years. An inverse treated probability weighted model was utilized to control for risk factors including age, gender, body mass index, year, and surgeon. RESULTS: There was no difference in risk of PPFX at 10 years (CTS 9% vs CB 5%; hazard ratio [HR] 1.4, P = .47). There was an increased risk of intraoperative fractures requiring fixation in the CB cohort (7/798 [5 calcar, 2 greater trochanter] vs 0/508, P < .001), while there was an increased risk of Vancouver B2 PPFX in the CTS cohort (7/508 vs 0/798; P < 001). There was a higher risk of femoral loosening in the CB cohort (6/798 vs 0/508; P < .0001). Higher survivorship free of revision (98% vs 91%; HR 4, P = .001) and free of reoperation (96% vs 88%; HR 2.5, P = .002) was seen at 10 years in the CB cohort. CONCLUSION: The risk of PPFX requiring implant revision was increased in the CTS cohort, while there was an increased risk of femoral component loosening and intraoperative fractures seen in the CB cohort. Surgeons should be aware of the different failure modes when choosing implant design for their patient.

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.

Low-Dose vs Regular-Dose Aspirin for Venous Thromboembolism Prophylaxis in Primary Total Joint Arthroplasty.

BACKGROUND: Consensus on whether low-dose (81 mg) or regular-dose (325 mg) aspirin (ASA) is more effective for venous thromboembolism (VTE) chemoprophylaxis in primary total joint arthroplasties (TJAs) is not reached. The goal of this study is to evaluate the efficacy of low-dose and regular-dose ASA for VTE chemoprophylaxis in primary total hip arthroplasties and total knee arthroplasties. METHODS: We retrospectively identified 3512 primary TJAs (2344 total hip arthroplasties and 1168 total knee arthroplasties) with ASA used as VTE chemoprophylaxis between 2000 and 2019. Patients received ASA twice daily for 4-6 weeks after surgery with 961 (27%) receiving low-dose ASA and 2551 (73%) receiving regular-dose ASA. The primary endpoint was 90-day incidence of symptomatic VTEs. Secondary outcomes were gastrointestinal (GI) bleeding events and mortality. The mean age at index TJA was 66 years, 54% were female, and mean body mass index was 31 kg/m2. The mean Charlson Comorbidity Index was 3.5. Mean follow-up was 3 years. RESULTS: There was no difference in 90-day incidence of symptomatic VTEs between low-dose and regular-dose ASA (0% vs 0.1%, respectively; P = .79). There were no GI bleeding events in either group. There was no difference in 90-day mortality between low-dose and regular-dose ASA (0.3% vs 0.1%, respectively; P = .24). CONCLUSION: In 3512 primary TJA patients treated with ASA, we found a cumulative incidence of VTE <1% at 90 days. Although this study is underpowered, it appears that twice daily low-dose ASA was equally effective to twice daily regular-dose ASA for VTE chemoprophylaxis, with no difference in risk of GI bleeds or mortality. LEVEL OF EVIDENCE: III, retrospective cohort study.

Total Hip Arthroplasty in Patients With Osteopetrosis.

BACKGROUND: Osteopetrosis is an inherited bone disease associated with high risk of osteoarthritis and fracture non-union, which can lead to total hip arthroplasty (THA). Bone quality and morphology are altered in these patients, and there are limited data on results of THA in these patients. The goals of this study were to describe implant survivorship, clinical outcomes, radiographic results, and complications in patients with osteopetrosis undergoing primary THA. METHODS: We identified 7 patients (9 hips) with osteopetrosis who underwent primary THA between 1970 and 2017 utilizing our total joint registry. The mean age at index THA was 48 years and included two males and five females. The mean follow-up was 8 years. RESULTS: The 10-year survivorship free from any revision or implant removal was 89%, with 1 revision and 1 resection arthroplasty secondary to periprosthetic femoral fractures. The 10-year survivorship free from any reoperation was 42%, with 4 additional reoperations (2 ORIFs for periprosthetic femoral fractures, 1 sciatic nerve palsy lysis of adhesions, 1 hematoma evacuation). Harris hip scores significantly increased at 5 years (P = .04). Five hips had an intraoperative acetabular fracture, and 1 had an intraoperative femur fracture. All postoperative femoral fractures occurred in patients with intramedullary diameter less than 5 mm at a level 10 cm distal to the lesser trochanter. CONCLUSION: Primary THA in patients with osteopetrosis is associated with good 10-year implant survivorship (89%), but a very high reoperation (58%) and periprosthetic femoral fracture rate (44%). Femoral fractures appear associated with smaller intramedullary diameters.

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project: Phase I Outcomes.

BACKGROUND: This study aimed to improve institutional value-based patient care processes, provider collaboration, and continuous process improvement mechanisms for primary total hip arthroplasties and total knee arthroplasties through establishment of a perioperative orthopedic surgical home. METHODS: On June 1, 2017, an institutionally sponsored initiative commenced known as the orthopedic surgery and anesthesiology surgical improvement strategy project. A multidisciplinary team consisting of orthopedic surgeons, anesthesiologists, advanced practice providers, nurses, pharmacists, physical therapists, social workers, and hospital administration met regularly to identify areas for improvement in the preoperative, intraoperative, and post-anesthesia care unit, and postoperative phases of care. RESULTS: Mean hospital length of stay decreased from 2.7 to 2.2 days (P < .001), incidence of discharge to a skilled nursing facility decreased from 24% to 17% (P = .008), and the number of patients receiving physical therapy on the day of surgery increased from 10% to 100% (P < .001). Press-Ganey scores increased from 74.9 to 75.8 (94th percentile), while mean and maximum pain scores, opioid consumption, and hospital readmission rates remained unchanged (lowest P = .29). Annual total hip arthroplasty and total knee arthroplasty surgical volume increased by 11.4%. Decreased hospital length of stay and increased surgical volume yielded a combined annual savings of $2.5 million across the 9 involved orthopedic surgeons. CONCLUSION: Through application of perioperative surgical home tools and concepts, key advances included phase of care integration, enhanced data management, decreased length of stay, coordinated perioperative management, increased surgical volume without personnel additions, and more efficient communication and patient care flow across preoperative, intraoperative, and postoperative phases. LEVEL OF EVIDENCE: III Therapeutic.

Contemporary Primary Total Knee Arthroplasty is Durable in Patients Diagnosed With Ankylosing Spondylitis.

INTRODUCTION: Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy affecting the axial spine and peripheral joints. Despite innovations in medical management, patients with AS experience two-fold the lifetime risk of total knee arthroplasty (TKA) compared to the general population. Moreover, recent data have indicated a correlation between spinal pathology and outcomes of TKAs. METHODS: Our institutional total joint registry identified 19 patients (28 knees) with a diagnosis of AS treated with primary TKA from 2000 to 2016. The mean age at TKA was 68 years, and 84% of patients were men. The mean follow-up period was 6 years. Outcomes included implant survivorship, clinical outcomes, and complications. RESULTS: Survivorship free from any revision was 88% at 10 years. A single patient required revision at 8 years for aseptic loosening. Survivorship free from any reoperation was 77% at 10 years. Reoperations included 2 manipulations under anesthesia and 1 superficial wound irrigation and debridement. Mean Knee Society score improved from 46 preoperatively to 89 postoperatively (P < .0001). The mean arc of motion improved from 108o preoperatively to 116° postoperatively (P = .01). There were 6 complications that did not require reoperation. CONCLUSION: Primary TKAs in patients with AS resulted in significant improvement in clinical outcomes with excellent 10-year implant survivorship. Although 2 manipulations under anesthesia were required, the range of motion was restored postoperatively. These data suggest that the contemporary primary TKA can achieve durable and reliable outcomes in patients with axial skeletal disease resulting from AS. LEVEL OF EVIDENCE: IV.

The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA.

BACKGROUND: Opioid prescription management is challenging for orthopaedic surgeons, and we lack evidence-based guidelines for responsible opioid prescribing. Our institution recently developed opioid prescription guidelines for patients undergoing several common orthopaedic procedures including TKA and THA in an effort to reduce and standardize prescribing patterns. QUESTIONS/PURPOSES: (1) How do opioid prescriptions at discharge and 30-day refill rates change in opioid-naïve patients undergoing primary TKA and THA before and after implementation of a novel prescribing guideline strategy? (2) What patient, surgical, and in-hospital factors influence opioid prescription quantity and refill rate? METHODS: New institutional guidelines for patients undergoing TKA and THA recommend a maximum postoperative prescription of 400 oral morphine equivalents (OME), comparable to 50 tablets of 5 mg oxycodone or 80 tablets of 50 mg tramadol. All opioid-naïve patients, defined as those who did not take any opioids within 90 days preceding surgery, undergoing primary TKA and THA at a single tertiary care institution were evaluated from program initiation on August 1, 2017, through December 31, 2017, as the postguideline era cohort. This group (n = 751 patients) was compared with all opioid-naïve patients undergoing TKA and THA from 2016 at the same institution (n = 1822 patients). Some providers were early adopters of the guidelines as they were being developed, which is why January to July 2017 was not evaluated. Patients in the preguideline and postguideline eras were not different in terms of age, sex, race, body mass index, education level, employment status, psychiatric illness, marital status, smoking history, outpatient use of benzodiazepines or gabapentinoids, or diagnoses of diabetes mellitus, peripheral neuropathy, or cancer. The primary outcome assessed was adherence to the new guidelines with a secondary outcome of opioid medication refills ordered within 30 days from any provider. Multivariable logistic regression analyses were performed with outcomes of guideline compliance and refills and adjusted for demographic, surgical, and patient care factors. Patients were followed for 30 days after surgery and no patients were lost to followup. RESULTS: Median opioid prescription and range of prescriptions decreased in the postguideline era compared with the preguideline era (750 OME, interquartile range [IQR] 575-900 OME versus 388 OME, IQR 350-389; difference of medians = 362 OME; p < 0.001). There was no difference among patients undergoing TKA before and after guideline implementation in terms of the 30-day refill rate (35% [349 of 1011] versus 35% [141 of 399]; p = 0.77); this relationship was similar among patient undergoing THA (16% [129 of 811] versus 17% [61 of 352]; p = 0.55). After controlling for relevant patient-level factors, we found that implementation of an institutional guideline was the strongest factor associated with a prescription of ≤ 400 OME (adjusted odds ratio, 36; 95% confidence interval, 25-52; p < 0.001); although a number of patient-level factors also were associated with prescription quantity, the effect sizes were much smaller. CONCLUSIONS: This study provides a proof of concept that institutional guidelines to reduce postoperative opioid prescribing can improve aftercare in patients undergoing arthroplasty in a short period of time. The current report evaluates our experience with the first 5 months of this program; therefore, longer term data will be mandatory to determine longitudinal guideline adherence and whether the cutoffs established by this pilot initiative require further refinement for individual procedures. LEVEL OF EVIDENCE: Level II, therapeutic study.

Smoking Cessation Before and After Total Joint Arthroplasty-An Uphill Battle.

BACKGROUND: Patients actively smoking at the time of primary total joint arthroplasty (TJA) are at increased risk of perioperative complications. Employing strategies for smoking cessation has therefore become routine. A potential benefit of cessation in anticipation of TJA may be long-term cessation. However, success rates and the longevity of successful smoking cessation attempts before TJA have yet to be presented. METHODS: Our institution's total joint registry documents self-reported smoking status. As such, all patients who underwent TJA from 2007 to 2018 were identified and grouped as nonsmokers, smokers (regularly smoking within 1 year before surgery), and former smokers (those who quit smoking within 1 year before surgery). Thereafter, postoperative smoking status was assessed with special attention to former smokers to see who remained smoke-free. RESULTS: From the 28,758 primary TJAs identified, 91.3% (26,244) were nonsmokers, 7.3% (2109) were smokers, and 1.4% (405) had quit smoking before surgery. Among former smokers, 86% were abstinent 1 year postoperatively but only 45% were still abstinent 8 years postoperatively. Conversely, 7% of smokers at the time of surgery eventually quit and 6% of prior nonsmokers started smoking over the same time period. CONCLUSION: Despite concerted efforts to help patients stop smoking before TJA, 7.3% remain smokers. Among those who are successful, less than half (45%) remain smoke-free after surgery. Compared to current smokers, however, patients who managed to quit before surgery are more likely to remain smoke-free after surgery. These findings demonstrate the tremendous challenge smoking represents in contemporary TJA practices. LEVEL OF EVIDENCE: Therapeutic level III.

Cost and Patient Outcomes Associated With Bilateral Total Knee Arthroplasty Performed by 2-Surgeon Teams vs a Single Surgeon.

BACKGROUND: Bilateral total knee arthroplasty (TKA) can be performed under a single-anesthetic (SA) or staged under a two-anesthetic (TA) technique. Recently, our institution began piloting a 2-surgeon team SA method for bilateral TKA. The purpose of this study was to compare the inpatient costs and clinical outcomes in the first 90 days after surgery between the team SA, single-surgeon SA, and single-surgeon TA approaches for bilateral TKA. METHODS: All primary TKAs performed from 2007 to 2017 by the 2 participating surgeons for each of the 3 groups of interest were identified: team SA (N = 42 patients; 84 knees), single-surgeon SA (N = 146 patients; 292 knees), single-surgeon TA (N = 242 patients; 484 knees). No patients were lost to follow-up. RESULTS: Median hospital cost (per TKA) for the episode(s) of care was as follows: team SA $20,962, single-surgeon SA $22,057, single-surgeon TA $31,145 (P < .001 overall; P = .0905 team SA vs single-surgeon SA). Rate of 90-day complications was 2.4% for team SA, 11.0% for single-surgeon SA, and 8.3% for single-surgeon TA (P = .2090). Discharge to skilled nursing facilities or rehab was as follows: team SA 31%, single-surgeon SA 53%, and single-surgeon TA after the second operation 34% (P < .001). CONCLUSION: This pilot project suggests that team SA bilateral TKA is a potentially cost-effective option with fewer complications compared to single-surgeon SA bilateral TKA. The less frequent disposition to skilled nursing facilities in the team SA group in conjunction with more efficient operating room utilization may further enhance the financial benefits.

Cotinine Testing Improves Smoking Cessation Before Total Joint Arthroplasty.

BACKGROUND: Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at an increased risk of perioperative complications. Serum cotinine testing is a sensitive and specific method to verify abstinence from smoking and may therefore improve a patient's chance of smoking cessation. The primary purpose of this study was to assess whether cotinine testing improves the self-reported quit rate among smokers before TJA. METHODS: Our hospital performs a high volume of TJAs and documents smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through an institutional total joint registry. As part of a retrospective analysis, this information was used to identify all self-reported smokers (regularly cigarette smoking within 1 year of TJA) who underwent unilateral TJA from 2007 to 2018. The cohort had a mean age of 66 years, 55% were female, and the mean body mass index was 31 kg/m2. Patients whose serum cotinine was obtained within 1 month before surgery were then separated from the cohort and compared to the smokers who did not undergo cotinine testing. RESULTS: Of the 28,758 primary TJAs identified, 8.8% (2514) were smokers. Serum cotinine testing was obtained on 103 of these patients. The abstinence rate (by means of self-reporting) before surgery significantly improved from 15.8% to 28.2% in the untested vs cotinine-tested groups, respectively (P = .005). Among all patients who underwent cotinine testing, 77% were negative (abstinent) and an additional 15% had cotinine levels between 3 and 8 ng/mL representing passive tobacco exposure. Among patients who stated they had quit smoking, 15% still had positive cotinine tests. CONCLUSION: Smoking cessation remains a major challenge in contemporary TJA practices despite a concerted effort to help patients quit. Our findings suggest that cotinine testing significantly improves the self-reported quit rates of smokers before surgery and helps identify the 15% who falsely report abstinence to ensure appropriate counseling of inherent risks. LEVEL OF EVIDENCE: Therapeutic level III.

Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery.

OBJECTIVE: The aim of this study was to conduct a prospective, multicenter survey of patients regarding postoperative opioid use to inform development of standardized, evidence-based, procedure-specific opioid prescribing guidelines. SUMMARY OF BACKGROUND DATA: Previous work has shown significant variation in the amount of opioids prescribed after elective procedures, calling for optimization of prescribing. METHODS: Adults (n = 3412) undergoing 25 elective procedures were identified prospectively from 3 academic centers (March 2017 to January 2018) to complete a 29-question telephone interview survey 21 to 35 days post-discharge (n = 688 not contacted, n = 107 refused). Discharge opioids were converted into Morphine Milligram Equivalents (MMEs). RESULTS: Of the 2486 patients who completed the survey, 91.2% received opioids at discharge [median 225 (interquartile range, IQR 125 to 381) MME]. A median of 43 (0 to 184) MMEs were consumed after discharge with 77.3% of patients having leftover opioids at the time of the survey. In total, 61.5% of prescribed opioids were unused; 31.4% of patients used no opioids, and 52.6% required <50 MME. Overall, 90.6% of patients were satisfied with their postdischarge pain control. While 28.3% reported being prescribed too many opioids, 9.0% felt they were not prescribed enough. Only 9.6% of patients disposed of remaining opioids. Of the 2068 opioid-naive respondents (83.2%), 33.6% consumed no opioids (range 5.2% to 80.0% by procedure) and 57.0% (65.7% nonorthopedic) consumed <50 MME. Utilization data and predictors of low/high opioid consumption informed development of postoperative prescribing guidelines. CONCLUSION: A large proportion of postoperative patients reported using no or few opioids following discharge. Guidelines were developed to minimize opioid prescribing and identify patients requiring low doses or additional multimodal pain control.

Preventing Complications Associated With Operating on Taper Corrosion.

BACKGROUND: Revision total hip arthroplasty for the treatment of taper corrosion has become increasingly common. The purpose of this portion of the symposium was to describe the most common complications of this procedure and to delineate specific measures that might be taken to prevent these complications. METHODS: A literature review was performed focusing on the results and complications of revision total hip arthroplasty performed for taper corrosion. RESULTS: The most common modes of failure after revision total hip arthroplasty in the setting of taper corrosion include the 4 I's: infection, instability, implant loosening, and ions (recurrent adverse local tissue reaction). CONCLUSION: Strategies specifically directed toward each of these 4 failure modes have the potential to significantly reduce the risk of complications.

Patients at Risk: Preoperative Opioid Use Affects Opioid Prescribing, Refills, and Outcomes After Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the effect of preoperative opioid use on opioid prescriptions, refills, and clinical outcomes after total knee arthroplasty (TKA). METHODS: A retrospective review identified 53 patients on preoperative opioids who were matched 1:2 to 106 opioid-naive patients undergoing primary TKA with at least 2-year follow-up. Opioid refills, Knee Society Score (preoperative and follow-up), morphine equivalent dose (MED) prescribed, and persistent opioid use were compared between groups. RESULTS: The average total MED prescribed at discharge was 1248 mg, ranging from 0 to 5600 mg. The average daily MED used before discharge was greater in the preoperative opioid group compared to the opioid-naive group (90 ± 75 mg vs 54 ± 42 mg; P = .001). The preoperative opioid group and opioid-naive group differed in terms of refills (1.3 ± 1.6 vs 0.4 ± 0.6; P = .0001), persistent opioid use (21 [39%] vs 5 [4%], P = .0001), postoperative KSS (85 ± 11 vs 90 ± 13; P = .01), and manipulations under anesthesia (4 [8%] vs 1 [1%], P = .03). Preoperative tramadol users had the same risk of refills, persistent opioid use, reduced KSS, and manipulation under anesthesia as those taking other opioids. CONCLUSION: Preoperative opioid users were discharged with less opioids, required more refills, were more likely to remain on opioids, and required more manipulations under anesthesia than opioid-naive patients. These risks extended to preoperative tramadol users.

Two-Stage Revision Total Hip Arthroplasty With a Specific Articulating Antibiotic Spacer Design: Reliable Periprosthetic Joint Infection Eradication and Functional Improvement.

BACKGROUND: Two-stage revision utilizing spacers loaded with high-dose antibiotic cement prior to reimplantation remains the gold standard for treatment of periprosthetic joint infections (PJI) in total hip arthroplasty (THA) in North America, but there is a paucity of data on mid-term outcomes. We sought to analyze the survivorship free of infection, clinical outcomes, and complications of a specific articulating spacer utilized during 2-stage revision. METHODS: One hundred thirty-five hips (131 patients) undergoing a 2-stage revision THA for PJI with a specific articulating antibiotic spacer design from 2005 to 2013 were retrospectively reviewed. Infections were classified according to the Musculoskeletal Infection Society criteria. Mean age at resection was 65 years and mean follow-up was 5 years (rang, 2-10). RESULTS: Survivorship free of any infection after reimplantation was 92% and 88% at 2 and 5 years, respectively. Patients with a host-extremity grade of C3 compared to all patients with a host grade of A [hazard ratio (HR) 4.1, P = .05] were significant risk factors for poorer infection-free survivorship after reimplantation. Harris hip scores improved from a mean of 58 to a mean of 71 in the spacer phase (P = .002) and a mean of 81 post-reimplantation (P = .001). Fourteen (10%) patients dislocated after reimplantation, 9 (7%) of which required re-revision. Trochanteric deficiency (HR 19, P < .0001), dislocation of the articulating spacer prior to reimplantation [which occurred in 7 (5%) patients, 5 of whom subsequently dislocated the definitive implant] (HR 16, P < .0001), and female gender (HR 5, P = .002) were significant risk factors for post-reimplantation dislocation. CONCLUSION: Insertion of an articulating antibiotic spacer during a 2-stage revision THA for PJI demonstrates reliable infection eradication and improvement in clinical function, including the spacer phase. Patients with trochanteric deficiency and an articulating spacer dislocation are at high risk of post-reimplantation dislocation; judicial use of a dual-mobility or constrained device should be considered in these patients.

Periprosthetic Joint Infection With Fungal Pathogens.

BACKGROUND: Although there is abundant information about bacterial periprosthetic joint infections (PJIs), there is a notable paucity of information about fungal PJIs. The goals of this study are to describe the patient demographics, diagnostic findings, and treatment results of fungal PJIs after total joint arthroplasty. METHODS: We identified 31 fungal PJIs (13 total hip arthroplasties and 18 total knee arthroplasties) in 31 patients treated between 1996 and 2014. This represented 0.9% of the 3525 PJIs treated at our institution during this time period. Candida species accounted for 81% of infections. The mean patient age at diagnosis of fungal PJI was 68 years. Mean follow-up after initiation of treatment was 4 years. RESULTS: In the total hip arthroplasty cohort, survivorship free from all-cause revision or implant removal was 44% at 2 years. Survivorship free from reinfection was 38% at 2 years. Mean Harris hip score was 27 at final follow-up.In the total knee arthroplasty cohort, survivorship free from all-cause revision was 70% at 2 years. Survivorship free from reinfection was 76% at 2 years. Mean Knee Society scores were 36 at final follow-up. CONCLUSION: Fungal PJIs are rare (0.9% of diagnosed PJIs). Survivorship free of all-cause revision or implant removal was very low in the hip group (44% at 2 years), but slightly better in the knee group (70% at 2 years). Moreover, clinical outcomes were poor with high perioperative complication rates. Improved treatment regimens are needed for this unsolved clinical problem.

What Risks are Associated with Primary THA in Recipients of Hematopoietic Stem Cell Transplantation?

INTRODUCTION: As patients who receive hematopoietic stem cell transplantation are at increased risk of avascular necrosis (AVN) and subsequent degenerative arthritis, THA may be considered in some of these patients, particularly as overall patient survival improves for patients undergoing stem-cell transplants. Patients receiving hematopoietic stem cell transplantation theoretically are at increased risk of experiencing complications, infection, and poorer implant survivorship owing to the high prevalence of comorbid conditions, immunosuppressive therapy regimens including corticosteroids, and often low circulating hematopoietic cell lines; however, there is a paucity of studies elucidating these risks. QUESTIONS/PURPOSES: We asked: (1) What is the overall mortality of patients with hematopoietic stem cell transplantation who have undergone THA? (2) What is the complication rate for these patients? (3) What are the revision and reoperation rates and implant survivorship for these patients? PATIENTS AND METHODS: Between 1999 and 2013, we performed 42 THAs in 36 patients who underwent stem-cell transplants. Other than those who died, all were available for followup at a minimum of 2 years; of the patients whose procedures were done more than 10 years ago and who are not known to have died, two (5%) had not been seen in the last 5 years and so are considered lost to followup. All patients underwent thorough evaluation by the transplant team before arthroplasty; general contraindications included active medical comorbidities or evidence of unstable end-organ damage, active rejection, and critically low circulating hematopoietic cell lines. Underlying primary diseases leading to hematopoietic stem cell transplantation included lymphoma (14/42; 33%), plasma cell disorders (10/42; 24%), leukemia (9/42; 21%), and amyloidosis (3/42; 7%). Complications, reoperations, revisions, and implant and patient survivorship, were recorded from chart review and data from the institutional total joint registry. Mean followup was 5 years (range, 2-15 years). RESULTS: Patient survivorship free of mortality was 91% (95% CI, 81%-100%) and 82% (95% CI, 68%-96%) at 2 and 5 years, respectively. Complications occurred in four of 42 THAs (10%); these complications included an intraoperative fracture and a venous thromboembolism. Revisions occurred in two of 42 (5%) THAs; there were no reoperations. Implant survivorship free of component revision for any reason or implant removal accounting for death as a competing risk was 93% (95% CI, 83%-100%) at 5 years. CONCLUSION: With appropriate medical evaluation and comanagement by transplant specialists, carefully selected patients with hematopoietic stem cell transplants may undergo elective primary THA, although complications do occur in this relatively fragile patient population. Although implant survivorship was modest at 93% at 5 years, there was not a high risk of revision for infection. Improved outcomes for these patients may be expected as their medical management advances and additional comparative studies may clarify other important patient factors. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Patient Perceptions of the Direct Anterior Hip Arthroplasty.

BACKGROUND: The quest for less invasive surgical approaches for total hip arthroplasty (THA) has garnered much attention recently in the community, as well as media outlets. There are very little data demonstrating the actual differences in these approaches. We are unaware of any information documenting patients' perceptions of the direct anterior approach (DAA) for THA. The purpose of this study was to collect information regarding patients' perceptions of the DAA THA. METHODS: We surveyed 166 consecutive new patients being evaluated for hip osteoarthritis in our outpatient clinic. Demographic data and their knowledge of the DAA were collected, as well as a number of questions on a 5-item Likert scale. RESULTS: Forty-six (28%) responded that they were aware of the DAA. Respondents primarily learned about the DAA from friends and family (58%), and healthcare professionals (38%). Respondents agreed or strongly agreed that the DAA is less painful (70%), reduces the amount of time spent on a cane after surgery (70%), damages tissues less (68%), allows patients to more quickly return to work (64%), and allows for shorter hospital stays (62%), compared to other procedures. In addition, 30% felt there is a consensus among surgeons that the DAA is the safest and most effective procedure for THA. CONCLUSION: Many people are unaware of the DAA, with a majority of healthcare information being transmitted by friends and family members. The patients' perceptions are inconsistent with published data about the DAA and are likely influenced by marketing and individuals surrounding them.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications.

BACKGROUND: Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA). METHODS: Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years. RESULTS: Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%). CONCLUSION: TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.