The role of MRI in the diagnosis of aseptic loosening following total hip arthroplasty.

INTRODUCTION: The role of advanced imaging in diagnosing aseptic implant loosening following total hip arthroplasty (THA) remains unclear. This study aimed to assess the diagnostic value of magnetic resonance imaging (MRI) in detecting aseptic loosening. METHODS: This was a retrospective review of 342 consecutive patients who underwent revision THA between July 2011 and April 2023 and had a pelvis MRI as part of the preoperative diagnostic evaluation. Among them, 62 patients had an intraoperative diagnosis of aseptic loosening of either the femoral or acetabular component. Patients were stratified based on the concordance between their MRI and radiographs findings. RESULTS: Preoperative MRI showed signs of aseptic loosening in 25/62 patients (sensitivity = 40.3%). Similarly, preoperative radiographs demonstrated signs of aseptic loosening in 27 patients (43.5%). Twelve patients (19.4%) had both MRI and radiographs predictive of aseptic loosening, 22 patients (35.5%) did not show signs of aseptic loosening in either MRI or radiographs, and for 28 patients (45.2%), the results were discordant. Among the patients with a negative radiograph for aseptic loosening (n = 35), 13 patients (37.1%) showed signs of aseptic loosening on MRI. CONCLUSION: Aseptic loosening remains an elusive diagnosis, and the findings of this study suggest that the utility of MRI and radiographs as part of the diagnostic process is limited. However, in cases of presumed aseptic loosening with inconclusive radiographs findings, MRI may play a role in improving the diagnostic process. LEVEL OF EVIDENCE: III.

Treating Osteoarthritis in Jehovah's Witness Patients.

This article addresses the challenges surrounding hip and knee osteoarthritis (OA) treatment in Jehovah's Witnesses (JWs), focusing on the complexities arising from their refusal of blood products and transfusions. Acknowledging the heightened risk of blood loss anemia during joint replacement surgery, this review explores documented strategies that enable safe elective joint arthroplasty in JW patients, emphasizing comparable initial diagnostic methods and non-operative treatments up until the pre-operative stage. Special considerations should be taken in the perioperative and intraoperative stage. Despite these challenges, safe arthroplasty is feasible with satisfactory outcomes through a combination of careful preoperative optimization, blood saving protocols, and cultural sensitivity.

Clinical outcomes of total joint arthroplasty in patients with bowel ostomies.

INTRODUCTION: The influence of prior colostomy or ileostomy on patients undergoing joint arthroplasty remains poorly understood. Our study aimed to assess whether patients with an ostomy undergoing hip and knee arthroplasties have worse postoperative outcomes and increased rates of revisions. METHOD: A single-center, retrospective review of patients with a history of bowel ostomy who underwent a primary total hip arthroplasty (THA), hemiarthroplasty (HA), and total knee arthroplasty (TKA) from 2012 to 2021. A total of 24 THAs, 11 HAs, and 25 TKAs in patients with open small or large bowel stoma were identified. A ten-to-one propensity score match was utilized to establish cohorts with comparable demographics but no prior ostomy procedure. RESULTS: Patients with stomas undergoing elective THA showed greater 90-day ED visits (20.0 vs. 5.0%, P = 0.009), 90-day all-cause readmissions (20.0 vs. 5.0%, P = 0.009), 90-day non-orthopedic readmissions (10.0 vs. 0.5%, P < 0.001), 90-day readmissions for infection (5.0 vs. 0.5%, P = 0.043), all-cause revisions (15.0 vs. 0.5%, P < 0.001), revisions for PJI (5.0 vs. 0%, P = 0.043), and revisions for peri-prosthetic fracture (10.0 vs. 0%, P < 0.001). Patients with stomas undergoing non-elective hip arthroplasties exhibited a longer mean LOS (12.1 vs. 7.0 days, P < 0.001) and increased 90-day all-cause readmissions (40.0 vs. 17.3%, P = 0.034), 90-day orthopedic readmissions (26.7 vs. 6.0%, P = 0.005), all-cause revisions (13.3 vs. 2.0%, P = 0.015), revisions for peri-prosthetic fracture (6.7 vs. 0%, P = 0.002), and revisions for aseptic loosening (6.7 vs. 0%, P = 0.002). There were no significant differences in readmission or revision rates between ostomy patients undergoing TKA and a matched control group. CONCLUSION: Patients undergoing hip arthroplasties with an open stoma are at an increased risk of hospital encounters and revisions, whereas TKA patients with stomas are not at increased risk of complications. These findings emphasize the importance of recognizing and addressing the unique challenges associated with this patient population.

Equivalent Survivorship of Total Hip Arthroplasty in Patients Who Have Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) can have orthopaedic manifestations related to decreased bone mineral density and increased fracture risk. The impact of IBD-spectrum diseases, including Crohn's disease (CD) and ulcerative colitis (UC), on the overall performance of total hip arthroplasty (THA), is not well understood. The present study sought to evaluate whether patients who have IBD were at an increased risk of THA failure compared to those who did not have IBD. METHODS: The Statewide Planning and Research Cooperative System was used to compare postoperative outcomes between patients who have IBD (CD and UC) and patients who do not have IBD from 2010 to 2020. A total of 119,094 patients were included in the study, of whom 1,165 had a diagnosis of IBD. Overall, 501 of those had CD, while 664 had UC. RESULTS: When controlling for comorbidities, patients who had CD had longer hospital length of stay (CD: 3.6 ± 2.5 versus UC: 3.4 ± 2.1 versus control: 3.2 ± 2.3 days, P < 0.001), higher rates of 90-day readmission (CD: 13.6 versus UC: 8.3 versus control: 7.7%, P < 0.001) and 1-year readmission (CD: 20.4 versus UC: 15.1 versus control: 12.8%, P < 0.001), and higher rates of 90-day emergency room visits (CD: 15.4 versus UC: 12 versus control: 11.1%, P = 0.007). There were no differences in all-cause revision or revision for periprosthetic joint infection between CD and UC compared with control patients. CONCLUSIONS: Patients who have UC had more emergency room visits and hospital readmissions following THA; however, survival analysis demonstrated that IBD patients are not at an increased risk of revision or periprosthetic joint infection after THA.

Total Hip Arthroplasty Patients Who Have Ostomies Have an Increased Risk of Revisions for Periprosthetic Joint Infection, but Total Knee Arthroplasty Patients Do Not.

BACKGROUND: Patient comorbidities can lead to worse outcomes and increase the risk of revisions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Sparse research is available on the effects of ostomies on postoperative outcomes. Our study aimed to assess whether patients who have ostomies, who underwent TKA or THA, have worse outcomes and increased rates of all-cause and periprosthetic joint infection (PJI)-related revisions. METHODS: We performed a retrospective cohort study comparing the outcomes of THA and TKA patients who have and do not have a history of ostomy using the Statewide Planning and Research Cooperative System. Patient demographics, ostomy diagnosis, 3-month emergency department visits and readmissions, and revisions were collected. A total of 126,414 THA and 216,037 TKA cases were included. Log-rank testing and a Cox proportional hazards model were used to account for covariates. RESULTS: In total, 463 THA patients (0.4%) had ostomies. They had a longer length of stay (4.0 versus 3.1 days, P < 0.001) and were less likely to be discharged home (55.3 versus 62.2%, P = 0.01). They had higher rates of PJI-related revisions (1.9 versus 0.9%, P = 0.02) and had increased odds of PJI-related revision (OR [odds ratio] = 2.2, P = 0.02). Of TKA patients, 619 patients (0.3%) had an ostomy. They had a longer length of stay (3.6 versus 3.3 days, P = 0.02) and was less likely to be discharged home (49.4 versus 52.4%, P = 0.16). However, there was no difference in the rate (1.8 versus 1.4%, P = 0.49) or odds (OR = 1.2, P = 0.53) of PJI-related revision. CONCLUSIONS: THA, but not TKA, patients who have ostomies have an increased risk of PJI-related revisions. The proximity of the surgical incision to the ostomy site may play a role in the risk of PJI in THA patients.

Incidence of Upper Extremity Neuropathies at a Single Tertiary Care Institution in the United States: Trends in Recent Years, Including the COVID-19 Pandemic.

OBJECTIVE: This study examined trends in upper extremity (UE) neuropathies at a large urban tertiary care center in the Northeastern United States over the past five years, including the period of the COVID-19 pandemic. METHOD: A retrospective medical record review was conducted from 2018 to 2022. We collected data from unique patient records identified using International Classification of Diseases, Tenth Revision (ICD-10) codes for UE neuropathies. We characterized subjects by age, demographics, and duration of symptoms.  Results: This study included 288 pediatric patients and 51,997 adult patients newly diagnosed with UE neuropathy. Most patients were aged 55+; 0.4% of all patients diagnosed with UE neuropathy were children. Across all ages, there was an overall increase in UE neuropathy diagnoses in the past five years, with the most noticeable increases from 2018 to 2019 (+5,761 diagnosed individuals, or +122%) and from 2020 to 2021 (+2,769 diagnosed individuals, or +28.8%). CONCLUSION: Our institution's UE neuropathy diagnoses have increased in the past five years. Of note, there was a significantly increased rate of UE neuropathy diagnoses from 2020 to 2021. This increase coincides with the COVID-19 pandemic, which is leading to a changing environment for many Americans. These societal changes will likely become indelible after the pandemic; safety practices should be enacted to avoid these debilitating neuropathies.

Perioperative Demographic and Laboratory Characteristics of Failed Debridement, Antibiotics, and Implant Retention: Can We Determine Which Patients Will Fail?

BACKGROUND: Debridement, antibiotics, and implant retention (DAIR) are the mainstays surgical treatment for acute periprosthetic joint infection (PJI). However, reoperation following DAIR is common and the risk factors for DAIR failure remain unclear. This study aimed to assess the perioperative characteristics of patients who failed initial DAIR treatment. METHODS: A retrospective review was conducted on 83 patients who underwent DAIR for acute PJI within 3 months following index surgery from 2011 to 2022, with a minimum one-year follow-up. Surgical outcomes were categorized using the Musculoskeletal Infection Society outcome reporting tool (Tiers 1 to 4). Patient demographics, laboratory data, and perioperative outcomes were compared between patients who had failed (Tiers 3 and 4) (n = 32) and successful (Tiers 1 and 2) (n = 51) DAIR treatment. Logistic regression was also performed. RESULTS: After logistic regression, Charlson Comorbidity Index (odds ratio [OR]: 1.57; P = .003), preoperative C-reactive protein (OR: 1.06; P = .014), synovial white blood cell (OR: 1.14; P = .008), and polymorphonuclear cell (PMN%) counts (OR: 1.05; P = .015) were independently associated with failed DAIR. Compared with total hip arthroplasty, total knee arthroplasty patients (OR: 6.08; P = .001) were at increased risk of DAIR failure. The type of organism and time from primary surgery were not correlated with DAIR failure. CONCLUSIONS: Patients who had failed initial DAIR tended to have significantly higher Charlson Comorbidity Index, C-reactive protein, synovial white blood cell, and PMN%. The total knee arthroplasty DAIRs were more likely to fail than the total hip arthroplasty DAIRs. These characteristics should be considered when planning acute PJI management, as certain patients may be at higher risk for DAIR failure and may benefit from other surgical treatments. LEVEL OF EVIDENCE: III.

Artificial Intelligence Language Models Are Useful Tools for Patients Undergoing Total Ankle Replacement.

BACKGROUND: Artificial intelligence (AI) large language models (LLMs), such as Chat Generative Pre-trained Transformer (ChatGPT), have gained traction as both augmentative tools in patient care but also as powerful synthesizing machines. The use of ChatGPT in orthopaedic foot and ankle surgery, particularly as an informative resource for patients, has not been described to date. The purpose of this study was to assess the quality of information provided by ChatGPT in response to commonly asked questions about total ankle replacement (TAR). METHODS: ChatGPT was asked 10 frequently asked questions about TAR in a conversational thread. Responses were recorded without follow-up, and subsequently graded A, B, C, or F, corresponding with "excellent response," "adequate response needing mild clarification," "inadequate response needing moderate clarification," and "poor response needing severe clarification." RESULTS: Of the 10 responses, 2 were grade "A," 6 were grade "B," 2 were grade "C," and none were grade "F." Overall, the LLM provided good-quality responses to the posed prompts. Conclusion. Overall, the provided responses were understandable and representative of the current literature surrounding TAR. This study highlights the potential role LLMs in augmenting patient understanding of foot and ankle operative procedures. LEVELS OF EVIDENCE: IV.

Socioeconomic Disparities in Online Patient Portal Utilization Among Total Knee Arthroplasty Recipients.

BACKGROUND: Since 2021, the Centers for Medicare and Medicaid Services have mandated that patients have open access to their medical records. Many institutions use online portals, which allow patients to access their health information and communicate with care teams. Our research aimed to evaluate demographic patterns for online patient portal utilization in patients undergoing total knee arthroplasty (TKA). Further, we assessed if and how portal engagement contributes to perioperative outcomes. METHODS: This study retrospectively reviewed primary and elective TKA from 2017 to 2022 at a single academic institution. Patients were stratified into 2 groups based on their online portal status: activated (A) or not-activated (NA). Baseline characteristics and postoperative outcomes were collected from the electronic medical record and compared. RESULTS: In total, 10,995 patients were included: 8,330 (75.8%) were A and 2,625 (24.2%) were NA. The NA group was significantly older (P < .001); more likely to be Black (P < .001), women (P < .001), single/divorced/widowed (P < .001), non-English speaking (P < .001), and Medicare or Medicaid insured (P < .001); from zip codes with median incomes below $50,000 (P < .001), and more likely to be American Society of Anesthesiologists class III or IV (P < .001). Patient-reported outcome measure completion rates were significantly lower in the NA group (15.3 versus 47.7%, P < .001). Lengths of stay (LOS) were significantly higher in the NA group (2.7 versus 2.1 days, P < .001). The NA group was significantly more likely to be discharged to skilled nursing facilities (P < .001). Comparable rates of 90-day emergency department visits, readmissions, as well as 90-day and 2-year revisions, were observed across groups. CONCLUSIONS: There are significant disparities in online portal activation status based on patient demographics. Patients who have A portals had significantly higher Patient-reported outcome measure completion rates, shorter LOS, and higher rates of home discharge. Further research should determine which other factors may affect patient portal utilization and inform interventions to improve portal utilization among minority populations.

Mid-term outcomes of a kinematically designed cruciate retaining total knee arthroplasty.

BACKGROUND: Advances in implant material and design have allowed for improvements in total knee arthroplasty (TKA) outcomes. A cruciate retaining (CR) TKA provides the least constraint of TKA designs by preserving the native posterior cruciate ligament. Limited research exists that has examined clinical outcomes or patient reported outcome measures (PROMs) of a large cohort of patients undergoing a CR TKA utilizing a kinematically designed implant. It was hypothesized that the studied CR Knee System would demonstrate favorable outcomes and a clinically significant improvement in pain and functional scores. AIM: To assess both short-term and mid-term clinical outcomes and PROMs of a novel CR TKA design. METHODS: A retrospective, multi-surgeon study identified 255 knees undergoing a TKA utilizing a kinematically designed CR Knee System (JOURNEY™ II CR; Smith and Nephew, Inc., Memphis, TN) at an urban, academic medical institution between March 2015 and July 2021 with a minimum of two-years of clinical follow-up with an orthopedic surgeon. Patient demographics, surgical information, clinical outcomes, and PROMs data were collected via query of electronic medical records. The PROMs collected in the present study included the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and Patient-Reported Outcomes Measurement Information System (PROMIS®) scores. The significance of improvements in mean PROM scores from preoperative scores to scores collected at six months and two-years postoperatively was analyzed using Independent Samples t-tests. RESULTS: Of the 255 patients, 65.5% were female, 43.8% were White, and patients had an average age of 60.6 years. Primary osteoarthritis (96.9%) was the most common primary diagnosis. The mean surgical time was 105.3 minutes and mean length of stay was 2.1 d with most patients discharged home (92.5%). There were 18 emergency department (ED) visits within 90 d of surgery resulting in a 90 d ED visit rate of 7.1%, including a 2.4% orthopedic-related ED visit rate and a 4.7% non-orthopedic-related ED visit rate. There were three (1.2%) hospital readmissions within 90 d postoperatively. With a mean time to latest follow-up of 3.3 years, four patients (1.6%) required revision, two for arthrofibrosis, one for aseptic femoral loosening, and one for peri-prosthetic joint infection. There were significant improvements in KOOS JR, PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Mobility, and PROMIS Physical Health from preoperative scores to six month and two-year postoperative scores. CONCLUSION: The evaluated implant is an effective, novel design offering excellent outcomes and low complication rates. At a mean follow up of 3.3 years, four patients required revisions, three aseptic and one septic, resulting in an overall implant survival rate of 98.4% and an aseptic survival rate of 98.8%. The results of our study demonstrate the utility of this kinematically designed implant in the setting of primary TKA.

The significance of heterotopic ossification following total ankle arthroplasty: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to evaluate the prevalence and clinical significance of heterotopic ossification (HO) following total ankle replacement (TAR). METHODS: During August 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies reporting HO following TAR. Data regarding surgical characteristics, pathological characteristics, subjective clinical outcomes, ankle range of motion, radiographic outcomes, reoperation rates were extracted and analysed. RESULTS: Twenty-seven studies with 2639 patients (2695 ankles) at a weighed mean follow-up time of 52.8 ± 26.9 months were included. The pooled prevalence rate was 44.6% (0.25; 0.66). The implant with the highest rate of HO was the INBONE I (100%) and BOX (100%) implants. The most common modified Brooker staging was grade 1 (132 patients, 27.0%). Random effects models of standardized mean differences found no difference in American orthopedic foot and ankle society (AOFAS) scores, visual analog scale scores (VAS) and ankle range of motion (ROM) between patients with HO and patients without HO. Random effects models of correlation coefficients found no correlation between AOFAS, VAS and ROM and the presence of HO. The surgical intervention rate for symptomatic HO was 4.2%. CONCLUSION: This systematic review and meta-analysis found that HO is a common finding following TAR that is not associated with inferior clinical outcomes. Surgical intervention was required only for moderate-to-severe, symptomatic HO following TAR. This study is limited by the marked heterogeneity and low level and quality of evidence of the included studies. Further higher quality studies are warranted to determine the precise prevalence and impact of HO on outcomes following TAR.

Human versus artificial intelligence-generated arthroplasty literature: A single-blinded analysis of perceived communication, quality, and authorship source.

BACKGROUND: Large language models (LLM) have unknown implications for medical research. This study assessed whether LLM-generated abstracts are distinguishable from human-written abstracts and to compare their perceived quality. METHODS: The LLM ChatGPT was used to generate 20 arthroplasty abstracts (AI-generated) based on full-text manuscripts, which were compared to originally published abstracts (human-written). Six blinded orthopaedic surgeons rated abstracts on overall quality, communication, and confidence in the authorship source. Authorship-confidence scores were compared to a test value representing complete inability to discern authorship. RESULTS: Modestly increased confidence in human authorship was observed for human-written abstracts compared with AI-generated abstracts (p = 0.028), though AI-generated abstract authorship-confidence scores were statistically consistent with inability to discern authorship (p = 0.999). Overall abstract quality was higher for human-written abstracts (p = 0.019). CONCLUSIONS: AI-generated abstracts' absolute authorship-confidence ratings demonstrated difficulty in discerning authorship but did not achieve the perceived quality of human-written abstracts. Caution is warranted in implementing LLMs into scientific writing.

Innovations in the Isolation and Treatment of Biofilms in Periprosthetic Joint Infection: A Comprehensive Review of Current and Emerging Therapies in Bone and Joint Infection Management.

Periprosthetic joint infections (PJIs) are a devastating complication of joint arthroplasty surgeries that are often complicated by biofilm formation. The development of biofilms makes PJI treatment challenging as they create a barrier against antibiotics and host immune responses. This review article provides an overview of the current understanding of biofilm formation, factors that contribute to their production, and the most common organisms involved in this process. This article focuses on the identification of biofilms, as well as current methodologies and emerging therapies in the management of biofilms in PJI.

Two-Year Outcomes of Novel Dual-Mobility Implant in Primary Total Hip Arthroplasty.

Introduction: Dual-mobility (DM) implants for total hip arthroplasty (THA) have gained popularity due to their potential to reduce hip instability and dislocation events that may lead to revision surgery. These implants consist of a femoral head articulated within a polyethylene liner, which articulates within an outer acetabular shell, creating a dual-bearing surface. Our study aimed to report our observations on the survivorship of a novel DM implant for primary total hip arthroplasty at two years. Methods: We conducted a retrospective, multicenter study to assess the clinical outcomes of patients undergoing a THA with a novel DM implant (OR3O acetabular system™, Smith & Nephew, Inc., Memphis, TN) from January 2020 to September 2021. Patient demographics, surgical information, and survivorship data were collected from medical records for patients with a minimum of two years of follow-up. Primary outcomes included overall implant survivorship at two years as well as aseptic survivorship, revision rates of the DM acetabular shell, and average time to revision. Patient-reported outcomes were collected in the form of HOOS JR. Results: A total of 250 hips in 245 patients had a minimum two-year follow-up. Primary osteoarthritis (80%) was the most common indication for index THA. The average aseptic survivorship of the DM acetabular components at two years for the cohort was 98.4% and survivorship of the acetabular implants overall was 97.6%. There were a total of four (1.6%) aseptic revisions of the DM acetabular component. Reasons for aseptic acetabular revision included one case of instability, one intraprosthetic dislocation, one periprosthetic acetabular fracture, and one malpositioned acetabular cup resulting in impingement. The mean time of follow-up was 893.9 days. Eighty-seven patients had preoperative and two-year HOOS JR available. HOOS JR improved by an average of 38.5 points. Conclusion: This novel DM acetabular implant demonstrates excellent survivorship at two years follow-up with low rates of instability and intraprosthetic dislocation and no episodes of metal-on-metal corrosion. Use of the DM implant demonstrated clinically relevant improvements in patient-reported outcomes at two years.

Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study.

PURPOSE: Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF. METHODS: Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching. RESULTS: Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively. CONCLUSION: Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk. LEVEL OF EVIDENCE: Level III, Retrospective study.

Aseptic Acetabular Revisions ≤90 Days, 91 Days to 2 Years, and >2 Years After Total Hip Arthroplasty: Comparing Etiologies, Complications, and Postoperative Outcomes.

BACKGROUND: Isolated acetabular component revision is an effective treatment for revision total hip arthroplasty patients who have well-fixed femoral implants. We aimed to evaluate the modes of acetabular failure following primary total hip arthroplasty and to identify factors associated with increased morbidities and postoperative outcomes. METHODS: We conducted a retrospective analysis and identified 318 isolated aseptic acetabular revisions. We separated patients by ≤90 days, 91 days to 2 years, and >2 years for acetabular revisions and compared demographics, reasons for revision, 90-day readmissions, rerevisions, and postrevision infections. Revisions ≤90 days, 91 days to 2 years, and >2 years accounted for 10.7, 19.2, and 70.1% of revisions, respectively. Revisions ≤90 days, 91 days to 2 years, and >2 years had their primary total hip arthroplasty at a mean age of 66, 63, and 55 years (P < .001), respectively. RESULTS: Revisions within 90 days were mainly indicated for dislocation/instability (58.8%) or periprosthetic fracture (23.5%) while revisions over 2 years were indicated for polyethylene wear/osteolysis (37.2%). Patients with revisions past 90 days were more likely to require rerevision compared to patients with revisions within 90 days (P < .001). There were no differences in readmissions (P = .28) or infection rates (P = .37). CONCLUSIONS: Acetabular revisions within 90 days were more commonly indicated for instability and periprosthetic fracture, while those over 2 years were indicated for polyethylene wear. Revisions past 90 days were more likely to require subsequent rerevisions without increased 90-day readmissions or infections. LEVEL III EVIDENCE: Retrospective cohort study.

The Influence of Tourniquet and Adductor Canal Block Use on Pain and Opioid Consumption after Total Knee Arthroplasty.

Reducing pain and opioid consumption after total knee arthroplasty (TKA) is an important perioperative consideration. Though commonly used, the combined influence of tourniquets and adductor canal blocks (ACBs) on pain and opioid consumption is unknown. This study evaluated inpatient opioid consumption and pain between patients with TKA based on tourniquet and/or ACB use. Pain and opioid consumption were highest when a tourniquet, but no ACB was used, and lowest when an ACB, but no tourniquet was used - though absolute differences in pain scores were not clinically significant. Tourniquet and ACB use should be considered as part of TKA opioid-sparing protocols.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2040-2060.

Background: National projections of future joint arthroplasties are useful in understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for revision total joint arthroplasty procedures from 2040 through 2060. Methods: The study uses 2000-2019 data from the CMS Medicare Part-B National Summary and combines procedure counts using CPT codes for revision total joint arthroplasty procedures. In 2019, revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) procedures totaled 53,217 and 30,541, respectively, forming a baseline from which we generated point forecasts between 2020 and 2060 and 95% forecast intervals (FI). Results: On average, the model projects an annual growth rate of 1.77% for rTHAs and 4.67% for rTKAs. By 2040, rTHAs were projected to be 43,514 (95% FI = 37,429-50,589) and rTKAs were projected to be 115,147 (95% FI = 105,640-125,510). By 2060, rTHAs was projected to be 61,764 (95% FI = 49,927-76,408) and rTKAs were projected to be 286,740 (95% FI = 253,882-323,852). Conclusions: Based on 2019 total volume counts, the log-linear exponential model forecasts an increase in rTHA procedures of 42% by 2040 and 101% by 2060. Similarly, the estimated increase for rTKA is projected to be 149% by 2040 and 520% by 2060. An accurate projection of future revision procedure demands is important to understand future healthcare utilization and surgeon demand. This finding is only applicable to the Medicare population and demands further analysis for other population groups.

Total Knee Arthroplasty in a Patient with Ipsilateral Painless Hip Arthrodesis: Technical Surgical Tips and a Novel Method for Intraoperative Navigation-Assisted Planning.

Total knee arthroplasty (TKA) in the setting of a previous ipsilateral hip fusion/arthrodesis is an uncommon and challenging procedure. There is little information available in the literature on the challenges and techniques available to perform TKA in these patients. For a traditional TKA procedure, the patient is placed in the supine position and various knee-positioning devices are used to allow for adequate knee and hip flexion, which is required for surgical exposure and tibia preparation. Ipsilateral hip arthrodesis presents two major challenges: (1) Hip flexion is crucial for adequate knee flexion while the patient is supine during the TKA procedure, and (2) the use of advanced technology, specifically computer navigation and robotic-assisted surgery techniques, is limited due to the inability to acquire the hip center of rotation during surgery, due to the lack of hip motion. Therefore, equipment and positioning must be adjusted by the surgeon to facilitate TKA in these patients. This article reports the case of a 72-year-old male patient with a long-standing, painless right hip arthrodesis, presenting with end-stage osteoarthritis of the right knee, leg-length discrepancy, and an 11.6° difference between the mechanical and anatomical axes of the femur. We describe the unique surgical planning as well as the surgical positioning options that allow for adequate knee flexion and proper surgical exposure. Furthermore, we describe a novel method of computer-assisted navigation for intra-operative planning and execution utilizing a reflected tibia as a template for the distal femoral cut.

Can pain be improved with retention of the posterior cruciate ligament during total knee arthroplasty?

PURPOSE: The purpose of the current study was to determine if differences exist between cruciate-retaining (CR) and posterior-stabilized (PS) implant articulations for total knee arthroplasty (TKA) with regards to early post-operative pain. METHODS: We retrospectively reviewed patients who underwent primary TKA, with the same TKA implant design, at our institution between January 2018 and July 2021. Patients were stratified based on whether they received a CR or non-constrained PS (PSnC) articulation and propensity score matched in a 1:1 ratio. A sub-analysis matching patient who received a constrained PS implant (PSC) to those undergoing CR TKA and PSnC TKA was also carried out. Opioid dosages were converted to morphine milligram equivalents (MME). RESULTS: 616 patients after CR TKA were matched 1:1 to 616 patients with a PSnC implant. There were no significant differences between demographic variables. There were no statistically significant differences in opioid usage measured by MME on post-operative day (POD) 0 (p = 0.171), POD1 (p = 0.839), POD2 (p = 0.307), or POD3 (p = 0.138); VAS pain scores (p = 0.175); or 90-day readmission rate for pain (p = 0.654). A sub-analysis of CR versus PSC TKA demonstrated no significant differences in opioid usage on POD0 (p = 0.765), POD1 (p = 0.747), POD2 (p = 0.564), POD3 (p = 0.309); VAS pain scores (p = 0.293); and 90-day readmission rate for pain (p > 0.9). CONCLUSION: Our analysis demonstrated no significant difference in post-operative VAS pain scores and MME usage based on implant. The results suggest that neither the type of articulation or constraint used for primary TKA has a significant impact on immediate post-operative pain and opioid consumption. LEVEL III EVIDENCE: Retrospective Cohort Study.