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BACKGROUND: The purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants. METHODS: A retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship. RESULTS: The re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86% and 64%, and survivorship free from re-revision for aseptic loosening was 100% and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR) increased from 43 preoperatively to 60 at 1 year (P < 0.001). CONCLUSION: In patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Mid-term survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI.
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Background: The outcomes of revision total hip arthroplasty (rTHA) have become increasingly important as their volume increases. Computer navigation, a reliable method to improve component positioning during primary total hip arthroplasty (THA), is not well studied in the rTHA setting. Given that dislocation rates following rTHA are significantly higher than those of primary THA, component positioning becomes paramount in these cases. Methods: Here, we present two case reports and surgical techniques, one of a 77-year-old man undergoing rTHA for recurrent hip instability following primary THA, and one of a 61-year-old woman undergoing rTHA for severe iliopsoas bursitis who was at increased risk for instability and dislocation given her history of large segment spinal fusion. Results: Both patients achieved optimal acetabular component positioning after rTHA with imageless computer navigation. Conclusions: The use of imageless computer navigation in rTHA provides accurate and reproducible component positioning during acetabular rTHA.
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BACKGROUND: Interprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. METHODS: We retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement and 1 total femur replacement. Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (n = 9), and in 1 case, total femur replacement (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). RESULTS: The 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for refracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral total knee arthroplasty component was associated with increased risk for reoperation (P = .007) and PJI (P = .044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = .72). CONCLUSIONS: An IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between 2 stemmed components were at the highest risk for reoperation.
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BACKGROUND: Plain radiographs remain the standard for diagnosing osteoarthritis (OA). Total hip arthroplasty (THA) is generally offered only for advanced OA by plain radiographs. Advanced imaging is used as an adjunct to assess OA severity in cases of progressive symptoms with less advanced OA by plain radiographs. The objective of this study was to compare outcomes following THA in patients who have advanced OA visualized by plain radiographs to patients who have less severe OA visualized by plain radiographs. METHODS: From February 2016 to February 2020, 93 patients who had Kellgren-Lawrence (KL) grade 0 to 2 OA and underwent THA were identified. The median age was 65 years, and 55% were women. They were matched 1:3 to patients who underwent THA for KL 4 OA based on age, sex, body mass index, and Charlson Comorbidity Index. The primary outcome was achievement of the Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference, substantial clinical benefit, and patient-acceptable symptom state at 1 year postoperatively. RESULTS: There was no difference between the KL 0 to 2 and KL 4 cohorts in the achievement of HOOS JR minimum clinically important difference (86 versus 85.6%, P = .922), substantial clinical benefit (81.7 versus 80.2%, P = .751), or patient-acceptable symptom state (89.2 versus 85.6%, P = .374). The KL 0 to 2 cohort had a similar improvement in their 2-year HOOS JR (42.5 versus 38.6, P = .019). CONCLUSIONS: In this series, there was no difference in outcomes following primary THA between patients who have severe OA on plain radiographs (KL 4) compared to those who have less severe OA (KL 0 to 2). In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA.
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BACKGROUND: Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty. METHODS/RESULTS: This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons 2023 annual meeting, including an overview of the Vancouver classification and its implications on treatment and subsequent complications, an updated approach to the management of intraoperative fractures, and finally, contemporary strategies for both osteosynthesis as well as revision arthroplasty for PFFs. CONCLUSION: As the incidence of PPF continues to increase, arthroplasty and trauma surgeons must be prepared to address this challenging complication with a contemporary understanding of the treatment options and their outcomes.
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BACKGROUND: Identification of femoral component debonding in the work-up of painful total knee arthroplasty (TKA) often poses a diagnostic challenge. The purpose of this study was to compare the sensitivity and specificity of radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) for identifying femoral component loosening with debonding at the time of revision of a primary TKA with a recalled polyethylene insert. METHODS: Using an institutional database, we identified all cases of revision TKA performed for this specific implant recall following a primary TKA between 2014 and 2022. Patients who had a preoperative radiograph, CT, and MRI were included (n = 77). Sensitivity, specificity, and positive and negative likelihood ratio (LR) for predicting loosening were compared among the imaging modalities, using the intraoperative evidence of implant loosening as the gold standard. RESULTS: At the time of revision surgery, the femoral component was noted to have aseptic loosening with debonding in 46 of the 77 (60%) of the TKAs. There were no significant differences in demographics in the cohort with femoral debonding compared to those with well-fixed implants. The CT demonstrated a sensitivity of 28% and a specificity of 97%, while the MRI demonstrated a sensitivity of 37% and a specificity of 94% for detecting femoral loosening due to debonding. Both CT and MRI demonstrated poor negative LRs for femoral loosening (LR 0.7). CONCLUSIONS: In this series of revision TKAs for a specific recalled component, neither CT nor MRI accurately diagnosed femoral component debonding. For patients who have this implant, it is imperative to interrogate the implant-cement interface intraoperatively and prepare for full revision surgery as well as marked bone loss secondary to osteolysis.
Subject(s)
Arthroplasty, Replacement, Knee , Knee Prosthesis , Magnetic Resonance Imaging , Prosthesis Failure , Reoperation , Tomography, X-Ray Computed , Humans , Female , Male , Aged , Middle Aged , Knee Prosthesis/adverse effects , Femur/surgery , Femur/diagnostic imaging , Retrospective Studies , Sensitivity and Specificity , Aged, 80 and over , Knee Joint/surgery , Knee Joint/diagnostic imagingABSTRACT
BACKGROUND: Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs. METHODS: A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation. RESULTS: There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort. CONCLUSIONS: No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.
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BACKGROUND: There is no consensus on whether direct anterior approach (DAA) or postero-lateral approach (PLA) total hip arthroplasty (THA) confers a lower risk of postoperative complications. Robotic assistance in THA results in a more consistently accurate component position compared to manual THA. The objective of this study was to compare rates of dislocation, reoperation, revision, and patient-reported outcome measures between patients undergoing DAA and PLA robotic-assisted primary THA. METHODS: We identified 2,040 consecutive robotic-assisted primary THAs performed for primary osteoarthritis, using DAA (n = 497) or PLA (n = 1,542) between 2017 and 2020. The mean follow-up was 18 months. Kaplan-Meier analysis estimated survivorship free of dislocation, reoperation, and revision. Achievement of patient acceptable symptom state and minimum clinically important difference were used to compare changes in the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Visual Analog Scale. RESULTS: Dislocation was rare in this series (14 in 2,040, 0.7%), including 1 of 497 (0.2%) in the DAA cohort and 13 of 1,542 (0.8%) in the PLA cohort (P = .210). There was no difference in 2-year reoperation-free survivorship (97.8 versus 98.6%, P = .59) or revision-free survivorship (98.8 versus 99.0%, P = .87) at any time point. After controlling for age, sex, and body mass index, there was no difference in dislocation, reoperation, or revision. At 6-week follow-up, after controlling for age, sex, and body mass index, patients in the DAA cohort had higher odds of achieving HOOS JR minimum clinically important difference (odds ratio = 2.01, P = .012) and HOOS JR patient acceptable symptom state (odds ratio = 1.72, P = .028). There were no differences in patient-reported outcome measures by 3 months. CONCLUSIONS: For robotic-assisted primary THA, DAA may confer enhanced early (<6 weeks) functional recovery compared to the PLA, but there was no significant difference in postoperative dislocation, reoperation, or revision rates.
Subject(s)
Arthroplasty, Replacement, Hip , Osteoarthritis, Hip , Patient Reported Outcome Measures , Postoperative Complications , Reoperation , Robotic Surgical Procedures , Humans , Arthroplasty, Replacement, Hip/methods , Reoperation/statistics & numerical data , Female , Male , Robotic Surgical Procedures/methods , Aged , Middle Aged , Osteoarthritis, Hip/surgery , Postoperative Complications/etiology , Postoperative Complications/epidemiology , Retrospective Studies , Aged, 80 and over , Treatment Outcome , AdultABSTRACT
Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.
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BACKGROUND: Sleep disturbance is a common problem following total knee arthroplasty (TKA). The objective of this study was to determine if exogenous melatonin improves sleep quality following primary TKA. METHODS: A randomized, double-blind, placebo-controlled trial was conducted. A total of 172 patients undergoing unilateral TKA for primary knee osteoarthritis were randomized to receive either 5 mg melatonin (n = 86) or 125 mg vitamin C placebo (n = 86) nightly for 6 weeks. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) at 6 weeks and 90 days postoperatively. Secondary outcomes included 6-week and 90-day patient-reported outcome measures (PROMs), morphine milligram equivalents prescribed, medication compliance, adverse events, and 90-day readmissions. RESULTS: Mean PSQI scores worsened at 6 weeks before returning to the preoperative baseline at 90 days in both groups. There were no differences in PSQI scores between melatonin and placebo groups at 6 weeks (10.2 ± 4.2 versus 10.5 ± 4.4, P = .66) or 90 days (8.1 ± 4.1 versus 7.5 ± 4.0, P = .43). Melatonin did not improve the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, Visual Analog Scale for pain, or Veterans Rand 12 Physical Component Score or Mental Component Score at 6 weeks or 90 days. Poor sleep quality was associated with worse PROMs at 6 weeks and 90 days on univariate and multivariable analyses, but melatonin did not modify these associations. There were no differences in morphine milligram equivalents prescribed, medication compliances, adverse events, or 90-day readmissions between both groups. CONCLUSIONS: Exogenous melatonin did not improve subjective sleep quality or PROMs at 6 weeks or 90 days following TKA. Poor sleep quality was associated with worse patient-reported function and pain. Our results do not support the routine use of melatonin after TKA.
Subject(s)
Arthroplasty, Replacement, Knee , Melatonin , Osteoarthritis, Knee , Sleep Quality , Humans , Melatonin/administration & dosage , Melatonin/therapeutic use , Double-Blind Method , Male , Female , Aged , Middle Aged , Osteoarthritis, Knee/surgery , Sleep Wake Disorders/etiology , Sleep Wake Disorders/drug therapy , Patient Reported Outcome Measures , Treatment Outcome , Awards and PrizesABSTRACT
BACKGROUND: Patients undergo total knee arthroplasty (TKA) at widely disparate stages of osteoarthritis, raising the possibility of high heterogeneity among patients enrolled in TKA research studies. Obscuration of treatment effectiveness and other problems that may stem from cohort heterogeneity can be controlled in clinical studies by rigorously defining target patients. The purpose of this review was to determine the extent to which randomized controlled trials (RCTs) on TKA use osteoarthritis severity, as defined by radiographic grade or patient-reported outcome measures (PROMs), in their inclusion criteria, and to investigate potential impact on outcome. METHODS: A search of PubMed, Embase, Scopus, Web of Science, and Cochrane databases used a combination of terms involving TKA, PROMs, and radiographic scoring. A total of 1,227 studies were independently reviewed by 2 screeners for the above terms. RCTs with ≥100 patients (236) and with <100 patients (325) undergoing TKA were analyzed with regard to the specific inclusion criteria and recruitment process. RESULTS: Among the identified RCTs with ≥100 patients, 18 (<8%, with a total of 2,952 randomized patients) used specific radiographic scoring or PROM thresholds in their inclusion criteria. Eleven of the 18 studies used specific radiographic scoring, such as the Kellgren-Lawrence or Ahlbäck classifications. Three studies used preoperative PROM thresholds: Knee Society Knee Score of <60, Knee Society Function Score of <60, Oxford Knee Score of <20, and Hospital for Special Surgery Score of <60. Among studies with <100 patients, 48 (<15%) used specific inclusion criteria. CONCLUSIONS: The vast majority of RCTs (>85%) did not enroll patients based on disease severity, as measured by PROM score thresholds or radiographic classifications, in their inclusion criteria. The lack of consistent inclusion criteria likely results in heterogeneous cohorts, potentially undermining the validity of RCTs on TKA. LEVEL OF EVIDENCE: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Arthroplasty, Replacement, Knee , Osteoarthritis, Knee , Patient Selection , Humans , Osteoarthritis, Knee/surgery , Patient Reported Outcome Measures , Randomized Controlled Trials as Topic , Severity of Illness IndexABSTRACT
BACKGROUND: Periprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients. METHODS: A consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period. RESULTS: Non-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001). CONCLUSIONS: In this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems.
Subject(s)
Arthroplasty, Replacement, Hip , Hip Prosthesis , Periprosthetic Fractures , Humans , Female , Aged , Male , Arthroplasty, Replacement, Hip/adverse effects , Periprosthetic Fractures/epidemiology , Periprosthetic Fractures/etiology , Periprosthetic Fractures/prevention & control , Hip Prosthesis/adverse effects , Reoperation/adverse effects , Prosthesis Design , Femur/surgery , Risk Factors , Retrospective StudiesABSTRACT
BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.
Subject(s)
Arthroplasty, Replacement, Hip , Femoral Fractures , Hip Prosthesis , Periprosthetic Fractures , Prosthesis-Related Infections , Humans , Female , Male , Arthroplasty, Replacement, Hip/adverse effects , Reoperation/adverse effects , Retrospective Studies , Prosthesis-Related Infections/epidemiology , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/surgery , Femur/surgery , Femoral Fractures/epidemiology , Femoral Fractures/etiology , Femoral Fractures/surgery , Periprosthetic Fractures/epidemiology , Periprosthetic Fractures/etiology , Periprosthetic Fractures/surgery , Hip Prosthesis/adverse effects , Risk FactorsABSTRACT
BACKGROUND: The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES: (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS: A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS: The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION: Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE: Level III, prognostic study.
Subject(s)
Musculoskeletal Diseases , Occupational Diseases , Orthopedic Procedures , Orthopedics , Male , Humans , Middle Aged , Female , Prevalence , Occupational Diseases/epidemiology , Occupational Diseases/prevention & control , Occupational Diseases/etiology , Musculoskeletal Diseases/epidemiology , Musculoskeletal Diseases/etiology , Ergonomics/methods , Orthopedic Procedures/adverse effectsABSTRACT
BACKGROUND: The radiographic assessment of bone morphology impacts implant selection and fixation type in total hip arthroplasty (THA) and is important to minimize the risk of periprosthetic femur fracture (PFF). We utilized a deep-learning algorithm to automate femoral radiographic parameters and determined which automated parameters were associated with early PFF. METHODS: Radiographs from a publicly available database and from patients undergoing primary cementless THA at a high-volume institution (2016 to 2020) were obtained. A U-Net algorithm was trained to segment femoral landmarks for bone morphology parameter automation. Automated parameters were compared against that of a fellowship-trained surgeon and compared in an independent cohort of 100 patients who underwent THA (50 with early PFF and 50 controls matched by femoral component, age, sex, body mass index, and surgical approach). RESULTS: On the independent cohort, the algorithm generated 1,710 unique measurements for 95 images (5% lesser trochanter identification failure) in 22 minutes. Medullary canal width, femoral cortex width, canal flare index, morphological cortical index, canal bone ratio, and canal calcar ratio had good-to-excellent correlation with surgeon measurements (Pearson's correlation coefficient: 0.76 to 0.96). Canal calcar ratios (0.43 ± 0.08 versus 0.40 ± 0.07) and canal bone ratios (0.39 ± 0.06 versus 0.36 ± 0.06) were higher (P < .05) in the PFF cohort when comparing the automated parameters. CONCLUSIONS: Deep-learning automated parameters demonstrated differences in patients who had and did not have early PFF after cementless primary THA. This algorithm has the potential to complement and improve patient-specific PFF risk-prediction tools.
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The combination of an aging population and increased utilization of total hip arthroplasty (THA) is leading to a higher incidence of conversion THA, defined as conversion from previous hip fracture surgery to THA. Conversion THA is a more technically challenging, time-consuming, and costly procedure compared to primary THA and frequently involve more medically complex patients. Thus, the aim of this review is to provide a rubric for surgeons to use when preparing for a conversion THA. We have assessed the compatibility of commonly available extraction devices with popular femoral nails. Furthermore, we review technical pearls for conversion THA including equipment planning, operative setup, intraoperative imaging, extraction sequencing, and troubleshooting commonly encountered obstacles.
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OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
Subject(s)
Arthroplasty, Replacement, Knee , Osteoarthritis, Hip , Osteoarthritis, Knee , Osteoarthritis , Rheumatology , Surgeons , Humans , Osteoarthritis, Hip/complications , Osteoarthritis, Hip/surgery , Osteoarthritis, Knee/complications , Osteoarthritis, Knee/surgery , Pain , United StatesABSTRACT
OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
Subject(s)
Arthroplasty, Replacement, Knee , Osteoarthritis , Rheumatology , Surgeons , Humans , Osteoarthritis/therapy , Pain , United StatesABSTRACT
OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.