Efficacy and Safety of Catheter Interventions for Postoperative Urinary Retention After Primary Hip and Knee Total Joint Arthroplasty.

INTRODUCTION: Postoperative urinary retention (POUR) is a common barrier to rapid-discharge hip and knee total joint arthroplasty (TJA). We evaluated the efficacy and safety of catheterization intervention methods for POUR before and after discharge. METHODS: A total of 1,659 primary TJAs were retrospectively reviewed. POUR resolutions before and after discharge were evaluated relative to catheterization type and other covariates. Complications before and within 90 days of discharge were quantified. A total of 113 POUR cases comprised the analysis sample of 76 hips and 37 knees in 51 women and 62 men with an average age and body mass index of 68.6 (range 22 to 92) years and 31.7 (range 16 to 49) kg/m2. RESULTS: POUR resolved before discharge for 82.3% (93/113) of patients, with equivalent resolution rates for intermittent catheterization alone (84.2%, 32/38) compared with indwelling catheterization with or without intermittent catheterization (82.6%, 57/69, P < 0.999), equivalent time to resolution (P = 0.319), and no difference in complication rates (P = 0.999). Complication rates within 90 days of discharge were higher for patients treated with indwelling catheters before discharge (P = 0.049). Resolution before discharge was more likely with increasing body mass index (P = 0.026) and less likely for patients with a history of urinary retention (P = 0.033). 60 percent (12/20) of patients with unresolved POUR were discharged with self-intermittent catheterization and 40% (8/20) with indwelling catheters, with no differences in efficacy and safety based on the catheterization type (P = 0.109). DISCUSSION: Before discharge, we observed equivalent resolution rates and equivalent time to resolution for indwelling and intermittent catheterization alone without compromising patient safety. Intermittent catheterization is favored, however, because in situ catheter exposure is dramatically reduced and postdischarge complication rates are lower. Additional research is needed to develop evidence-based POUR guidelines for outpatient TJA.

Survivorship and Patient Outcomes of Conforming Bearings in Modern Primary Total Knee Arthroplasty: Mean 3.5 Year Follow-Up.

BACKGROUND: Conforming and congruent bearings in total knee arthroplasty (TKA) have rapidly increased due to the benefits of increased stability and the potential for replicating normal knee kinematics. However, limited data exist for these newly available bearings. This study evaluated revision-free survivorship and patient-reported outcome measures (PROMs) of a large granular database of primary TKAs using a single conforming bearing design. METHODS: A total of 1,306 consecutive primary TKAs performed using a single conforming bearing design (85% cemented and 15% cementless) were retrospectively reviewed. Kaplan-Meier (KM) survivorship estimates were calculated based on the latest clinical follow-up. The PROMs and minimal clinically important differences (MCIDs) were evaluated. A total of 93% of cases achieved minimum 1-year clinical follow-up (mean 3.5 years; range, 1 to 7), with a subset of 261 cases that achieved minimum 5-year follow-up (mean 5.8 years; range, 5 to 7). RESULTS: All-cause and aseptic KM survivorship estimates were 97.6 (95% CI [confidence interval], 97 to 99) and 98.1% (95% CI, 97 to 99) at 7.0 years. Revision-free survivorship did not differ by cemented or cementless fixation (98 versus 97%, P = 0.163). All PROM scores significantly improved from preoperative baseline (P < 0.001), and ≥ 86% of patients achieved MCIDs for Knee Society pain and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) total scores. A total of 89% of cases reported their knees to 'sometimes or always' feel normal. For cases with minimum 5-year PROMs, 93% were 'very satisfied' or 'satisfied.' CONCLUSION: Conforming-bearing TKA demonstrated excellent survivorship up to 7.0 years. In addition, PROMs were comparable to other designs reported in the literature. While mid-term (mean 3.5-year) results are promising, long-term data are warranted on survivorship due to potential polyethylene wear in conforming bearings with more surface area in contact with articulating surfaces.

Comparison of Delphi Consensus Criteria and Musculoskeletal Infection Society Outcome Reporting Tool Definitions of Successful Surgical Treatment of Periprosthetic Knee Infection.

BACKGROUND: Agreement on success following surgical treatment for periprosthetic joint infection (PJI) is important for comparing the efficacy of different surgical approaches with varying consequences and outcomes and setting patient expectations. We compared success rates following two-stage exchange arthroplasty for knee PJI using two expert-consensus definitions of success. METHODS: Prospectively documented data for 57 knees treated by a single surgeon at an academic tertiary care center were retrospectively reviewed. Treatment outcomes were quantified using the Delphi Consensus Criteria and the Musculoskeletal Infection Society Outcome Reporting Tool (MSIS ORT). RESULTS: Success rates were 81% using the Delphi Consensus Criteria and 56% using the MSIS ORT (P = .008). The MSIS ORT success rates increased to 76% when aseptic revisions and deaths unrelated to PJI were not penalized as failures of treatment. Predicted probabilities of successful treatment in a hypothetical case scenario were lowest based on the MSIS ORT and similarly higher using Delphi Consensus Criteria and MSIS ORT modified for both women (53.0, 90.8, and 88.7%) and men (29.1, 89.1, and 89.3%). CONCLUSIONS: Study observations underscore the need for a uniformly accepted single definition of surgical treatment success.

Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?

BACKGROUND: Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients. METHODS: This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed. RESULTS: Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients. CONCLUSIONS: Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation.

The Fate of Unresurfaced Patellae in Contemporary Total Knee Arthroplasty: Early to Midterm Results.

BACKGROUND: Leaving the patella unresurfaced in total knee arthroplasty (TKA) has increased significantly over the past decade in the United States, likely due to modern patella-friendly implants, complications with resurfacing, and the knowledge that historical studies were scientifically confounded. This study evaluated revision-free survivorship out to 8.5 years in a cohort of contemporary primary TKAs with patella-friendly femoral components and unresurfaced patellae. METHODS: A total of 1,053 consecutive primary TKAs with unresurfaced patellae were retrospectively reviewed. A selective patellar nonresurfacing protocol was used for all cases. Kaplan-Meier survivorship estimates were calculated based on patellar revision and the latest follow-up. An aggressive lateral patellar facetectomy was performed in 78% (823 of 1,053) of cases. The cohort was 62% women and 43% American Society of Anesthesiologists physical status classification I or II with a mean age and body mass index of 65 years (range, 35 to 94) and 35 kg/m2 (range, 18 to 65), respectively. RESULTS: A total of 4 (0.4%, 4 of 1,053) unresurfaced patellae were revised. Three were resurfaced as part of other procedures: 2 for global instability and one for aseptic loosening at a mean of 1.6 years; and one patella was resurfaced by an outside surgeon for unexplained pain. The all-cause revision-free survivorship estimate specifically related to the patella was 98.9% (95% confidence interval, 98 to 100) out to 8.5 years. No significant difference in survivorship was related to patellae with or without a lateral patellar facetectomy (99.5 versus 98.1%, P ≥ .191); however, 3 of 4 patellar revisions occurred in TKAs without a lateral patellar facetectomy (P = .035). CONCLUSIONS: The results of this study demonstrate excellent revision-free survivorship related to unresurfaced patellae, particularly when a lateral facetectomy was performed. These early to midterm results using modern patella-friendly femoral components are promising and comparable to resurfaced patellae in the literature. LEVEL OF EVIDENCE: IV.

Durability of Primary Total Hip Arthroplasty With Cementless Stems Without a Collar in Elderly Patients Age 75 Years and Over.

BACKGROUND: Cementless femoral fixation in total hip arthroplasty (THA) has increased in prevalence worldwide. However, cementless fixation in elderly patients is controversial due to the risks of periprosthetic fracture and aseptic loosening. This study evaluated outcomes in patients undergoing primary THA utilizing a cementless stem without a collar, comparing those less than 75 years to those older than 75 years. METHODS: Between 2011 and 2021, there were 2,605 cementless THAs performed by 4 surgeons utilizing a highly porous metal fixation surface without a collar and consistent clinical protocols. There were 469 patients who had an age ≥ 75 years. Revision rates, intraoperative fractures, and 90-day mortality were compared between cohorts. In the ≥ 75 year age group, there were more women, more American Society of Anesthesiologists physical status classification III or IV, a lower body mass index, and more kidney disease, osteoporosis, and thyroid disease (P ≤ .002). RESULTS: All-cause revision rates trended lower for the ≥75 year age group compared to < 75 year (1.9 versus 3.5%, P = .082) at 20-months of follow-up. Moreover, there was no difference in all-cause femoral component revisions comparing ≥ 75 to < 75 year age groups (1.5 versus 2.2%, P = .375), with only 3 of 10 femoral revisions due to aseptic loosening being in the ≥ 75 year age group. Intraoperative fracture (0.2 versus 0.5%, P = .701) and 90-day mortality (0.2 versus 0.1%, P = .460) did not differ between ≥ 75 and < 75 year age groups. CONCLUSIONS: Older patients had comparable revision rates compared to younger patients using cementless femoral fixation without a collar. Furthermore, there was no difference in 90-day mortality or intraoperative fracture rates. Study findings provide evidence for the safety and durability of cementless THA using collarless femoral stems in elderly patients ≥ 75 years of age. LEVEL OF EVIDENCE: III.

Infection Rates After Aseptic Revision Total Hip Arthroplasty With Extended Oral Antibiotic Prophylaxis.

INTRODUCTION: Few US studies have investigated the efficacy of extended oral antibiotic prophylaxis (EOAP) in the prevention of periprosthetic joint infection (PJI) after aseptic revision total hip arthroplasty (R-THA). This study compared PJI rates in aseptic R-THA performed with EOAP with PJI rates in published studies of aseptic R-THA patients not receiving EOAP. METHODS: Prospectively documented data on 127 consecutive aseptic R-THAs were retrospectively reviewed. Evidence-based perioperative infection prevention protocols were used, and all patients were discharged on 7-day EOAP. Superficial and deep infections at 30 and 90 days postoperatively and at mean latest follow-up of 27.8 months were statistically compared with all US studies reporting the prevalence of PJI after aseptic R-THA. Complications related to EOAP within 120 days of the index procedure also are reported. RESULTS: No superficial or deep infections were observed at 30 and 90 days postoperatively when 7-day postdischarge EOAP was used. Superficial and deep infection rates were 1.57% (two patients) and 3.15% (four patients) at mean latest follow-up, respectively. Comparisons with published 30-day PJI rates of 1.37% ( P = 0.423) and 1.85% ( P = 0.257) were not statistically significant. Two of four comparisons with published 90-day PJI rates of 3.43% ( P = 0.027) and 5.74% ( P = 0.001) were statistically different. The deep PJI rate of 3.15% at mean latest follow-up was significantly lower than two of three published rates at equivalent follow-up including 10.10% ( P = 0.009) and 9.12% ( P = 0.041). No antibiotic-related complications were observed within 120 days of the index procedure. DISCUSSION: Study findings possibly support the use of EOAP after aseptic R-THA to prevent catastrophic PJI with revision implants, indicating that the efficacy of EOAP cannot be definitively ruled-in or ruled-out based on available evidence.

Instability in Patients With Lumbar Spine Disease Undergoing Posterior Approach and Lateral Approach Primary Total Hip Arthroplasty.

INTRODUCTION: Dislocation rates in patients who have fixed spinopelvic motion have been reported up to 20%. Few studies have directly compared dislocation rates in patients who have spine pathology undergoing total hip arthroplasty (THA) through different surgical approaches. This study compared postoperative dislocation rates in patients who had lumbar spine disease and underwent primary THA using a posterior or direct lateral approach. METHODS: Between 2011 and 2017, consecutive cohorts of primary THAs were retrospectively reviewed. One surgeon routinely used a posterior approach, while the other used a direct lateral approach. Chart and radiographic review were conducted to identify patients who had lumbar spine disease. Dislocations among cohorts with and without lumbar spine disease were compared by posterior and direct lateral approaches. RESULTS: The overall dislocation rate was 1.3% (15/1,198). The top four predictors of dislocation were presence of lumbar spine disease (odds ratio [OR] 5.0; P = 0.014), posterior surgical approach (OR, 6.5; P = 0.074), cases performed for fracture (OR, 4.4; P = 0.035), and women (OR, 4.6; P = 0.050). Dislocation rates among direct lateral approach patients who had lumbar spine pathology were significantly lower than posterior approach patients who had lumbar spine pathology (0.0% versus 3.6%; P = 0.011). DISCUSSION: Although dislocation rates were low in both groups, study results suggest that a direct lateral approach for primary THA may reduce postoperative dislocations for patients who have limited spinopelvic motion due to lumbar spine pathology. Furthermore, surgeons using the posterior approach might consider optimizing the femoral head to acetabular cup ratio in patients who have lumbar spine disease.

Implant Position, Survivorship, and Patient-Reported Outcomes in Manual Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: Two related recent reports described high error rates for implant positioning and reduced implant survivorship in manual unicompartmental knee arthroplasty (MUKA) compared to robotic-assisted unicompartmental knee arthroplasty (RUKA). The present study scientifically replicated these reports by comparing MUKAs similarly performed by an experienced high-volume surgeon in similar patients using the same study methods as these reports. METHODS: A total of 216 consecutive MUKAs were retrospectively evaluated radiographically for achievement of implant positioning targets. Achievement of targets was compared to the published MUKA and RUKA outcomes and correlated with revision rates and patient-reported outcome measures. RESULTS: There were 20% of study MUKAs compared to 88.1% of comparison MUKAs (P < .001) and 31.4% of comparison RUKAs (P < .048) that failed to meet all 7 implant positioning targets. The MUKA revision rates were significantly lower in the study sample than for comparison MUKAs (3.2% versus 14.2%, P < .001). Implant survivorship was 91.7% (95% confidence interval 84.9, 98.5%) at 8.9 years compared to 70.0% (95% confidence interval 56.0, 80.0%) at 10.2 years, respectively. Most patient-reported outcome measures did not differ based on achievement of implant positioning targets (P ≥ .072). CONCLUSIONS: Present study findings indicate that observations in the 2 recent reports may not be generalizable to all UKA surgeons. Additional data on the relationship between implant positioning and revision as well as functional outcomes are needed to identify appropriate robotic arthroplasty applications.

Ten Flaws of Systematic Mechanical Alignment Total Knee Arthroplasty.

Mechanical alignment (MA) and its tenets have been considered essential for total knee arthroplasty (TKA) success since they were introduced in 1973. However, over time, there have been colossal advances in our knowledge and understanding of the anatomy and kinematics of the knee, as well as in surgical precision and implants. However, the MA systematic principles of prosthetic arthroplasty and implant position related to the lower-extremity mechanical axis, have only recently been called into question. The high rates of dissatisfaction and residual pain reported after MA TKA prompted this questioning, and that leaves plenty of room for improvement. Despite the general consensus that there is great variability between patients' anatomy, it is still the norm to carry out a systematic operation that does not consider individual variations. Evolving to a more personalized arthroplasty surgery was proposed as a rational and reasonable option to improve patient outcomes. Transitioning to a personalized TKA approach requires questioning and even disregarding certain MA TKA principles. Based on current knowledge, we can state that certain principles are erroneous or unfounded. The aim of this narrative review was to discuss and challenge 10 previously accepted, yet we believe, flawed, principles of MA, and to present an alternative concept, which is rooted in personalized TKA techniques.

Predictors of Failure to Achieve Planned Same-Day Discharge after Primary Total Joint Arthroplasty: a Multivariable Analysis of Perioperative Risk Factors.

INTRODUCTION: Failure to achieve planned same-day discharge (SDD) primary total joint arthroplasty (TJA) occurs in as many as 7% to 49% of patients in the United States. This study evaluated the association between 43 perioperative risk factors and SDD failure rates. METHODS: A retrospective analysis of prospectively collected data from 466 primary TJAs with planned SDD to home was performed. Surgeries were performed at an academic tertiary care center comprising a hospital facility and a stand-alone ambulatory surgery center (ASC) on the same campus. Factors associated with failed SDD were identified using a multivariable analysis. RESULTS: Only one of 316 (0.3%) patients who underwent surgery in the ASC failed planned SDD ( P < 0.001) compared with 33.3% of 150 patients who underwent surgery in the hospital. The ASC failure was because of pain that interfered with physical therapy. Sixty-two percent (n = 31) of hospital failures were attributed to medical complications, 24% (n = 12) to physical therapy clearance, 8% (n = 4) to not being seen by internal medicine or therapy on the day of surgery, and 6% (n = 3) to unknown causes. Failure was increased in patients with preoperative anemia ( P = 0.003), nonwhite patients ( P = 0.002), patients taking depression/anxiety medication ( P = 0.015), and for every 10-morphine milligram equivalent increase in opioids consumed per hour in the postacute care unit ( P = 0.030). DISCUSSION: Risk stratification methods used to allocate patients to ASC versus hospital outpatient TJA surgery predicted SDD success. Most failures were secondary to medical causes. The findings of this study may be used to improve perioperative protocols enabling the safe planning and selection of patients for SDD pathways.

Incidence and Predictors of Subsidence Using Modular, Tapered, Fluted Titanium Femoral Stems in Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: Tapered, fluted titanium (TFT) femoral stems have become the gold standard in revision total hip arthroplasty (rTHA). However, there is a paucity of data on TFT stem subsidence rates following aseptic rTHA. Subsidence can lead to instability, mechanical failure, leg-length discrepancy, and may require revision surgery. This study evaluated the incidences and predictors of TFT subsidence in aseptic rTHA. METHODS: A total of 102 TFT femoral stems of 4 designs were retrospectively reviewed. Stem subsidence was measured on digital radiographs taken immediately after surgery and at standard clinical follow-up. Patient characteristics, risk factors for subsidence, revision etiologies, and implant characteristics were recorded. Patient-reported outcome measures were also evaluated for a subset of cases. RESULTS: Overall, 12% of stems subsided >1 cm, and subsidence was minimal (<3 mm) in ≥64% of cases. From immediate postoperative to 1-month radiographic follow-up, 79% of stems subsided a mean of 2.9 mm (range, 0.1 to 12 mm). Beyond 1 month, subsidence was minimal for ≥77% of cases. In multivariate analyses, women and less femoral implant canal fill were associated with greater subsidence (P ≤ .034). The TFT stem design was not associated with early subsidence (P = .816). There were no modular junction fractures. There were 2 fractures and 2 subsidence-related revisions for aseptic loosening that occurred postoperatively. CONCLUSIONS: The amount of subsidence in TFT stems was low and was detectable in the early (less than 1 year) postoperative period. Maximizing TFT stem fill within the femoral canal appears to reduce the risk of subsidence without increasing femoral fracture rates and should be the goal with implantation of these devices. LEVEL OF EVIDENCE: IV-Case Series, No Control Group.

Static Non-articulating Knee Spacers Are Associated with a High Degree of Morbidity in Challenging Clinical Scenarios.

The morbidity associated with the use of static non-articulating knee spacers for the treatment of periprosthetic joint infection (PJI) in challenging clinical scenarios has not been well described. From 2011-2019, 63 molded block static spacers were utilized at two academic institutions for the treatment of PJI with associated severe soft tissue compromise (59%), collateral ligament deficiency (49%), extensor mechanism compromise (48%), or type 3 bone defects (44%). Complications and outcomes were assessed. Complications with the use of static spacers were common and included further bone loss (46%), spacer migration (16%), extensor mechanism compromise (16%), cast or related soft tissue injuries (16%), fracture (13%), and spacer breakage (3%). Ultimately, 22% of patients underwent amputation. Patient variables such as age and body mass index were not associated with outcomes. Static knee spacers are associated with substantial morbidity in challenging clinical scenarios and alternatives may need to be considered. (Journal of Surgical Orthopaedic Advances 32(2):122-126, 2023).

Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Primary Total Knee Arthroplasty.

BACKGROUND: Body mass index (BMI) cutoffs have been established for total knee arthroplasty (TKA) patients due to increased risk of medical complications in obese patients. However, evidence-based medical optimization may mitigate risk in these patients. This study examined the influence of BMI on patient-reported outcome measures (PROMs) following primary TKA with specialized perioperative optimization. METHODS: Between 2016 and 2020, 1,329 consecutive primary TKAs using standardized perioperative optimization were retrospectively reviewed. Patients were categorized into ordinal groups based on BMI in 5 kg/m2 increments (range, 17 to 61). Primary outcomes related to activity level, pain, function, and satisfaction were evaluated. BMI groups ≥35 had significantly lower age, more women, and higher prevalence of comorbidities (P ≤ .004). Mean follow-up was 1.7 years (range, 1 to 5 years). RESULTS: Each successive BMI group from 35 to ≥50 demonstrated continually greater improvement in pain with level walking and stair climbing (P ≤ .001), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P = .001), and greater satisfaction (P = .007). No patients who had a BMI ≥35 were revised for aseptic loosening, and rates of periprosthetic joint infection were not different between BMI groups (P = 1.000). CONCLUSION: Despite being more debilitated preoperatively, patients who had a BMI ≥35 experienced greater improvements in PROMs compared to patients who had lower BMI. Given the significant improvements in PROMs and quality of life in obese patients, with appropriate perioperative optimization, these patients should not be prohibited from having a TKA when appropriately indicated. LEVEL OF EVIDENCE: III.

Optimizing Asymmetric Native Knee Flexion Gap Balance Promotes Superior Outcomes in Primary Total Knee Arthroplasty.

INTRODUCTION: Replicating native knee kinematics remains the ultimate goal of total knee arthroplasty (TKA). Technology, such as robotics, provides robust intraoperative data; however, no evidence-based targets currently exist for improved clinical outcomes. Furthermore, some surgeons target a rectangular flexion space in TKA unlike the native knee. This study evaluated the effect of in vivo flexion gap asymmetry on patient-reported outcome measures (PROMs) in contemporary TKA. METHODS: In vivo tibiofemoral joint space dimensions were measured during 129 TKAs using a calibrated tension device before and after complete posterior cruciate ligament resection. PROMs were compared based on the final dimensions and the change in flexion gap dimensions at 90° of flexion: (1) equal laxity, (2) lateral laxity, and (3) medial laxity. Groups did not differ by demographics ( P ≥ 0.347), clinical follow-up ( P = 0.134), tibiofemoral alignment ( P = 0.498), or preoperative PROMs ( P ≥ 0.093). Mean follow-up for the cohort was 1.5 years (range, 1-3). RESULTS: Pain with climbing stairs, pain while standing upright, and knees "always feeling normal" scores were superior for patients with equal or lateral laxity compared with medial laxity ( P ≤ 0.064). Pain with level walking, University of California Los Angeles activity level, KOOS JR, and satisfaction scores also tended to be superior for patients with equal or lateral laxity, although it lacked statistical significance ( P ≥ 0.111). DISCUSSION: Results of this study suggest that patients with either an equally tensioned rectangular flexion space or with later-flexion lateral laxity after posterior cruciate ligament resection may achieve superior PROMs. Findings support the clinical benefit of facilitating posterolateral femoral roll back in flexion, which mimics native knee kinematics and further helps define targets for advanced technology.

Coronal and Sagittal Component Position in Contemporary Total Knee Arthroplasty: Targeting Native Alignment Optimizes Clinical Outcomes.

BACKGROUND: Advanced technologies, like robotics, provide enhanced precision for implanting total knee arthroplasty components; however, optimal component position and limb alignment remain unknown. This study sought to identify sagittal and coronal alignment targets that correlate with minimal clinically important differences (MCIDs) in patient-reported outcome measures (PROMs). METHODS: A total of 1,311 consecutive total knee arthroplasties were retrospectively reviewed. Posterior tibial slope (PTS), femoral flexion (FF), and tibio-femoral alignment (TFA) were measured radiographically. Patients were grouped based on whether they achieved multiple MCIDs for PROM scores. Classification and regression tree machine learning models were utilized to identify optimal alignment zones. The mean follow-up was 2.4 years (range, 1 to 11). RESULTS: The change in PTS and postoperative TFA were most predictive for achieving MCIDs in 90% of the models. Approximating native PTS within 4° correlated with MCID achievement and superior PROMs. Preoperative varus and neutral aligned knees were more likely to meet MCIDs and superior PROM scores when not overcorrected into valgus postoperatively (≥7°). Preoperative valgus-aligned knees correlated with MCID achievement when postoperative TFA was not overcorrected into substantial varus (<0°). Albeit less impactful, FF ≤ 7° correlated with MCID achievement and superior PROMs regardless of preoperative alignment. Sagittal and coronal alignment measurements had moderate to strong interactions in 13 of 20 models. CONCLUSION: Optimized PROM MCIDs correlated with approximating native PTS while maintaining similar preoperative TFA and incorporating moderate FF. Study findings demonstrate interactions between sagittal and coronal alignment which may optimize PROMs, highlighting the importance of three-dimensional implant alignment targets. LEVEL OF EVIDENCE: III.

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

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

Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty.

BACKGROUND: Postoperative dislocation is considered the main drawback of posterior approach total hip arthroplasty (THA). Thinner highly cross-linked polyethylene and dual-mobility bearings allow maximizing femoral head diameter per a given cup size. This study evaluated dislocation rates as large femoral head bearings were introduced into a practice over an 11-year period. METHODS: A total of 1,511 consecutive primary THAs were retrospectively reviewed. Demographics, implant sizes, femoral head-acetabular cup ratio, and dislocation status were collected from the electronic medical record. Data were evaluated using time series analysis techniques as larger femoral heads, thinner polyethylene liners, and dual-mobility bearings were introduced. The cohort was 57% women with mean age and body mass index of 62 years (range, 13 to 93) and 31 kg/m2 (range, 13 to 54), respectively. RESULTS: The overall dislocation rate was 0.98%. Use of femoral head sizes ≥ 40 millimeters increased from 4% in the years 2010 to 2016 to 51% in the years 2017 to 2021, correlating with a 50% reduction in dislocation rate from 1.4% to 0.7% (P = .279). Also, no dislocations occurred in patients who had dual-mobility bearings or ≥ 40-millimeter femoral heads (P = .007). Twelve of 14 dislocations occurred in cases with head-cup ratio < 0.7 (P = .013). Thirteen of 14 dislocations were in women (P = .005). CONCLUSION: Maximizing the femoral head diameter per given cup size correlated with a decrease in dislocation rate in modern posterior approach THA. Furthermore, these results suggest that dual-mobility articulations should be reserved for high-risk patients or patients in whom a 40-millimeter femoral head is not possible. LEVEL OF EVIDENCE: IV-consecutive case series; no control group.

Cementless Total Knee Arthroplasty Over the Past Decade: Excellent Survivorship in Contemporary Designs.

BACKGROUND: Cementless fixation in total knee arthroplasty (TKA) is re-emerging due to improvements in biomaterials, surgical technique, and implant design. Albeit rare, failure of osseointegration typically occurs within the first 2 years, and limited data exist on survivorship of the modern cementless TKA designs. This study evaluated clinical survivorship of 2 contemporary cementless TKA designs at minimum 2-year follow-up. METHODS: A total of 627 cementless TKAs were performed up to July 2022. Three hundred thirty-nine cases were eligible for 2-year follow-up. Indications centered around bone quality and involved predominantly younger patients. The 2 designs consisted of tibial components with a highly porous titanium ingrowth surface, a central keel, and peripheral cruciform pegs with a porous cobalt-chromium femur. Survivorship estimates were calculated using right-censored non-parametric Kaplan-Meier methodologies. A total of 226 TKAs obtained minimum 2-year follow-up with a mean of 3.6 years (range, 2 to 10). RESULTS: The all-cause revision rate was 2.4% (8 of 339). The revision rate due to aseptic loosening was 0.6% (2 of 339) consisting of 2 femoral components. No tibial components were revised for aseptic loosening. Kaplan-Meier survivorship free from aseptic loosening was 99% (95% confidence interval 98 to 100) at a maximum of 10 years. CONCLUSION: These results demonstrate encouraging survivorship of cementless fixation in primary TKA with use of contemporary ingrowth biomaterials and modern implant designs. This particular tibial implant design with a highly porous titanium fixation surface, central keel, and peripheral cruciform pegs demonstrated excellent clinical survivorship without failure which may portend superior fixation. LEVEL OF EVIDENCE: IV-case series, no control group/historical control group.