Diaphyseal Impaction Grafting Combined with Metaphyseal Cones: Outcomes in 88 Revision Total Knee Arthroplasties.

BACKGROUND: Metaphyseal cones with cemented stems can be successfully utilized in most revision total knee arthroplasties (TKAs). However, if the diaphysis has been previously violated, fixation of the cemented stem, which is important for cone ingrowth and construct survival, can be compromised. The initial results of our novel technique combining diaphyseal impaction bone-grafting with a metaphyseal cone were promising but required additional study. The purpose of the present study was to assess results of this technique in a larger cohort. METHODS: A metaphyseal cone combined with diaphyseal impaction grafting and a cemented stem was utilized in 88 revision TKAs at our institution, including 35 from our prior study. The mean age at the time of revision was 67 years, and 67% of patients were male. Patients had had a mean of 4 prior knee arthroplasty procedures. The 2 most common reasons for revision were aseptic loosening (78%) and 2-stage reimplantation for periprosthetic joint infection (PJI) (19%). The mean follow-up was 4 years. RESULTS: At the time of the latest follow-up, no cone-impaction grafting constructs required re-revision for aseptic loosening. Five-year survivorship free from any revision of the cone-impaction grafting construct and free from any reoperation was 95% and 65%, respectively. A total of 25 knees (28%) underwent reoperation, with the 2 most common indications being PJI and periprosthetic fracture. All cones were osseointegrated, and all bone graft appeared stable or incorporated. One patient had radiographic evidence of tibial component loosening despite a well-fixed cone; however, this patient was asymptomatic and had not undergone revision at 9 years. CONCLUSIONS: When presented with a sclerotic, polished diaphyseal canal with deficient cancellous bone and concomitant metaphyseal bone loss, our technique of combining diaphyseal impaction grafting with a metaphyseal cone proved extremely durable in this larger series of patients. No cone-impaction grafting constructs required re-revision for aseptic loosening. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association Between Tranexamic Acid and Decreased Periprosthetic Joint Infection Risk in Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Over 2 Million Patients.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis to evaluate the association between tranexamic acid (TXA) use during primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA), and the risk of developing periprosthetic joint infection (PJI) after these procedures. METHODS: A systematic review was carried out from inception to October 17, 2022. There were 6 studies that were ultimately included in the meta-analysis. The association between the development of PJI and TXA was analyzed using odds ratios (ORs) with 95% confidence intervals (CIs) and estimates of risk difference (RD). Subgroup analysis was performed to evaluate only studies reporting out to 90 days of follow-up versus more than 90 days of follow-up. RESULTS: Among 2,098,469 arthroplasties, TXA utilization was associated with an overall lower risk of PJI (OR = 0.63 [95% CI 0.42 to 0.96], P < .001) and a 0.4% lower incidence of PJI (RD = -0.0038, 95% CI [-0.005 to -0.002], P < .001). When subgrouping the studies according to length of follow-up, TXA was associated with a lower risk of PJI (OR = 0.43 [95% CI 0.35 to 0.53], P < .001) and a 1% lower incidence of PJI (RD = -0.0095 [95% CI -0.013 to -0.005], P < .001) in patients followed for more than 90 days. CONCLUSIONS: This meta-analysis demonstrates that TXA use is associated with a reduced risk of PJI, with our RD analysis identifying an approximately 0.4% reduction in PJI rates with TXA use. These findings provide even more data to support the routine use of TXA during primary THA and primary TKA.

What's New in Periprosthetic Femur Fractures?

Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty (THA). This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons (AAHKS) 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 periprosthetic femur fractures.

Contemporary Aseptic Revision Total Hip Arthroplasty in Patients ≤50 Years of Age: Results of >500 Cases.

BACKGROUND: There has been a paucity of long-term outcomes data on aseptic revision total hip arthroplasties (THAs) in the young adult population. The purpose of this study was to evaluate implant survivorship, complications, and clinical outcomes in a large cohort of contemporary aseptic revision THAs in patients ≤50 years of age at the time of the surgical procedure. METHODS: We identified 545 aseptic revision THAs performed at a single academic institution from 2000 to 2020 in patients who were 18 to 50 years of age. Patients who underwent conversion THAs and patients with a history of any ipsilateral hip infection were excluded. The mean age was 43 years, the mean body mass index (BMI) was 29 kg/m2, and 63% were female. The index indication for revision THA was aseptic loosening in 46% of cases, polyethylene wear or osteolysis in 28% of cases (all revisions of conventional polyethylene), and dislocation in 11% of cases. There were 126 hips (23%) that had undergone at least 1 previous revision (median, 1 revision [range, 1 to 5 revisions]). The mean follow-up was 10 years. RESULTS: In the entire cohort, the 20-year survivorship free of any re-revision was 76% (95% confidence interval [95% CI], 69% to 82%). There were 87 re-revisions, with 31 dislocations, 18 cases of aseptic loosening of the femoral component, and 16 periprosthetic joint infections (PJIs) being the most common reasons for re-revision. Dislocation as the indication for the index revision was associated with an increased risk of re-revision (hazard ratio, 2.9; p < 0.001). The 20-year survivorship free of any reoperation was 73% (95% CI, 66% to 78%). There were 75 nonoperative complications (14%), including 32 dislocations. The mean Harris hip score significantly improved (p < 0.001) from 65 preoperatively to 81 at 10 years postoperatively. CONCLUSIONS: Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. Dislocation, aseptic loosening of the femoral component, and PJI were the most common reasons for re-revision. Index revision THAs for dislocation had a 3 times higher risk of re-revision. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Highly Porous Acetabular Cup and Augment Constructs in Complex Revision Total Hip Arthroplasty: What Predicts 10-Year Implant Survivorship?

BACKGROUND: Porous tantalum acetabular cup and augment constructs have demonstrated favorable outcomes up to 5 years postsurgery despite severe bone loss during revision total hip arthroplasty (THA). Prior literature lacks long-term studies with substantial case numbers. This study aims to assess long-term clinical and radiographic outcomes 10 years postsurgery in patients undergoing revision THA with porous tantalum acetabular cup-augment constructs and determine factors associated with long-term survivorship. METHODS: Between 2000 and 2012, 157 revision THAs were performed in cases with major acetabular defects (mainly Paprosky type IIIA and IIIB) utilizing porous tantalum cup-augment constructs. Pelvic discontinuity was noted intraoperatively in 17 hips (11%). Postoperative radiographs were evaluated at regular intervals for implant stability and radiolucent lines. There were 49 patients who had complete radiographic follow-up at 10 years or longer postsurgery. RESULTS: The 10-year survivorship free of revision of the cup-augment construct for aseptic loosening was 93%, free of any acetabular construct revision was 91%, free of any hip rerevision was 77%, and free of any reoperation was 75%. Pelvic discontinuity was associated with increased risk of reoperation (hazard ratio [HR] = 2.8), any hip rerevision (HR = 3.2), any cup-augment construct revision (HR = 11.8), and aseptic construct revision (HR = 10.0). Of unrevised cases with radiographs at 10 years, 4 hips showed radiographic loosening. Mean Harris hip scores improved from 47 preoperatively to 79 at 10 years. CONCLUSIONS: Porous tantalum acetabular cup-augment constructs used in revision THA with severe acetabular bone loss provide excellent implant survivorship at 10 years when the acetabulum is intact. Due to lower survivorship of cup-augment constructs in cases of pelvic discontinuity, additional construct fixation or stabilization methods are recommended, when a discontinuity is present. LEVEL OF EVIDENCE: IV.

Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship.

BACKGROUND: Arthroplasty registries often use traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data. METHODS: We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation was calculated for patients who have TM. The same survivorship end points were recalculated with censoring performed when a patient transitioned to an MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years. RESULTS: From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90% and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio = 1.16, P = .033), and there was a trend toward higher survivorship free from any revision (95 versus 93% at 15 years; hazard ratio = 1.16, P = .074). CONCLUSIONS: Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.

Cemented dual-mobility constructs in uncemented revision acetabular components.

Aims: Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct. Methods: We identified 64 patients (65 hips) who had a single-design cemented DM cup cemented into an uncemented acetabular shell during revision THA between 2018 and 2020 at our institution. Cups were cemented into either uncemented cups designed for liner cementing (n = 48; 74%) or retained (n = 17; 26%) acetabular components. Median outer head diameter was 42 mm. Mean age was 69 years (SD 11), mean BMI was 32 kg/m2 (SD 8), and 52% (n = 34) were female. Survival was assessed using Kaplan-Meier methods. Mean follow-up was two years (SD 0.97). Results: There were nine cemented DM cup revisions: three for periprosthetic joint infection, three for acetabular aseptic loosening from bone, two for dislocation, and one for a broken cup-cage construct. The two-year survivals free of aseptic DM revision and dislocation were both 92%. There were five postoperative dislocations, all in patients with prior dislocation or abductor deficiency. On radiological review, the DM cup remained well-fixed at the cemented interface in all but one case. Conclusion: While dislocation was not eliminated in this series of complex revision THAs, this technique allowed for maximization of femoral head diameter and optimization of effective acetabular component position during cementing. Of note, there was only one failure at the cemented interface.

Periprosthetic Hip and Knee Infection: Is an Ipsilateral Uninfected Total Joint Arthroplasty at Risk?

BACKGROUND: Periprosthetic joint infections (PJIs) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) may occur in the setting of an uninfected ipsilateral prosthetic joint. However, the risk to that uninfected ipsilateral joint is unknown. We analyzed the survivorship free from PJI in at risk THAs and TKAs following treatment of an ipsilateral knee or hip PJI, respectively. METHODS: Using our institutional total joint registry, we identified 205 patients who underwent treatment for PJI (123 THAs and 83 TKAs) with an at-risk ipsilateral in situ knee or hip, respectively, between 2000 and 2019. In total, 54% of index PJIs were chronic and 46% were acute. The mean age was 70 years, 47% were female, and the mean body mass index was 32. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 6 years. RESULTS: The 5-year survivorship free of PJI in an at-risk THA after an ipsilateral TKA was treated for PJI was 97%. The 5-year survivorship free of PJI in an at-risk TKA when the ipsilateral THA was treated for PJI was 99%. Three PJIs occurred (2 THAs and 1 TKA), all over 1 year from the index ipsilateral PJI treatment. One hip PJI was an acute hematogenous infection that resulted from pneumonia. The other 2 new PJIs were caused by the same organism as the index PJI and were due to a failure of source control at the index joint. CONCLUSIONS: When diagnosed with PJI in a single joint, the risk of developing PJI in an ipsilateral prosthetic joint within 5 years was low (1 to 3% risk). In the rare event of an ipsilateral infection, all occurred greater than one year from the index PJI and 2 of 3 were with the same organism when source infection control failed. LEVEL OF EVIDENCE: Prognostic Level III.

Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years.

BACKGROUND: To make an informed decision about total hip arthroplasty (THA), surgeons and patients need to understand the absolute and relative risks of periprosthetic joint infection (PJI). We sought to evaluate the long-term risk of PJI following primary THA stratified by body mass index (BMI) and PJI-related risk factors. METHODS: We identified 21,550 primary THAs performed from 2000 to 2021 at a single institution. Patients were stratified as having 0, 1, or ≥ 2 PJI risk factors (diabetes, chronic kidney disease, nonprimary osteoarthritis, immunosuppression, or active smoking) and into BMI categories. The 15-year cumulative risk of PJI was evaluated by BMI and PJI risk factors. RESULTS: For the entire cohort, the 15-year absolute risk of PJI was 2%. For patients who did not have PJI risk factors, the absolute risk of PJI at 15 years was 1% in normal weight, 2% in class III obesity, and 4% in class IV obesity. Patients who had class III and IV obesity had a 3-times and 9-times higher relative risk of PJI, respectively (P = .03, P < .001). Among patients who had ≥ 2 PJI risk factors, the absolute risk of PJI at 15 years was 2% in normal weight, 4% in class III obesity, and 18% in class IV obesity. CONCLUSIONS: Healthy patients who had class III and IV obesity had a 3-times and 9-times increased risk of PJI at 15 years relative to normal weight patients. However, the absolute risk of PJI at 15 years was 2 and 4%, respectively. Given emerging data questioning whether BMI modification decreases PJI risk, surgeons and patients must consider both a 3-times to 9-times increased relative risk of PJI and a 2 to 4% absolute risk of PJI at 15 years for healthy patients who had a BMI ≥ 40. LEVEL OF EVIDENCE: IV.

New Ceramic Heads With Titanium Sleeves on Retained Femoral Components: Results of Over 500 Revision Total Hip Arthroplasties.

BACKGROUND: Ceramic heads are frequently combined with titanium sleeves in revision total hip arthroplasties (THAs), ostensibly to protect the ceramic head from existing damage to the retained trunnion. Although widely adopted, data on the performance and safety of this construct are minimal. The purpose of this study was to describe implant survivorships, radiographic results, and clinical outcomes of patients who underwent revision THA with a ceramic head and titanium sleeve on a retained femoral component. METHODS: We identified 516 revision THAs with femoral component retention (328 acetabular-only revisions and 188 bearing surface exchanges) treated with a new ceramic head and titanium sleeve between 2000 and 2020. Mean age at revision was 64 years, 56% were women, and mean body mass index was 30. The indications for revision THA were adverse local tissue reaction (25%), acetabular loosening (24%), dislocation (17%), infection (5%), and other (29%). Kaplan-Meier survivorships were analyzed, radiographs reviewed, and Harris Hip Scores evaluated. Mean follow-up was 4 years (range, 2 to 10). RESULTS: There were no reoperations or failures for ceramic head fracture, taper corrosion, or head/sleeve disengagement. The 10-year survivorship free of any re-revision was 85%. Indications for the 57 re-revisions included dislocation (33), infection (13), acetabular component loosening (7), periprosthetic fracture (2), psoas impingement (1), and sciatic nerve irritation (1). The 10-year survivorship free of any reoperation was 82%. There were an additional 14 reoperations. Radiographically, 1.9% had progressive femoral radiolucent lines, and 4.7% had progressive acetabular radiolucent lines. Mean Harris Hip Score was 81 at 2 years. CONCLUSIONS: New ceramic heads with titanium sleeves in revision THAs with retained femoral components were durable and reliable with no cases of ceramic head fracture or taper complications at mean 4-year follow-up, including those revised for adverse local tissue reaction. LEVEL OF EVIDENCE: IV.

Marlex Mesh Reconstruction of the Extensor Mechanism: A Concise 5-Year Follow-up of 2 Previous Reports.

LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Precision or Pitfall? Evaluating the Accuracy of ICD-10 Coding for Cemented Total Hip Arthroplasty: A Multicenter Study.

BACKGROUND: The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Procedure Coding System (ICD-10-PCS) was adopted in the U.S. in 2015. Proponents of the ICD-10-PCS have stated that its granularity allows for a more accurate representation of the types of procedures performed by including laterality, joint designation, and more detailed procedural data. However, other researchers have expressed concern that the increased number of codes adds further complexity that leads to inaccurate and inconsistent coding, rendering registry and research data based on ICD-10-PCS codes invalid and inaccurate. We aimed to determine the accuracy of the ICD-10-PCS for identifying cemented fixation in primary total hip arthroplasty (THA). METHODS: We retrospectively reviewed all cemented primary THAs performed at 4 geographically diverse, academic medical centers between October 2015 and October 2020. Cemented fixation was identified from the ICD-10-PCS coding for each procedure. The accuracy of an ICD-10-PCS code relative to the surgical record was determined by postoperative radiograph and chart review, and cross-referencing with institution-level coding published by the American Joint Replacement Registry (AJRR) was also performed. RESULTS: A total of 552 cemented THA cases were identified within the study period, of which 452 (81.9%) were correctly coded as cemented with the ICD-10-PCS. The proportion of cases that were correctly coded was 187 of 260 (72%) at Institution A, 158 of 185 (85%) at Institution B, 35 of 35 (100%) at Institution C, and 72 of 72 (100%) at Institution D. Of the 480 identified cemented THA cases at 3 of the 4 institutions, 403 (84%) were correctly reported as cemented to the AJRR (Institution A, 185 of 260 cases [71%]; Institution B, 185 of 185 [100%]; and Institution C, 33 of 35 [94%]). Lastly, of these 480 identified cemented THA cases, 317 (66%) were both correctly coded with the ICD-10-PCS and correctly reported as cemented to the AJRR. CONCLUSIONS: Our findings revealed existing discrepancies within multiple institutional data sets, which may lead to inaccurate reporting by the AJRR and other registries that rely on ICD-10-PCS coding. Caution should be exercised when utilizing ICD-10 procedural data to evaluate specific details from administrative claims databases as these inaccuracies present inherent challenges to data validity and interpretation.

How Many Patients Qualify for Extended Oral Antibiotic Prophylaxis Infection Following Primary and Revision Hip and Knee Arthroplasties?

Extended oral antibiotic prophylaxis (EOAP) has been suggested to reduce rates of periprosthetic joint infection (PJI) postoperatively after total joint arthroplasty (TJA). The purpose of this multicenter study is to define how many TJA patients are considered high risk for developing PJI based on published EOAP criteria and determine whether this status is associated with socioeconomic or demographic factors. All primary and aseptic revision TJAs performed in 2019 at three academic medical centers were reviewed. High-risk status was defined based on prior published EOAP criteria. Area deprivation index (ADI) was calculated as a measure of socioeconomic status. Data were reported as means with standard deviation. Both overall and institutional differences were compared. Of the 2,511 patients (2,042 primary and 469 revision) in this cohort, 73.3% met criteria for high risk (primary: 72.9% [1,490] and revision: 74.6% [350]). Patient's race or age did not have a significant impact on risk designation; however, a larger proportion of high-risk patients were women (p = 0.002) and had higher Elixhauser scores (p < 0.001). The mean ADI for high-risk patients was higher (more disadvantaged) than for standard-risk patients (64.0 [20.8] vs. 59.4 [59.4]) (p < 0.001). Over 72% of primary and revision TJA patients at three medical centers met published criteria for EOAP. These patients were more often women, had more comorbidities, and lived in more disadvantaged areas. Our findings suggest that most patients qualify for EOAP, which may call for more stringent criteria on who would benefit extended antibiotic prophylaxis.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

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.

What is the Impact of Social Deprivation on Mental and Physical Health Before and After Primary Total Knee Arthroplasty?

Background: The purpose of the present study was to investigate the relationship between socioeconomic status and Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) scores before and after primary total knee arthroplasty (TKA). We hypothesized that patients with greater social deprivation would have lower PROMIS-GH scores at 3 months and 1 year following primary TKA. Methods: We retrospectively reviewed data from patients who underwent unilateral primary TKA and completed PROMIS-GH preoperatively and at 3 months (n = 257) or 1 year (n = 154) postoperatively. Area Deprivation Index (ADI), calculated from 9-digit zip codes, was used to measure social deprivation. Participants were grouped into quartiles by ADI score. Minimal clinically important difference in PROMIS-GH mental (PROMIS-MH) and physical health (PROMIS-PH) component scores were compared between ADI groups. Results: Participants in the highest ADI quartile (most disadvantaged) had significantly lower PROMIS-MH and PROMIS-PH scores at every time point relative to the lowest ADI quartile (least disadvantaged) (P < .05 for all). Both ADI groups experienced significant improvements in PROMIS-PH following TKA (P < .001 for all), but not in PROMIS-MH (P > .05 for all) at 3-months and 1-year postoperatively. Magnitude of improvement in PROMIS-PH and rates of achievement of minimal clinically important difference did not significantly differ between ADI groups (P > .05 for all). Conclusions: Socially disadvantaged patients benefit equally from primary TKA but are more likely to have persistently lower 1-year postoperative PROMIS-GH scores relative to less disadvantaged patients. Social deprivation should be accounted for when using PROMIS-GH to assess clinical outcomes for research and quality measures. Level of Evidence: IV, retrospective cohort study.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

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.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

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.

Defining Clinically Meaningful Subgroups for Risk Stratification in Patients Undergoing Revision Total Hip Arthroplasty: A Combined Unsupervised and Supervised Machine Learning Approach.

BACKGROUND: Studies developing predictive models from large datasets to risk-stratify patients under going revision total hip arthroplasties (rTHAs) are limited. We used machine learning (ML) to stratify patients undergoing rTHA into risk-based subgroups. METHODS: We retrospectively identified 7,425 patients who underwent rTHA from a national database. An unsupervised random forest algorithm was used to partition patients into high-risk and low-risk strata based on similarities in rates of mortality, reoperation, and 25 other postoperative complications. A risk calculator was produced using a supervised ML algorithm to identify high-risk patients based on preoperative parameters. RESULTS: There were 3,135 and 4,290 patients identified in the high-risk and low-risk subgroups, respectively. Each group significantly differed by rate of 30-day mortalities, unplanned reoperations/readmissions, routine discharges, and hospital lengths of stay (P < .05). An Extreme Gradient Boosting algorithm identified preoperative platelets < 200, hematocrit > 35 or < 20, increasing age, albumin < 3, international normalized ratio > 2, body mass index > 35, American Society of Anesthesia class ≥ 3, blood urea nitrogen > 50 or < 30, creatinine > 1.5, diagnosis of hypertension or coagulopathy, and revision for periprosthetic fracture and infection as predictors of high risk. CONCLUSION: Clinically meaningful risk strata in patients undergoing rTHA were identified using an ML clustering approach. Preoperative labs, demographics, and surgical indications have the greatest impact on differentiating high versus low risk. LEVEL OF EVIDENCE: III.

Projected Prevalence of Obesity in Aseptic Revision Total Hip and Knee Arthroplasty.

Background: The purpose of this study was to develop projections of the prevalence of obesity in aseptic revision THA and TKA patients through the year 2029. Methods: The National Surgical Quality Improvement Project (NSQIP) was queried for years 2011-2019. Current procedural terminology (CPT) codes 27134, 27137, and 27138 were used to identify revision THA and CPT codes 27486 and 27487 were used to identify revision TKA. Revision THA/TKA for infectious, traumatic, or oncologic indications were excluded. Participant data were grouped according to body mass index (BMI) categories: underweight/normal weight, <25 kg/m2; overweight, 25-29.9 kg/m2; class I obesity, 30.034.9 kg/m2; class II obesity, 35.0-39.9 kg/m2; morbid obesity ≥ 40 kg/m2. Prevalence of each BMI category was estimated from year 2020 to year 2029 through multinomial regression analyses. Results: 38,325 cases were included (16,153 revision THA and 22,172 revision TKA). From 2011 to 2029, prevalence of class I obesity (24% to 25%), class II obesity (11% to 15%), and morbid obesity (7% to 9%) increased amongst aseptic revision THA patients. Similarly, prevalence of class I obesity (28% to 30%), class II obesity (17% to 29%), and morbid obesity (16% to 18%) increased in aseptic revision TKA patients. Conclusion: Prevalence of class II obesity and morbid obesity demonstrated the largest increases in revision TKA and THA patients. By 2029, we estimate that approximately 49% of aseptic revision THA and 77% of aseptic revision TKA will have obesity and/or morbid obesity. Resources aimed at mitigating complications in this patient population are needed. Level of Evidence: III.