Fellowship Training in Arthroplasty Improves Treatment Success of Debridement, Antibiotics, and Implant Retention for Periprosthetic Knee Infections.

Background: Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a "simple" procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training. Methods: A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment. Results: A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002). Conclusions: TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty. Level of Evidence: IV.

Lower Rates of Reoperation Following Partial or Complete Revision Arthroplasty Compared to Debridement, Antibiotics, and Implant Retention for Early Postoperative and Acute Hematogenous Periprosthetic Hip Infection.

BACKGROUND: This study aimed to: 1) compare treatment outcomes between debridement, antibiotics, and implant retention (DAIR) and partial or complete revision arthroplasty (RA) for early postoperative and acute hematogenous total hip arthroplasty periprosthetic joint infection (PJI) and 2) identify factors associated with treatment outcome. METHODS: The study consisted of a retrospective cohort of patients who underwent surgery for PJI between 2004 and 2021. There were 76 patients (74.5%) who underwent DAIR and 26 patients (25.5%) who underwent RA. Treatment success was defined as treatment eradication at a minimum of a 2-year follow up. Bivariate regression analysis was used to assess the effect of different factors on treatment outcomes. Kaplan-Meier survivorship was performed to compare survivorship between cohorts. RESULTS: At a mean follow-up of 8.2 years (range, 2.2 to 16.4), significantly more DAIR failed treatment (DAIR, 50 [65.8%]; 10 [38.5%]; P = .015). The 8-year Kaplan-Meier survivorship was 35.1% [95% confidence interval (CI), 24.3 to 45.9] for patients treated with DAIR and 61.5% [95% CI, 42.9 to 80.1] for those treated with RA (log rank = 0.039). Bivariate regression analysis showed performing a RA was associated with a higher likelihood of treatment success (odds ratio 4.499, 95% CI 1.600 to 12.647, P = .004), whereas a higher body mass index was associated with treatment failure (odds ratio 0.934, 95% CI 0.878 to 0.994, P = .032). CONCLUSIONS: To reduce the rate of recalcitrant infection following early postoperative or acute hematogenous total hip arthroplasty PJI, RA may be of benefit over DAIR. This is especially relevant in the early postoperative period, when components can be readily exchanged.

Long term results of total hip arthroplasty with cemented and cementless tapered femoral component.

BACKGROUND: Excellent midterm results for total hip arthroplasties (THA) with cementless, tapered porous Taperloc® femoral stems have been reported. Reports regarding such cemented stems, however, are lacking. OBJECTIVES: To evaluate the long-term outcomes of both cemented and cementless THAs with the Taperloc femoral component. METHODS: The medical records of 71 patients (76 hips), operated on between January 1991 and December 2003, who had a minimum follow-up of 10 years were available for analysis. Functional analysis was performed with the Harris hip score (HHS) questionnaire and the numerical analogue scale (NAS). Radiographic analysis was performed for subsidence, radiolucent lines and osteolysis. RESULTS: The cohort was comprised of 47 female and 24 male patients, with a mean age of 59.7 ± 12.4 years. The mean follow-up was 17.8 ± 4.4 years. 52.6% of THAs analyzed were cementless and 47.4% were cemented. Post-operative radiographs were available for 57 surgeries. Subsidence, hypertrophic ossification, radiolucent lines and osteolysis were noted in 4 (7%), 2 (2.6%), 14 (18.4%) and 11 (14.5%) hips respectively. The average HHS score at a mean follow-up of 20.1 ± 3.9 years was 62.1 (±27.7) and the NAS score was 4.6 (±3.6). During the study period, five revision surgeries were performed due to stem-related problems, one of which was for aseptic loosening. CONCLUSIONS: Our long-term experience with the Taperloc stem, both cemented and cementless, demonstrates good outcomes, with low rates of failure. This makes this prosthesis an attractive option for THAs. LEVEL OF EVIDENCE: IV.

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study.

BACKGROUND: Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up. METHODS: Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria. RESULTS: Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA. CONCLUSIONS: A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets. LEVEL OF EVIDENCE: Case series (IV).

Failed 2-Stage Revision Knee Arthroplasty for Periprosthetic Joint Infection-Patient Characteristics and Outcomes.

BACKGROUND: Chronic prosthetic joint infection (PJI) is most frequently treated with 2-stage revision in conjunction with antibiotic treatment. The aims of this study were 1) to investigate the characteristics of patients who have recurrent infection following 2-stage revision for PJI and 2) to identify risk factors associated with treatment failure. METHODS: A multicenter retrospective review of 90 total knee arthroplasty (TKA) patients who underwent 2-stage revision for treatment of PJI from March 1, 2003 to July 31, 2019, and had recurrent PJI was conducted. The minimum follow-up was 12 months (median follow up of 2.4 years). Microorganisms, subsequent revision, PJI control status, and final joint status were collected. The infection-free survival after initial 2-stage revision was plotted utilizing the Kaplan-Meier method. RESULTS: Mean survival time to reinfection was 21.3 months (range, 0.3 to 160.5). There were 14 recurrent infections that were acute PJIs treated with debridement, antibiotics, and implant retention (DAIR), while 76 were chronic and treated with repeat 2-stage revision. The most common pathogen identified for both index and recurrent PJI was coagulase-negative Staphylococci. Pathogen persistence was observed in 14 (22.2%) of recurrent PJIs. In total, 61 (67.8%) patients possessed a prosthetic reimplantation at their most recent follow-up, and 29 (35.6%) patients required intervention following repeat 2-stage. CONCLUSION: Overall, 31.1% of the patients obtained infection control after treatment of a failed 2-stage revision due to PJI. The high rate of pathogen persistence and the relatively low survival time to recurrence suggests a need to more closely monitor PJIs cases within 2 years.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

The walls of the femoral neck as an auxiliary tool for femoral stem positioning.

BACKGROUND: Femoral anteversion is a major contributor to functionality of the hip joint and is implicated in many joint pathologies. Accurate determination of component version intraoperatively is a technically challenging process that relies on the visual estimation of the surgeon. The following study aimed to examine whether the walls of the femoral neck can be used as appropriate landmarks to ensure appropriate femoral prosthesis version intraoperatively. METHODS: We conducted a retrospective study based on 32 patients (64 hips) admitted to our centre between July and September 2020 who had undergone a CT scan of their lower limbs. Through radiological imaging analysis, the following measurements were performed bilaterally for each patient: anterior wall version, posterior wall version, and mid-neck femoral version. Anterior and posterior wall version were compared and evaluated relative to mid-neck version, which represented the true version value. RESULTS: Mean anterior wall anteversion was 20° (95% CI, 17.6-22.8°) and mean posterior wall anteversion was -12° (95% CI, -15 to -9.7°). The anterior walls of the femoral neck had a constant of -7 and a coefficient of 0.9 (95% CI, -9.8 to -4.2; p < 0.0001; R2 0.77).The posterior walls of the femoral neck had a constant of 20 and a coefficient of 0.7 (95% CI, 17.8-22.5; p < 0.0001; R2 0.60). CONCLUSIONS: Surgeons can accurately obtain femoral anteversion by subtracting 7° from the angle taken between the anterior wall and the posterior femoral condyles or by adding 20° to the angle taken between the posterior wall and the posterior femoral condyles.

Is the routine use of local antibiotics in the management of periprosthetic joint infections justified?

Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.

Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection?

BACKGROUND: First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients. PATIENTS AND METHODS: This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05. RESULTS: The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52). CONCLUSIONS: A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.

Revision total hip arthroplasty for periprosthetic fracture: epidemiology, outcomes, and factors associated with success.

The aging population and the increasing number of patients with primary total hip arthroplasties (THA) has equated to an increased incidence of periprosthetic fractures (PPF) of the hip. These injuries are a significant source of patient morbidity and mortality, placing a financial burden on healthcare systems worldwide. As the volume of PPF is expected to along with the growing volume of primary and revision THA, it is important to understand the outcomes and factors associated with treatment success. The choice of procedure is in large part guided by the help of the Vancouver Classification system, which is a valid and reproducible system that classifies fractures based on several factors including site of fracture, implant stability and bone stock. PPFs account for approximately 18% of revision THA (rTHA) procedures. rTHA for PPFs is commonly indicated in Vancouver B2 and B3 fractures, to bypass a lack of metaphyseal support with diaphyseal fixation. Such revisions are technically challenging and typically require urgent treatment, with inherent difficulties in patient optimization, leading to a notable rate of post-operative complications, re-revision and mortality. This article reviews epidemiology, health economics and risk factors for PPFs. It additionally reviews outcomes associated with rTHA for PPFs including peri-operative complications, indications for re-operation, rates of re-operation and rates of mortality. Finally, it aims to identify evidence-based factors that have been associated with successful management including modifiable patient-related factors, uncemented vs. cemented stems, stem design (porous coated stems vs. fluted tapered stems), modularity, dislocation and its impact on outcomes following rTHA and strategies for managing bone loss.

Periprosthetic joint infection following hip hemiarthroplasty : factors associated with infection and treatment outcome.

AIMS: The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. METHODS: A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years' follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. RESULTS: A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). CONCLUSION: HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components.Cite this article: Bone Jt Open 2022;3(12):924-932.

Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review.

➢: Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks. ➢: IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty. ➢: Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required. ➢: A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.

Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review.

➢: Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy. ➢: Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma. ➢: Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty. ➢: Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy. ➢: A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.

Hip Arthroplasty With the Use of a Reconstruction Cage and Porous Metal Augment to Treat Massive Acetabular Bone Loss: A Midterm Follow-Up.

BACKGROUND: Acetabular reconstruction in the context of massive acetabular bone loss is challenging. In rare scenarios where the extent of bone loss precludes shell placement (cup-cage), reconstruction at our center consisted of a cage combined with highly porous metal augments. This study evaluates survivorship, complications, and functional outcomes using this technique. METHODS: Patients with minimum 2-year follow-up were included. Baseline characteristics were collected. Preintervention and postintervention ambulatory scores were collected. Kaplan-Meier (KM) survival analysis for cage failure requiring revision surgery was conducted. Binomial regression analysis was performed to assess for correlation of aseptic cage failure with baseline characteristics. Preintervention and postintervention ambulatory aid requirements were compared. RESULTS: A total of 41 patients were identified. Mean follow-up was 6.4 years (range 2.8-11.0). Four (9.8%) aseptic cage revisions were identified. Aseptic KM survival analysis was 87.4% (95% confidence interval 75.3-99.6) at 10 years. Aseptic KM survival was 45.0% versus 92.8% at 9 years (P = .14) for patients with vs without pelvic discontinuity. KM survival for all-cause failure was 61.6% (95% confidence interval 44.0-79.2) at 10 years. Binomial regression did not demonstrate correlation of cage failure with baseline characteristics. Wilcoxon signed-rank test demonstrated a significant reduction in ambulatory aide requirement after surgery (mean rank 11.47 vs 9.00, Z = -2.95, P = .003). CONCLUSION: In scenarios of massive acetabular bone loss where a cup-cage is not a viable option, good survivorship free from aseptic cage failure can be expected at mid-term follow-up using an antiprotrusio cage combined with porous metal augments. Success requires extensive experience in revision surgery.

Does Revision of an Acetabular Shell With Insertion of an Uncemented Constrained Liner Confer Benefit Over Cementing Into a Well-Ingrown Shell?

BACKGROUND: During revision total hip arthroplasty (THA), a constrained acetabular liner (CAL) may be inserted to enhance hip stability. It is unclear, however, whether cementation of a CAL into a retained cup offers an advantage compared to revision of the acetabular cup and insertion of an uncemented CAL. The purpose of our study was to compare outcomes and survivorship between the 2 methods. METHODS: We identified a total of 177 patients who underwent revision THA with a specific CAL at our center between July 2004 and May 2019 (114 cup revisions and insertion of an uncemented CAL, 63 cementations of a CAL into a retained cup). Kaplan-Meier (KM) survival analysis was performed for implant survival free from aseptic failure of the CAL for both cohorts. RESULTS: The average follow-up time was 7.2 and 7.02 years for the cemented and uncemented cohort, respectively (P = .55). Five patients (7.93%) in the cemented CAL group experienced failure of the CAL, whereas 10 patients (8.77%) in the uncemented CAL cohort experienced failure (P = .21). Kaplan-Meier (KM) survival analysis demonstrated comparable survivorship at 10 years (P = .055). CONCLUSION: The results of our study suggest comparable survivorship between cementing a CAL into a retained cup and inserting an uncemented CAL in a revised acetabular cup. As a result of these findings along with the benefits associated with cementing a CAL, we encourage surgeons to readily consider this option in the management of recurrent instability.

Increased Rates of Tibial Aseptic Loosening in Primary Cemented Total Knee Arthroplasty With a Short Native Tibial Stem Design.

BACKGROUND: Emerging evidence has suggested that both obesity and a short, native tibial stem (TS) design may be associated with early aseptic loosening in total knee arthroplasty. The use of short, fully cemented stem extensions may mitigate this risk. As such, we devised a multicenter study to confirm or negate these claims. METHODS: A search of our institutional research databases was done. A minimum 2-year time from index procedure was selected. Cohorts were created according to patient body mass index and the presence (stemmed tibia [ST]) or absence (nonstemmed tibia [NST]) of a short TS extension. Kaplan-Meier survival analyses for aseptic loosening and log-rank tests were done. RESULTS: A total of 1,350 patients were identified (ST = 500, NST = 850). The mean time to the final follow-up in cases without aseptic loosening for the ST cohort was 3.5 years (2.8-6.3) and 5.0 years (2.9-6.3) for the NST cohort (P < 0.001). Kaplan-Meier survival analysis at 6 years was superior for the ST cohort (100%, 98.5%; P = 0.025), and a trend toward superior 5-year survival was observed for body mass index <40 kg/m2 (99.1%, 93.2%; P = 0.066). The mean time to aseptic loosening was 2.4 years (0.9-4.5), with approximately 40% occurring within the first 2 years. CONCLUSIONS: Short, native TS design is associated with early aseptic loosening in primary cemented total knee arthroplasty. This can be mitigated through the use of an ST. More cost-effective solutions include (1) use of implants with longer native stem designs or (2) redesign of short TS implants.

Digital templating in total hip arthroplasty using contralateral healthy hip results in decreased accuracy.

The accuracy of pre-operative digital templating for total hip arthroplasty (THA) using the diseased versus unaffected contralateral joint remains unclear. As such, we devised a study to compare templating precision between the operated hip joint versus the healthy side for patients with osteoarthritis (OA). The study hypothesis was that preoperative templating accuracy of THA on the ipsilateral diseased hip joint would be higher compared to the contralateral healthy hip in patients with OA. We retrospectively reviewed 100 patients who underwent THA for unilateral OA at our center from January 2018 to January 2020. Retrospective preoperative digital templating was performed separately on both the operated hip joint and the healthy contralateral hip joint by a single surgeon who was blinded by the in-situ components sizes. Accuracy of each group was compared to the implanted components. Assessment of the 100 included cases demonstrated superior acetabular component size prediction when templating was performed using the diseased hip compared to the healthy contralateral side (68.0% versus 51.0%, p<0.001). No differences between the cohorts were found regarding templating accuracy of femoral stem sizes (72.0% and 69.0%, p=0.375) or neck offset (73.0% and 69.0%, p=0.289). Templating acetabular cup size using the ipsilateral diseased hip is more accurate than using the contralateral healthy hip in patients with unilateral OA.

Comparing Sequential vs Simultaneous Tourniquet Inflation in Bilateral Total Knee Arthroplasty.

BACKGROUND: There is little evidence on outcomes of tourniquet use during bilateral total knee arthroplasty (BTKA). Tourniquet use in BTKA effects postoperative outcomes and efficiency inside the operating room. This study evaluates the safety and efficacy of simultaneous tourniquet inflation in BTKA. MATERIALS AND METHODS: A retrospective review was performed on BTKA patients between March 2013 and May 2018. A total of 285 patients were divided into 2 cohorts. Patients in the simultaneous cohort had concomitant elevation of both tourniquets, but the sequential cohort did not. Perioperative variables were collected, and postoperative complications were tracked for a minimum of 90 days. Patients followed a uniform postoperative protocol. Complications were grouped by category to increase statistical power and compared using a noninferiority test. "Clinically noninferior" was defined as a margin ≤5%. RESULTS: The simultaneous cohort had significantly (P < .05) higher American Society of Anesthesiologists class and smokers. Tourniquet time, delta hemoglobin, and surgical time were significantly lower. For the complication categories of "Any Thrombotic Event", "Respiratory", and "Soft Tissue/Wound", the difference in occurrence rates was no more than 2.8%, 2.8%, and 5.2% between cohorts, respectively. The "Cardiovascular (non-MI)" group was no more than 9.3% different, that is, authors are 95% confident that 3 of 4 complication categories meet the clinically noninferior threshold. CONCLUSION: The study demonstrates the noninferiority of simultaneous as compared to sequential tourniquet inflation in BTKA. Patients with cardiac history may need sequential inflation or staged TKA. The information presented in the study assists surgeons in safely and efficiently performing BTKA.

Lack of small tibial component size availability for females in a highly utilized total knee arthroplasty system.

PURPOSE: Surgeons must rely on manufacturers to provide an appropriate distribution of total knee arthroplasty (TKA) sizes. There is a lack of literature regarding current appropriateness of tibial sizing schemes according to sex. As such, a study was devised assessing the adequacy of off-the-shelf tibial component size availability according to sex. METHODS: A search was conducted to identify all primary TKAs between July 2012 and June 2019 performed using a single implant. Baseline patient characteristics were collected (age, weight, height, BMI, and race). Two cohorts were created according to patient sex. Tibial sizes for each cohort were collected. Tibial component bar graph and histogram were created according to component sizes. Skewness and kurtosis were calculated for each distribution. Overhang was noted and measured radiographically. RESULTS: A total of 864 patients were identified, 38.7% males and 61.3% females. Most patients were Caucasian, and BMI was similar between cohorts. Tibial size distribution for males was as follows: 0.3% C, 4.8% D, 16.5% E, 40.1% F, 31.4% G, 6.9% H. Tibial size distribution for females was as follows: 30.8% C, 42.8% D, 23.0% E, 2.6% F, 0.8% G, 0.0% H. Histograms and normal curves demonstrated a fairly symmetric distribution of sizes for males (skewness = - 0.31, kurtosis = - 0.03). The distribution for females was positively skewed (skewness = 0.57, kurtosis = 0.12). Overall, overhang was noted in 16.6% of all size C tibias. CONCLUSIONS: The results of this study highlight an implant-specific discrepancy in size availability affecting female patients which could result in inferior outcomes. The authors urge manufacturers to critically assess current implant size distribution availability to ensure both genders are adequately, and equally represented. LEVEL OF EVIDENCE: IV.

The Effect of Femoral Head Size, Neck Length, and Offset on Dislocation Rates of Constrained Acetabular Liners.

BACKGROUND: Constrained acetabular liners (CALs) are used in both primary and revision total hip arthroplasty in cases where stability and abductor deficiency are of concern. The efficacy of CALs has been shown to be design dependent. There is clear evidence that the use of small head sizes and shorter offset in unconstrained total hip arthroplasty is associated with higher rates of dislocation. To our knowledge, no such study has assessed the effect of femoral head size, neck length, and offset for CALs. METHODS: We performed a retrospective study assessing the outcomes of CALs with minimum 2-year follow-up. A Kaplan-Meier survivorship analysis was conducted for all patients and for patients revised for instability. A binomial regression analysis was performed to assess for variables significantly associated with CAL failure. RESULTS: A total of 285 CALs in 281 patients were identified with a mean follow-up of 5.7 years. Ten-year Kaplan-Meier survival analyses were as follows: all indication 91.9% vs instability 85.5% (P = .15). Increasing neck length was associated with lower rates of failure (odds ratio, 0.81; P = .042). Femoral head size, offset, and abductor reconstruction were not significantly associated with CAL failure. CONCLUSION: Larger head size has not been demonstrated to lead to lower failure in CALs. Increasing neck length was associated with lower failure rate. Surgeons should be cautious when attempting to ream to larger acetabular shell sizes for the purpose of using larger heads with CALs. Increasing neck length may instead be targeted intraoperatively.