The incidence of subsequent hip arthroscopy after rectus-sparing periacetabular osteotomy.

Aims: Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures. Methods: From June 2012 to March 2022, 349 rectus-sparing PAOs were performed and followed for a minimum of one year (mean 6.2 years (1 to 11)). The mean age was 24 years (14 to 46) and 88.8% were female (n = 310). Patients were evaluated at final follow-up for patient-reported outcome measures (PROMs). Clinical records were reviewed for complications or subsequent surgery. Radiographs were reviewed for the following acetabular parameters: lateral centre-edge angle, anterior centre-edge angle, acetabular index, and the alpha-angle (AA). Patients were cross-referenced from the two largest hospital systems in our area to determine if subsequent HA was performed. Descriptive statistics were used to analyze risk factors for HA. Results: A total of 16 hips (15 patients; 4.6%) underwent subsequent HA with labral repair and femoral osteochondroplasty, the most common interventions. For those with a minimum of two years of follow-up, 5.3% (n = 14) underwent subsequent HA. No hips underwent total hip arthroplasty and one revision PAO was performed. Overall, 17 hips (4.9%) experienced a complication and 99 (26.9%) underwent hardware removal. All PROMs improved significantly postoperatively. Radiologically, 80% of hips (n = 279) reached the goal for acetabular correction (77% for acetbular index and 93% for LCEA), with no significant differences between those who underwent subsequent HA and those who did not. Conclusion: Rectus-sparing PAO is associated with a low rate of subsequent HA for intra-articular pathology at a mean of 6.2 years' follow-up (1 to 11). Acetabular correction alone may be sufficient as the primary intervention for the majority of patients with symptomatic acetabular dysplasia.

Early Radiographic and Clinical Outcomes of an Additive-Manufactured Acetabular Component.

Background: Additive manufacturing has recently gained popularity and is widely adopted in the orthopaedic industry. However, there is a paucity of literature on the radiographic and clinical outcomes of these relatively novel components. The aim of this study was to assess the 2-year clinical and radiographic outcomes of a specific additive-manufactured acetabular component in primary total hip arthroplasty. Methods: We performed a retrospective review of 60 patients who underwent primary total hip arthroplasty with the use of the Stryker's TRIDENT II acetabular component. Evaluation of radiographs was performed at 6 weeks, 1 year, and 2 years postoperatively. Radiographs were evaluated for radiolucencies in Charnley and DeLee zones, signs of biologic fixation, and acetabular inclination and anteversion measurements. Patient-reported outcomes and complications were also obtained. Results: There were no cases of component loosening or changes in component position during follow-up, with an average follow-up time of 1.7 years. A radiolucent line was identified in one patient in zone 1 at 6 weeks; this was absent at 1 year. Radiographic signs of cup biologic fixation were present in 85% of cases by final follow-up. The average inclination was 45.1 (SD = 4.0), and the average anteversion was 26.9 (SD = 5.2). Patient-Reported Outcomes Measurement Information System scores significantly increased at the final follow-up, and there were no complications in this cohort. Conclusions: This study demonstrated excellent radiographic and clinical outcomes with this novel additive-manufactured acetabular component at early follow-up. Although longer-term follow-up is warranted, this additively manufactured highly porous titanium acetabular component demonstrated excellent biologic fixation and reliable fixation at mid-term follow-up.

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection.

BACKGROUND: Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood. METHODS: A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05. RESULTS: A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts. CONCLUSIONS: Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Similar Efficacy and Lower Cost Associated With Ceftazidime Compared to Tobramycin Coupled With Vancomycin in Antibiotic Spacers in the Treatment of Periprosthetic Joint Infection.

BACKGROUND: Vancomycin and tobramycin have traditionally been used in antibiotic spacers. In 2020, our institution replaced tobramycin with ceftazidime. We hypothesized that the use of ceftazidime/vancomycin (CV) in antibiotic spacers would not lead to an increase in treatment failure compared to tobramycin/vancomycin (TV). METHODS: From 2014 to 2022, we identified 243 patients who underwent a stage I revision for periprosthetic joint infection. The primary outcome was a recurrent infection requiring antibiotic spacer exchange. We were adequately powered to detect a 10% difference in recurrent infection. Patients who had a prior failed stage I or two-stage revision for infection, acute kidney injury prior to surgery, or end-stage renal disease were excluded. Given no other changes to our spacer constructs, we estimated cost differences attributable to the antibiotic change. Chi-square and t-tests were used to compare the two groups. Multivariable logistic regressions were utilized for the outcomes. RESULTS: The combination of TV was used in 127 patients; CV was used in 116 patients. Within one year of stage I, 9.8% of the TV group had a recurrence of infection versus 7.8% of the CV group (P = .60). By final follow-up, results were similar (12.6 versus 8.6%, respectively, P = .32). Adjusting for potential risk factors did not alter the results. Cost savings for ceftazidime versus tobramycin are estimated to be $68,550 per one hundred patients treated. CONCLUSIONS: Replacing tobramycin with ceftazidime in antibiotic spacers yielded similar periprosthetic joint infection eradication success at a lower cost. While larger studies are warranted to confirm these efficacy and cost-saving results, our data justifies the continued investigation and use of ceftazidime as an alternative to tobramycin in antibiotic spacers.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees.

BACKGROUND: Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. METHODS: All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). RESULTS: There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. CONCLUSIONS: The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Dysplastic Hips That Are Too Late for Periacetabular Osteotomy Are Not Too Early for Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is often performed in symptomatic patients who have hip dysplasia and do not qualify for periacetabular osteotomy. The impact of osteoarthritis (OA) severity on postoperative outcomes in dysplasia patients who undergo THA is not well described. We hypothesized that dysplasia patients who have mild OA have slower initial recovery postoperatively but similar one-year patient-reported outcome measures (PROMs) compared to dysplasia patients who have severe OA. METHODS: We performed a retrospective review at a single academic institution over a 6-year period of patients who have dysplasia who underwent THA compared to patients who have primary OA who underwent THA. There were 263 patients who had dysplasia, compared to 1,225 THA patients who did not have dysplasia. Within the dysplasia cohort, we compared PROMs stratified by dysplasia and OA severity. The diagnosis of dysplasia was verified using the radiographic lateral center edge angle. A minimum one-year follow-up was required. The PROMs were collected through one year postoperatively. Logistic and linear regression models were used, adjusting for age, sex, body mass index, and Charlson comorbidity index. RESULTS: No significant differences were found in postoperative PROMs or revision rates (P = .58). When stratified by dysplasia severity, patients who had lower lateral center edge angle had more improvement in physical function scores from preoperative to 2 weeks (P < .01) and higher physical function scores at 2 weeks (P = .03). When stratified by OA severity, patients who had a worse Tönnis score had more improvement in physical function scores from preoperative to 2 weeks (P < .01). Recovery curves in dysplasia patients based on dysplasia and OA severity were not significantly different at 6 weeks, 1 year, and 2 years postoperative. CONCLUSIONS: Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. We believe that THA is a reasonable surgical intervention for symptomatic dysplasia patients who have mild arthritis and do not qualify for periacetabular osteotomy.

Decreased Patellar Fractures and Subluxation With Patellar Component Replacement at Stage-One Spacer.

BACKGROUND: Periprosthetic joint infection is a devastating complication of total knee arthroplasty and is often treated with 2-stage revision. We retrospectively assessed whether replacing the patellar component with articulating stage-one spacers was associated with improved outcomes compared to spacers without patellar component replacement. METHODS: A total of 139 patients from a single academic institution were identified who underwent an articulating stage-one revision total knee arthroplasty and had at least 1-year follow-up. Of the 139 patients, 91 underwent patellar component removal without replacement, while 48 had a patellar component replaced at stage-one revision. Patellar fracture and reinfection at any point after stage-one were recorded. Knee range of motion (ROM), patellar thickness, lateral tilt, and lateral displacement were measured at 6-weeks post stage-one. Chi-square, Fisher's exact, and t-tests were utilized for comparisons. There were no significant demographic differences between groups. RESULTS: Patellar component replacement at stage-one revision was associated with fewer patellar fractures (2.1 versus 12.1%, P = .046), less lateral patellar displacement (1.7 versus 16.0 mm, P < .01), and improved pre to postoperative knee ROM 6 weeks after stage-one (+5.9 versus -11.4°, P = .03). There was no difference in reinfections after stage-2 revision for the replaced or unreplaced patellar groups (15.4 versus 15%, P = 1.000). While the mean time between stage-one and stage-2 was not different (5.2 versus 4.5 months, P = .50), at one-year follow-up, significantly more patients in the patellar component replacement group were satisfied and refused stage-2 revision (45.8 versus 3.3%, P < .001). CONCLUSIONS: Replacing the patellar component at stage-one revision is associated with a decreased rate of patellar fracture and lateral patellar subluxation, improved ROM, and possible increased patient satisfaction, as reflected by nearly half of these patients electing to keep their spacer. There was no difference in reinfection rates between the cohorts.

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty.

BACKGROUND: Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. METHODS: We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05. RESULTS: The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). CONCLUSIONS: Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

The Empty Ischial Fossa Sign: A Visual Representation of Relative Inadequate Anteversion in the Posteriorly Tilted Pelvis.

Background: Instability is a known complication following total hip arthroplasty (THA) and is influenced by spinopelvic alignment. Radiographic markers have been investigated to optimize the acetabular cup position. This study evaluated if the empty ischial fossa (EIF) sign and the position of the trans-teardrop line were predictive of postoperative instability. Methods: All patients who underwent THA from 2011 to 2018 at a single institution were retrospectively reviewed. Pelvic tilt was measured using a trans-teardrop line compared to the superior aspect of the pubic symphysis on standing anteroposterior pelvis radiographs. Postoperative dislocations were identified through chart review and radiographic review. The EIF sign was determined by the presence of uncovered bone below the posterior inferior edge of the acetabular component at the level of the native ischium and posterior wall on standing postoperative anteroposterior radiographs. Results: One thousand seven hundred fifty patients (952 anterior approach and 798 posterior approach) were included. The EIF sign was present in 458 patients (26.2%) and associated with an increased dislocation rate (3.9% vs 0.9%, P < .0001). Patients with spondylosis/instrumented fusion, and positive EIF sign had a dislocation risk of 5.1% vs 1.3% (P = .001). A postoperative outlet pelvis was not significant for increased dislocation risk (odds ratio 2.16, P = .058). Patients with combined spondylosis/fusion, posterior approach, outlet pelvis, and EIF sign had a dislocation rate of 14.5%. Conclusions: The EIF sign was an independent risk factor for postoperative instability and may represent failure to account for pelvic tilt. Avoidance of the EIF sign during cup positioning may help reduce dislocations following THA.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch.

BACKGROUND: Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS: All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS: Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS: With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty.

BACKGROUND: Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA. METHODS: There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations. RESULTS: Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002). CONCLUSIONS: Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.

Metallosis and Corrosion Associated With Revision Total Knee Arthroplasties With Metaphyseal Sleeves.

Metallosis and corrosion have been associated with metal-on-metal and modular total hip arthroplasty but are rarely described in the setting of primary or revision total knee arthroplasty (TKA). In this series, we report on cases of metallosis due to mechanically assisted crevice corrosion at modular junctions of machined trunnion-bore tapers in a revision TKA system with metaphyseal sleeves. The unique design of metal modular junctions used in sleeve-based revision TKA, along with potential patient and surgical factors, may predispose these designs to fretting, corrosion, and adverse reaction to metal debris. We now consider metallosis and corrosion in the workup of painful or failed revision TKAs with sleeves. Future studies that investigate the incidence of this phenomenon may be warranted.

A Novel Method to Calculate Functional Pelvic Tilt Using a Standing Anteroposterior Pelvis Radiograph.

Background: Functional patient-specific acetabular component positioning is important in total hip arthroplasty. We preoperatively evaluate the pelvic tilt (PT) on standing anteroposterior (AP) pelvis radiographs using a novel measurement and then recreate this intraoperatively using imaging. The purpose of this study was to determine if there is a linear correlation between this novel measurement and the actual PT. Methods: A retrospective study of 200 patients was performed, measuring PT on standing lateral radiographs as the angle between the anterior superior iliac spines and the pubic symphysis. On the AP pelvis radiographs, the trans-teardrop (TT) line was drawn between the teardrops. The vertical distance between the TT line and the top of the pubic symphysis (TTPS) was then measured. A ratio was made between the lengths of both lines to account for the overall size of the pelvis (TTPS/TT). Linear regression analysis was then performed between PT and TTPS/TT. Results: There was a strong linear correlation between the TTPS/TT ratio on AP pelvis radiographs and PT on lateral radiographs (r = 0.785, r2 = 0.616, P < .001). On subanalysis of the female cohort, the correlation became even stronger (r = 0.864, r2 = 0.747, P < .001). Using regression analysis, a linear equation was created (PT = 97.32 [TTPS/TT] - 5.51), to calculate the PT using the TTPS/TT ratio. Conclusions: There is a strong linear correlation between the TTPS/TT ratio and PT. Using this information, a surgeon can reliably use the distance between the TT line and the superior pubic symphysis on an AP radiograph to recreate the patient's functional PT intraoperatively, allowing for a more accurate patient-specific placement of the acetabular component.

A Multilingual Chatbot Can Effectively Engage Arthroplasty Patients Who Have Limited English Proficiency.

BACKGROUND: In the United States, English language proficiency is widely accepted as a key social determinant of health. For patients with limited English proficiency (LEP), language barriers can make the delivery of perioperative instructions challenging. The purpose of this study was to evaluate whether a multilingual chatbot could effectively engage LEP patients and improve their outcome after total joint arthroplasty (TJA). METHODS: We identified 1,282 TJA patients (705 knees, 577 hips) who enrolled in a short message service (SMS) chatbot from 2020-2022. Forty-seven patients enrolled in the chatbot received their messages in a language other than English. A historical control of 68 LEP patients not enrolled in the chatbot was identified. Chi-squared, Fisher's exact test, and t-tests were performed to measure the effect that conversational engagement had on emergency department (ED) visits, hospital readmissions, and reoperations. RESULTS: There was no difference in the conversational engagement between LEP patients and those with English as their primary language (EPL) (12.3 versus 12.2 text responses, P = .959). The LEP cohort who enrolled in the chatbot had fewer readmissions (0% versus 8.3%, P = .013) and a near significant reduction in ED visits (0.9% versus 8.0%, P = .085) compared to those not enrolled. There was no difference in reoperations between the 2 cohorts. CONCLUSION: LEP and EPL patients engaged equally with the multilingual chatbot. LEP patients who enrolled in the chatbot had fewer readmissions and a near significant reduction in ED visits. Multilingual platforms such as this chatbot may provide more equitable care to our frequently encountered LEP patients.

Recovery Curves for Patient Reported Outcomes and Physical Function After Total Hip Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are frequently used for evaluating patient satisfaction and function following total hip arthroplasty (THA). Functional measures along with chronologic modeling may help set expectations perioperatively. Our goal was to define the trajectory of recovery and function in the first year following THA. METHODS: Prospective data from 1,898 patients in a multicenter study was analyzed. The PROMs included the Hip disability and Osteoarthritis Score for Joint Replacement and EuroQol-5 dimension. Physical activity was recorded on a wearable technology. Data was collected preoperatively and at 1, 3, 6, and 12 months postoperatively. Generalized estimating equations were used to evaluate outcomes over time. RESULTS: Significant improvement occurred between preoperative and postoperative time points for all PROMs. The PROMs showed the greatest proportional recovery within the first month postoperatively, each improving by at least 1 minimal clinically important difference (MCID). Daily steps and flights of stairs took longer to reach at least 1 MCID (3 months and 1 year, respectively). Gait speed and walking asymmetry returned to baseline by 3 months, but did not reach a MCID of improvement by 1 year. CONCLUSION: Patients can be counseled that the greatest proportional improvement in PROMs is within 1 month after THA, while function surpasses preoperative baselines by 3 months, and gait quality may not improve until after 1 year. This can help set realistic expectations and target interventions toward patients deviating from the norm.

Outcomes are Compromised When Revising Patellofemoral Arthroplasties for Patellar Component Failures.

BACKGROUND: Outcomes of patellofemoral arthroplasty (PFA) to total knee arthroplasty (TKA) conversion are reported to be similar to primary cases. The purpose of this study was to determine whether the cause for conversion from PFA to TKA correlated to outcomes when compared to a matched cohort. METHODS: A retrospective chart review was performed to identify aseptic PFA to TKA conversions between 2000 and 2021. A cohort of primary TKAs was matched by patient sex, body mass index, and American Society of Anesthesiology score. Clinical outcomes, including range of motion, complication rates, and patient reported outcomes measurement information systems scores, were compared. Chi-squared, Fisher's Exact, and t-tests were performed. There were 20 PFA to TKA conversions that met inclusion criteria and were matched to 60 primary cases. RESULTS: There were 7 cases revised for arthritis progression, 5 for femoral component failure, 5 for patellar component failure, and 3 for patellar maltracking. PFA to TKA conversions for patellar failure (fracture, component loosening) had worse postoperative flexion (115 versus 127°, P = .023) and more complications of stiffness (40 versus 0%, P = .046) than primary TKAs. Conversions for failed patellar components had worse patient reported outcomes measurement information systems physical function (32 versus 45, P = .0046), physical health (42 versus 49, P = .0258), and pain scores (45 versus 24, P = .0465). No differences were found in rates of infection, manipulations under anesthesia, or reoperations. CONCLUSION: PFA to TKA conversion outcomes were similar to primary TKA, except in patients who had failed patellar components and demonstrated worse postoperative range of motion and patient-reported outcomes. Surgeons should avoid thin patellar resections and extensive lateral releases to minimize patellar failures.

Recovery Curve for Patient Reported Outcomes and Objective Physical Activity After Primary Total Knee Arthroplasty-A Multicenter Study Using Wearable Technology.

BACKGROUND: This study aimed to describe the trajectory of recovery based on patient-reported outcomes (PROs) and objective metrics of physical activity measures over the first 12 months post-total knee arthroplasty (TKA). METHODS: In total, 1,005 participants who underwent a primary unilateral TKA surgery between November 2018 and September 2021 from a multisite prospective study were analyzed. Generalized estimating equations were used to evaluate PROs and objective physical activity measures over time. RESULTS: All Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), EuroQol-5D (EQ-5D), and steps per day scores were greater than preoperative scores (P < .05). The flights of stairs per day, gait speed, and walking asymmetry all declined at 1 month (all, P < .001). However, all subsequent scores improved by 6 months (all, P < .01). The greatest clinically important differences from previous visit in KOOS JR (ß = 18.1; 95% Confidence Interval (CI) = 17.2, 19.0), EQ-5D (ß = 0.11; 95% CI = 0.10, 0.12), steps per day (ß = 1,169.3; 95% CI = 1,012.7, 1,325.9), gait speed (ß = -0.05; 95% CI = -0.06, -0.03), and walking asymmetry (ß = 0.00; 95% CI = -0.03, 0.03) were observed at 3 months. CONCLUSION: The KOOS JR, EQ-5D, and steps per day measures showed earlier improvements than other physical activity metrics, with the greatest magnitude of improvement within the first 3 months post-TKA. The greatest magnitude of improvement in walking asymmetry was not observed until 6 months, while gait speed and flights of stairs per day were not observed until 12 months. This data may further help provide expectation setting information to patients before surgery, and may aid in identifying outliers to the normal recovery curve who may benefit from targeted interventions.

Extensor Mechanism Disruption Remains a Challenging Problem.

BACKGROUND: Extensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking. METHODS: Patients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan-Meier curves, and factors for success were determined with logistic regressions. RESULTS: Of fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion. CONCLUSIONS: This multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.