Temporal Trends of Revision Etiologies in Total Knee Arthroplasty at a Single High-Volume Institution: An Epidemiological Analysis.

BACKGROUND: Temporal changes in revision total knee arthroplasty (rTKA) may have implications in determining the etiology for implant failure. The purpose of this study was to 1) perform an epidemiologic analysis of etiologies that required rTKA and 2) determine whether temporal changes existed for revision over the study period. METHODS: All rTKA procedures performed at a single institution from 2009 to 2019 were analyzed. Revision procedures were stratified into 2 time periods, 2009-2013 and 2014-2019, to assess for changes over time. Patients' electronic medical record, operative report, and radiographs were reviewed to ensure diagnosis information was accurately documented in relation to the predominate etiology necessitating the revision procedure. RESULTS: Three thousand and nine patients undergoing rTKA between 2009 and 2019 were identified with a mean age of 64.6 years. A total of 1,666 (55.4%) patients were female, and the majority of patients were Caucasian (2,306, 76.6%). The 3 most frequent rTKA etiologies were aseptic loosening (35.1%), periprosthetic infection (33.2%), and instability (16.0%). A higher proportion of patients underwent rTKA for arthrofibrosis (5.1% vs 3.4%, P = .023) and periprosthetic joint infection (38.9% vs 28.6%, P < .001) between 2009 and 2013, while a significantly higher proportion of patients underwent rTKA for instability (12.6% vs 18.8%, P < .001) between 2014 and 2019. CONCLUSION: Aseptic loosening was the most common cause for rTKA over the last decade. rTKA for arthrofibrosis and periprosthetic joint infection was more frequent between 2009 and 2013, while a significantly higher proportion of patients underwent rTKA for instability in 2014-2019. Future studies will need to focus on identifying and reducing risk factors for the trending causes of rTKA.

An epidemiological analysis of revision aetiologies in total hip arthroplasty at a single high-volume centre.

AIMS: Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. METHODS: All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient. RESULTS: In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001). CONCLUSION: Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems.Cite this article: Bone Joint Open 2020;2(1):16-21.

The Effect of Depression on Patient-Reported Outcomes After Total Joint Arthroplasty Is Modulated by Baseline Mental Health: A Registry Study.

BACKGROUND: Depression and poor mental health are known to be negative predictors of patient-reported outcomes after total joint arthroplasty. Although previous studies have examined these risk factors in isolation to each other, they are, in reality, closely related, and yet each represents a different aspect of one's psychological well-being. The objective of this study was to investigate the association between depression and patient-reported outcomes, taking into account patients' baseline mental health. METHODS: Our prospective, institutional joint registry was queried for patients who had undergone primary elective total joint arthroplasty and had a minimum follow-up of 1 year. Baseline mental health was measured by the Short Form-12 Mental Component Summary (SF-12 MCS). Four cohorts were analyzed on the basis of the presence or absence of depression and patients' SF-12 MCS scores at the time of the surgical procedure, which were categorized as either poor or good on the basis of previously defined cutoffs. The primary outcomes were the net changes in SF-12 MCS, SF-12 Physical Component Summary (PCS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at 4 and 12 months postoperatively. Univariate and mixed-effects model analyses were performed to control for potential confounding factors. RESULTS: Patients with depression but good baseline mental health achieved gains in patient-reported outcomes that were comparable with those of normal controls (p > 0.05). Patients with poor baseline mental health achieved significant gains in all patient-reported outcomes, but the changes were largest for those without depression (p < 0.05). Only patients with depression and poor baseline mental health did not cross the threshold for good mental health at the time of the latest follow-up despite achieving similar gains in physical function compared with their counterparts who did not have depression. CONCLUSIONS: The effect of depression on patient-reported outcomes is more complex but less pessimistic than previously thought. Patients with depression undergoing total joint arthroplasty may have significant improvements in their patient-reported outcomes, but the net gains are modulated by their mental health at the time of the surgical procedure. Preoperative screening of patients with depression using the SF-12 MCS may help to identify those who are at risk for attaining suboptimal patient-reported outcomes and may benefit from counseling or psychiatric referral for optimization before undergoing a surgical procedure. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Regeneration of Articular Cartilage by Human ESC-Derived Mesenchymal Progenitors Treated Sequentially with BMP-2 and Wnt5a.

The success of cell-based therapies to restore joint cartilage requires an optimal source of reparative progenitor cells and tight control of their differentiation into a permanent cartilage phenotype. Bone morphogenetic protein 2 (BMP-2) has been extensively shown to promote mesenchymal cell differentiation into chondrocytes in vitro and in vivo. Conversely, developmental studies have demonstrated decreased chondrocyte maturation by Wingless-Type MMTV Integration Site Family, Member 5A (Wnt5a). Thus, we hypothesized that treatment of human embryonic stem cell (hESC)-derived chondroprogenitors with BMP-2 followed by Wnt5a may control the maturational progression of these cells into a hyaline-like chondrocyte phenotype. We examined the effects of sustained exposure of hESC-derived mesenchymal-like progenitors to recombinant Wnt5a or BMP-2 in vitro. Our data indicate that BMP-2 promoted a strong chondrogenic response leading to terminal maturation, whereas recombinant Wnt5a induced a mild chondrogenic response without promoting hypertrophy. Moreover, Wnt5a suppressed BMP-2-mediated chondrocyte maturation, preventing the formation of fibrocartilaginous tissue in high-density cultures treated sequentially with BMP-2 and Wnt5a. Implantation of scaffoldless pellets of hESC-derived chondroprogenitors pretreated with BMP-2 followed by Wnt5a into rat chondral defects induced an articular-like phenotype in vivo. Together, the data establish a novel role for Wnt5a in controlling the progression from multipotency into an articular-like cartilage phenotype in vitro and in vivo. Stem Cells Translational Medicine 2017;6:40-50.

A Review of Databases Used in Orthopaedic Surgery Research and an Analysis of Database Use in Arthroscopy: The Journal of Arthroscopic and Related Surgery.

PURPOSE: The purpose of this study was to evaluate how database use has changed over time in Arthroscopy: The Journal of Arthroscopic and Related Surgery and to inform readers about available databases used in orthopaedic literature. METHODS: An extensive literature search was conducted to identify databases used in Arthroscopy and other orthopaedic literature. All articles published in Arthroscopy between January 1, 2006, and December 31, 2015, were reviewed. A database was defined as a national, widely available set of individual patient encounters, applicable to multiple patient populations, used in orthopaedic research in a peer-reviewed journal, not restricted by encounter setting or visit duration, and with information available in English. RESULTS: Databases used in Arthroscopy included PearlDiver, the American College of Surgeons National Surgical Quality Improvement Program, the Danish Common Orthopaedic Database, the Swedish National Knee Ligament Register, the Hospital Episodes Statistics database, and the National Inpatient Sample. Database use increased significantly from 4 articles in 2013 to 11 articles in 2015 (P = .012), with no database use between January 1, 2006, and December 31, 2012. CONCLUSIONS: Database use increased significantly between January 1, 2006, and December 31, 2015, in Arthroscopy. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Shoulder Arthroplasty: Disposition and Perioperative Outcomes in Patients With and Without Rheumatoid Arthritis.

Shoulder arthroplasty (SA) is used to treat pain and disability associated with rheumatoid arthritis (RA). Although SA is an effective procedure in patients with RA, more investigation of perioperative outcomes is needed. We conducted a study to compare the perioperative complication rates and demographics of patients with and without RA. Given the potential for anemia of chronic disease and the systemic inflammatory nature of RA, we hypothesized that the perioperative complication profile of RA patients would be worse than that of non-RA patients. Data on SA patients were obtained from the Nationwide Inpatient Sample for the period 2006-2011. Of the 34,970 SA patients identified, 1674 had a primary diagnosis of RA and 33,296 did not. Demographics, hospital disposition factors, and complications were compared using regression analysis. Analyses of 14 different perioperative outcome measures demonstrated no significant difference in any category except blood transfusions; the blood transfusion rate was significantly higher (P < .001) for RA patients (9.00%) than for non-RA patients (6.16%). RA patients had longer hospital length of stay (2.196 vs 2.085 days; P < .001), higher inflation-adjusted charges ($54,284 vs $52,663; P = .018), and lower home discharge rates (63.0% vs 67.6%; P < .001). These results suggest that the complex nature of RA plays a role in perioperative SA outcomes. RA patients' longer hospital stays were not clinically significant. Research on postoperative care, billing practices, and hospital protocols is needed to determine the cause of these outcomes.