Arthroplasty Today最新文献

Background

Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors.

Methods

This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution.

Results

Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training.

Conclusions

This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Background

Periprosthetic fractures (PPFs) after total joint arthroplasty (TJA) can be devastating, yet their long-term impact has not been well described. The aim of this study is to compare the long-term outcomes of patients who sustained a PPF about a TJA with those of patients who underwent an uncomplicated TJA.

Methods

Patients who sustained a PPF after primary TJA between 2005 and 2014 were identified. Seventeen patients with a minimum 2-year follow-up (PPF cohort) were compared to a matched cohort of 67 patients who underwent uncomplicated TJA. Demographic data, comorbidities, surgical details, and complications were analyzed. Quality of life and functional outcomes were assessed with 12-Item Short Form Health Survey (SF-12), Western Ontario and McMasdter Universities Arthritis Index (WOMAC), and Knee Society Function Score.

Results

The overall complication rate was 41.2% in the PPF group, including 3 additional fractures (17.6%), 2 wound infections (11.8%), one prosthetic joint infection (5.8%), and one painful patellar hardware necessitating removal (5.8%). At 2 years, both physical and mental components of the SF-12 were significantly lower for the PPF cohort vs control (SF-12-P, 28.7 ± 4.4 vs 40.8 ± 10.3, P < .001, SF-12-M, 36.7 ± 5.07 vs 55.0 ± 8.19, P < .0001). WOMAC pain and function scores were also significantly worse in the PPF cohort vs control at 2 years (WOMAC-pain, 38.8 ± 29.9 vs 87.4 ± 22.1; P < .0001, WOMAC-function, 40.7 ± 8.7 vs 76.1 ± 20.3; P < .0001). At 2 years, score improvements from prearthroplasty baseline were significantly greater in the control cohort vs PPF for SF-12-physical, WOMAC-pain, and WOMAC-function.

Conclusions

Patients who sustained PPFs following TJA have poor long-term outcomes despite appropriate treatment. These results can help counsel patients and encourage heightened efforts to minimize the risk of PPF.

Level of Evidence

Level III.

Effective communication is vital for patient safety, yet failures are common, often due to outdated methods. This study aimed to assess whether in-ear communication devices improve communication in orthopedic surgery simulations compared to traditional loud voice methods. Fifteen participants underwent simulations using both in-ear wireless devices and standard communication. Results showed significant improvements with in-ear devices in correctly identifying phrases (78.6% vs 44%), effectiveness (7.9/10 vs 4.9/10), and clarity (8/10 vs 4/10), all P < .001. Participants also favored in-ear devices in usability assessments. Sound levels recorded were comparable between groups. In conclusion, in-ear communication is safe and effective in orthopedic settings, potentially enhancing efficiency and safety. These devices can mitigate loud noises, benefiting surgeon well-being and patient outcomes.

Background

There is a paucity of validated risk stratification tools to assess which patients can safely and predictably undergo outpatient total hip (THA) or knee arthroplasty (TKA) in an ambulatory surgery center (ASC).

Methods

Our novel patient selection tool was prospectively applied to 190 consecutive primary THA and TKA performed by a single surgeon at a single ASC. We identified the proportion of patients discharged home the same day, those requiring a one-night stay, or those with failed discharge within 23 hours. A retrospective chart review was performed to determine if any demographic parameters were risk factors for an overnight stay.

Results

Overall, 190 (100%) patients selected for outpatient THA and TKA were discharged home within 23 hours. One hundred and four patients (55%) were discharged the same day of surgery, whereas 86 (45%) required overnight stay and were discharged on postoperative day 1. Female sex (odds ratio [OR]: 4.1, 95% confidence interval [CI]: 2.0-8.2, P < .001), THA (OR: 2.5, 95% CI: 1.1-5.5, P = .022), and heavier body mass index (OR: 1.0, 95% CI: 1.0-1.2, P = .022) were identified as independent risk factors for staying overnight in the ASC.

Conclusions

In this pilot study, we found that 100% of outpatient THA and TKA-eligible patients were able to be discharged home by postoperative day 1. Additionally, we found that this selection tool is safe and effective at predicting short-stay discharge in an ASC.

Background

Two-stage exchange arthroplasty remains the gold standard for treating chronic hip periprosthetic joint infections. However, controversy remains regarding the optimal spacer type, particularly among patients with increased dislocation risk. This study reports on the outcomes of articulating hip spacers utilizing a single constrained-liner design.

Methods

All patients who underwent treatment for hip periprosthetic joint infection at a single institution were screened. Patients were included if they received an articulating spacer utilizing a constrained liner of a single manufacturer design. Indications for constrained liner, demographic variables, and surgical variables were recorded. Patients were assessed for dislocation and component loosening prior to the second stage or at the final follow-up if the second stage was not undertaken. Comparative analysis was performed.

Results

Overall, 26 constrained liners were utilized in 25 patients. Indications for constrained liner included history of dislocation (n = 14), massive proximal femoral bone loss (n = 14), greater trochanteric deficiency (n = 12), and absent abductors (n = 7). Many patients had more than one indication. In total, 9 hips (34.6%) underwent a second stage at an average of 7.4 months, while 17 hips never underwent a second stage with an average follow-up of 27.6 months. One patient experienced failure of their constrained liner prior to the second stage due to pelvic discontinuity and massive acetabular bone loss.

Conclusions

Utilization of a constrained liner as an articulating spacer is a viable option for patients at high risk of instability. Meticulous cement technique, appropriate component position, and implant selection are crucial in achieving successful outcomes.

Background

Patients with genetic skeletal dysplasias often require lower extremity total joint arthroplasty (TJA) due to early joint degeneration; however, little data exists regarding the outcomes of TJA in this population. Our purpose was to review the literature to determine the complication rates, revision rates, implant survivorship, and patient-reported outcomes of total knee arthroplasty and total hip arthroplasty (THA) in those with genetic skeletal dysplasias.

Methods

A systematic literature review of online databases (PubMed and Google Scholar) was conducted. Studies that reported the outcomes of THA or total knee arthroplasty in patients with genetically confirmed skeletal dysplasias were included. Case reports and studies that defined dysplasia based on height alone were excluded. Fourteen studies met the criteria for data extraction and analysis.

Results

Our review yielded a sample of 596 skeletal dysplasia patients with a median follow-up of 6.01 years (1.7-15.9). Mean age was 54.04 years, and mean body mass index was 29.1 kg/m². Cementless fixation was utilized in 65.7% of THAs, while all knees were cemented. Hip implant survivorship was 79% at 10 years and 56% at 20 years. Knee implant survivorship was 92% at 10 years and 46% at 20 years. Hip and knee revisions were 15.3% and 13.5%, respectively. The most common indication was aseptic loosening and polyethylene wear. Patient-reported outcomes improved across all domains.

Conclusions

The literature regarding lower extremity TJA in those with genetic skeletal dysplasias demonstrates appropriate 10-year implant survivorship and improvement in patient-reported outcomes across all survey domains.

Background

Polyurethane tibial and acetabular inserts that release high concentrations of antibiotics were used with debridement and implant retention to treat prosthetic joint infections. The hypothesis was that a low-friction, antibiotic-releasing bearing could provide a simpler, safer, and more patient-accepted treatment for infection using antibiotic cement and intravenous antibiotics.

Methods

Patients (n = 106) with culture-positive infections received antibiotic inserts. Vancomycin and tobramycin were mixed into the polyurethane polymer at 7% by weight. Contraindications to debridement antibiotics and implant retention were a sinus tract, loose prostheses, and/or the wound could not be closed. Measurable outcomes were success in controlling infection, complications, patient acceptable symptomatic state, and need for revision surgery. Antibiotic levels were measured in joint fluid and blood; laboratory mechanical wear tests were performed; and results were compared to bone cement and polyethylene containing antibiotics.

Results

Antibiotic-infused spacers sustained joint fluid antibiotic levels 8-12 times the therapeutic level and produced low serum levels with no toxicities. Mechanical testing showed low wear and retained mechanical integrity. All patients achieved complication-free remission of infection at a follow-up of 5-26 years. All patients had Harris hip and Knee Society scores above 85, and 68% achieved patient acceptable symptomatic state.

Conclusions

All patients achieved remission of infection, fewer complications compared to revision using antibiotic bone cement, no antibiotic toxicity or adverse drug reactions, and 68% achieved patient acceptance. The antibiotic polyurethane inserts provided antibacterial efficacy comparable with currently used bone cement spacers, and their wear rate was approximately 20 times lower than bone cement as an articulation.

Background

There is a paucity of data regarding compensation for early-career adult reconstruction surgeons. This study aims to quantify the time throughout the full episode of care for a Medicare primary total hip/knee arthroplasty and convert to per-hour pay for early-career arthroplasty surgeons at various geographic locations and practice settings. Using Center for Medicare and Medicaid Services data, this study also compares the compensation of early-career vs established total joint arthroplasty (TJA) surgeons.

Methods

Between January 2022 and January 2023, 3 early-career surgeons in 3 different locations collected prospective data on time spent in patient care during the global period following primary TJAs (pTJAs). A weighted average time spent per pTJA during global period was calculated with the 2024 work relative value unit and conversion factor to establish a per-hour rate. This rate was compared to the compensation rates of other healthcare-related fields and established TJA surgeons using Relative Value Scale Update Committee (RUC) values.

Results

A total of 334 pTJAs (148 hips and 186 knees) were performed among 3 surgeons, and per-hour rates of $87.62 and $87.70 were found, respectively. These are less than hospital/healthcare system/health insurance/med tech CEOs, lawyers, dentists, and travel nurses. Early-career TJA surgeons were found to take 7.98%-8.68% longer than RUC standard times for a TJA episode of care.

Conclusions

This study quantifies the per-hour compensation of early-career arthroplasty surgeons, who earn lower compensation rates to travel nurses and take longer than Center for Medicare and Medicaid Services RUC times for pTJAs. Given the increasing demand for pTJAs, decreasing reimbursement rates, and concern over burnout, access to quality pTJA care for patients is concerning.

Background

Every degree of change in pelvic tilt (PT) leads to a 0.7° change in anteversion and a 0.3° change in inclination. This study aimed to determine the significance of contralateral hip arthritis on changes in PT using preoperative and postoperative anteroposterior radiographs.

Methods

There were 193 primary total hip arthroplasties done by 2 surgeons at a single academic tertiary referral center reviewed between September 2021 and January 2023. PT was calculated as Tilt = −(ln[(B/A) × (1/0.483)]) / 0.051. Value A is the distance from the base of the SI joint to the superior margin of the obturator foramen; value B is the height of the obturator foramen. After exclusions, contralateral hips were identified as being normal (n = 75), arthritic (n = 39) (Tönnis grade 3/4), replaced (n = 34), or having undergone simultaneous bilateral total hip arthroplasty (n = 5) on postoperative films. Difference in PT was measured between preoperative and postoperative films taken 1-3 months after surgery. Analyses for statistical significance were calculated using t-tests and one-way analysis of variance.

Results

Average change in PT in patients with normal contralateral hips was −5.2° with an absolute mean difference of 7.6°, −1.5° for arthritic contralateral hips with an absolute mean difference of 5.0°, −1.6° for replaced contralateral hips with a mean absolute difference of 4.3°, and 2.2° for bilateral hips with a mean absolute difference of 2.6° (P < .01).

Conclusions

Differences in postoperative PT changes between healthy, arthritic, and replaced contralateral hip study groups were significant. Changes in preoperative to postoperative tilt may have implications for optimal cup placement.

Background

The primary objective of this study was to determine the accuracy and precision of component positioning of the ROSA Robotic System for total knee arthroplasty (TKA).

Methods

A Preferred Reporting Items for Systematic Reviews and Meta-Analysis systematic review was conducted using 4 electronic databases (MEDLINE, EMBASE, Pubmed, and Cochrane Library) to identify all clinical and radiological studies reporting information about the use and results of the ROSA system. The criteria for inclusion were published research articles evaluating the accuracy of component positioning, learning curve, component alignment, complications, and functional outcomes in adults who underwent robotic-assisted TKA. The National Institutes of Health Quality Assessment Tool was used to evaluate the quality of all the included studies.

Results

A total of 26 studies were assessed for eligibility, and 17 met the inclusion criteria. Nine studies reported on the accuracy and precision of component positioning. The ROSA platform for TKA had a cutting error of less than 0.6^° for all coronal and sagittal parameters. Pooled analysis demonstrated accuracy within 0.61-1.87^° and precision within 0.97-1.34^° when the final intraoperative plan was compared to postoperative radiographs with fewer outliers. Four studies reported improved functional scores with ROSA-assisted TKA than conventional TKA within 1 year of surgery. There was no difference in overall complication rates when compared to conventional TKA.

Conclusions

The ROSA system is both highly accurate and precise, with fewer outliers when analyzed at various time points, including postoperative standing radiographs. Future studies with robust methodology and longer follow-up are required to demonstrate whether these findings have any clinical benefits in the long term.