Journal of Arthroplasty最新文献

Background: The Centers for Medicare & Medicaid Services (CMS) has made the collection of patient-reported outcome measures (PROMs) mandatory for inpatient total knee arthroplasty (TKA). The reporting of the proportion of patients who reach the substantial clinic benefit (SCB) threshold between pre- and postoperative PROMs based on Knee Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores is also necessary for reimbursement. Our study evaluated characteristics among patients who did and did not meet SCB to understand trends that may help surgeons to comply with CMS policies and maximize patient outcomes following TKA.

Methods: A retrospective review was performed of patients undergoing primary TKA between January 2021 and August 2024 at a single large academic center. Demographic, operative, and outcome variables were compared between patients who met SCB and those who did not. Multivariable analysis was performed to identify risk factors for failure to achieve SCB. A total of 807 of 3,538 patients (23%) were eligible for inclusion based on completion of both pre- and postoperative KOOS JR surveys; 62% of whom reached SCB.

Results: There were few differences in demographics and no significant differences in complications between subgroups. Patients had strikingly different PROM profiles; the group failing to meet SCB reported less pain and higher function preoperatively and more pain, lower function, and lower satisfaction postoperatively in comparison to patients meeting SCB. Patients who had a preoperative KOOS JR interval score > 53.65 were 5.01 times more likely not to achieve SCB (95% confidence interval (CI) 3.63 to 6.98; q < 0.001).

Conclusions: Our results demonstrate the difficulty of collecting PROMs in accordance with the CMS mandate and point to distinct differences in PROM profiles related to SCB achievement. Attaining SCB following TKA is a metric of patient satisfaction, and these findings can help guide patient expectations.

Background: This study aimed to determine how preoperative hip flexion-extension range of motion (ROM) and sagittal vertical axis (SVA) affect postoperative ROM recovery, changes in sagittal spino-pelvic alignment, and patient-reported outcomes (PROMs) following total hip arthroplasty (THA).

Methods: We retrospectively reviewed 416 patients who underwent primary cementless THA. Spino-pelvic parameters in standing and sitting positions and PROMs were evaluated preoperatively and at six months, one year, and two years postoperatively. Patients were divided into four groups based on preoperative hip flexion-extension ROM and SVA: the limited ROM (hip flexion ≤ 60° and/or extension less than 0°) and high SVA (≥ 50 mm) group (LR-H group; n = 60), the limited ROM and normal SVA (less than 50 mm) group (LR-N group; n = 77), the preserved ROM (flexion greater than 60° and extension ≥ 0°) and high SVA group (PR-H group; n = 56), and the preserved ROM and normal SVA group (PR-N group; n = 223).

Results: All groups showed significant improvement in hip flexion-extension ROM postoperatively; however, the LR-H group maintained significantly lower values than the other groups at two years. This group showed the lowest sacral slope and lumbar lordosis in both standing and sitting positions, the highest SVA in both positions, and persistent highest spino-pelvic mobility. Longitudinally, this group showed minimal improvement in global sagittal alignment. The LR-H group showed significantly lower achievement rates of minimal important change for PROMs compared to other groups.

Conclusions: Preoperative limited flexion-extension ROM combined with high SVA significantly affects ROM recovery, sagittal spino-pelvic alignment, and PROMs following THA, suggesting that preoperative evaluation of both factors may be important for understanding postoperative outcomes and informing treatment strategies.

Background: Injury to the popliteal artery (PA) is a severe complication during total knee arthroplasty (TKA). Current information on the anatomical proximity of the PA to the posterior tibial cortex is mostly derived from imaging studies, which may not accurately represent surgical conditions. Additionally, anatomical differences between sexes remain unclear. This cadaver study aimed to determine the anatomical relationship between the PA and tibial landmarks at clinically relevant tibial resection levels during TKA, emphasizing potential sex-based differences.

Methods: Overall, 102 knees from 51 formalin-embalmed cadavers (24 men, 27 women) were dissected. An Akagi line-based coordinate system defined the tibial landmarks, and three standard tibial resection levels employed in TKA (joint line, 10 mm distal, and 15 mm distal) were evaluated. The posterior, lateral, and shortest distances from the posterior tibial cortex to the PA were measured. Multivariate linear regression analyses that adjusted for lower leg length were used to assess sex-based anatomical differences.

Results: The PA progressively approached the posterior tibial cortex distally; the median shortest distances significantly decreased from 10.0 mm (joint line) to 5.0 mm (15 mm distal). After adjusting for lower leg length, multivariate linear regression analysis revealed men as independently associated with greater posterior (P = 0.043) and shortest (P = 0.045) distances only at the joint level. However, these sex-based differences were no longer significant at deeper resection levels.

Conclusion: During TKA, the anatomical risk of PA injury significantly increases at deeper tibial resection levels. Although there are sex-based anatomical differences at the joint line, they disappear at clinically relevant distal resection levels, highlighting the need for careful surgical vigilance regardless of patient sex.

Background: Increasing femoral head size or using lipped polyethylene acetabular liners both reduce revision risk due to dislocation after total hip arthroplasty (THA). At some cup sizes, surgeons must choose between larger heads or lipped liners. This study compares 32 mm heads with 10° lipped liners versus 36 mm heads with neutral liners for stability and revision risk.

Methods: A national registry was queried for primary posterior-approach THAs. A total of 24,921 procedures were included: 17,386 with 32 mm femoral heads and 10° lipped cross-linked polyethylene (XLPE) liners, and 7,535 with 36 mm femoral heads and neutral XLPE liners. Kaplan-Meier analysis, multivariable logistic regressions, and t-tests evaluated 90-day, 2-year, and 8-year revision rates due to dislocation. A sub-analysis was performed for patients who had a body mass index (BMI) ≥ 30. The secondary outcomes included all-cause revision, infection, aseptic loosening, and periprosthetic fracture.

Results: The 90-day, 2-year, and 8-year rates of revision for dislocation were higher in the 32 mm and 10° lipped liner cohort. The Kaplan-Meier curve analyses demonstrated the rate of revision for dislocation was significantly higher in the 32 mm and 10° lipped liner group during the first month following THA (hazard ratio (HR) 5.58; P = 0.019), but was not significant at any later time points. Among obese patients, those who received 32 mm heads and lipped liners had over three times higher odds of revision for persistent dislocation throughout eight years of follow-up (HR 3.28; P = 0.012).

Conclusion: With a 50 mm acetabular cup, a 36 mm femoral head, and a neutral acetabular liner, greater protection from revision of THA due to dislocation is conferred, particularly during the first postoperative month. In obese patients, the elevated dislocation risk with 32 mm heads and lipped liners persists throughout 8-year follow-up highlighting the sustained clinical benefit of larger head size in this population.

Background: Elevated body mass index (BMI) contributes to the development of osteoarthritis and demand for total knee arthroplasty (TKA). Increased BMI is an established risk factor for complications following primary TKA. However, literature on BMI and outcomes of revision TKA (rTKA) is less conclusive. This study evaluated the association between BMI and outcomes in the early postoperative period following aseptic rTKA. We hypothesized that increasing BMI would be associated with a higher risk of unfavorable short-term outcomes.

Methods: A retrospective review of 470 patients who underwent aseptic rTKA within one regional health system from 2017 to 2022 was performed. Revisions were due to infection (39.8%), instability (23.7%), arthrofibrosis (11.8%), and aseptic loosening (11.8%). Patients were categorized by BMI from electronic medical records at the time of rTKA. The primary outcome was early reoperation, assessed at 30 and 90 days postoperatively. The secondary outcomes included readmission, major complications, and minor complications at 30 and 90 days postoperatively. Multivariate regression models considering BMI as a continuous variable were used to determine the impact of BMI on outcomes.

Results: Elevated BMI was associated with slightly increased risk of overall reoperation (odds ratio (OR): 1.03, P = 0.036) and 30-day readmission (OR: 1.05, P = 0.029). Rising BMI was also associated with greater length of stay (P = 0.005), supplemental oxygen requirement to at least postoperative day two (P = 0.016), and postoperative hypoxemia beyond 24 hours (P = 0.038). No associations were noted between BMI and 30- or 90-day reoperation, 90-day readmission, or other postoperative complications (all P > 0.05).

Conclusion: Revision TKA is an essential intervention to restore function after failed primary TKA. This study suggests that failure rates and complications following rTKA remain high compared to primary procedures, with increased risk for overall re-reoperation and early readmission at 30 days. Otherwise, the complication profile was similar across the spectrum of BMI values. Further research is warranted to clarify the role of BMI in operative planning and prognosis.

Background: Population-based data on long-term dislocation risks are currently lacking in literature. Thus, the purpose of this study was to investigate the long-term cumulative incidence of dislocation after total hip arthroplasty (THA) stratified by femoral head size. Furthermore, we investigated the difference in cumulative incidence of dislocation over different time periods.

Methods: We conducted a population-based cohort study utilizing data from the Danish Hip Arthroplasty Register (DHR) and the Danish National Patient Register (DNPR). The cohort comprised 56,515 THAs. The study included patients who had a primary THA due to primary osteoarthritis, performed in Denmark from 2000 to 2016. Follow-up was extended until death, implant removal, or December 31, 2021, to ensure a potential minimum five-year follow-up period. We utilized a recently validated algorithm to include dislocations that were treated with closed reduction without revision. Cumulative incidence of dislocation was estimated using the Aalen-Johansen estimator with death and implant removal as competing risks. Cumulative incidence of dislocation was stratified by femoral head size and the three time periods: 2000 to 2004, 2005 to 2009, and 2010 to 2016.

Results: The 10-year cumulative incidence of dislocation was 8.8% (95% confidence interval (CI), 8.4 to 9.3) for 28-mm femoral heads, 7.4% (95% CI, 7.0 to 7.9) for 32-mm, and 5.7% (95% CI, 5.4 to 6.0) for 36-mm. Changes over time showed an increase in dislocations for 28- and 32-mm femoral heads, whereas no difference was found for the 36-mm group.

Conclusion: We found that the cumulative incidence of dislocation continued to increase after surgery. It varied from 5.7 to 8.8% after 10 years. The larger femoral heads were associated with lower dislocation rates. Furthermore, we found that 28- and 32-mm femoral heads were associated with a higher cumulative incidence of dislocation in patients who were operated on in more recent years.

Background: Previous research on periprosthetic fractures (PPF) following total knee arthroplasty (TKA) has primarily addressed late postoperative complications. Evidence concerning intraoperative and early (≤ 90 day) fractures remains limited, particularly within Eastern European and Middle Eastern populations. This study aimed to evaluate the incidence and identify risk factors for such fractures in a large national cohort.

Methods: A retrospective analysis was conducted on 1,243 patients and 1,440 knees who underwent primary TKA between 2014 and 2023. Fractures developed in 35 knees (2.4%) intraoperatively or within 90 days after surgery and constituted the study group. Patients in the fracture group were older, with a mean age of 71 ± 8.8 years compared with 68 ± 7.6 years in the non-fracture group (P = 0.014). Demographic data, comorbidities, preoperative coronal alignment, and characteristics of the implants were compared between the two groups. Uni- and multivariate regression analyses were performed to determine risk factors based on the location of the fracture.

Results: In multivariate regression analyses, independent risk factors for femoral PPF included the use of a constrained condylar insert without a femoral stem (odds ratio (OR): 54, 95% confidence interval (CI): 3.7 to 1016; P = 0.002), a diagnosis of osteoporosis (OR: 20.5, 95% CI: 5.4 to 77.2; P = 0.001), anterior femoral notching (OR: 11.4, 95% CI: 2.9 to 44.6; P = 0.001), and the use of a posterior-stabilized femoral component (OR: 6.9, 95% CI: 1.8 to 27; P = 0.003). For tibial fractures, preoperative valgus alignment was identified as a risk factor (OR: 11, 95% CI: 2.7 to 45.9; P = 0.001).

Conclusions: Preoperative identification and optimization of osteoporotic patients, careful management of valgus deformities, avoidance of anterior femoral notching, and the use of femoral stems when employing high-constraint inserts may help reduce the risk of PPF.

Introduction: Repeat two-stage revision remains a salvage option for managing recurrent periprosthetic joint infection (PJI) of the hip after a failed initial revision. However, the evidence base for this approach is limited. This study aimed to evaluate treatment outcomes and identify risk factors for failure following repeat two-stage revision arthroplasty for hip PJI.

Methods: We conducted a retrospective review of prospectively maintained databases from two tertiary centers to identify patients who underwent repeat two-stage revision for chronic hip PJI between 1991 and 2022. Treatment success was defined using the 2019 Musculoskeletal Infection Society (MSIS) Tier 1 criteria. Kaplan-Meier survivorship analysis and Cox regressions were used to assess outcomes and potential predictors of reinfection. There were 52 patients who met the inclusion criteria. There were 16 patients who did not proceed to second-stage implantation, leaving 36 cases who completed repeat two-stage exchange. Mean follow-up of 10.7 years (range, 0.3 to 33.4).

Results: Using MSIS Tier-1 criteria, treatment success was achieved in 21 of 36 patients (58.3%). All-cause implant survival was 66.2% at five years, while survival free from PJI was 76.4%. At final follow-up, recurrent PJI occurred in 11 cases, with further surgery or long-term suppressive antibiotics required in 15 patients. There were no variables, including body mass index, American Society of Anesthesiologists, or McPherson host grade, predictive of failure. A change in causative organism was observed in 47.2% of culture-positive cases.

Conclusion: Repeat two-stage revision for hip PJI is associated with low success rates, even in carefully selected patients. These findings highlight the complexity of managing recurrent infection and underscore the need for realistic counselling, multidisciplinary care, and consideration of alternative strategies.

Background: Although cementless stems are increasingly favored in primary total hip arthroplasty (pTHA), the impact of stem designs on postoperative complications such as periprosthetic femoral fracture (PFF) remains debated. This study compared PFF rates between cemented and cementless pTHA, focusing on cementless stem geometries.

Methods: We systematically searched PubMed, Embase, Web of Science, Scopus, Google Scholar, and CENTRAL from inception through March 2025. Eligible studies compared cemented and cementless stems in adults undergoing elective pTHAs, reported PFF incidence, and specified cementless stem design. Using a random-effects model, we calculated pooled odds ratios (OR) and 95% confidence intervals (95% CI) for primary (PFF) and secondary outcomes (aseptic loosening, dislocation, periprosthetic joint infection (PJI), surgical site infection, and all-cause revision). There were eighteen studies (55,942 pTHAs) included. Subgroup analyses were performed by cementless stem designs and age. Meta-regression was conducted to investigate heterogeneity across the study.

Results: The pooled PFF rate was 1.3% (95% CI: 0.9 to 2.0) for cementless and 0.9% (95% CI: 0.6 to 1.5) for cemented pTHA (OR = 1.38; 95% CI: 0.95 to 2.02; P = 0.089; I² = 45.4%). Quadrangular stems (Type B2) significantly reduced PFF risk (OR = 0.78; 95% CI: 0.64 to 0.96, P = 0.033; I² = 0.0%), while anatomic fit-and-fill stems (Type C2) increased this risk (OR = 2.86; 95% CI = 2.10 to 3.90, P < 0.001; I² = 0.0%) and all-cause revision risk (OR = 1.16; 95% CI = 1.10 to 1.22, P = 0.001; I² = 0.0%). Cementless stems were associated with lower aseptic loosening (OR = 0.36; 95% CI = 0.23 to 0.56; P < 0.001; I² = 50.0%).

Conclusion: Quadrangular stems were protective against PFF, while anatomic designs increased PFF and all-cause revision rates. These findings highlight the need for stem-specific considerations in surgical decision-making.

Background: The popularity of condylar-stabilized (CS) designs in primary total knee arthroplasty (TKA) is increasing. However, CS designs lack consistent classification and registry data examining survivorship. This study assessed revision risk and patient-reported outcome measures (PROMs) among CS designs and compared them to cruciate-retaining (CR) and posterior-stabilized (PS) designs using the American Joint Replacement Registry (AJRR).

Materials and methods: The AJRR was queried for all patients 65 years of age and older undergoing elective primary TKA with CR (n = 111,622), PS (n = 282,487), or CS (n = 162,648) designs between January 2012 and December 2021, with a minimum two-year follow-up. The CS designs were classified as anterior-stabilized (n = 96,897), ultracongruent (n = 29,427), medial-stabilized (n = 21,555), medial-pivot (n = 11,171), and lateral-stabilized (n = 3,598). Outcomes analyzed included all-cause revision, revision for infection, aseptic revision, and patient-reported outcome measures (PROMs).

Results: Compared to the CR designs, medial-stabilized designs demonstrated lower all-cause adjusted hazard ratio (aHR) = 0.77, confidence interval (CI): 0.66 to 0.90, P < 0.001) and aseptic revision risk (aHR = 0.75, CI: 0.62 to 0.90, P = 0.002), lateral-stabilized designs had higher all-cause (aHR = 1.62, CI: 1.29 to 2.03, P < 0.001) and aseptic revision risk (aHR = 1.53, CI: 1.22 to 1.91, P < 0.001), and medial-pivot designs had higher all-cause (aHR = 1.23, CI: 1.02 to 1.48, P = 0.028) revision risk. There were no other differences when comparing the CR designs to the CS design subgroups. The PS designs had a higher risk of aseptic failure (aHR = 1.09, CI: 1.01 to 1.17, P < 0.001) compared to the CS designs, but there was no difference between the CR and the CS designs. There was no significant difference in the likelihood of achieving the minimal clinically important difference (MCID) in PROMs between groups at one-year postoperatively.

Conclusions: The CS designs demonstrate improved survivorship compared to the PS designs and have comparable revision risk to the CR designs. Among the CS designs, medial-stabilized designs demonstrate decreased revision risk, while lateral-stabilized and medial-pivot designs have a higher risk of revision. There was no difference in achieving MCID in PROMs among designs.