Journal of Arthroplasty最新文献

Background: Osteonecrosis (ON) of the knee commonly affects the medial femoral condyle, leading to secondary unicompartmental arthritis. While most studies on unicompartmental knee arthroplasty (UKA) in patients who have ON focus on cemented fixation, the outcomes of cementless UKA remain unknown. This study evaluated survival, functional and radiological outcomes, and assessed potential differences for cemented and cementless medial mobile-bearing UKA in patients who had ON.

Methods: This retrospective, single-center study analyzed 119 patients who underwent medial UKA for ON between 2020 and 2022, with a minimum follow-up of two years. Patients were stratified into cemented (n = 63, women/men 71/29%, mean age 70 ± nine years, BMI 29 ± 4) and cementless (n = 56, women/men 34/66%, mean age 72 ± eight years, BMI 28 ± 4) groups. Demographics were similar between groups, except for sex, with more men in the cementless UKA group (P < 0.001). Kaplan-Meier survival analysis compared survival rates for aseptic loosening, implant revision (exchange of the femoral or tibial component), and any reoperation. Functional outcomes were assessed using the Oxford Knee Score (OKS) and the UCLA (University of California, Los Angeles) Activity Score.

Results: At 50 months, cumulative survival rates showed no significant differences between cemented and cementless UKA for aseptic loosening (100 versus 97.7%; P = 0.35), implant revision (97.5 versus 93.3%; P = 0.36), or any reoperation (92.1 versus 87.0%; P = 0.35). There was one case of aseptic tibial subsidence that occurred in the cementless group in a patient who had femoral ON. Functional outcomes were excellent in both groups, with no significant differences in OKS (cemented/cementless: 42.6 ± 5.4 versus 43.5 ± 6.3; P = 0.12) or UCLA Activity Scores (6.1 ± 1.0 versus 6.1 ± 1.2; P = 0.57).

Conclusions: Cementless medial mobile-bearing UKA is a safe treatment option for ON in the medial compartment, offering stable primary fixation and implant survival comparable to cemented fixation. However, future research with sex-balanced cohorts and extended follow-up is needed to confirm these findings.

Background: The addition of corticosteroids to multimodal cocktail periarticular injections (MCPI) during total knee arthroplasty (TKA) has raised concerns about the risks of periprosthetic joint infection (PJI) despite their proven benefits. This study aimed to evaluate the impact of corticosteroid-enhanced multimodal cocktail periarticular injections (MCPI-S) on the incidence of PJI in patients undergoing TKA.

Methods: A retrospective cohort study was conducted using a longitudinally maintained institutional database, including 20,382 patients who underwent primary TKA between 2000 and 2018. Patients were divided into two groups: those receiving MCPI-S containing triamcinolone acetate and those receiving MCPI without corticosteroids. There were 10,094 patients who received MCPI, while 10,288 received MCPI-S during TKA. The primary outcome was the incidence of PJI within two years postoperatively. Statistical comparisons were performed using Mann-Whitney U and Pearson's Chi-square tests, with significance set at P < 0.05.

Results: The overall incidence of PJI was 0.4% (89 cases). The MCPI group had a PJI rate of 0.5% (51 cases) compared to 0.4% (38 cases) in the MCPI-S group (P = 0.14). The types of surgical interventions that required to manage PJI were similar between the groups (P = 0.43). There were no significant differences observed in demographic variables, except for a median age difference of 0.4 years, which was not clinically relevant.

Conclusions: The addition of corticosteroids, specifically triamcinolone acetate, to MCPI during TKA does not increase the risk of PJI. These findings provide strong evidence supporting the safety and efficacy of MCPI-S as part of a multimodal pain management strategy, offering reassurance for its routine use in clinical practice to enhance postoperative recovery.

Level of evidence: III.

Background: The Centers for Medicare and Medicaid Services now mandates the collection of patient-reported outcome measures (PROMs) before and after total knee arthroplasty (TKA), though their utility in predicting clinical outcomes remains unclear. This study compared the power of preoperative PROMs to predict clinical outcomes after TKA to established indices, including the Charlson Comorbidity Index and the Risk Assessment and Prediction Tool (RAPT).

Methods: We retrospectively reviewed 2,923 patients undergoing elective, primary, unilateral TKA who completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and four Patient-Reported Outcomes Measurement Information System (PROMIS) domains within 90 days preoperatively. Outcomes included same-day discharge (SDD) rate, prolonged length of stay (LOS ≥ 48 hours), nonhome discharge, 90-day readmission, and revision surgery. Predictive utility was assessed using receiver operating characteristic curves (area under the curve [AUC]) and multivariable logistic regressions.

Results: The RAPT was the strongest predictor of SDD (AUC = 0.697), extended LOS (AUC = 0.703), and nonhome discharge (AUC = 0.877). The PROMIS Physical Health (AUC = 0.609 for SDD; 0.607 for LOS; 0.696 for discharge) and PROMIS Mental Health (AUC = 0.613; 0.610; 0.655) demonstrated modest predictive value. In adjusted models, higher PROMIS Mental Health was associated with greater odds of SDD (odds ratio (OR) = 1.027, P = 0.003) and lower odds of extended LOS (OR = 0.975, P < 0.001). Higher PROMIS Physical Health was associated with decreased odds of nonhome discharge (OR = 0.935, P = 0.017). The Charlson Comorbidity Index was the strongest predictor of 90-day readmission (AUC = 0.604) and the only significant variable in adjusted models. There were no PROMs that were significant predictors of readmission or revision.

Conclusions: Preoperative PROMs are associated with some clinical outcomes following TKA, but demonstrate limited predictive power compared to established tools like the RAPT score. These findings underscore the need for more robust, outcome-aligned PROMs to improve surgical planning in a value-based care model.

Background: Obesity is an increasingly prevalent comorbidity that confers greater risks of postoperative complications following total joint arthroplasty, underscoring the need for viable preoperative weight loss. The objective of this study was to compare the risk of 90-day adverse events in patients undergoing total knee arthroplasty (TKA) following bariatric surgery versus treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RA).

Methods: A retrospective review of a national research network from May 1, 2005, to February 12, 2025, identified patients undergoing TKA with bariatric surgery or GLP-1 RA prescriptions in the 18 months preceding their joint arthroplasty. Following propensity score matching, 4,652 patients were selected for comparison in both the bariatric surgery and GLP-1 RA cohorts. For each cohort, patient demographics, 90-day orthopaedic and surgical complications, readmissions, and emergency department visits were collected. Statistical differences in relative risk (RR) between each complication were calculated with t-tests and Chi-square tests.

Results: In the 90-day postoperative period, patients who underwent bariatric surgery before TKA experienced greater rates of periprosthetic fractures (RR: 2.4; P = 0.016), periprosthetic joint infections (RR: 1.7; P = 0.002), revision surgeries (RR: 1.926; P = 0.005), cardiac events (RR: 1.255; P < 0.001), readmissions (RR: 1.316; P = 0.015), and emergency department visits (RR: 1.2; P < 0.001).

Conclusions: A significantly increased risk of postoperative events was identified in patients who underwent bariatric surgery. These findings, along with existing literature, suggest that GLP-1 RA use may be a preferred option for preoperative weight loss optimization in TKAs. Overall, greater clinical understanding is provided for this drug and may inform surgical decision-making regarding weight management strategies and their associated risks.

Background: The possible contribution of bronchoscopy to elevated periprosthetic joint infection (PJI) risks after total joint arthroplasty (TJA), including total knee arthroplasty (TKA) and total hip arthroplasty (THA), is a critical knowledge gap, despite its widespread use. This study aimed to (1) determine the PJI and revision rates over 30 months following TKA and THA in patients who underwent bronchoscopy within 18 months after surgery and (2) assess the role of the interval between arthroplasty and bronchoscopy in influencing these outcomes.

Methods: In this retrospective study, a large national database that includes data from more than 165 million cases was used to identify patients who had bronchoscopy within 18 months after TJA and patients who had not. These two groups were matched at a 1:1 ratio according to confounding factors. A total of 2,128 patients underwent bronchoscopy in the THA group, whereas 3,101 patients did so in the TKA group. The PJI and revision rates were assessed over 30 months following the TJA. To investigate the effect of bronchoscopy timing on PJI rates, we divided patients into four groups based on the time between their arthroplasty and bronchoscopy.

Results: Multivariate logistic regression revealed a statistically significant increase in the risk of PJI and revision in patients who underwent bronchoscopy within 18 months after TKA (PJI: odds ratio = 1.55, P < 0.001; revision: odds ratio = 1.35, P = 0.035), but not after THA. Further period subanalysis on the PJI rate indicated that patients undergoing bronchoscopy within zero to three months and six to nine months after TKA had a higher risk of PJI. There were no statistically significant differences observed in other periods.

Conclusions: Our research provides conclusive evidence that bronchoscopy increases the risk of PJIs, especially within the nine months following TKA. These results highlight how important it is for perioperative patient care to have multidisciplinary collaboration and precise risk management techniques.

Background: The third-generation ceramic-on-ceramic total hip arthroplasty (THA) offers excellent wear resistance and biocompatibility but is associated with unique complications such as ceramic fracture and squeaking. While fourth-generation ceramics have become the standard, long-term outcomes of third-generation bearings remain clinically relevant, especially in patients still living with these implants.

Methods: We retrospectively reviewed 533 hips in 417 patients who underwent primary alumina-on-alumina THA using ceramic bearings with a minimum 15-year follow-up (mean 17.4). After excluding deaths and losses to follow-up, 317 hips in 234 patients were analyzed. Kaplan-Meier analysis assessed implant survivorship, and multivariate logistic regressions identified risk factors for ceramic fractures, reoperations, and audible joint noises.

Results: The 20-year implant survivorship was 85.2% when considering reoperation for any cause and 94.4% when limited to ceramic fracture. Most fractures (11 of 12) occurred after 10.9 years postoperatively. Significant risk factors for ceramic fracture included men (odds ratio (OR) = 6.94, P = 0.022), higher body mass index (exponential β = 1.22, P = 0.035), short-neck heads (OR = 9.17, P = 0.020), sandwich liners (OR = 17.41, P = 0.007), and prior audible noise (OR = 6.03, P = 0.013). Squeaking and clunking were particularly associated with increased fracture and reoperation risk. Despite these complications, average patient-reported outcome measures remained within acceptable ranges.

Conclusions: A gradual decline in survivorship was observed beyond 15 years in third-generation ceramic-on-ceramic THAs, with a notable incidence of late-onset ceramic fractures. Risk factors included men, higher body mass index, short-neck heads, sandwich liners, and articular noises. The use of 28-mm heads, even with medium necks, should be avoided when possible in favor of 32-mm or larger heads. For patients who have previously had a 28-mm implant, annual follow-up is recommended to monitor for late complications.

Background: Sleep disturbances are common after total joint arthroplasty (TJA) and are associated with impaired recovery, increased complications, and prolonged hospital stays. Although various pharmacological interventions have been evaluated to improve postoperative sleep quality among TJA patients, consensus on their efficacy and safety remains elusive.

Methods: We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered the protocol in the International Prospective Register of Systematic Reviews. A comprehensive search of PubMed, Embase, Scopus, and Web of Science was performed on October 5, 2024, with no language or publication date restrictions. Randomized controlled trials comparing pharmacological interventions versus routine postoperative care in TJA patients were included. Data on subjective sleep quality scores and objective measures like actigraphy and polysomnography were extracted, and the risk of bias was assessed using the National Institutes of Health randomized controlled trial tool. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. There were 24 studies involving 2,934 patients included.

Results: Meta-analysis revealed that zolpidem significantly improved sleep quality (Hedges' g = -1.510; P < 0.001) and enhanced objective sleep parameters up to three weeks postoperatively. Anticonvulsants significantly improved sleep scores (Hedges' g = -0.603; P < 0.001), although they were associated with higher adverse event rates. Melatonin and corticosteroids showed minimal or no benefit on sleep quality.

Conclusions: Although zolpidem offers significant short-term improvements in postoperative sleep quality in TJA patients, its routine use is limited by safety concerns and adverse events. Melatonin, corticosteroids, and anticonvulsants provide inconsistent benefits, underscoring the need for more rigorous, standardized, and longer-term studies to establish optimal pharmacological strategies for enhancing postoperative recovery.

Level of evidence: II.

Background: With the expansion of total hip arthroplasty (THA) into younger populations, the number of periprosthetic fractures (PPFs) seen among young patients is expected to increase. Therefore, the aim of this study was to identify risk factors for PPF following THA in patients younger than 50 years METHODS: In total, 270,986 patients were included in this study. Patients who underwent primary THA with subsequent PPF within two years of surgery were stratified into five age cohorts: younger than 20, 21 to 30, 31 to 40, 41 to 50, and 51 to 60 years of age. Risk factors were identified using multivariate regression with the age 51- to 60-year cohort as reference. After applying the Bonferroni correction, a P-value of less than 0.03 was used as the cutoff for significance. All statistical analysis was conducted using R software (Vienna, Austria).

Results: In patients younger than 50 years, risk factors for PPF included undergoing THA for osteonecrosis (OR (odds ratio): 1.5; P < 0.001). Other risk factors included a history of arrhythmia (OR: 1.4; P < 0.001), peripheral vascular disease (OR: 1.2; P = 0.002), paralysis (OR: 1.3; P = 0.03), neurologic disease (OR: 1.8; P < 0.001), pulmonary disease (OR: 1.3; P < 0.001), chronic kidney disease (OR: 1.3; P < 0.001), anemia with blood loss (OR: 1.6; P = 0.01), and alcohol abuse (OR: 1.9; P = 0.001). Protective factors included hip osteoarthritis (OR: 0.8; P < 0.001), men (OR: 0.7; P < 0.001), and age of 40 to 50 years (OR: 0.8; P < 0.001).

Conclusions: Several risk factors for PPFs following THA in patients younger than 50 years were identified. Of note, hip osteoarthritis, men, and age 41 to 50 years were protective factors against PPFs. As the proportion of younger patients undergoing THA continues to increase, our results can be used to guide surgeons in identifying patients at increased risk for PPF and improve patient outcomes.

Background: Evidence supporting the favorable outcomes of total knee arthroplasty (TKA) in patients over 65 years of age is well established; however, less is known in younger cohorts, particularly in those less than 50 years old. Registries have shown an increasing demand for TKA in the younger population. This review aimed to determine the patient profile, implant survival rates, and functional outcomes of TKA in patients aged < 50 years.

Methods: A literature search in PubMed, EMBASE, and Cochrane was conducted, involving studies on TKA in patients aged < 50 years published from January 1, 2004, and December 31, 2024. Data from 15 studies included 17,705 patients. Data synthesis included study design, country, patient demographics, body mass index, follow-up duration, methodological quality (Methodological Index for Non-Randomized Studies score), surgical indications, and implant types. Meta-analyses assessed implant survivorship and postoperative Knee Society functional score and pre- and postoperative range of motion. Statistical analyses were performed using Review Manager version 5.3.

Results: Primary osteoarthritis was the most common indication for TKA in 11 studies, and aseptic loosening was the leading cause of revision in seven studies. Survivorship rates were 97% for less than five years, 95% for five to 10 years, and 87% for greater than 10 years, with the longest mean follow-up at 17 years. The mean postoperative range of motion was 121.5° (95% confidence interval: 107.6 to 135.4), and the mean postoperative Knee Society functional score was 85.3 (95% confidence interval: 79.1 to 91.5).

Conclusions: The patients profiled in this study have a mean age of 41 years, are more likely to be women, and have high body mass index, with comorbidities such as inflammatory joint conditions and predisposing factors, including corticosteroid use and prior surgeries, which may impact outcomes. There was favorable survivorship and functional outcomes comparable with TKA in other age groups of similar follow-ups. These findings aid in patient counseling, expectation setting, and TKA selection for this age group.

Background: Length of stay (LOS) is a substantial driver of costs following primary total knee arthroplasty (TKA), leading to increased efforts targeting same-day discharge (SDD). However, patient selection for SDD TKA remains a challenge, with 7 to 49% of patients failing to achieve planned SDD with current stratification tools. This study aimed to develop and assess multiclass machine learning (ML) models for patient selection for SDD TKA as well as risk for prolonged LOS using a large national patient cohort.

Methods: The database was queried to identify 167,859 primary TKAs between 2017 and 2023. The LOS was categorized into SDD (LOS = zero days), discharge within one to three days, and prolonged LOS (> three days). Machine learning models, including artificial neural networks, random forests (RF), k-nearest neighbors, and XGBoost, were developed and evaluated using the confusion matrix, Cohen's kappa, and the area under the receiver operating characteristic curve.

Results: Same-day discharge, discharge within one to three days, and prolonged LOS rates were 2.1, 88.1, and 9.8%, respectively. The RF demonstrated the best performance in predicting different LOS groups with an average precision of 90.2% and a recall of 90.3%. For multiclass classification, RF had an accuracy of 90.3%, a Cohen's kappa of 0.85, and a micro-averaged area under the receiver operating characteristic curve of 0.97. Prominent predictors of LOS included anesthesia type, sex, body mass index, American Society of Anesthesiologists score, hypertension, age, and operation time.

Conclusions: Our findings demonstrate the ability of ML models to accurately identify SDD-eligible and at-risk patients for prolonged LOS after primary TKA. Our models may assist surgeons with patient selection for outpatient surgery, thereby improving outcomes, resource allocation, and cost efficiency of TKA.