Journal of Arthroplasty最新文献

Background: This study sought to evaluate patient-reported outcome measures (PROMs) before primary total joint arthroplasty (TJA) and after successful treatment for periprosthetic joint infection (PJI), with the hypothesis that patients still demonstrate clinical improvement despite the occurrence of PJI.

Methods: A single tertiary academic center's institutional database was retrospectively reviewed for patients who underwent primary TJA, developed PJI, and were managed for PJI from January 2019 to December 2023. Patients who did not have PROMs recorded were excluded from the study. Pre- and postoperative generic and joint-specific PROMs were collected. Patient pre-primary and post-final revision surgery for PJI PROMs were subsequently compared. The minimum follow-up after PJI treatment was six months. A total of 55 patients (31 TKA and 24 THA) were included with a mean follow-up of 1.8 years (range, six months to 4.5 years). All PJIs were managed via debridement, antibiotics, and implant retention (DAIR), 1-stage, 1.5-stage, 2-stage revision, or resection arthroplasty.

Results: After final revision surgery for PJI in TKA, patients had lower median patient-reported outcome measure information system (PROMIS) pain interference (PI) scores than before their primary surgery (62.0 [55.0, 67.0] versus 67.0 [65.0, 70.5]; P < 0.01). However, median PROMIS physical function (PF) post-final revision for PJI and pre-primary scores were similar (38.0 [33.0, 42.0] versus 34.0 [29.5, 40.0]; P = 0.08). After final revision surgery for PJI in THA, patients had lower median PROMIS PI scores than before their primary surgery (57.5 [53.8, 64.0] versus 68.0 [66.5, 74.0]; P < 0.01). After final revision surgery for PJI, patients also had higher median PROMIS PF scores than before their primary surgery (39.5 [33.5, 48.2] versus 29.5 [28.8, 34.2]; P < 0.01).

Conclusion: Patients who have been successfully managed for PJI show improvement in generic and joint-specific PROMs compared to their pre-primary TJA PROMs.

Introduction: Biomechanical studies suggest mobile-bearing rotating platform total knee arthroplasty (TKA-RP) has limited tolerance of asymmetric flexion gaps, and improper balancing may result in polyethylene insert instability. We sought to identify a distinctive pattern of polyethylene insert damage associated with clinical failure of TKA-RP.

Methods: There were nine patients who had an index TKA-RP and underwent a revision for symptomatic flexion instability (clinical cohort) from 2013 to 2019. There were 30 TKA-RPs (registry cohort) that were randomly selected from an all-cause revision retrieval database with archived clinical and demographic data. Based upon prior biomechanical testing, we hypothesized a distinctive pattern of polyethylene damage would occur on the postero-lateral articular surface with dynamic instability. Polyethylene inserts were inspected by three experienced reviewers using the modified Hood method and categorized according to clinical instability and damage pattern. Each registry implant was dichotomized with damage either consistent or not, with that observed in the clinical cohort.

Results: Of the nine, seven clinical cohort inserts exhibited a consistent pattern of polyethylene damage on the postero-lateral articular surface, ranging from localized loss of machine lines on the insert margin to gross deformation of the articular surface lip with loss of peripheral wall contour. In five of these seven knees, both components were secure at revision. Of the 30 registry cohort patients, nine reported mechanical symptoms of clinical instability. There were eight inserts that exhibited a polyethylene damage pattern similar to that observed in the "clinical cohort"; only two knees had both components secure at revision.

Conclusions: The majority (15 of 18) of retrieved TKA-RP inserts associated with clinical instability exhibited a distinctive pattern of postero-lateral articular surface polyethylene damage, suggesting posterior condyle subluxation over the peripheral insert wall as predicted by cadaveric testing. Concomitant aseptic loosening did not preclude this hallmark damage pattern.

Level of evidence: Level IV.

Introduction: The impact of previous pelvic osteotomy (PO) on outcomes following conversion to total hip arthroplasty (THA) remains unclear. Our systematic review aimed to compare the outcomes of patients undergoing THA following PO to those undergoing primary THA.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a search of five online databases was performed to identify articles published between January 1, 2000, and January 1, 2024, reporting on outcomes of patients who did and did not have previous PO undergoing THA. Articles with a minimum 2-year follow-up were included. The risk of bias was evaluated through the Methodological Index for Non-Randomized Studies (MINORS) tool. A total of 17 articles reporting on 542 THAs with previous POs were included. All articles were of moderate or high quality.

Results: Although the data was mixed for certain outcomes, a majority of included studies demonstrated that patients who had a previous PO had similar functional outcomes and survivorship, as well as complication and reoperation rates, compared to patients undergoing primary THA. However, a history of PO resulted in consistently longer operative times, higher estimated blood loss, and less medialization of the acetabular component.

Conclusion: Patients who had a previous PO were found to have comparable functional outcomes, complication rates, and survivorship following THA relative to controls who did not have a previous surgical history. The differences in acetabular component positioning and intraoperative outcomes allude to the increased operative complexity of conversion THA. More information is needed to determine how factors such as osteotomy type and timing between osteotomy and THA impact the evaluated outcomes.

Background: Despite several markers being evaluated and available in recent years, diagnosing periprosthetic joint infection (PJI) remains challenging. There is a pressing need to explore reliable, economical, convenient, highly sensitive, and specific diagnostic biomarkers to diagnose PJI. This study aimed to investigate the diagnostic value of combined serum markers with CRP and ESR in PJI.

Methods: A total of 841 revision arthroplasty cases, including 435 PJI and 406 non-PJI patients, were enrolled from January 2010 through December 2022. The diagnostic values of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), CRP + ESR (CE), CRP/hemoglobin ratio (CHR), CRP/albumin ratio (CAR), CRP/hemoglobin + albumin ratio (C/HAR), ESR/hemoglobin ratio (EHR), ESR/albumin ratio (EAR), ESR/hemoglobin + albumin ratio (E/HAR), and hemoglobin + albumin (HA) were evaluated using sensitivity, specificity, and receiver operating characteristics analysis with area under the curve (AUC). The optimal threshold was determined using the Youden index.

Results: The CHR had the highest AUC (0.87, 95% CI [confidence interval] 0.85 to 0.90) and sensitivity (0.81, 95% CI 0.77 to 0.85) compared to other markers. The CHR exhibited reliable diagnostic adequacy for PJIs caused by low-virulent organisms (sensitivity 0.83, 95% CI 0.76 to 0.89; specificity 0.83, 95% CI 0.79 to 0.86). However, CHR displayed poor sensitivity (0.77, 95% CI 0.67 to 0.86) in patients who have diabetes.

Conclusions: The CHR demonstrated better diagnostic strength in detecting chronic PJI than other classical markers, especially in identifying low-grade infections. Our findings offer new insights into a more accurate and comprehensive picture of pathogens and hosts, thereby improving the accuracy of diagnostic algorithms.

Background: Postoperative knee range of motion (ROM) is among the most frequently reported functional metrics following total knee arthroplasty (TKA). Despite the major use of ROM as a metric, minimal literature exists assessing the progression of motion postoperatively over time or its implications on patient-reported outcome measures (PROMs). As such, this study aimed to (1) determine the recovery trajectory in knee ROM during the first year following primary TKA and (2) determine if a correlation existed between patients' ROM recovery trajectory and PROM scores.

Methods: Data was collected prospectively on all patients undergoing a unilateral primary TKA between 2017 and 2019. Standardized goniometric measurements were used to measure knee flexion and extension at five time points: preoperatively, intraoperatively, and postoperatively at two weeks, six weeks, and one year. In addition, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) was collected preoperatively and at the one-year postoperative visit. A total of 306 TKA procedures were performed on 269 patients, and of those patients, 63.9% (N = 172) were women and 36.1% (N = 97) were men who had a mean age of 67 years (range, 29.0 to 89.4) and a mean body mass index (BMI) of 30.8 (range, 18.2 to 49.0).

Results: Mean knee flexion significantly increased from 112.8 (range, 63.0 to 140.0) degrees preoperatively to 119.0 (range, 95.0 to 140.0) degrees at one year postoperatively (mean difference = 4.61, P < 0.001). More specifically, 97.4% of flexion was restored by six weeks (111.2; range, 58.0 to 132.0) postoperatively. Knee extension also significantly improved from 5.9 (range, -5.0 to 32.0) degrees to 0.9 (range, 0 to 8.0) degrees at one-year follow-up (mean difference = 5.03, P < 0.001). A weak positive correlation existed between preoperative ROM and KOOS JR scores (r = 0.24, P < 0.01).

Conclusion: Knee flexion ROM is restored in a nonlinear trajectory following a primary TKA, with over 90% of the progress occurring within the first six weeks postoperatively. In contrast, knee extension ROM is restored in a more linear manner. At one year postoperatively, target ROM fell between preoperative and intraoperative measurements. Neither ROM nor the recovery trajectory of motion correlates with KOOS-JR scores. As such, this information can be valuable when attempting to set expectations for patient recovery.

Introduction: Healthcare finance in the United States is continually changing with increased consolidation of healthcare organizations, fluctuating reimbursement cycles, and shifting institutional and federal policy. The economics of practicing medicine are dynamic and challenging relative to other professions. The purpose of this study is to analyze compensation trends in orthopaedic surgery over the past 20 years compared to other professions.

Methods: Income data for orthopaedic surgeons and other professions every five years from 2000 to 2020 was collected from the United States Bureau of Labor Statistics and peer-reviewed literature. Income data were adjusted for inflation and analyzed to identify trends in compensation.

Results: The rate of absolute income trajectory over two decades for orthopaedic surgeons when adjusted for inflation was -38%. Outside of healthcare professions, economists, lawyers, and engineers saw some of the highest increases with inflation-adjusted increases at +31, 26, 24%, respectively. Orthopaedic surgeon salary rates declined the most of all professions analyzed, including all healthcare workers.

Conclusion: Adjusted orthopaedic surgeon compensation has declined significantly in the two decades between 2000 to 2020. Compared to other high-skilled professions, orthopaedic compensation showed the greatest decline in adjusted rates over time. This trend carries major implications for the future of the field, potentially affecting recruitment, satisfaction, burnout, and patient access to care. It underscores the need for a re-evaluation of compensation models in orthopaedic surgery to ensure sustainability.

Background: Controversy continues to exist regarding the most appropriate femoral implant selection in older patients undergoing total hip arthroplasty (THA). Our study aimed to compare the survivorship, reasons for revision, and patient-reported outcome measures (PROMs) of uncemented versus cemented THA in patients aged ≥ 70 years.

Methods: This retrospective study reviewed primary THAs performed on patients aged ≥ 70 years between January 1, 2007, and October 1, 2019. A total of 2,136 patients [cemented (n = 355), cementless (n = 1,781)] were included. Demographics including age (77 versus 83), Body Mass Index (BMI) (29 versus 26), and sex (59 versus 83% women) were different between the cementless and cemented THA cohorts, respectively. Patient characteristics, implant characteristics, revision information, mortality, and PROMs [Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Veterans Rand 12 Item Health Survey (VR12), and the Harris Hip Score (HHS)] were collected. Kaplan-Meier survivorship was performed with all-cause, aseptic, and aseptic stem revisions as the endpoint. Change scores were calculated and compared with independent t-tests.

Results: There were no differences in the 5- and 10-year cumulative survival in the cementless and cemented THA cohorts for all-cause (P = 0.11), aseptic (P = 0.83), and aseptic stem revisions (P = 0.61). Both cohorts demonstrated excellent long-term survival for all-cause (96.8 versus 95.5), aseptic (97.8 versus 98.3), and aseptic stem (98.4 versus 98.3) revisions. There were no differences in change scores for WOMAC (33.9 versus 35.3, P = 0.48), VR12 Mental (0.56 versus 1.42, P = 0.58), VR12 Physical (8.9 versus 8.0, P = 0.21), and HHS (43.1 versus 44.9, P = 0.25) scores between the cementless and cemented cohorts at the latest follow-up.

Conclusion: No difference was found in survival rates of cementless compared to cemented stems for all causes and aseptic causes in patients aged ≥ 70 years undergoing elective THA. Both cementless and cemented femoral stems provide a safe and efficacious option for performing THA in older patients.

Introduction: As total hip arthroplasty (THA) transitions to the outpatient setting, so will some revision procedures. However, revisions are more complex and have greater impact physiologic stress on the patient. Therefore, the purposes of this study were to (1) evaluate the number of patients discharged within 24 hours following revision; (2) compare the proportion of patients discharged following ball/liner exchange versus any component revision; and (3) determine the factors leading to successful discharge within 24 hours following revision THA (rTHA).

Methods: There were 2,446 rTHA surgeries between 2017 and 2023 reviewed, of which 944 (38.6%) were included in the final analysis. There were 415 (44%) ball/liner exchanges and 529 (56%) component revisions. Septic revisions and patients who stayed in the hospital for > 72 hours were excluded. Patients were split into two cohorts: (1) those discharged within 24 hours and (2) those who stayed in the hospital between 24 to 72 hours. Basic demographics and multiple perioperative factors were compared between cohorts.

Results: There were 192 (20%) patients discharged within 24 hours following the rTHA, 126 (30.4%) following ball/liner exchange versus 66 (12.5%) following any component revision (P < 0.001). Medical complications that required intervention occurred in 179 (34%) patients undergoing ball/liner exchange compared to 270 (65%) patients undergoing any component revision (P < 0.01). There were no significant differences in patient comorbidities between cohorts, but patients undergoing any component revision were older, had greater estimated blood loss, more complications, and a longer time to PT (physical therapy) clearance, which was 29.6 hours in the ball/liner cohort compared to 39.1 hours in any component revision cohort (P < 0.0001).

Conclusions: Despite modern enhanced recovery protocols, discharge within 24 hours following aseptic rTHA remains uncommon. Medical complications requiring active management occurred in nearly 50% of patients. The strongest predictors of same-day discharge were time to achieving PT milestones and the absence of perioperative complications.

Background: This study examines the association between insurance type (Medicaid, Medicare, and private) and 90-day complications and patient-reported outcomes (PROs) following primary total joint arthroplasty.

Methods: Data from a single health system comprised of six hospitals was queried to include patients who underwent total joint arthroplasty (TJA) from 2013 to 2023. The cohort consisted of 65,300 TJA cases (49,936 patients), with 52.6% privately insured, 42.64% Medicare, and 4.77% Medicaid. Medicaid patients were younger, with higher body mass index (BMIs:, smoking rates, and preoperative opioid usage (P < 0.001). Patients were categorized by insurance type and demographic information, comorbidities, 90-day outcomes, complications, and PROs were analyzed.

Results: Medicaid patients had 81.7% higher emergency department visit odds than those privately insured and 63.6% more than Medicare (P < 0.0001). Medicaid payer status was associated with 63.3% increased odds of developing deep vein thrombosis (DVT) compared to private insurance (P = 0.0119). Medicaid and Medicare patients faced 24.3 and 31.1% greater readmission odds than privately insured (P < 0.0001), respectively. Medicare patients had higher odds of urinary tract infections (UTI), periprosthetic joint infections (PJI), dislocation, and fracture (P < 0.0001). Conversely, private-payer patients were less likely to take preoperative medications and had fewer 90-day postoperative complications (P < 0.0001). Medicaid patients reported the lowest preoperative and postoperative Patient Reported Outcomes Measurement Information System (PROMIS) Mental and Physical scores, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Hip Injury and Osteoarthritis Outcome Score (HOOS), although they exhibited the greatest improvement in KOOS and HOOS scores after surgery.

Conclusion: Insurance payer type is significantly associated with postoperative outcomes, with Medicaid and Medicare patients experiencing higher complication rates and lower PROs than their privately insured counterparts. These disparities underscore the necessity for tailored preoperative and postoperative management in TJA patients based on insurance status.

Background: This study evaluated the effectiveness of antiseptic irrigation solutions, specifically chlorhexidine, and povidone-iodine, compared to normal saline after primary total joint arthroplasty (TJA) in preventing periprosthetic joint infection (PJI).

Methods: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE, Embase, and the Cochrane Library databases for studies comparing the use of different intraoperative irrigation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 11 studies, including 67,742 patients, were included. The outcome of interest was the rate of deep infections. Statistical analysis was conducted using a random-effect model, with heterogeneity assessed via I² statistics.

Results: The random-effect model analysis revealed a PJI rate of 1.02% (95% CI [confidence interval]: 0.77 to 1.35; I² = 90%) for the total cohort. Among 24,025 patients who received irrigation with either povidone-iodine or chlorhexidine, the PJI rate was 0.86% (95% CI: 0.63 to 1.17; I² = 75%). Povidone-iodine significantly reduced the risk of PJI compared to saline (RR [risk ratio] 0.60, 95% CI: 0.37 to 0.95; P = 0.029; I² = 61%). However, no significant difference was observed in the subgroups for THA (RR 0.92, 95% CI: 0.52 to 1.61; P = 0.57; I² = 0%) and TKA (RR 0.92, 95% CI: 0.47 to 1.77; P = 0.21; I² = 35%). Chlorhexidine also reduced the risk compared to saline (RR 0.60, 95% CI: 0.45 to 0.82; P = 0.001; I² = 0%). There was no significant difference between povidone-iodine and chlorhexidine (RR = 1.60, 95% CI: 0.84 to 3.06; P = 0.154; I² = 0%).

Conclusion: In this meta-analysis, chlorhexidine and povidone-iodine had a significantly reduced risk of PJI as compared with saline irrigation in TJA. There was no significant difference between chlorhexidine and povidone-iodine.