Journal of Arthroplasty最新文献

Background: Registry and industry data show increasing utilization of large (36 mm) heads in primary total hip arthroplasty (THA). Recent analysis of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) has reported reduced dislocation rates with 36 mm heads compared to 32- and 28-mm heads; however, the effect of age, fixation, approach, cup size, and bearing surface upon revision risk and head size has not been examined, with little data on all-cause revision.

Methods: The AOANJRR data were examined for all ceramic and metal head THA with highly crosslinked polyethylene between September 1999 and December 2022. There were 272,258 THAs identified. Cumulative percent revision (CPR) following THA was examined with further subanalysis of age, fixation, approach, cup size, and bearing surface for 32- and 36-mm heads.

Results: The CPR was higher for 36 mm heads from 1 month (HR [hazard ratio] 1.14 (1.08 to 1.20), P < 0.001). Subgroup analysis showed these differences varied depending on age, sex, approach, cup size, and bearing surface. There were differences in reasons for revision between head sizes, with significantly more revisions with 36 mm heads for fracture (HR 1.30 (1.18 to 1.42), P < 0.001), particularly for ≥ 65-year-olds, and loosening (HR 1.21 (1.09 to 1.34, P < 0.001), and significantly more revisions for dislocation (to a lesser degree) with 32 mm heads (HR 1.18 (1.07 to 1.30), P < 0.001).

Conclusions: Our study shows an association between larger head size and increased CPR. This difference is most clearly seen in metal-on-highly crosslinked polyethylene articulations, anterior approach, and 54- to 55-mm cup size in men < 65 years, although it still exists to a lesser extent in men ≥ 65 years. For women, the pattern was similar, although not as apparent. Comparing 36- to 32-mm heads, 36 mm showed reduced early dislocation; however, revision for fracture and loosening was increased. With an increasing trend toward larger head sizes both in the AOANJRR and elsewhere, consideration must be given in these particular subgroups as to whether larger head size confers the intended survival advantages.

Background: Periprosthetic joint infection is a severe complication after hip arthroplasty. While one-stage revision is increasingly used in Germany and other countries, the two-stage procedure remains the gold standard in much of the world. Meta-analyses report comparable or superior success rates for one-stage procedures, but it is unclear whether results from large orthopaedic centers can be reproduced in registry data reflecting broader clinical practice.

Methods: This observational cohort study used German Endoprosthesis Registry data (2013 to 2023) to compare re-revision and mortality rates between one-stage and two-stage revision total hip arthroplasty (RTHA). Cases included first-time RTHA (one-stage: n = 12,418; two-stage: n = 1,000) and multiple RTHA (one-stage: n = 2,459; two-stage: n = 810). Kaplan-Meier estimates were applied for analysis.

Results: Re-revision rates after first-time RTHA were similar at five years (21.1% one-stage versus 19.9% two-stage, P = 0.068), though slightly higher at one year for one-stage (16.1% versus 14.1%, P = 0.022). In multiple revisions, one-stage showed higher re-revision rates (one year: 26.5 versus 21.0%; five years: 32.2 versus 26.5%, P = 0.001). Mortality after first-time RTHA was higher for one-stage at one year (9.9 versus 6.3%, P = 0.014), but not significant at five years (26.5 versus 23.9%, P = 0.077). In multiple RTHA, mortality remained higher in the one-stage group (one year: 12.8 versus 5.5%, P < 0.001; five years: 31.9 versus 23.7%, P = 0.008).

Conclusions: Despite the excellent results reported for one-stage RTHA by individual large centers, nationwide data show significantly higher mortality rates in this procedure. This discrepancy raises concerns about broader implementation outside of specialized centers. Significant differences within the first year indicate an increased perioperative mortality for one-stage revision. While the re-revision rates are comparable, the increased mortality risk suggests that the one-stage approach cannot be recommended for wide use.

Background: Patients who have chronic pain may experience worse outcomes after total knee arthroplasty (TKA), yet its impact on postoperative metrics remains unclear. This study evaluated the prevalence of chronic pain diagnoses and their association with health care utilization, patient-reported outcome measures, and satisfaction.

Methods: A retrospective analysis of 13,894 primary unilateral TKAs performed from 2016 to 2022 at a tertiary center was conducted. Chronic pain diagnoses were identified via International Classification of Diseases, 9th Revision (338.2, 338.4) and 10th Revision (G89.2, G89.4) codes. Outcomes were compared using multivariable logistic regression. The patient-reported outcome measures included Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Shortform, Joint Replacement (JR), and Veterans RAND 12-Item Mental Component Score. Minimal clinically important difference and patient acceptable symptom state thresholds were assessed.

Results: Chronic pain was present in 23.4% (3,258 of 13,894) of patients. These patients had higher odds of 90-day readmission (OR [odds ratio] 1.27, 95% CI [confidence interval]: 1.1 to 1.46; P < 0.001) but were less likely to have a length of stay ≥ two days (OR 0.85, 95% CI: 0.76 to 0.95; P = 0.004). There was no significant association found with nonhome discharge (P = 0.301). Patients who had chronic pain had increased odds of failing to reach minimal clinically important difference in KOOS JR (OR 1.2, 95% CI: 1.0 to 1.43; P = 0.049) and Veterans RAND 12-Item Mental Component Score (OR 1.15, 95% CI: 1.03 to 1.29; P = 0.01). They were also more likely to fail patient acceptable symptom state thresholds in KOOS Pain (OR 1.25; P < 0.001), Physical Function Shortform (OR 1.22; P < 0.001), and JR (OR 1.28; P < 0.001). In addition, chronic pain patients had higher odds of dissatisfaction at one year (OR 1.17, 95% CI: 1.04 to 1.32; P = 0.011).

Conclusions: Chronic pain was independently associated with increased 90-day readmission risk and poorer postoperative outcomes, including failure to reach clinically relevant pain relief, functional improvement, and satisfaction. These findings highlight the need for targeted preoperative optimization strategies for chronic pain patients undergoing TKA.

Level of evidence: III (prospective).

Background: We aimed to explore the relationship between preoperative patient-reported outcome measure (PROM) phenotypes based on pain, function, and mental health with postoperative achievement of minimal clinically important difference, patient acceptable symptom state thresholds, and satisfaction at one year in patients undergoing medial unicompartmental knee arthroplasty (mUKA).

Methods: A prospective institutional cohort of 941 patients undergoing mUKA from 2016 to 2022 was included. Of these, 143 underwent robotic-assisted mUKA and 798 underwent manual mUKA. Preoperative scores on Knee injury and Osteoarthritis Outcome Score for Pain (KOOS Pain), KOOS Physical Function Shortform, and the Veterans RAND 12-Item Health Survey Mental Component Score were used to develop eight distinct PROM phenotypes representing above (+) or below (-) the median score for the cohort.

Results: Select preoperative PROM phenotypes were associated with a lower likelihood of failure to achieve minimal clinically important difference for KOOS Physical Function Shortform and Joint Replacement, while they were more likely to fail to achieve patient acceptable symptom state thresholds for all KOOS domains.

Conclusions: Patients undergoing mUKA who have certain baseline PROM phenotypes may not reach an acceptable symptomatic state, despite experiencing meaningful improvements at one year. These phenotypes could help determine surgical timing and identify high-risk patients who may benefit from targeted preoperative interventions and expectation management.

Background: Morbid obesity (body mass index [BMI] > 40) is associated with complications following total joint arthroplasty (TJA) and often prevents same-day discharge. However, advances in medical optimization are reshaping how patients who have a higher BMI are evaluated. This study examined whether modern preoperative optimization strategies can enable safe TJA for patients who have elevated BMIs at an ambulatory surgery center (ASC) by comparing complication rates (24-hour, one to 90 days) of patients in different BMI classes.

Methods: We retrospectively analyzed 2,367 patients who underwent primary TJA at an academic ASC from January 21, 2021, through September 18, 2024. Patients were categorized into five BMI groups per National Institutes of Health and World Health Organization reference ranges: normal weight (BMI < 25; n = 368), overweight (BMI 25 to < 30; n = 717), obesity class 1 (BMI 30 to <35; n = 675), obesity class 2 (BMI 35 to < 40; n = 417), and obesity class 3 (BMI ≥ 40; n = 190). Differences in presurgical wait times, intraoperative data, postanesthesia care unit (PACU) data, and complication rates were analyzed.

Results: There was no significant difference in immediate (24-hour) complications and complications between one and 90 days between BMI groups (P = 0.19 and P = 0.63, respectively). Increasing BMI did not correlate with higher complication rates when controlling for other covariates. Higher BMI was associated with longer presurgical wait times, shorter PACU time, and higher final PACU pain scores before discharge.

Conclusions: This study underscores the importance of personalized medical optimization in enhancing the safety of TJA for patients who have elevated BMIs. Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ASCs, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection.

Background: Fellowship training has become increasingly popular in the field of orthopaedics, with adult reconstruction being one of the most heavily pursued training pathways among residents. However, the value of this training is underexplored in the literature. This study sought to compare the incidences of complications, including periprosthetic joint infections (PJIs), periprosthetic fractures (PPFXs), and dislocations, between patients who underwent elective total hip arthroplasty (THA) by an arthroplasty-trained surgeon versus a nonarthroplasty surgeon at 90 days, one year, and two years.

Methods: We utilized a national database to identify a national cohort of patients who underwent elective THA from 2010 to 2021. From this set of patients, we obtained a physician report, which included the name, National Provider Identifier, and location of the operating surgeon. A web search was utilized to identify whether the physician had undergone fellowship training in adult reconstruction. Utilizing this information, patients were split into two cohorts based on their surgeon: arthroplasty-trained and nonarthroplasty-trained. A propensity score match was used to match patients based on demographics, comorbidities, and surgeon case volume, resulting in two cohorts of 177,777 patients each.

Results: At 90 days, patients in the nonarthroplasty cohort experienced higher incidences of surgical site infection (P = 0.002), venous thromboembolism (P = 0.006), PJI (P = 0.035), PPFX (P = 0.001), aseptic revision (P < 0.001), and dislocation (P < 0.001). At one and two years, these trends continued, with patients in the nonarthroplasty cohort experiencing higher rates of PJI, PPFX, aseptic revision, and dislocation (all P < 0.05).

Conclusions: Patients who underwent elective THA with arthroplasty-trained surgeons experienced fewer complications up to two years postoperatively.

Background: Primary THA may be performed with femoral stems that differ in shape and geometry. The purpose of this meta-analysis was to evaluate the revision and complication risks of the following stem designs: (1) anatomic; (2) single-wedge; (3) single-taper; and (4) taper wedge.

Methods: A comprehensive search of four electronic databases (PubMed, CINAHL Plus, EMBASE, and SCOPUS) was performed for all articles pertaining to this topic from January 2015 to January 2025. A total of 18 studies were selected for inclusion. There were: (1) 12,969 anatomic; (2) 17,115 single-taper; (3) 19,326 single-wedge; and (4) 1,965 taper wedge stems.

Results: The revision rate was highest within the anatomic stem cohort (3.9%; 95% confidence interval [CI], 3.6 to 4.2), with lower rates being found in single-taper (relative risk [RR], 0.38; 95% CI, 0.34 to 0.43; P = 0.0001), single-wedge (RR, 0.31; 95% CI, 0.27 to 0.35; P = 0.0001), and taper wedged stems (RR, 0.52; 95% CI, 0.4 to 0.68; P = 0.0001). Periprosthetic joint infection risk was 0.22% (95% CI, 0.15 to 0.31) within anatomic stems and was higher in single-taper (RR, 2.12; 95% CI, 1.5 to 2.98; P = 0.0002) and taper wedge cohorts (RR, 2.52; 95% CI, 1.27 to 5.01; P = 0.004). Aseptic loosening rate with anatomic stems was 0.65% (95% CI, 0.52 to 0.79), and the single wedge was lower (RR, 0.72; 95% CI, 0.56 to 0.92; P = 0.014). The risk of instability in anatomic stems was 0.44% (95% CI, 0.33 to 0.56) with a much lower rate in single-taper (RR, 0.7; 95% CI, 0.51 to 0.94; P = 0.025) and single-wedge stems (RR, 0.15; 95% CI, 0.09 to 0.25; P = 0.0001). Periprosthetic fracture incidence in anatomic stems was 1.4% (95% CI, 1.2 to 1.6). The rates were much lower in single-taper (RR, 0.74; 95% CI, 0.63 to 0.87; P = 0.001) and single-wedge cohorts (RR, 0.21; 95% CI, 0.16 to 0.27; P = 0.0001).

Conclusion: Anatomic stems had a higher risk of revision, instability, and fracture. The risk of periprosthetic joint infection was highest in taper wedge stems. Future research should focus on comparative studies that further investigate any potential increased risk of certain complications following primary THA based on various construct designs. Revision risk was highest in the anatomic stem cohort.

Background: A two-stage exchange arthroplasty is the standard treatment for chronic periprosthetic joint infection (PJI) of total hip arthroplasty (THA), though one-stage exchange arthroplasty is gaining interest. The proportion of THA PJIs eligible for one-stage exchange arthroplasty remains unclear. We aimed to determine what proportion of patients undergoing two-stage exchange arthroplasty for THA PJI met one-stage criteria and how eligibility impacted outcomes.

Methods: Between 2000 and 2020, there were 368 two-stage exchange arthroplasties for THA PJI at our institution. The mean age was 65 years, the mean body mass index (BMI) was 32, and 60% were men. The one-stage exchange arthroplasty eligibility criteria included unilateral PJI with preoperatively identified susceptible, nonfungal, and non-multi-resistant bacteria; McPherson A host status; no prior two-stage exchange arthroplasty; minimal bone or soft-tissue loss; and absence of sepsis. Cumulative incidences of reoperation for infection, re-revision for infection, any reoperation, and any re-revision were compared utilizing a competing risk model. The mean follow-up was five years.

Results: Overall, 23% met the eligibility criteria for one-stage exchange arthroplasty. The most common reasons for ineligibility were host grade (52%) and unidentified organism (25%). At two years, cumulative incidences of reoperation for infection for ineligible and eligible patients were 11 and 11%, respectively. At two years, the cumulative incidences of re-revision for infection for ineligible and eligible patients were 6 and 2%, respectively. Ineligible patients had a significantly higher 2-year cumulative incidence of any re-revision compared to eligible patients (12 versus 5%, respectively; HR [hazard ratio] = 2.5). There was no significant difference in the 2-year cumulative incidence of any reoperation between ineligible and eligible patients (18 versus 15%, respectively).

Conclusions: Only 23% of two-stage exchange arthroplasties for hip PJIs met the published eligibility criteria for one-stage exchange arthroplasty. The 2.5-fold increased hazard of any re-revision among ineligible patients must be considered when evaluating data comparing the two surgical strategies.

Level of evidence: III (retrospective).

Background: Some patients requiring joint arthroplasty are predisposed to preoperative venous thromboembolism (VTE). However, the impact of preoperative VTE has been infrequently reported. The objective was to investigate the risk factors and postoperative changes of preoperative VTE and assess joint arthroplasty safety.

Methods: This study included patients who underwent hip and knee arthroplasty between 2015 and 2022. The incidence and risk factors of preoperative VTE were analyzed, and management strategies for different patient groups were summarized. All patients underwent dynamic lower-limb vascular Doppler ultrasound examinations preoperatively, postoperatively, and during follow-up. Postoperative complications in patients who had preoperative VTE were documented, and factors influencing changes in preoperative VTE were systematically analyzed. The analysis included 7,878 patients, who had an average age of 65 years (range, 18 to 99). A total of 590 patients (7.5%) presented with preoperative VTE, including 423 hip arthroplasty and 167 knee arthroplasty cases. Among these, three cases (0.5%) had pulmonary embolism, 39 (6.6%) had proximal deep vein thrombosis (DVT), and 548 (92.9%) had distal DVT.

Results: Postoperatively, 85 patients experienced VTE progression, 379 had no change, and 106 showed improvement. There were no significant differences in mortality or pulmonary embolism rates between the preoperative VTE group and the non-VTE group (P > 0.05). Risk factors for the progression of preoperative VTE after surgery included unilateral DVT, postoperative D-dimer levels greater than five mg/L, and bed rest exceeding one day (P < 0.05). Conversely, hip fracture was associated with improved postoperative VTE outcomes, while prolonged bed rest was a hindering factor (P < 0.05). At the 3-month follow-up, 131 patients were found to have DVT. Within one year postoperatively, no patients developed symptomatic VTE, and 10 patients died from non-thrombus-related causes.

Conclusions: This study demonstrated that joint arthroplasty was safe for patients who had preoperative VTE. In addition, early ambulation after surgery aided thrombus improvement.

Background: Postoperative cognitive dysfunction (POCD) is a major complication in elderly patients undergoing total knee arthroplasty (TKA), often linked to neuroinflammation. Repetitive transcranial magnetic stimulation (rTMS) has shown potential in modulating neural activity and reducing inflammation, but its perioperative efficacy in preventing POCD remains underexplored. This study aimed to evaluate the effectiveness of perioperative rTMS in reducing POCD and inflammation in elderly patients undergoing TKA.

Methods: In this single-center, randomized, double-blind trial, 60 elderly patients (≥ 60 years) scheduled for primary, elective TKA were randomly assigned to either an active-rTMS or sham-rTMS group. The active-rTMS group received 10 Hz stimulation targeting the dorsolateral prefrontal cortex for five consecutive days perioperatively, while the sham-rTMS group underwent identical procedures with the coil positioned perpendicularly to the skull to ensure no active stimulation. Cognitive function was assessed using the Montreal Cognitive Assessment, and serum inflammatory biomarkers, including interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor alpha, and high mobility group box 1, were measured on preoperative days six and one and postoperative days three (POD three) and seven (POD seven).

Results: The active-rTMS group demonstrated significantly higher Montreal Cognitive Assessment scores at postoperative days three and seven (POD three: 25.3 ± 1.4 versus 23.7 ± 2.1, P = 0.001; POD seven: 26.1 ± 1.2 versus 24.4 ± 1.7, P < 0.001) and a lower cumulative POCD incidence (two versus 10 cases, P = 0.01). Postoperative levels of IL-1β, IL-6, tumor necrosis factor alpha, and high mobility group box 1 were significantly reduced in the active-rTMS group (P ≤ 0.002), indicating attenuated neuroinflammation.

Conclusions: Perioperative rTMS significantly reduces POCD incidence and inflammation in elderly patients undergoing TKA, supporting its potential as a noninvasive strategy to preserve cognitive function.