Journal of Arthroplasty最新文献

Background: We determined the long-term (≥ 20 years) clinical outcomes of metaphyseal-fitting anatomic cementless implants with alumina ceramic-on-ceramic (C-O-C) or alumina ceramic-on-highly cross-linked polyethylene (C-O-HXLPE) bearings.

Methods: Consecutive primary total hip arthroplasty (THA) procedures were performed in 250 patients (500 hips; 140 men, 110 women) aged < 65 years. This is a series of bilateral THA patients who were randomized to receive a C-O-C bearing on one side and a C-O-HXLPE on the contralateral side. The mean age at the time of THA was 45 years (range, 31 to 65), with a mean follow-up of 25.5 years (range, 20 to 30). Osteolysis was assessed using radiographs and computed tomography scans, whereas polyethylene wear was measured using a computer software program.

Results: There was no hip in either group that had osteolysis. The mean polyethylene penetration rate of the HXLPE liner was 0.041 ± 0.005 mm/year. The survival rate in the C-O-C bearing group was 96.8% (95% confidence interval [CI], 92 to 100) for the femoral component and 97.2% (95% CI, 92 to 100) for the acetabular component at a mean of 25.5 years of follow-up. In the C-O-HXLPE bearing group, the survival rate for both femoral and acetabular components was 97.6% (95% CI, 92 to 100) at a mean of 25.5 years of follow-up. The clinical and functional results (Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, and University of California, Los Angeles, activity score) improved significantly (P < 0.05) at the final follow-up in both groups.

Conclusions: At a mean follow-up of 25.5 years, a metaphyseal-fitting anatomic cementless femoral stem with alumina C-O-C or alumina C-O-HXLPE bearings demonstrated excellent long-term function, with no osteolysis and no ceramic femoral head or acetabular liner fractures.

Background: In this study, we investigated the 20-year wear properties and survivorship of a highly cross-linked polyethylene liner (PE) used in total hip arthroplasty. We expected wear properties of less than one mm/year and improved survivorship when compared to the current literature after 20 years of follow-up.

Methods: A retrospective review of our institution's electronic medical record was conducted from 1999 to 2003. Patients who underwent total hip arthroplasty by a single fellowship-trained orthopedic surgeon with placement of a highly cross-linked polyethylene with 20-year follow-up were included. Patients who lacked appropriate follow-up or adequate electronic medical record data, or who were unreachable via telephone were excluded. In total, 89 patients were reviewed to determine revision rates. In addition, the earliest hip radiographs were compared to recent follow-up images via an independent reviewer utilizing computer software to quantify wear.

Results: The majority of patients underwent surgery secondary to end-stage primary osteoarthritis (70.8%). Out of 89 patients, there were seven revisions (7.9%). Of those revisions, one was secondary to osteolysis (14.3%), two were due to infection (28.6%), and four were due to dislocation (57.1%). There were 66 patients who underwent wear rate analysis, showing a mean linear wear rate of 0.06 ± 0.07 (mm/year). The mean volumetric wear rate was 11.8 ± 13.2 (mm³/year). At 20 years, the survival probability of this PE for all-cause revision was 93.5% (95% confidence interval: 88.2 to 99.2), while the survival probability for revision due to osteolysis was 98.6% (95% confidence interval: 95.9 to 99.9).

Conclusions: When utilizing a highly cross-linked, electron beam-radiated, and melt-annealed PE, only one patient underwent revision for osteolysis. Implementation of these liners demonstrates minimal volumetric and linear wear rates and shows excellent long-term survivability after 20 years follow-up.

Background: Creating optimal training environments for future academic leaders in arthroplasty is a topic of increasing interest. This study determined the training characteristics associated with future academic faculty appointments after arthroplasty fellowship training.

Methods: This was a retrospective case-control study of arthroplasty fellowship graduates in the United States (2017 to 2023). The primary outcome of interest was academic faculty appointment, which was assigned if the arthroplasty fellowship graduate was employed at a teaching hospital. Demographic, bibliometric, and training characteristics of arthroplasty fellowship graduates were obtained. Bivariate analyses were performed to elucidate the training characteristics associated with future academic faculty appointments.

Results: There were 1,100 arthroplasty fellowship graduates, and 267 had academic faculty appointments (24.3%). Women arthroplasty fellowship graduates were more likely to obtain academic faculty appointments than men (38.6 versus 23.3%, P = 0.006). Allopathic graduates were more likely to obtain academic faculty appointments than osteopathic graduates (25.7 versus 14.2%, P = 0.005). Arthroplasty fellowship graduates who have future academic faculty appointments had more peer-reviewed publications during medical school (2.0 ± 2.6 versus 1.1 ± 4.0, P = 0.001) and orthopaedic surgery residency training (10.2 ± 8.7 versus 4.8 ± 15.8, P = 0.001) than their counterparts in private practice. Several characteristics of arthroplasty fellowship programs were associated with future academic faculty appointments, including geographic region (P = 0.003), greater number of faculty (P = 0.001), and greater number of annual fellows (P = 0.001).

Conclusions: Several characteristics were associated with future academic faculty appointments in arthroplasty, including higher scholarly productivity during medical school and orthopaedic surgery residency training. These data may help future arthroplasty trainees and faculty align on desired academic career goals.

Background: Total hip arthroplasty (THA) has trended toward increased utilization of the direct anterior approach (DAA) and robotic assistance in recent years. This study aimed to characterize self-reported trainee exposure to THA techniques during residency.

Methods: This study anonymously surveyed orthopaedic surgery residents using 21 multiple-choice questions. Orthopaedic surgery residency program coordinators were asked to forward the survey to their residents. Demographic and residency program information, exposure to THA techniques, and confidence performing these procedures were collected. Descriptive statistics, Kruskal-Wallis tests, and ordinal logistic regression were performed.

Results: There were 94 residents who responded to the survey, with most respondents from the Northeast (39.4%) and university hospital-based programs (50.0%). There were 57 (60.6%) who responded that over half of THAs utilized the DAA, while 26 (27.7%) responded that the posterior approach (PA) was primarily utilized. There were 80 (85.1%) who had no exposure to the supercapsular approach, and 34 (36.2%) and 48 (51.1%) had no exposure to anterolateral and direct lateral approaches, respectively. All respondents had exposure to multiple surgical approaches. There were 50 (53.2%) who reported zero exposure to robotic-assisted THA. Program region was associated with the greatest exposure to DAA (P < 0.001), anterolateral (P = 0.021), posterior (P = 0.018), and supercapsular (P < 0.001) approaches. Compared to the PA, residents who were most exposed to DAA reported higher levels of comfort (P = 0.027). Resident comfort increased with advancing postgraduate year (P < 0.001). There were 50 (53.2%) who responded they were planning to perform THAs in practice, with 61 (64.9%) stating they would use the DAA and 30 (31.9%) responding they would use the PA.

Conclusions: The increase in popularity of the DAA in THA has also been realized in orthopaedic resident training. Most respondents reported satisfaction with their experience and reported exposure to multiple techniques.

Background: The purpose of this study was to evaluate the clinical, functional, and radiographic outcomes in patients who underwent two-stage cementless arthrodesis following multiple revision surgeries for periprosthetic joint infection, after a mean follow-up of 57.0 months (range, two to 208).

Methods: From 2002 to 2012, 31 patients underwent a two-stage revision for periprosthetic joint infection using an intramedullary modular arthrodesis system. The follow-up evaluation included clinical and functional data, as assessed using the Oxford Knee Score. Furthermore, a gait analysis using three-dimensional motion analysis was performed for five patients. There were 29 patients available for clinical and radiographic follow-up. The mean bone defect was 3.9 centimeters.

Results: There was one reoperation for postoperative hematoma with preservation of the arthrodesis. There were six reinfections after arthrodesis. In three of these cases, preservation of the arthrodesis system was possible after repeated revision surgeries. In two cases, the recurrent infection was treated with another two-stage revision and rearthrodesis. In one case, the arthrodesis system was removed, and a spacer was implanted. The Kaplan-Meier survival rate was 87.2% (95% confidence interval, 65.3 to 95.7) at 17.3 years for revision for any reason. The risk of reinfection was 19% following two-stage arthrodesis. The limb salvage rate was 100%.

Conclusions: Periprosthetic joint infection can be successfully treated with arthrodesis using a modular intramedullary arthrodesis system without bone-to-bone fusion. Although the risk of reinfection following two-stage revision is 19%, this treatment approach may provide patients with improved quality of life by relieving pain and restoring joint stability.

Background: Computer navigation has been used in total knee arthroplasty in an attempt to improve component alignment and clinical outcomes, although few studies directly compare computer navigation to traditional instrumentation in the same patient.

Methods: Bilateral total knee arthroplasties performed during the same surgical intervention utilizing computer navigation in one knee and traditional instrumentation in the contralateral knee were prospectively collected and followed. Reoperations and adverse events were documented. Statistical analyses were performed between the two groups to determine differences in clinical outcomes.

Results: There were 79 patients who had a mean follow-up of 11.8 years (range, five to 16). When comparing computer navigation to traditional instrumentation cohorts, mean postoperative femoral component coronal angle (94.9 versus 94.9°, P = 0.88), femoral component flexion (2.1 versus 1.8°, P = 0.53), tibial component coronal angle (89.7 versus 90°, P = 0.24), and posterior tibial slope (2.4 versus 2.9°, P = 0.15) showed no statistical differences. Computer navigation demonstrated a decrease in posterior tibial slope outliers (1 versus 8, P = 0.018) compared to traditional instrumentation, but no differences in the other component angles. Clinically, there were no differences in mean postoperative extension (0.2 versus 0.2°, P = 0.97), flexion (127.3 versus 127.1°, P = 0.85), functional Knee Society Scores (91.3 versus 90.5, P = 0.77), reoperation rate (6.3 versus 2.5%, P = 0.44), or closed manipulation rate (2.5 versus 3.8%, P = 0.65) at final follow-up comparing computer navigation to traditional instrumentation, respectively. Computer navigation reoperation indications included two patellar osteolysis, one infection, one patellar clunk syndrome, and one symptomatic arthrotomy nonabsorbent suture removal. Traditional instrumentation reoperation indications included one infection and one arthrotomy dehiscence.

Conclusions: Computer navigation reduced posterior tibial slope outliers, although this did not translate to any appreciable difference in clinical outcome at 11 years' mean follow-up in the hands of a fellowship-trained total joint specialist.

Background: Total knee arthroplasty (TKA) is a widely performed procedure for end-stage knee osteoarthritis, with over 1.2 million annual cases projected by 2025. While generally successful, TKA can lead to perioperative complications, including disruptive bleeding or hemorrhagic events requiring medical intervention. This study aimed to (1) quantify the incidence of disruptive bleeding; (2) identify patient demographics and the Elixhauser comorbidity burden associated with disruptive bleeding; and (3) quantify the effects of disruptive bleeding on health care utilization (length of stay, 90-day readmission rates, and costs).

Methods: This was a cohort study analyzing adult patients undergoing primary TKA in 2019 using a large national health care database. After identifying baseline patient demographics, the Elixhauser comorbidity index (ECI) was categorized from 0 to ≥ 6 and analyzed for association with disruptive bleeding using multivariable logistic regressions. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess bleeding risk by ECI category. Generalized linear models evaluated the impact of disruptive bleeding on hospital stays, costs, and readmissions, adjusting for demographics.

Results: Among 175,384 TKA patients, 8,991 (5.1%) experienced disruptive bleeding. African American race and Medicare insurance status were associated with increased disruptive bleeding (P < 0.05), while age and sex were not. The odds of disruptive bleeding increased with comorbidity burden, from OR = 1.20 (95% CI 1.06 to 1.36) for ECI = 1 to OR = 2.39 (95% CI 1.82 to 3.12) for ECI ≥ 6. Disruptive bleeding was associated with longer hospital stays (mean increase: 2.4 days, P < 0.001), higher costs ($18,700 versus $17,600, P < 0.001), and greater 90-day readmission risks (7.4 versus 5.3%, P < 0.001).

Conclusions: Disruptive bleeding in TKA is associated with a higher comorbidity burden, leading to prolonged hospitalizations, increased costs, and greater readmission risks. Improved risk stratification and perioperative management strategies are needed to reduce complications and optimize patient outcomes.

Background: Traumatic brain injuries (TBIs) are a common neurological injury and can cause impaired cognition and fatigue. However, it is unknown how these systemic effects may influence surgical recovery following a total hip arthroplasty (THA). In this study, we asked whether a prior TBI was associated with a higher risk of postoperative medical and surgical complications.

Methods: Using a national claims database, we examined adult patients undergoing a primary THA, excluding those who had a hip infection, hip fracture, or incomplete demographic information. This resulted in 81,586 (10.5%) patients who had a prior TBI diagnosis and 697,562 (89.5%) patients who did not. We examined the incidence of postoperative complications, including revision surgery, acute kidney injury (AKI), pulmonary embolism (PE), pneumonia, and urinary tract infection (UTI). Multivariate regression models were used to assess the risk of 90- and 365-day complications based on prior TBI diagnosis.

Results: We found that a prior diagnosis of a TBI was associated with greater rates of 90- and 365-day revision surgery and certain medical complications, including AKI, PE, pneumonia, and UTI (P < 0.05). In the multivariable regression analysis, the association between prior diagnosis of a TBI and greater risk of 90-day all-cause revision surgery persisted. This was greatest among patients who have a 1-year history of a TBI (odds ratio: 1.28; 95% confidence interval: 1.07 to 1.51; P = 0.005). For 365-day medical complications, prior TBI was associated with a greater risk of AKI, PE, pneumonia, and UTI (P < 0.05 for all).

Conclusions: Our findings highlight a prior TBI diagnosis as a potential risk factor for increased surgical and medical complications following a THA. Further research is needed to explore the impact of a TBI on the physiological post-THA state to inform preoperative interventions and reduce the risk of TBI-related adverse events.

Background: Heterotopic ossification (HO) is a common complication following hip arthroplasty that can limit hip range of motion. Oral direct factor Xa (FXa) inhibitors are commonly used anticoagulants after arthroplasty; however, they have a high risk of local bleeding and hematoma formation, which are significant triggers for HO formation. To our knowledge, there is no evidence regarding whether FXa inhibitors use will increase HO incidence following hip arthroplasty.

Methods: In this retrospective propensity score-matched cohort study conducted at a national orthopaedic center in Shanghai (2019-2023), 944 patients undergoing hip arthroplasty for acute femoral neck fracture were evaluated. After exclusions and 1:1 matching (sex, age, body mass index, injury side, nonsteroidal anti-inflammatory drugs use), 362 patients were included in each group (FXa inhibitors vs. no FXa inhibitors). All patients received low-molecular-weight heparin during hospitalization and no other anticoagulants.

Results: In the propensity score-matched population, the incidence of HO was 29.2% in the FXa inhibitors group and 15.7% in the no-FXa inhibitors group (7.7% and 2.4% for clinically important HO, respectively). Logistic regression analyses revealed that FXa inhibitors usage was significantly associated with a higher rate of HO (odds ratio, 2.22; 95% confidence interval, 1.55 to 3.20; P < 0.001) compared to no usage. Additionally, FXa inhibitors use was also linked to an increased risk of clinically significant HO (odds ratio, 3.29; 95% confidence interval, 1.59 to 7.48; P = 0.002). None of the baseline covariates demonstrated a significant influence on the association between FXa inhibitors use and HO incidence (P > 0.05 for all). Sensitivity analyses further corroborated these results.

Conclusions: Direct FXa inhibitors use may be a new risk factor of HO development following hip arthroplasty for acute femoral neck fracture.

Level of evidence: Therapeutic Level II.