Journal of Arthroplasty最新文献

Introduction: Randomized controlled trials (RCTs) remain the gold standard for evaluating the efficacy and safety of novel interventions. This systematic review assessed the current quality of hip and knee arthroplasty RCTs using a modified Jadad scale, along with other key metrics, including trial registration and conduct of power analyses.

Methods: PubMed was queried in May 2024 to identify hip and knee arthroplasty RCTs published from 2014 through 2023 in four leading orthopaedic journals. Each RCT was scored using a modified Jadad scale, which assesses randomization, blinding, and participant withdrawal, categorizing studies into low, moderate, or high quality. Chi-square analyses were used to assess associations between article characteristics.

Results: Of 566 RCTs, 47.5% were graded as high quality, 39.8% as moderate quality, and 12.7% as low quality according to the modified Jadad scale, largely due to a lack of double blinding. Low or moderate quality was more common in RCTs that reported industry funding (relative risk [RR], 1.27; 95% confidence interval [CI], 1.08 to 1.49; P = 0.006) or those focused on surgical technology (RR, 1.65; 95% CI, 1.42 to 1.90; P < 0.001). Trial registration was not reported in 41.2% of articles, funding statements were not identified in 22.3% of RCTs, and a priori power analyses were not conducted in 16.3% of RCTs. Of the 474 RCTs that did conduct a power analysis, 130 (27.4%) did not retain enough patients to meet sufficient statistical power per their power analyses. Among these 130 studies, 77 (59.2%) did not identify any statistically significant difference between groups.

Conclusion: More than half of recent hip and knee arthroplasty RCTs were of low to moderate quality, with notable deficiencies in blinding, trial registration, and power analyses. Continued efforts to improve methodological rigor and transparency are essential to advance the quality and credibility of arthroplasty research.

Background: Total knee arthroplasty (TKA) performed for post-traumatic osteoarthritis (PTOA) is associated with higher complication and revision rates than TKA for primary osteoarthritis (OA). This study aimed to compare implant survival and identify risk factors for revision in TKA performed for PTOA versus OA using registry data.

Methods: The TKA procedures from 2012 to 2022 in the German Arthroplasty Register (EPRD) were analyzed (n = 289,382). The incidence of PTOA was 2.4% (n = 6,982). Implants were categorized as unconstrained or constrained (varus-valgus stabilized or hinge). Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to assess implant survival, adjusted revision risk, and independent risk factors for revision.

Results: A total of 10,341 complications were recorded, with PTOA showing a higher complication rate than OA (5.7 versus 3.5%; P < 0.001). Aseptic revision rates were higher for unconstrained TKA in PTOA (P < 0.001), but not for constrained TKA (P = 0.1), whereas septic revision rates were higher for PTOA with both implant designs (both P < 0.001). The most common reasons for revision were infection (19%) and instability (8%). After adjustment for age, sex, body mass index, weighted Elixhauser score, fixation method, patellar resurfacing, and hospital case volume, a 45% higher risk of revision was observed after TKA for PTOA compared with OA. For unconstrained TKA in PTOA, the revision risk was 36% higher compared with OA (hazard ratio = 1.36; P < 0.001). Independent risk factors for revision in unconstrained TKA for PTOA included hospital volumes ≤ 200 annual cases and TKA without patellar resurfacing.

Conclusion: An increased adjusted risk of revision was observed after TKA for PTOA compared with OA. While aseptic revision rates varied by implant constraint, septic revision rates were higher in PTOA independent of constraint. Lower hospital volume and the absence of patellar resurfacing in unconstrained implants further increased revision risk, whereas higher implant constraint was protective regarding the risk of aseptic revision.

Background: As implants in primary total hip arthroplasty (THA) continue to evolve, surgeons may elect to combine femoral and acetabular components from different manufacturers. However, the prevalence of mixing implants in contemporary hip arthroplasty is unknown, as is the consequence that this may or may not have on implant survival.

Methods: A nationwide registry was used to select patients 65 years or older who underwent primary THA between 2012 and 2021 and who had a minimum 2-year follow-up to create a retrospective cohort comparison of patients who had matched versus mixed manufacturer components. A total of 434,985 cases were identified [matched: 413,607 (95%), mixed: 21,378 (5%)]. The unadjusted and adjusted risk of all-cause revision, as well as revision for aseptic loosening, infection, instability, and periprosthetic fracture, were modeled with cause-specific Cox models.

Results: Mixing THA components increased over time from less than 2% of cases in 2012 to nearly 17% in 2021 (P < 0.001). The mixed cohort more commonly utilized dual mobility bearings (27%, 4,956 versus 7%, 24,631; P < 0.001) and triple-tapered femoral stem designs (18%, 7,185 versus 9%, 27,987; P < 0.001). After controlling for potential confounding variables, there was no difference between the two groups in terms of all-cause revision (hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.9 to 1.1), revision for aseptic loosening (HR 1.2, 95% CI 0.9 to 1.6), revision for infection (HR 1.2, 95% CI 0.9 to 1.4), revision for instability (HR 1.0, 95% CI 0.8 to 1.2), or revision for periprosthetic fracture (HR 0.9, 95% CI 0.7 to 1.2). There was no difference in revision-free survival time between groups.

Conclusion: Mixing implants from different manufacturers in primary THA does not result in an associated difference in the risk of early revision between mixed versus matched manufacturer components.

Background: The time spent providing postoperative care for total hip arthroplasty (THA) and total knee arthroplasty (TKA) has increased provider workload, drawing attention to the Relative Value Scale Update Committee's (RUC) current estimation of work Relative Value Units (wRVUs). Our aim for this study was to quantify the postoperative work performed by the surgeon and their team for THA and TKA during the 90-day global period. We hypothesized that the work intensity and time spent on postoperative communication were higher than estimated by current wRVUs.

Methods: We retrospectively evaluated all patients undergoing primary total joint arthroplasty (TJA) at our institution between January 1, 2019, and December 31, 2024. Primary outcomes included the number of postoperative interactions from discharge to 90 days after surgery. These included office visits, telehealth visits, phone calls, and patient portal messages.

Results: From 2019 to 2024, the average number of postoperative TJA interactions per patient increased across all modalities. Telephone encounters spiked during the COVID-19 pandemic and remain elevated, while portal messages rose more than fivefold. Office visits averaged 2.3 per patient, exceeding the two currently recognized in RUC valuations. Administrative tasks and telehealth also showed steady annual growth. Meanwhile, hospital lengths of stay decreased from 44.5 hours in 2018 to 32.6 hours in 2022. These findings highlight a shift of postoperative care from institutional settings to surgeon offices and virtual platforms.

Conclusion: Over the past five years, postoperative care for THA and TKA has increasingly relied on surgeon teams, resulting in a measurable rise in office visits, virtual encounters, and administrative messaging not reflected in current RUC valuations. With declining physician reimbursement, these findings underscore the need to update valuation models to capture the true scope of postoperative care in current joint arthroplasty practice.

Introduction: Surgeon volume and experience may impact patient-reported outcome measures (PROMs) and costs in total knee arthroplasty. However, whether the same relationship exists in unicompartmental knee arthroplasty (UKA) is unclear. We investigated whether surgeon volume and experience drove variations in PROMs or Time-Driven Activity-Based Costing (TDABC) in UKA.

Methods: We sourced data from a prospectively maintained multi-institutional arthroplasty registry. Patients completed the Knee Injury and Osteoarthritis Outcome Score - Physical Function Short-form (KOOS-PS) with thresholds for minimal clinically important difference (MCID) and patient acceptable symptom state (PASS). A stratum-specific likelihood ratio (SSLR) analysis was used to categorize surgeons into volume and experience levels: low-volume (annual volume less than 16); mid-volume (annual volume 16 to 40); high-volume (annual volume greater than 40). The SSLR analysis did not identify meaningful thresholds for surgeon experience. Because not all registry centers perform TDABC, our PROM analysis investigated 794 UKAs performed by 32 surgeons, while our TDABC sub-analysis investigated 416 UKAs performed by 12 surgeons. Chi-square tests and one-way analyses of variance compared MCID, PASS, and costs between groups.

Results: Low-volume UKA surgeons were associated with prolonged operating room times (low-volume: 110 versus high-volume: 73 minutes; P < 0.001) and lengths of stay (low-volume: 1.2 versus high-volume: 0.6 days; P < 0.001). Both MCID and PASS achievements were similar across volume levels (P = 0.80 and 0.84, respectively). However, low-volume surgeons were associated with increased costs (low-volume: 744 versus mid-volume: 662 and high-volume: 662 cost units (CUs); P < 0.001).

Conclusion: Low-volume UKA surgeons had increased costs. However, MCID and PASS achievements were similar for UKA surgeons of all volume levels. There were no meaningful thresholds for surgeon experience. These results may reassure surgeons of all experience levels to pursue UKAs, while remaining aware of the positive influence of volume on cost-effectiveness.

Background: A subset of total knee arthroplasty (TKA) patients experiences suboptimal recovery manifested by a decline in function, activity, or both. Smart implantable devices (SIDs) capable of continuous, adherence-independent kinematic monitoring offer an opportunity for early risk identification. This study aimed to determine whether early gait data from a smart implant could predict 90-day recovery outcomes reported as a three-class measure (green, yellow, and red).

Methods: Kinematic data were obtained from 4,281 devices implanted in TKA patients. Data from 2,809 SIDs formed the training dataset, and 1,472 formed the validation dataset. There were seven daily gait parameters from postoperative days eight to 90 that were reduced to two composite scores, function (tibial range of motion, knee range of motion, and stride length) and activity (step count, walk speed, distance, and cadence), based on principal components analyses. "Starting" (days, eight to 21) and "Outcome" (days, 77 to 90) ellipses were calculated for each patient, and a three-class outcome measure was assigned based on the proportion of the 95% confidence ellipse area within predefined function/activity quadrants. Multivariate logistic regression models using starting ellipse parameters were tested to predict the three-class outcomes at 90 days.

Results: The distribution of outcomes was consistent across datasets (training: 42 green, 42 yellow, and 15% red; validation: 45 green, 40 yellow, and 16% red; P = 0.2). Using early gait data, the model achieved a sensitivity of 0.780, specificity of 0.612, positive predictive value of 0.712, negative predictive value of 0.692, and overall accuracy of 0.704 in the validation cohort. Sensitivity was highest in women under age 65 years (0.801).

Conclusion: Passively collected implant-based gait data within the first three postoperative weeks can reasonably predict 90-day recovery class after TKA. Early kinematic modeling may enable timely, targeted interventions to improve functional recovery and satisfaction.

Background: The mobile bearing knee arthroplasty features a highly congruent mobile meniscal bearing allowing both rotation and antero-posterior translation. At present, it remains unclear whether fixed bearing platforms are clinically advantageous over mobile bearings. In this randomized trial, we sought to compare patient-reported outcomes, complications, and revision rates in patients undergoing fixed versus mobile bearing total knee arthroplasty (TKA) for osteoarthrosis.

Methods: In this randomized trial, data from 207 patients (105 patients who had mobile bearing TKA and 102 patients who had fixed bearing TKA) were gathered between 2001 and 2006. Overall, the mean age at surgery was 61 years (range, 42 to 71) with 104 men and 102 women. The primary outcome was the Oxford Knee Score (OKS) over a 10-year follow-up period. The secondary outcomes were the Western Ontario and McMaster Universities (WOMAC) arthritis index, Bristol Knee Score, and postoperative complications. Failure of an implant was defined as revision for any reason and/or removal of any implant for any reason and expressed as a risk ratio.

Results: For the primary outcome measure with OKS, there was a statistically significant difference in patient-reported outcome measure (PROM) in favor of the fixed bearing group at two-year follow-up (mean difference in OKS was 3.6; 95% confidence interval (CI): 0.51 to 6.69, P = 0.0226). There was no statistically significant effect demonstrated in the reoperation rate between the two intervention groups over a 19-year period (the risk ratio was found to be 1.51 (95% CI: 0.79 to 2.87, P = 0.2096)) or in PROMs at 10 years.

Conclusions: At two-year follow-up, there was no clinically meaningful difference in patient-reported outcome measures (PROMs) between fixed-bearing and mobile-bearing total knee arthroplasty. In addition, no difference in reoperations was noted at any time point up to the 19-year follow-up.

Introduction: Dual-mobility (DM) constructs were developed to improve stability in total hip arthroplasty (THA) and may be of particular utility in revision THA, given the increased risk of instability. The aim of this systematic review was to assess dislocation rates of DM versus fixed-bearing (FB) constructs in revision THA.

Methods: PubMed and Embase database searches were performed for studies published between database inception and December 31, 2024. Inclusion criteria consisted of studies evaluating dislocation rates of DM versus FB constructs in revision THA. Levels of evidence and Modified Coleman Methodology (MCM) scores were determined. Studies with a mean follow-up of less than two years, studies with fewer than 30 patients in each group, and non-English manuscripts were excluded. A total of 22 studies were included. All studies were level III evidence, except for one study (level II). Of the 22 revision THA manuscripts, the mean MCM score was 55.1 (range, 45 to 79).

Results: A total of 21 studies demonstrated favorable dislocation rates for DM compared to FB constructs in revision THA. There were 15 studies that met statistical significance (P < 0.05). When limiting analysis to the 15 studies that met statistical significance, the overall rates of dislocation were 4.4 versus 6.9% for DM versus FB, respectively. Dislocation rates for the DM cohort ranged from 0 to 8.3%, and the FB cohort dislocation rate ranged from 3.4 to 15.5%.

Conclusion: Given the currently available literature, the use of DM constructs is associated with a lower dislocation risk in revision THA.

Introduction: Recurrent periprosthetic joint infection (PJI) after two-stage revision total knee arthroplasty remains challenging. Repeat two-stage revision is a salvage option, but outcomes are poorly defined. This multicenter study evaluated the success of repeat two-stage knee revision for chronic PJI.

Methods: A retrospective review of prospectively maintained databases at two tertiary centers identified 61 patients treated between 1995 and 2022. There were 13 (21.3%) who did not undergo reimplantation, leaving 48 patients (31% women) who had a mean follow-up of 12.1 years. The primary outcome was treatment success per 2019 MSIS Tier 1 criteria. Kaplan-Meier analysis estimated implant survivorship; Cox regression identified predictors of failure.

Results: Treatment success was achieved in 21 of 48 cases (39.6%). Among 27 failures, 21 underwent further infection surgery, two remained on lifelong suppressive antibiotics, and four had aseptic revision. Amputation was required in 11 patients (22.9%). The five- and 10-year implant survival for all-cause revision was 63.2 and 42.3%, respectively; for PJI-specific revision, 65.1 and 47.7%. Younger age was the only independent predictor of failure (OR [odds ratio] 0.898 per year; 95% CI [confidence interval] 0.836 to 0.965; P = 0.003). Excluding culture-negative cases, 31% had a new infecting organism at repeat revision, and polymicrobial infection increased (12.5%).

Conclusion: Repeat two-stage revision for recurrent knee PJI yields low infection control rates and major morbidity, including a 23% amputation rate. Younger patients are at greater risk of failure. These findings underscore the need for careful patient selection and exploration of alternative strategies.