Journal of Arthroplasty最新文献

Background: Implant survival following total hip arthroplasty (THA) may differ by femoral stem design. In a series of patients, a consistent pattern of low-energy periprosthetic fracture (PPF) with a specific blade design stem was observed. Therefore, we conducted a cohort study comparing revision risk with this specific stem to other stems.

Methods: Adult patients who underwent primary cementless THA for osteoarthritis with a highly crosslinked polyethylene liner and large femoral head (≥ 28 mm) were identified using data from a US-based healthcare system's registry (2010 to 2022). There were 9,425 THAs using the specific blade stem compared to 67,484 THAs using other stems. Multivariable Cox regressions were used to evaluate 90-day revision due to PPF and aseptic revision.

Results: The crude PPF revision incidence was 0.8 and 0.4% for the specific blade stem and other stems, respectively. In adjusted analyses, a higher risk of PPF revision (hazard ratio [HR] = 2.19, 95% confidence interval [CI] = 1.60 to 3.01) and aseptic revision (HR = 1.84, 95% CI = 1.40 to 2.42) with the specific blade stem was observed. This higher risk was observed when comparing the specific blade stem to other type 1 stems (PPF: HR = 2.19, 95% CI = 1.54 to 3.11; aseptic: HR = 1.56, 95% CI = 1.14 to 2.12), as well as to type 2 stems (PPF: HR = 2.12, 95% CI = 1.48 to 3.05; aseptic: HR = 1.90, 95% CI = 1.41 to 2.56), and to type 5 stems (aseptic: HR = 4.71, 95% CI = 2.03 to 10.92).

Conclusions: While revision incidence was low, the specific blade stem was associated with a two-times higher risk of 90-day PPF revision when compared to other stems. These findings may guide surgeons in stem selection where PPF is a concern.

Background: Recently, the Centers for Medicare and Medicaid Services (CMS) mandated the collection of patient-reported outcome measures (PROMs) for all primary total joint arthroplasties (TJAs), reinforcing their role in evaluating clinical outcomes. This systematic review investigated the calculation methods and anchor questions used to derive key PROM-based thresholds such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and the patient acceptable symptom state (PASS) for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

Methods: Databases were queried for articles from 2000 to 2025 specific to the HOOS JR and KOOS JR. Articles were reviewed by two reviewers and included if they were in the English language and derived either the MCID, SCB, and/or PASS metrics specific to primary TJA procedures. Study characteristics, MCID, SCB, and/or PASS thresholds, and methods of derivation were extracted.

Results: A total of 17 studies with 44,935 patients who met the final inclusion criteria were included. With respect to the HOOS JR, 10 studies derived a distribution-based MCID (range, 3.9 to 11.0 points), six studies derived an anchor-based MCID (range, 14.8 to 38.1 points), one study derived an SCB (22 points), and three studies derived a PASS score (range, 73.5 to 81.0). Specific to the KOOS JR, nine studies derived a distribution-based MCID (range, 4.0 to 8.7 points), six derived an anchor-based MCID (range, 14.0 to 30.7 points), one derived an SCB (20 points), and two derived a PASS score (range, 63.7 to 71.0 points).

Conclusion: Substantial variability existed in the calculation methods reported for deriving the metrics specific to the MCID, SCB, and PASS scores. As such, it is imperative to standardize methodology and utilization for the calculation of MCIDs, SCB, and PASS metrics to allow for improved assessment of PROMs specific to total joint arthroplasty.

Background: This study sought to determine knee kinematics after cruciate-substituting (CS) total knee arthroplasty (TKA) using an insert with or without the posterior cruciate ligament (PCL) in the same-specimen fresh-frozen cadavers using a within-knee repeated-measures design.

Methods: There were eight specimens that underwent TKA with a medial-dished (MD) type insert, one of the CS designs, using an image-free robotic-assisted surgical system. Knee kinematics were evaluated using an image-free knee navigation system. We recorded the kinematics of the native knee, TKA with MD and PCL preservation (MD PCL+), and TKA with MD and PCL dissection (MD PCL-) from full extension to maximum flexion using the navigation system. Differences in the rotational and antero-posterior (A-P) positions between the native knee and TKA in each MD group were examined for statistical significance.

Results: At full extension, knees in both MD groups were initially in a more internally rotated position compared with the native knee. In the initial-flexion phase, the MD PCL+ group exhibited rotational position changes similar to those of the native knee, whereas the MD PCL- group did not. There was no significant difference in rotational position beyond mid-flexion between knees in either of the MD groups and the native knee. The A-P position through to the mid-flexion position was similar between the native knee and knees in both MD groups. Compared with the native knee, there was no significant difference after mid-flexion in the MD PCL+ group, but the anterior position was significantly greater after 80° in the MD PCL- group.

Conclusions: In TKA using the MD insert, preservation of the PCL better reproduces the A-P and rotational kinematics of the native knee compared with dissection of the PCL.

Background: Starting in 2027, the Centers for Medicare & Medicaid Services (CMS) will penalize hospitals that do not have complete paired patient-reported outcome measures (PROMs) data on at least 50% of patients undergoing inpatient total hip (THA) and knee arthroplasty (TKA). Patients must also meet the minimum substantial clinical benefit (SCB) threshold for Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Injury and Osteoarthritis Outcome Score Joint Replacement scores (22 and 20 points, respectively). The purpose of this study was to identify the risk factors for patients who did not have complete paired PROMs and did not meet the minimum SCB following surgery.

Methods: We included 5,165 primary THA and TKA patients between 2022 and 2023 at 22 hospitals. We collected data on demographics, medical comorbidities, insurance types, and socioeconomic status. Surveys were collected 90 to zero days preoperatively and 300 to 425 days postoperatively, consistent with CMS rules. A multivariate regression analysis was performed to identify independent risk factors for not meeting new CMS PROMs requirements.

Results: There were 764 patients (14.8%) who met the CMS paired PROMs reporting requirement, whereas 554 (72.5%) met the SCB threshold. Risk factors for failing to meet paired PROMs collections included higher Charlson Comorbidity Index (odds ratio (OR) 1.10, 95% confidence interval (CI): 1.01 to 1.19, P = 0.049), Medicare insurance (OR 1.27, 95% CI: 1.04 to 1.52, P = 0.016), and lower socioeconomic status (OR 2.08, 95% CI: 1.37 to 3.33, P = 0.001). There were no risk factors identified for failing to meet the SCB PROMs threshold in multivariate analysis.

Conclusions: Overall, paired PROMs data collection was far below the CMS 50% threshold, suggesting all hospitals may face substantial financial risk beginning in 2027. Safety net facilities caring for THA and TKA patients who have greater medical complexity and lower socioeconomic status are at an even higher risk for penalties for noncompliance.

Background: Postoperative stiffness after total knee arthroplasty (TKA) is uncommon, but may lead to major knee dysfunction. Manipulation under anesthesia (MUA) is an effective tool for improving postoperative stiffness. We hypothesized that intra-articular corticosteroid administration during MUA better preserves postmanipulation range of motion (ROM) compared to MUA without a glucocorticoid adjunct.

Methods: A retrospective review of 103 MUAs by six arthroplasty surgeons at our institution from 2014 to 2023. Patients were included if they underwent MUA after a primary TKA for osteoarthritis or osteonecrosis and were excluded from analysis if they had bilateral MUA, MUA after revision TKA, or TKA for post-traumatic osteoarthritis. Patients were separated into groups based on whether they received a concurrent corticosteroid injection (CSI) during MUA. Age, sex, and time to MUA were similar between groups. Range of motion was assessed before MUA, intraoperatively following MUA, and at 1-month, 3-month, 6-month, and 1-year follow-up visits. Validated patient-reported outcome measures (PROMs) collected relative to initial TKA were assessed pre-MUA, and three months and one year after MUA. All patients were screened for complications and reoperations.

Results: Compared to patients undergoing MUA without CSI, patients receiving CSI had similar improvement in ROM at one, three, six, and 12 months postmanipulation. There were similar improvements in PROMs between the groups, with the largest improvements observed at one year in Western Ontario and McMaster Universities Osteoarthritis Index pain and function, Short Form-12 physical, and Knee Society Score scores. Complications and reoperations were similar between the groups, and there were no infections associated with intra-articular CSI in our cohort.

Conclusions: The use of CSI concurrently with MUA was not associated with improved ROM or PROMs but demonstrated safety. The benefit of its use may be further elucidated by future randomized controlled trials.

Background: Robotic-assisted total hip arthroplasty (rTHA) has been shown to assist with precision in component placement. However, limited evidence exists evaluating its effects on minimum 10-year clinical outcomes. The purpose of this study was to report the minimum 10-year clinical outcomes in a case series of patients who underwent rTHA.

Methods: Prospectively collected data from patients who underwent primary rTHA between June 2011 and April 2015 were analyzed. Patients who had a complete minimum 10-year follow-up, including radiographs and validated patient-reported outcomes (PROs), were included. A total of 215 hips met the inclusion criteria. The PROs included the Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR), Forgotten Joint Score-12 (FJS-12), visual analog scale (VAS) pain, and patient satisfaction. Radiographic assessment included acetabular cup inclination, version, leg-length discrepancy, and cup placement relative to the Lewinnek and Callanan safe zones.

Results: At final follow-up, patients reported excellent outcomes, with mean HHS 93.0 ± 12.6, HOOS-JR 89.1 ± 16.1, FJS-12 85.2 ± 22.4, VAS pain 1.0 ± 1.9, and satisfaction 9.1 ± 1.8. The high FJS-12 score reflects that patients rarely or almost never thought about their hip in daily life. There were six revisions (2.8%): one for aseptic loosening (0.5%), one for leg-length discrepancy (0.5%), and four for acute postoperative infection (1.9%). Survivorship free of revision was 97.2% at 10 years. Radiographic analysis demonstrated that 91.1% of cups were within the Lewinnek safe zone and 87.4% within the Callanan safe zone. Notably, there were no cases of instability or dislocation.

Conclusion: Robotic-assisted primary THA was associated with a high degree of accuracy in component placement and durable clinical outcomes with high patient satisfaction and low revision rates at a minimum 10-year follow-up.

Background: Patient-reported outcome measures (PROMs) are increasingly utilized in medial unicompartmental knee arthroplasty (UKA). Total knee arthroplasty studies have shown preoperative PROMs across multiple domains (knee physical function, general physical health, mental health, etc.) influence achievement of minimal clinically important difference (MCID) or patient acceptable symptom state (PASS). However, the utility of preoperative PROMs in medial UKA is underexplored. We investigated the impact of preoperative PROMs across multiple domains on MCID and PASS achievement in medial UKA.

Methods: We retrospectively sourced 911 medial UKAs from a prospectively maintained multi-institutional arthroplasty registry. The following preoperative PROMs were recorded: 1) Knee Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS); 2) Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-10a (PF-10a); 3) PROMIS Global Physical; and 4) PROMIS Global Mental. These PROMs measure the following domains, respectively: 1) knee-specific physical function; 2) general physical function; 3) general physical health; and 4) general mental health. Multivariable forward binary logistic regression models identified factors independently associated with achievement of literature-derived, anchor-based KOOS-PS thresholds for MCID and PASS.

Results: Achievement of MCID was associated with a lower preoperative KOOS-PS score (P = 0.001) and a higher preoperative PROMIS Global Physical score (P = 0.013). Achievement of PASS was associated with a higher preoperative KOOS-PS score (P < 0.001), higher preoperative PROMIS Global Physical score (P = 0.038), higher preoperative PROMIS Global Mental score (P = 0.018), and higher preoperative PROMIS PF-10a score (P = 0.029).

Conclusion: Medial UKA patients who have severe knee symptoms have a high rate of MCID, but a low rate of PASS. Conversely, patients who have mild knee symptoms have a low rate of MCID, but a high rate of PASS. Higher baseline physical functioning, general physical health, and general mental health increase the likelihood of PASS achievement. Evaluating medial UKA patients who have several preoperative PROMs across multiple domains (knee physical function, general physical health, mental health, etc.) may aid counseling. Although PROMs are subjective and are not perfect measures, they are nevertheless validated and widely utilized, offering insights that can guide clinical decision-making. Preoperative PROMs should not restrict access to care.

Background: This study examined whether the timing of total hip or knee arthroplasty (TJA) relative to elective hand surgery (HS) is associated with perioperative TJA outcomes, as both are among the most common orthopaedic procedures in the United States.

Methods: A retrospective cohort study was conducted of patients who underwent elective HS and TJA between 2011 and 2024. Patients were grouped by surgical order: HS first (HSF, n = 645) and TJA first (TJAF, n = 785). Differences between HSF and TJAF were assessed. Multivariable logistic regressions, Cox proportional hazards regressions, and linear regressions were used to adjust for patient demographics and comorbidities. The HSF patients were older (67.1 versus 64.3 years, P < 0.001), more prone to be discharged home (90.7 versus 83.8%, P < 0.001), and had a shorter length of stay (45.6 versus 60.4 hours, P < 0.001) compared to TJAF patients.

Results: Surgical order showed no association with 90-day emergency department visits and readmissions. Multivariable Cox regressions revealed that HSF was associated with a significantly higher hazard of aseptic revision (hazard risk (HR) = 2.65, P = 0.012). Functional TJA outcomes did not differ (P > 0.05) between groups. Although both groups improved in Patient-Reported Outcomes Measurements Information System (PROMIS) Pain Intensity and Pain Interference scores after TJA, HSF patients showed significantly less improvement in Pain Intensity at all timepoints (P < 0.05). Surgical order was not associated with improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Hip Injury and Osteoarthritis Outcome Score for Joint Replacement, or PROMIS Pain Interference scores.

Conclusions: The timing of these elective surgeries is associated with TJA outcomes. While HSF is linked to a higher adjusted risk of aseptic revision, it is also independently associated with less adjusted improvement in PROMIS Pain Intensity. These findings suggest that although surgical order impacts specific recovery metrics, a patient's comorbidities may be the primary driver of complications.

Background: Cephalosporins are the primary prophylactic antibiotic in primary total hip and knee arthroplasty (THA and TKA). There is interest in augmenting this effect by adding intraoperative vancomycin via intrawound, intraosseous, or intravenous routes. However, low periprosthetic joint infection (PJI) rates have hindered statistical power and consensus within prior research. This study aimed to compare 90-day infectious and medical complications and 5-year revision-free survival among patients who did and did not have intraoperative vancomycin within a large, nationally representative population.

Methods: Within a national database, adult patients undergoing primary THA or TKA for osteoarthritis from January 2010 to April 2023 who received same-day cefazolin prophylaxis were identified. Exclusion criteria included methicillin-resistant Staphylococcus aureus or PJI history, prior infection within 90 days, and any antibiotic prescription within 90 days before and three days following surgery. Patients who did and did not have the addition of intraoperative vancomycin were matched (1:1) on age, sex, Elixhauser Comorbidity Index, body mass index greater than 40, type II diabetes, insulin use, smoking status, and geographic region. Among 78,778 THA patients, 20,841 (26.5%) received intraoperative vancomycin, yielding 17,051 matched patients per group. Among 171,274 TKA patients, 49,145 (28.7%) received vancomycin, yielding 43,569 matched patients per group. The 90-day complications were assessed using univariable and multivariable logistic regressions. The 5-year revision-free survival was evaluated with Kaplan-Meier analysis and log-rank testings. Significance was defined as P < 0.003, per Bonferroni correction.

Results: Across both procedures, intraoperative vancomycin was not associated with reduced 90-day odds of superficial surgical site infection or PJI, nor increased odds of any other adverse event. The 5-year revision-free survival was comparable between both the THA and TKA matched groups.

Conclusions: In this cohort, intraoperative vancomycin was not associated with lower odds of 90-day surgical site infection or PJI, nor improved 5-year revision-free survival.

Background: The Centers for Medicare & Medicaid Services (CMS) has made the collection of patient-reported outcome measures (PROMs) mandatory for inpatient total knee arthroplasty (TKA). The reporting of the proportion of patients who reach the substantial clinical benefit (SCB) threshold between preoperative and postoperative PROMs based on Knee Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores is also necessary for reimbursement. Our study evaluated characteristics among patients who did and did not meet SCB to understand trends that may help surgeons to comply with CMS policies and maximize patient outcomes following TKA.

Methods: A retrospective review was performed of patients undergoing primary TKA between January 2021 and August 2024 at a single large academic center. Demographic, operative, and outcome variables were compared between patients who met SCB and those who did not. Multivariable analysis was performed to identify risk factors for failure to achieve SCB. A total of 807 of 3,538 patients (23%) were eligible for inclusion based on completion of both preoperative and postoperative KOOS JR surveys; 62% of whom reached SCB.

Results: There were few differences in demographics and no significant differences in complications between subgroups. Patients had strikingly different PROM profiles; the group failing to meet SCB reported less pain and higher function preoperatively and more pain, lower function, and lower satisfaction postoperatively in comparison to patients meeting SCB. Patients who had a preoperative KOOS JR interval score > 53.65 were 5.01 times more likely not to achieve SCB (95% confidence interval 3.63 to 6.98; q < 0.001).

Conclusions: Our results demonstrate the difficulty of collecting PROMs in accordance with the CMS mandate and point to distinct differences in PROM profiles related to SCB achievement. Attaining SCB following TKA is a metric of patient satisfaction, and these findings can help guide patient expectations.