Journal of Arthroplasty最新文献

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.

Introduction: Distal femoral replacement (DFR) is a salvage procedure to manage massive bone loss in total knee arthroplasty (TKA). Few studies report mid-term (five to 10 years) to long-term (>10 years) outcomes of DFR for non-oncologic indications. The purpose of this study was to report the implant survival of DFRs in non-oncologic TKA for the entire cohort and by indication, as well as patient-reported clinical outcomes.

Methods: We retrospectively identified all DFR performed for non-oncologic indications from 2002 to 2021 at our institution. There were three patients who had less than a 2-year follow-up who were excluded (no revisions after DFR). There were 45 DFR included who had a mean follow-up of 6.6 years (range, 2.0 to 17.2). The mean age was 75 years (range, 53 to 94), the mean body mass index was 29.2 (range, 19.2 to 52.4), and 64.4% were women. Indications for index DFR were mechanical TKA failure (40.0%), periprosthetic fracture (33.3%), and periprosthetic joint infection (26.7%). There were fourteen (31.1%) patients who underwent revision after index DFR. Reasons for the first revision were infection (seven), fracture (three), hinge dislocation (two), loosening (one), and extensor mechanism rupture (one). All DFRs were rotating hinge designs with fully cemented stems. Kaplan-Meier analysis was used to determine all-cause revision-free Survival and patient-reported outcomes were collected.

Results: The revision-free survival for the entire cohort was 74.6% at five years and 60.2% at 10 years. By indication for index DFR, six of the 12 infection patients, five of the 18 mechanical failure patients, and three of the 15 fracture patients underwent revision. Differences in revision-free survival by indication were not statistically different (P = 0.221). At the final follow-up, the mean Oxford knee score was 25 (range 5 to 40), with 69% patient satisfaction.

Conclusion: A DFR for non-oncological indications is associated with high revision rates. Mid-term (five to 10 years) and long-term (10 years) revision-free survival is poor, and patient satisfaction is modest. Differences in survival by indication for DFR were not statistically significant. DFR remains a valuable salvage procedure, but patients need to be counseled on the expected outcome.

Background: Reoperations following total hip arthroplasty (THA) remain a major clinical challenge, with their incidence and socioeconomic burden rising despite advances in surgical techniques and prosthesis design. This study aimed to evaluate the predominant causes of reoperations following THA over two decades at a tertiary referral hospital, comparing trends between 2004 and 2013, and 2014 and 2023.

Methods: We analyzed all reoperations performed at a tertiary referral hospital between January 2004 and December 2023. A total of 515 hips (483 patients) were included after excluding multiple reoperations on the same hip. The causes of reoperation were stratified into two time periods (2004 to 2013 and 2014 to 2023) to analyze trends. The time interval from primary THA to reoperations was also evaluated.

Results: The main cause of reoperation after primary THA was aseptic loosening, accounting for 52.4% of cases, followed by infection (13.2%), periprosthetic fracture (PPF) (10.7%), wear/osteolysis (8.5%), ceramic fracture (5.8%), and instability/dislocation (5.6%). The proportion of aseptic loosening decreased significantly from 62.5 to 40.4%, while the proportions of infection, PPF, ceramic fracture, and instability/dislocation increased (P < 0.001). The causes of reoperation varied according to the time interval. Instability, PPF, and infection were early causes, and wear/osteolysis and aseptic loosening were relatively later causes of reoperations.

Conclusion: Aseptic loosening was the most common cause of reoperation following primary THA. However, the proportion of infection and PPF increased as a cause of reoperations, while the proportion of aseptic loosening decreased with time. Surgeons should consider that the main cause of reoperations differed according to the time interval from primary THA to reoperation.

Background: This study examined the impact of simulated wear particles on inflammatory cell-induced corrosion (ICIC).

Methods: A 30-day macrophage-lymphocyte co-culture experiment was conducted using American Society of Testing and Materials F1537 cobalt-chromium-molybdenum (CoCrMo) disks, with activators and CoCrMo particles added at none, low (1:10), medium (1:100), and high (1:500) cell-particle ratios. Supernatants collected on days 10 and 30 were analyzed for tissue necrosis factor alpha (TNFα) and interleukin 6 (IL-6) levels via enzyme-linked immunosorbent assay. Disks were examined for ICIC damage using scanning electron microscopy (SEM), and the oxygen percentage on their surfaces was analyzed with energy-dispersive X-ray spectrometry (EDS) and X-ray photoelectron spectrometry (XPS).

Results: Most disks showed damage consistent with ICIC. Day 10 TNFα was higher in medium and high particle groups compared to groups without particles, while IL-6 was unexpectedly lower in those groups. On day 30, the activated medium particle group showed higher IL-6 than the non-activated group. The EDS showed no significant differences in %O (P = 0.77), but XPS results indicated significant differences (P < 0.0001) at high particle concentrations.

Conclusion: Overall, the data suggested that increased TNFα reflected a heightened inflammatory response, particles might temporarily inhibit IL-6 release, and there is likely a synergistic effect between activators and particles on cellular responses.

Background: Despite the growing interest in alternative alignment strategies, advancement in surgical technique, and implant design, several studies have demonstrated that a large number of patients continue to be dissatisfied following total knee arthroplasty (TKA). The purpose of this study was to outline differences in three-dimensional (3D) knee morphology associated with sex and deformity of the arthritic knee and compare these to available off-the-shelf and patient-specific implants.

Methods: A total of 85,604 preoperative computed tomography scans of patients undergoing TKA were analyzed. Distal femur geometry was quantified via 11 measurements taken from 3D models and landmarks. These values were then compared to the geometries of 12 common TKA implants from the American Joint Replacement Registry.

Results: The average overall alignment of the studied population was found to be 3.3° varus with the average hip-knee-ankle (HKA) angle being smaller in men than women. Femoral distal offset was found to play an important role in driving both varus and valgus deformities. Nearly 40% of knees in the cohort had a distal condylar offset (DCO) and 25.6% had a posterior condylar offset (PCO) that would require beyond the traditionally acceptable 3° varus/valgus or require internal rotation when using the most common off-the-shelf (OTS) implants on the market. The range of adequate coverage across the evaluated implant systems ranged from 20 to 63%. On average, less than half (41%) of the patient population fell within the bounds considered to be a proper fit for the 12 OTS implant systems evaluated.

Conclusions: To our knowledge, this study is the largest 3D analysis of osteoarthritic knees to date and identified crucial differences in knee morphology among patients undergoing TKA. These data demonstrate a consistent asymmetry of femoral geometry, despite most off-the-shelf femoral implants being symmetric. In addition, there was a larger PCO and smaller DCO, questioning the utility of a single-radius femoral design in all patients.

Introduction: A two-stage exchange arthroplasty is the standard management method of chronic periprosthetic joint infections (PJIs) of the hip in North America. However, a subset of patients become reinfected and may require a repeat two-stage exchange arthroplasty. The purpose of the present study was to assess revisions, reoperations, and risk factors for failure associated with repeat two-stage exchange arthroplasties for recurrent PJIs after total hip arthroplasty (THA).

Methods: We identified 52 repeat two-stage exchange THAs completed from 2000 to 2021 at a single, high-volume academic medical center. The mean age was 61 years, 39% were women, and the mean body mass index (BMI) was 33. At the time of the repeat two-stage exchange, high-dose antibiotic spacers were used in 90% of patients (28 articulating, 19 non-articulating), and 10% had a resection arthroplasty in the interim between stages. The mean time from repeat first stage to reimplantation was 33 weeks. Kaplan-Meier survivorship estimates were calculated, and risk factors (including the McPherson staging system) were assessed. At the final follow-up, 54% of patients were on chronic antibiotic therapy. The mean follow-up was six years.

Results: The 7-year survivorships free of re-revision for reinfection, any re-revision, and any reoperation were 85%, 57%, and 50%, respectively. The leading indications for re-revision were dislocation (45%) and PJI (35%). McPherson host grade C was a significant risk factor for re-revision for infection (HR [hazard ratio] 5, P = 0.04). Additionally, increased operative time at reimplantation was a risk for any reoperation (HR 1.06, P < 0.01) and reoperation for infection (HR 1.07, P < 0.01). At the final follow-up, 98% of patients had a revision THA in situ (one hip disarticulation).

Discussion: Repeat two-stage exchange arthroplasty of the hip had a 7-year survivorship free of re-revision for infection that was 85%, but only 57% were free of any re-revision (most due to revision for dislocation). McPherson C hosts had a 5-fold increased risk of re-infection.

Background: The Coronal Plane Alignment of the Knee (CPAK) classification system was developed to assess personalized alignment strategies, such as kinematic alignment, in total knee arthroplasty (TKA). However, CPAK has not been studied with regard to patient-reported outcomes measures (PROMs). This study evaluated whether incidentally matching a patient's native preoperative CPAK classification with TKA implant position meaningfully impacted postoperative PROMs.

Methods: A retrospective review of 2,427 primary TKAs was performed. Knees were classified using the CPAK classification on standardized preoperative and postoperative short-leg radiographs using a 5-degree adjustment for the lateral distal femoral angle based on available literature. Surgeries were performed using adjusted mechanical alignment strategies with a three-degree boundary. Patients who had a matching preoperative and postoperative CPAK were compared to all other combinations. Modern PROMs and clinically important differences were analyzed utilizing univariate and multivariate analyses.

Results: There were 94.5% of native knees classified as CPAK-I to III, like published CPAK distributions. The distribution of postoperative CPAK classification was significantly different, with 25.6% of TKAs classified as CPAK-I to III (P < 0.001) and only 11.5% (N = 266) of postoperative CPAK matched the native preoperative classification. The CPAK was not associated with preoperative (P ≥ 0.208) or postoperative PROMs (P ≥ 0.085), except CPAK-I had significantly higher preoperative pain with level walking compared to CPAK-III only (P = 0.027). Patients who had matching preoperative and postoperative CPAK classes demonstrated no difference in PROMs at a median of 24 months of follow-up (P ≥ 0.143). Statistical power was ≥ 93.9%.

Conclusion: Study results demonstrate that matching a patient's native knee coronal alignment classified by CPAK was not predictive of PROMs. This supports prior research that suggests TKA outcomes are multifactorial and related to complex interactions between implant position in three dimensions as well as soft-tissue balance and kinematics.

Background: Implant malalignment may predispose patients to implant failure or pain following total knee arthroplasty (TKA). Previous studies indicate that robotically assisted TKA (RA-TKA) can achieve coronal alignment targets more accurately and precisely than manually instrumented TKA (M-TKA). The purpose of this study was to evaluate the accuracy of RA-TKA versus M-TKA in achieving predetermined coronal and sagittal alignment targets in TKA.

Methods: A total of 201 RA-TKAs performed by three high-volume, fellowship-trained surgeons between June 2021 and June 2022 were compared to a historical control of 365 M-TKAs performed between 2013 and 2017 by the same surgeons. Coronal and sagittal component alignment were assessed using standing anteroposterior and lateral radiographs. Included measurements were femoro-tibial alignment (FTA), medial distal femoral angle (DFA), proximal tibial angle (PTA), femoral sagittal angle (FSA), tibial sagittal angle (TSA), anterior condyle offset (ACO), and posterior condyle offset ratio (PCOR). Normal and outlier ranges were determined from prior studies. The proportions of outliers were compared using univariate analyses.

Results: The RA-TKA was more accurate than M-TKA in achieving all four sagittal alignment targets and two of the three coronal alignment targets. The RA-TKA group exhibited fewer radiographic outliers for DFA (zero versus 2.5%; P = 0.03), PTA (one versus 10.1%; P < 0.001), FSA (7.0 versus 15.6%; P < 0.01), TSA (5.0 versus 14.3%; P < 0.01), ACO (8.5 versus 30.6%; P < 0.01), and PCOR (1.5 versus 9.5%; P < 0.01). Patients in the RA-TKA group had a higher proportion with no radiographic outliers (58.2 versus 35.2%; P < 0.001) and a lower incidence of ≥ two outliers (5.5 versus 25%; P < 0.001) compared to the M-TKA group.

Conclusion: The RA-TKA is more effective than M-TKA in achieving coronal and sagittal alignment, potentially enhancing surgical outcomes.