Journal of Arthroplasty最新文献

Background: Statistical improvement in patient-reported outcomes (PROs) does not necessarily equate to clinical benefit. Clinometric outcome thresholds have been used to provide a better insight into postoperative functional status and patient satisfaction in total hip arthroplasty (THA). This study aimed to define and evaluate patient acceptable symptomatic state (PASS) at the 10-year follow-up time point for modified Harris Hip Score (mHHS), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR), and Forgotten Joint Score (FJS).

Methods: Prospectively collected data were retrospectively reviewed for all patients who underwent primary THA between 2008 and 2015. Patients were included in the study if they had complete PROs with anchor questions at the 10-year time point. The PASS thresholds were then defined using the anchor-based method for mHHS, HHS, HOOS-JR, and FJS. A total of 176 hips were included in the study, with 101 women (57.4%). The average age, body mass index, and follow-up time were 58 ± 8.2 years, 29.4 ± 5.1, and 124.9 ± 6.9 months, respectively.

Results: The areas under the curves were as follows: mHHS 0.87, HHS 0.87, HOOS-JR 0.87, and FJS 0.71, indicating acceptable to excellent discrimination for all defined thresholds. The threshold for achieving PASS at 10-year follow-up was as follows: mHHS 79.5, HHS 81.3, HOOS-JR 75.1, and FJS 76.0.

Conclusions: This study establishes the PASS thresholds for mHHS, HHS, HOOS-JR, and FJS at the 10-year follow-up time point following primary THA. These findings offer clinicians valuable reference points for assessing clinical success over the long term.

Background: Conventional randomized controlled trials are generally too underpowered to yield meaningful insights into the functional dependence of revision risk on surgeon-controlled implant alignment. However, matched case-control studies focused on patients undergoing revision surgery could produce such insights. We therefore asked: can we determine, through simulation, whether such matched case-control study designs could potentially produce sufficiently accurate estimates of the functional relationships between surgeon-controlled variables and aseptic revision risk to inform surgical alignment targets for total knee arthroplasty?

Methods: We evaluated the potential for a matched case-control methodology to achieve this goal using a simulation approach in which we characterized individual patients' risk of revision by implant life factor (ILF) functions that reflected the effects of both surgeon-controlled and patient-specific factors. We then synthesized simulated patients, emulated the matching process, and trained Naïve Bayes classifiers to estimate the influence of surgeon-controlled factors on implant survival. We repeated this process for various potential clinical study sizes and then calculated the errors in both the estimated ILF functions associated with the surgeon-controlled factors and the predicted optimal implant alignment.

Results: Across different study sizes, our classifier predicted the simulated functional relationships between ILF variables and optimal implant placement with reasonable accuracy. With as few as 300 revision candidates, we estimated the weighted absolute mean errors in predicting the ILF to be 3.3 ± 0.9% for coronal alignment, 2.6 ± 1.0% for tibial slope, and 5.4 ± 0.8% for femoral component rotation (relative to the transepicondylar axis). We predicted the optimal implant orientation to within 1.5 ± 1.2° for coronal alignment, 0.2 ± 1.2° for tibial slope, and 0 ± 0° for femoral component rotation.

Conclusions: Based on these simulations, it seems that a matched case-control methodology may represent an acceptably efficient approach to determining the impact of surgeon-controlled variables on the risk of aseptic revision in total knee arthroplasty.

Background: Minimum joint space width (mJSW) is a useful quantitative metric of osteoarthritis progression in the hip, particularly as a continuous variable compared to more common categorical classification systems. The purpose of this study was to develop an automated algorithm for measuring mJSW in native hips on antero-posterior pelvis radiographs.

Methods: An end-to-end algorithm was developed, consisting of a deep learning segmentation model plus a computer vision algorithm to measure mJSW in the hip joint. Trained researchers annotated 300 radiographs for training and validation of an automated segmentation model that identifies relevant structures for the measurement of mJSW. Trained annotators also independently measured mJSW in 375 additional images to provide ground truth measurements for the development and validation of a computer vision algorithm. External validation was performed on 75 images from the Osteoarthritis Initiative. Algorithm performance was measured by calculating the mean absolute error and constructing a Bland-Altman plot.

Results: The mean absolute error between the human and the algorithm's measurements was 0.87 ± 1.05 mm. In 70% of cases, the algorithm's mJSW measurements were less than one mm different from human measurements, in 84% the difference was less than 1.5 mm, and in 90% the difference was less than two mm. In the Osteoarthritis Initiative external validation cohort, mean absolute error was 0.86 ± 0.69 mm. The trained segmentation model obtained an average Dice score of 0.71 across all structures in the test set.

Conclusions: An automated model for measuring mJSW on antero-posterior pelvis radiographs was developed and externally validated. This algorithm performs well at the sub-millimeter level and may streamline longitudinal patient evaluation and population-level clinical research in the natural history of the hip joint.

Background: Recent increasing usage of cementless implants has raised the question of whether cemented versus cementless implants are more associated with the need for manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). The current study utilized a large, national, administrative database to characterize the incidence of MUA after cemented versus cementless TKA and considered the potential association of MUA with revision rates.

Methods: A large national database was queried for adult patients who underwent elective TKA. Those who had a contralateral TKA within six months of index surgery were excluded. Those who received cemented versus cementless TKA were determined and exactly matched 4:1 on age, sex, and Elixhauser Comorbidity Index. The 6-month postoperative incidences of MUA were compared between subgroups. The 5-year prosthetic revision rates were compared between those who underwent MUA versus those who did not within each subgroup and between subgroups among those who underwent MUA, using log-rank tests. Of 567,715 TKA patients, cemented implants were used for 539,070 (95.0%) and cementless for 28,645 (5.0%).

Results: Matched cemented and cementless subcohorts included 114,496 and 28,624 patients and had similar postoperative MUA rates of 3.4% for both groups (P = 0.5). Compared to patients who did not undergo MUA, those who did had higher 5-year revision rates within both cemented (7.5 versus 2.7%, P < 0.01) and cementless groups (7.1 versus 3.0%, P < 0.01). Among patients who underwent MUA, revision rates were similar between cemented and cementless groups (7.5 versus 7.1%, P = 1).

Conclusions: The 6-month postoperative incidences of MUA after TKA were equivalent between large, matched cemented and cementless populations (3.4% for both). While MUA was associated with decreased 5-year prosthetic survivorship for both cemented and cementless prostheses (underscoring its importance), it did not disproportionately impact rates for one versus the other.

Background: The purpose of this study was to compare outcomes for patients undergoing unicompartmental knee arthroplasty (UKA) by adult reconstruction fellowship-trained surgeons and non-fellowship-trained surgeons.

Methods: A large administrative claims database was queried for patients undergoing primary, elective UKA between 2010 and 2019 with a minimum of 5-year follow-up. Patients who underwent UKA by surgeons who were fellowship trained in adult reconstruction were matched 1:1 based on age, Elixhauser Comorbidity Index, obesity, osteoporosis, tobacco use, alcohol use, and insurance plan to patients who underwent UKA by non-adult reconstruction fellowship-trained surgeons. The incidence of 90-day medical and surgical complications, as well as 2- and 5-year complication and reoperation rates, was identified via International Classification of Diseases coding and compared between matched groups.

Results: The final cohort included 25,278 matched pairs of patients who underwent UKA either by fellowship-trained or non-fellowship-trained surgeons. There were no statistically significant differences in 90-day medical and surgical complication rates between cohorts (all P > 0.05). At both 2- and 5-year follow-ups, patients who underwent UKA by adult reconstruction fellowship-trained surgeons were less likely to experience periprosthetic fracture (two years: odds ratio [OR]: 0.58, P = 0.018; five years: OR: 0.62, P = 0.013), aseptic loosening (two years: OR: 0.78, P = 0.031; five years: OR: 0.71, P < 0.001), implant failure (two years: OR: 0.39, P < 0.001; five years: OR: 0.52, P < 0.001), mechanical complication (two years: OR: 0.77, P = 0.010; five years: OR: 0.81, P = 0.009), or require revision to total knee arthroplasty (two years: OR: 0.69, P < 0.001; five years: OR: 0.69, P < 0.001).

Conclusions: These data suggest that surgeons who had fellowship training in adult reconstruction demonstrated lower rates of complications and revision to total knee arthroplasty when performing UKA. The non-adult reconstruction fellowship-trained surgeons wishing to incorporate UKA into their practice may consider pursuing additional training to optimize outcomes for their patients.

Background: Fellowship training has become increasingly popular among orthopaedic residents, although its impact on arthroplasty outcomes has been underexplored. This study aimed to compare the incidences of complications, including periprosthetic joint infection (PJI), manipulation under anesthesia (MUA), aseptic revision, and aseptic loosening between patients who underwent primary total knee arthroplasty (TKA) by an arthroplasty-trained surgeon versus a non-arthroplasty-trained surgeon at 90 days, one year, and two years postoperatively.

Methods: A national insurance database was used to identify patients who underwent elective TKA from 2010 to 2021. A physician report was obtained for this cohort of patients, which included the name and National Provider Identifier of the operative surgeon. Using this information, we performed a web search to identify whether each physician had undergone adult reconstruction fellowship training. Once surgeons were classified by training, we split the patients into two cohorts: those operated on by arthroplasty-trained surgeons and non-arthroplasty-trained surgeons. We used a propensity score match to account for demographic differences, resulting in two cohorts with 361,362 patients each.

Results: At 90 days, patients who were operated on by non-arthroplasty-trained surgeons experienced increased rates of surgical site infection (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.26 to 1.54), venous thromboembolism (OR 1.14, 95% CI 1.02 to 1.26), PJI (OR 1.40, 95% CI 1.24 to 1.58), aseptic loosening (OR 1.62, 95% CI 1.15 to 2.29), and MUA (OR 1.23, 95% CI 1.16 to 1.30). At one and two years, higher incidences of PJI, aseptic loosening, and MUA persisted in the nonarthroplasty cohort. In addition, the nonarthroplasty cohort demonstrated higher odds of aseptic revision at one year (OR 1.16, 95% CI 1.04 to 1.28) and two years (OR 1.28, 95% CI 1.18 to 1.39).

Conclusions: Patients who underwent TKA with arthroplasty-trained surgeons experienced fewer complications at 90 days, one year, and two years postoperatively.

Background: The NarxCare Overdose Risk Score (ORS) is a measure of prescription drug use with scores ranging from 0 to 999, and higher scores suggest worse prescription drug use patterns, including opioids, sedatives, and stimulants. We aimed to evaluate the association of preoperative NarxCare ORS with clinically meaningful improvements in patient-reported outcome measures (PROMs) and satisfaction at one year.

Methods: Patients undergoing primary total knee arthroplasty at an academic health care system (2018 to 2022) were included. Of 6,710 patients, 44.8% had ORS 0, 28.0% had 100 to 199, and 15.1% had 200 to 299. The PROMs evaluated included the Knee Disability and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Joint Replacement (JR). Clinically relevant improvements were determined by the minimal clinically important difference (MCID), Patient Acceptable Symptoms State (PASS), and substantial clinical benefit (SCB) thresholds. Multivariable regression models were used to assess the relationship between baseline ORS and 1-year PROMs.

Results: Compared to ORS 0, higher ORS was linked to worse outcomes. TheMCID failure for KOOS-JR increased with ORS 100 to 199 (odds ratio (OR) = 1.28, P = 0.033), 200 to 299 (OR = 1.51, P = 0.003), 300 to 399 (OR = 1.84, P = 0.001), and 400 to 499 (OR = 2.27, P = 0.003). The PASS failure rose across KOOS Pain (OR = 1.23 to 2.59, P = 0.003), KOOS -PS (OR = 1.26 to 3.87, P ≤ 0.001), and KOOS-JR (OR = 1.45 to 2.69, P = 0.03) from ORs 100 to 199 to ≥ 500. Dissatisfaction at one year was associated with ORS 100 to 199 to ≥ 500 (OR = 1.21 to 2.85, P ≤ 0.026). The SCB failure for KOOS-JR was linked to ORS 100 to 499 (OR = 1.18 to 1.80, P ≤ 0.032).

Conclusions: Higher preoperative NarxCare ORS is independently associated with reduced odds of achieving meaningful improvements in pain, function, and satisfaction at one year after total knee arthroplasty. This readily available metric may help guide preoperative counseling and has important implications for evolving Centers for Medicare & Medicaid Services policies that tie reimbursement to PROM performance.

Introduction: Cutaneous psoriasis (PsC) and psoriatic arthritis (PsA) are associated with higher risks for soft-tissue infection.^48-50 However, there is sparse literature examining psoriasis and infectious complications following total hip arthroplasty (THA). Therefore, the purpose of this study was to observe and compare the rates of (1) superficial surgical site infections (superficial SSI), (2) deep surgical site infections (deep SSI), and (3) 90-day sepsis rates, and two-year revision rates following THA in patients who have PsC and PsA compared to patients who did not have psoriasis.

Methods: A retrospective database analysis was performed utilizing a large national database. Patients who underwent THA were identified using Current Procedural Terminology (CPT) codes. In total, 593,013 patients were included, of whom 10,230 patients (1.7%) had PsC and 1,445 patients (0.2%) had PsA. Patients were then classified into three cohorts: (1) PsA, (2) PsC, and (3) patients who do not have either condition (control). Multivariate logistic regressions were utilized to compare the outcomes between study cohorts.

Results: Patients who have PsC had higher 90-day superficial SSI (odds ratio (OR): 2.3; CI: 2.2 to 2.5; P < 0.001), deep SSI (OR: 1.4; 1.2 to 1.5; P < 0.001), wound complications (OR: 1.1; 1.1 to 1.3; P < 0.001), sepsis (OR: 2.8; 2.6 to 3.0; P < 0.001), and aseptic revision (OR: 1.2; CI: 1.2 to 1.3; P < 0.001), while patients who have PsA had higher 90-day superficial SSI (OR: 1.7; CI: 1.4 to 2.0; P < 0.001), sepsis (4.7; 4.3 to 5.2; P < 0.001), and deep SSI (2.9; 2.5 to 3.3; P < 0.001). In addition, both cohorts had a higher two-year all-cause revision PsC (1.2; 1.1 to 1.2; P < 0.001) and PsA (1.1; 1.0 to 1.3; P < 0.001).

Conclusion: This study showed both manifestations of psoriasis are associated with risks of complications following THA. In particular, both PsC and PsA were associated with higher rates of infections and all-cause revisions. These findings underscore the importance of perisurgical optimizations, including an interdisciplinary team to control flare-ups with enhanced infection prevention measures and patient counseling to reduce complications.

Background: Collared femoral stems have seen a resurgence in total hip arthroplasty (THA) due to improved axial and rotational mechanical stability and lower early complication rates, including periprosthetic fracture. However, the presence of a collar over the femoral calcar may cause pain due to iliopsoas impingement (IPI). The objective of this paper was to analyze temporal trends in collared stem use and determine risk factors for associated IPI.

Methods: A retrospective institutional review was conducted to assess collared stem utilization and the incidence of IPI resulting in arthroscopic iliopsoas fractional lengthening (IPFL) between 2002 and 2025. Patient demographics, collar design, and implant sizing were analyzed as risk factors for IPFL. A total of 108 IPFLs and 29,070 primary THAs was performed during the study period.

Results: While collared stem use remained relatively stable between 2002 and 2019, there was a significant increase (P = 0.003) in collar usage from 2020 onward, averaging 9.4% annual growth. A rise in IPFL procedures was observed over the same period, with a notable increase in cases involving collar overhang greater than two mm. Namely, collar overhang was observed in none of the IPFL cases in 2015, 16.7% of cases in 2020, and 31.6% of all cases in 2025 (P = 0.031). Constant length collar (CLC) stems, though comprising only 19.6% of all collared stems implanted during the time period, accounted for 51.7% of collar-related IPFL cases (P < 0.001), with smaller stem sizes (size ≤ three) particularly overrepresented (P < 0.001).

Conclusion: While collared stems offer mechanical advantages in THA, excessive collar overhang, especially in small femora with CLC designs, may increase the risk of IPI, resulting in subsequent surgical intervention. Surgeons should remain vigilant about this risk during planning and implant selection. Consideration of collar geometry and awareness of femoral size-related overhang may help reduce the need for secondary interventions.

Background: Various patient-reported outcome measures (PROMs) are used following total knee arthroplasty (TKA), but the timing of recovery plateaus and the presence of ceiling effects remain unclear. This study aimed to describe these characteristics of commonly used PROMs following TKA.

Methods: This retrospective analysis of prospective data included 229 patients (mean age, 64 years; range, 43 to 75) who underwent primary TKA. Outcomes were collected preoperatively, at six weeks, six months, and annually up to four years using the Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcome Score subscales, EuroQol 5-Dimension (EQ-5D), EuroQol Visual Analogue Scale (EQ-VAS), Objective Knee Society Score, and range of motion. Recovery trajectories were modeled using linear mixed-effects models, and plateaus were identified through pairwise comparisons. Ceiling effects and proportions of patients achieving the minimal important change (MIC), patient acceptable symptom state (PASS), and maximum scores were tracked over time.

Results: Knee-specific PROMs plateaued by two years, while health-related quality of life measures plateaued earlier (EQ-5D at one year, EQ-VAS at six months), as did physical outcome measures (one year). For knee-specific PROMs, the proportions achieving the MIC and PASS stabilized by one and two years, respectively, while maximum score achievement increased up to three years for all except the OKS. Ceiling effects emerged for all knee-specific PROMs except the OKS, developing between six months and three years. The FJS exhibited a ceiling effect by three years.

Conclusion: Current knee-specific PROMs plateau by two years following TKA. However, ceiling effects and increases in maximum score achievement up to three years suggest that further improvements are masked by instrument limitations. Routine collection of current PROMs beyond two years provides limited value, but extended follow-up remains important for research. Future PROM development should prioritize improved postoperative score distributions and assessment of high-level function.