Journal of Arthroplasty最新文献

"Standard of care" refers to the level of clinical practice that a reasonably competent physician is expected to provide under similar circumstances, based on evidence, specialty guidelines, and professional consensus. This article reviews current literature on the standard of care in total joint arthroplasty and orthopaedic surgery, clarifying its definition, application, and role in reducing malpractice risk through evidence-based protocols. Specifically, the authors examined (1) the definition and evolution of standard of care; (2) the role of clinical guidelines, including arthroplasty specific; (3) legal implications in malpractice; (4) differences in elective versus emergent arthroplasty; (5) postoperative protocols central to practice; and (6) challenges and open questions in defining and updating standards of care.

Background: In this study, we aimed to investigate the intra-articular concentration, antibacterial effect, and safety of a combination of vancomycin and epsilon-aminocaproic acid (EACA) in primary total knee arthroplasty (TKA).

Methods: There were 94 patients who underwent unilateral primary TKA and were randomized into the vancomycin plus EACA (VE) group and the vancomycin (V) group. There were 47 contemporary TKAs propensity score-matched to form the EACA (E) group. The VE group received vancomycin 30 mL (1,000 mg) plus EACA 20 mL, the V group received vancomycin plus saline, and the E group received saline plus EACA. Postoperative blood and drainage samples were collected for vancomycin analysis using liquid chromatography-tandem mass spectrometry. Perioperative blood loss, renal function, and bacterial tests for common periprosthetic joint infection pathogens were evaluated.

Results: Perioperative blood loss in the VE group was equivalent to that in the E group and significantly lower than that in the V group (P < 0.01). The intra-articular vancomycin levels in the VE group were higher than those in the V group at eight and 24 hours, while the serum levels were similar. Antimicrobial effects were comparable in the VE and the V groups, both of which were superior to those in the E group. There were no cases of acute renal injury, ototoxicity, or anaphylaxis.

Conclusions: The combination of intra-articular vancomycin and EACA maintained the vancomycin concentration without impairing the antifibrinolytic function of EACA, although it did not enhance the antibacterial effect of vancomycin.

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: Although untreated subchondral insufficiency fractures of the knee may result in progression of osteoarthritis, leading to arthroplasty in approximately 30% of cases, the factors associated with the requirement for arthroplasty remain unknown. We hypothesized that varus deformity would be associated with increased risk of nonoperative treatment failure and conversion to arthroplasty in patients who have subchondral insufficiency fractures with early osteoarthritis.

Methods: A retrospective cohort study was conducted on 162 patients aged greater than 60 years diagnosed with subchondral insufficiency fracture and early osteoarthritis (Kellgren-Lawrence grades 1 to 2) between March 2015 and December 2021. All patients received initial nonoperative treatment and were followed for a minimum of 36 months. Radiographic evaluation included hip-knee-ankle (HKA) angle measurement and osteoarthritis grading. Magnetic resonance imaging assessment evaluated subchondral insufficiency fracture location, meniscal tears, cartilage defects, and bone marrow edema. Kaplan-Meier survival analyses and Cox proportional hazards regressions were used to identify risk factors for progression to arthroplasty. At a median follow-up of 44 months, 50 patients (30.9%) required conversion to arthroplasty due to osteoarthritis progression.

Results: Patients who had moderate-to-severe varus deformity (HKA angle ≥ 5°) demonstrated a dramatically higher conversion rate of 50.0% (46 of 92) compared with only 5.7% (four of 70) in those who had normal-to-mild varus deformity (HKA angle less than 5°). In multivariable Cox regression analyses, moderate-to-severe varus deformity was the only significant predictor of treatment failure (hazard ratio [HR] 13.20, 95% confidence interval [CI] 4.53 to 38.48, P < 0.001). Traditional risk factors, including age, sex, meniscal pathology, cartilage defects, and bone marrow edema, were not significantly associated with conservative treatment failure.

Conclusions: Moderate-to-severe varus deformity (≥ 5°) is a significant predictor of conservative treatment failure in patients who have subchondral insufficiency fracture and early osteoarthritis, conferring a 13-fold increased risk of conversion to arthroplasty.

Level of evidence: Level III, observation cohort study.

Background: Modular fluted tapered (MFT) stems are widely used in femoral revision surgery for their ability to achieve diaphyseal fixation in the setting of bone loss. This study aimed to identify factors influencing MFT stem subsidence.

Methods: We retrospectively analyzed a cohort of 443 femoral revision procedures performed at a single institution, all using the same model of MFT stem. A total of 180 procedures met the inclusion criteria (≥ four radiographs) and were analyzed for subsidence during follow-up using a radiographic analysis. The mean radiological follow-up was 28.5 months (range, one to 120). Subsidence ≥ five mm was defined as excessive. Implant survivorship was assessed by rerevision rate. The relationship between clinical variables and excessive subsidence was examined using logistic regression and Bayesian modeling, guided by a directed acyclic graph.

Results: The mean stem subsidence at 12 months was 1.6 ± 2.3 mm. Among the full cohort, 18 stems (5.0%) underwent rerevision at a mean of 71.4 months. Excessive subsidence (≥ five mm) was observed in 8.3% of cases. Associative analysis identified severe bone defects (Paprosky IIIA to IIIB) as the main factor associated with excessive subsidence (odds ratio = 6.35, P = 0.001). Short MFT stems, extended trochanteric osteotomies, and men showed weaker, nonsignificant associations. Causal modeling confirmed the influence of bone defect severity and stem length and revealed that sex, age, weight, and height-modulated subsidence risk.

Conclusions: Short MFT stems and severe bone defects were associated with higher subsidence risk, while patient factors such as age, weight, and height-modulated this risk. Individualized implant choice and structured radiographic monitoring are essential to optimize outcomes in femoral revision surgery using MFT stems.

Background: Tourniquet deflation during total knee arthroplasty (TKA) produces abrupt reperfusion physiology, including hyperkalemia, acidosis, and hemodynamic instability. Frail patients are particularly vulnerable; however, this population has not been prospectively studied.

Methods: We conducted a prospective, observational study of frail adults (Clinical Frailty Scale ≥ 4) undergoing elective, unilateral, cemented TKA under spinal anesthesia with a pneumatic thigh tourniquet. There were 40 frail patients (mean age, 76 years [range, 65 to 88]; 65% women) included. Tourniquet duration averaged 84 minutes (range, 70 to 96). Patients with baseline hyperkalemia, severe renal dysfunction, significant arrhythmias, or planned revision or bilateral arthroplasty were excluded. Hemodynamics and arterial blood gases (pH, PaCO₂, lactate, potassium, and electrolytes) were recorded at baseline, pre-deflation, and one to 30 minutes post-deflation. The primary endpoint was the change in serum potassium after tourniquet release, and hemodynamic instability was analyzed as a key clinical outcome. The secondary outcomes included the incidence of hyperkalemia (≥ 5.5 mmol/L), acidosis (pH less than 7.30), hypotension, arrhythmias, post-anesthesia care unit (PACU) interventions, acute kidney injury (AKI), and hospital lengths of stay (LOS).

Results: After deflation, serum potassium rose from 4.3 ± 0.3 to 4.8 ± 0.4 mmol/L at five minutes (P < 0.001), peaking at 4.9 ± 0.4 mmol/L at 10 minutes (mean change, +0.5 mmol/L). Lactate increased from 1.2 ± 0.5 to 2.8 ± 0.9 mmol/L (P < 0.001). The mean arterial pressure decreased by 18% at three minutes post-deflation, with hypotension requiring vasopressors in 30% of patients. Hyperkalemia (≥ 5.5 mmol/L) occurred in three of 40 patients (7.5%), all within 10 minutes of deflation. Acidosis (pH < 7.30) was seen in four of 40 (10%). There were no sustained arrhythmias or cardiac arrests. In the PACU, 28% required vasopressor boluses, 15% received antiemetic treatment, and 10% required prolonged oxygen supplementation. AKI developed in two of 40 patients (5%) within 48 hours. Tourniquet duration was not significantly correlated with potassium change or hypotension (P > 0.05). The median PACU stay was 115 minutes (interquartile range [IQR], 90 to 150), and the median hospital LOS was five days (IQR, four to seven).

Conclusions: In frail patients undergoing TKA, tourniquet release caused significant, but transient increases in potassium and lactate, accompanied by frequent hypotension requiring intervention. Although severe complications were uncommon, physiologic derangements were more pronounced than those observed in non-frail cohorts. Proactive monitoring and early hemodynamic management are warranted to mitigate risk in this vulnerable population.

Background: Stem notching, resulting from impingement between the femoral stem and ceramic liner in ceramic-on-ceramic (CoC) total hip arthroplasty (THA), has been linked to adverse outcomes such as ceramic-related noise and ceramic component fractures. Despite its potential significance, its true incidence is infrequently documented, and the long-term clinical impact remains uncertain. This study aimed to assess the minimum 15-year outcomes and complications associated with stem notching in CoC THA.

Methods: We performed a retrospective cohort analysis of patients who received CoC THA between November 1997 and December 2003, with a minimum follow-up period of 15 years. Stem notching was diagnosed using radiographic evaluation and was observed in 21.5% of cases (63 of 293). The lesions were monitored for an average of 12.5 years from detection (range, one to 23.2). The primary endpoints included changes in notch depth and the occurrence of ceramic-related complications such as ceramic component fractures and noise generation. The secondary outcomes involved functional evaluation via the modified Harris Hip Score.

Results: Notch depth did not demonstrate meaningful progression beyond five years after identification. Lower cup inclination and higher anteversion were associated with the presence of notching. The incidence of ceramic component fractures was 6.3% in notched hips compared to 4.3% in hips without notches (P = 0.509), while noise was noted in 25.4% of notched hips and 22.6% of non-notched hips (P = 0.618). Functional assessment revealed similar outcomes between those who did and did not have notches (mean modified Harris Hip Score: 89.3 versus 91.2; P = 0.103).

Conclusions: Stem notching in CoC THA is a relatively common, but often overlooked phenomenon. Most notches remained stable over time and were not associated with inferior functional outcomes. Although hips with notches showed a higher rate of ceramic-related noise and head fractures, these differences were not statistically significant. Clinicians should recognize this finding, maintain routine follow-up, and reassure patients that a notch alone does not pose any immediate problem.

Level of evidence: Level III, retrospective therapeutic study.

Background: Traumatic brain injury (TBI) is a common neurological injury with widespread systemic effects, leading to increased pain and opioid utilization. In this study, we investigated how a prior TBI affects perioperative opioid utilization in patients undergoing a total knee arthroplasty (TKA) and the risk of prolonged opioid usage.

Methods: Using an administrative claims database, we identified patients undergoing a primary TKA from 2010 to 2022. Following inclusion and exclusion criteria, patients were categorized based on a prior diagnosis of a TBI, leading to a final TBI cohort of 127,369 patients and a control cohort of 1,116,605 patients. Our primary outcome was perioperative opioid utilization, defined as any opioid prescription between 30 days before and after surgery. Our secondary outcome was persistent opioid usage or continued opioid prescriptions 90 to 180 days after surgery. Multivariate regression models were used to assess the risk of persistent opioid usage based on TBI history, adjusting for demographics and comorbidities.

Results: Patients who had a prior TBI had greater perioperative opioid utilization compared to patients who did not have a prior TBI, with 987.5 versus 896.7 morphine milligram equivalents (P < 0.001). The TBI cohort also showed greater rates of persistent opioid usage compared to the control cohort: 22,258 patients (17.5%) versus 162,214 patients (14.5%) (P < 0.001). In the multivariate regression analyses, prior diagnosis of a TBI within one year before a TKA was associated with the greatest risk of persistent opioid usage (odds ratio [OR] 1.20, 95% confidence interval [CI]: 1.14 to 1.22, P < 0.001).

Conclusions: Prior diagnosis of a TBI is associated with greater perioperative opioid utilization and an increased risk of prolonged opioid utilization after a TKA. Further research should investigate the mechanisms of this association to target interventions for this population and ultimately reduce opioid consumption.

Background: This study aimed to evaluate whether preservation versus resection of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) affects clinical outcomes.

Methods: A systematic review and meta-analysis, searching multiple databases up to November 2024 for comparative studies of infrapatellar fat pad-preservation (IPFP-P) versus resection in primary TKA, was conducted. Outcomes assessed included rates of complications, visual analog scale for pain, and the rate of anterior knee pain, Knee Society Score, patellar tendon length, range of motion, and operative time. Data were pooled using random-effects meta-analysis. There were 21 studies (3,573 patients, 4,107 TKAs: 2,298 preserved, and 1,809 resected IPFP) included.

Results: The IPFP-P had a 76% reduction in the rate of complications within six weeks (relative risk = 0.24, 95% confidence interval [CI]: 0.12 to 0.48, P < 0.01), but not at later follow-up. The visual analog scale pain scores did not differ significantly between groups at any time point. The IPFP-P reduced the risk of anterior knee pain at three months (relative risk = 0.12, 95% CI: 0.02 to 0.94, P = 0.04), but this was not sustained at later follow-up. There were no significant differences found for operative time and Knee Society Score. However, infrapatellar fat pad-resection resulted in greater patellar tendon shortening at six and 12 months (mean difference = 2.68 mm at 12 months, P < 0.01), with a significant reduction in knee flexion at 12 months (mean difference = 2.92°, 95% CI: 0.52 to 5.33, P = 0.02).

Conclusions: The IPFP-P during TKA reduces early postoperative complications and short-term anterior knee pain compared to resection, without affecting operative time or long-term pain. Complete resection is associated with patellar tendon shortening and a slight decrease in flexion at 12 months but does not impact overall functional scores. These findings support IPFP-P as the preferred approach in TKA over complete resection.

Background: Total hip arthroplasty (THA) is increasing in utilization among young patients. While THA markedly improves outcomes in those who have degenerative hip disease, patients under 50 years face an extended lifetime risk for complications and revisions. Highly cross-linked polyethylene (HXLPE) is associated with reduced wear, revision rates, and osteolysis compared to conventional polyethylene, potentially enhancing implant longevity in this younger, active population. This study systematically reviewed and meta-analyzed the outcomes of THA using HXLPE in patients under 50 years of age at a minimum 10-year follow-up.

Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Searches were performed in Embase, Ovid Medline, Scopus, and Cochrane databases. Inclusion criteria targeted studies with patients under 50 years reporting original data on THA using HXLPE with a mean follow-up of ≥ 10 years. Data extraction was performed independently by two reviewers, and study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Multiple random-effects meta-analyses were performed to summarize outcomes. There were eighteen studies included (n = 1,587 hips) with a weighted mean follow-up of 14.1 years.

Results: Overall, revision-free survivorship was 98%, and the weighted mean improvement in Harris Hip Score was 43.7 points. A random-effects meta-analysis yielded a pooled linear wear rate of 0.024 mm/year (95% confidence interval (CI): 0.013 to 0.035). All wear rates remained well below the 0.1 mm/year threshold associated with osteolysis risk, regardless of femoral bearing material or size.

Conclusion: Total hip arthroplasty using highly cross-linked polyethylene in patients aged ≤ 50 years yields excellent clinical and radiographic outcomes with minimal wear observed up to 20 years postoperatively. Importantly, these benefits are largely maintained regardless of the femoral head bearing material or size. These findings support the continued use of HXLPE among young patients to maximize wear parameters and revision-free survival.