Journal of Arthroplasty最新文献

Introduction: Understanding patello-femoral and femoro-tibial kinematics is essential for optimizing outcomes following total knee arthroplasty (TKA). Registry data indicate higher revision rates in TKA patients who have unresurfaced patellae, yet the kinematic implications of patellar resurfacing remain underexplored. This study investigated the influence of patellar resurfacing on patellar height classification and knee kinematics.

Methods: A retrospective observational study of 167 Bicruciate-Stabilized (BCS) TKA patients who were from six surgeons was evaluated-128 with resurfaced and 39 with unresurfaced patellae. Subjects underwent fluoroscopic analysis during weight-bearing deep knee bends. Femoro-tibial kinematics, including antero-posterior condylar motion and axial rotation, were assessed via three-dimensional model-fitting. Patellar height was classified using the Blackburne-Peel ratio at 30° flexion.

Results: The resurfaced cohort exhibited a lower incidence of patella baja (22%) and alta (2%) compared to the unresurfaced group (38 and 5%, respectively), with patella baja significantly more common in the unresurfaced group (P = 0.033). The resurfaced group also demonstrated more lateral condylar rollback (-14.4 ± 5.4 versus -11.8 ± 5.6 mm, P = 0.012) and greater overall axial rotation during flexion (9.4 ± 5.4 versus 7.4 ± 5.8°, P = 0.043), with fewer instances of reverse axial rotation (7 versus 13%, P = 0.049). Finally, resurfaced knees had marginally greater weight-bearing range-of-motion (113 ± 16.9 versus 110 ± 10.8°, P = 0.369), though not statistically significant.

Conclusion: This study suggests that patellar resurfacing in BCS TKA may contribute to more favorable patellar height classifications, more natural kinematics, and reduced incidences of reverse rotation. The observed trends highlight the potential of resurfacing in achieving improved TKA kinematics, although variability in surgeon technique and lack of preoperative data limit the generalizability of these results.

Background: Onychomycosis, a fungal infection of the nail, is often perceived as a benign condition. The purpose of this study was to evaluate whether onychomycosis is associated with an increased risk of periprosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA).

Methods: Patients who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) were identified using a large national database. Control cohorts of patients who did not have a history of onychomycosis were 1:1 propensity score matched to comparison cohorts of patients who had onychomycosis diagnosed within the year prior to their surgery. The comparison cohorts were further stratified by receipt of antifungal treatment. The 90-day surgical site infection (SSI) and one-year PJI and reoperation rates were assessed. There was a total of 7,530 patients who had a history of onychomycosis, of which 4,620 patients underwent TKA, and 2,910 patients underwent THA.

Results: Onychomycosis was associated with increased one-year reoperations [odds ratio (OR): 1.43 (95% confidence interval (CI): 1.04 to 1.97), P = 0.029], but not with SSI or PJI (P > 0.05) after TKA. There were no significant differences in SSI, PJI, or reoperations (P > 0.05) after THA. Subgroup analyses revealed that patients who have onychomycosis and did not receive treatment had an elevated risk of one-year PJI (both TKA and THA: P < 0.05), with TKA patients demonstrating higher one-year reoperation rates [OR: 1.57 (95% CI: 1.10 to 2.25), P = 0.013] and THA patients showing a trend towards significance [OR: 1.53 (95% CI: 0.98 to 2.38), P = 0.060].

Conclusion: Untreated onychomycosis was associated with a significantly higher risk of one-year PJI in patients undergoing TJA and may represent a modifiable risk factor in the preoperative setting. Future research should evaluate whether treatment of onychomycosis reduces the risk of PJI and reoperations.

Background: Women report worse outcomes following total knee arthroplasty (TKA), but it remains unclear whether sex independently predicts outcomes or whether observed differences reflect baseline characteristics. This study aimed to characterize sex differences across a four-year recovery period and determine whether they persist after adjusting for confounding factors.

Methods: This prospective multicenter cohort study included 229 patients (114 women, 115 men; mean age 64 years) who underwent primary TKA. Patient-reported outcome measures (PROMs), including the Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, Forgotten Joint Score, and the EuroQol 5-Dimension (EQ-5D), along with physical measures (Objective Knee Society Score and range of motion), were collected preoperatively, at six weeks, six months, and annually up to four years postoperatively. Linear mixed-effects models assessed sex differences in postoperative trajectories with three levels of adjustment: unadjusted, demographic-adjusted, and baseline-adjusted (including preoperative scores).

Results: Women demonstrated lower-scoring postoperative trajectories than men across nearly all PROMs in unadjusted models, with the largest differences in functional outcomes (OKS: β = -2.7, P < 0.001; KOOS Activities of Daily Living (ADL): β = -5.7, P < 0.001). Women also had significantly worse preoperative scores across all knee-specific PROMs (P < 0.05). Demographic adjustment attenuated sex effects, leaving only OKS (P = 0.009) and KOOS ADL (P = 0.012) significant. After additional adjustment for preoperative scores, sex differences in all PROMs were eliminated (P > 0.05).

Conclusion: Sex was not an independent predictor of TKA outcomes once baseline characteristics and preoperative scores were accounted for. Women present with less favorable preoperative profiles, including worse pain and function, higher body mass index, and greater prevalence of anxiety and depression. Improving preoperative status in women through earlier referral, optimized management of affective disorders, and targeted interventions may help narrow disparities in TKA outcomes.

Introduction: Chronic obstructive pulmonary disease (COPD) is a common comorbidity among patients undergoing total knee arthroplasty (TKA). We compared preoperative characteristics, perioperative management methods, postoperative complications, and readmissions after TKA in patients who did and did not have COPD.

Methods: We performed a retrospective matched cohort study of primary, elective TKAs at an urban academic center (August 2012 to December 2020). We identified 785 patients who had COPD and matched them 1:3 to 2,274 patients who did not have COPD by age, sex, and body mass index (BMI). Groups were compared using univariate analyses. Multivariable regressions evaluated the independent associations of COPD with complications and 30-day readmissions. Temporal trends in complications and readmissions were assessed across the study period.

Results: Compared with non-COPD patients, those who had COPD had modest, but consistently higher prevalence of several cardiopulmonary and medical comorbidities, reflecting a higher overall comorbidity burden at baseline. Intraoperatively, COPD patients more often received general anesthesia (10.1 versus 7.6%, P = 0.037) and carried higher American Society of Anesthesiologists (ASA) classifications (Class III or IV: 51.1 versus 30.3%, P < 0.001). Univariate analyses showed higher rates of postoperative anemia (3.6 versus 2.1%, P = 0.033), any complication (11.7 versus 8.1%, P = 0.003), and 30-day readmission (5.2 versus 3.2%, P = 0.014) among COPD patients. However, in multivariable models, COPD was not independently associated with increased complications or readmissions. Complication rates among COPD patients declined markedly over time (from 41.3% early in the period to 5.1% by 2020), and by the end of the study, complication and readmission rates were comparable between groups.

Conclusion: Patients who have COPD undergoing TKA constitute a higher-risk population with more complex medical histories. Although crude analyses showed higher early complications and readmissions, these differences were not independent of confounders and diminished over time. Contemporary perioperative optimization and standardized care pathways appear to mitigate historical disadvantages for COPD patients undergoing TKA.

Introduction: Manipulation under anesthesia (MUA) is a common treatment for stiffness following total knee arthroplasty (TKA). The purpose of this study was to evaluate the outcomes following MUA and identify risk factors for additional surgical intervention.

Methods: This study analyzed 227 knees that underwent MUA following primary TKA with one-year follow-up. The 39 patients (17.2%) who required additional intervention were compared to 174 patients who underwent MUA without further interventions. There were no differences in body mass index, American Society of Anesthesiologists class, and prior knee surgeries. The mean follow-up was 38.5 months (range, 12 to 119.5) in the failure group and 39.2 (range, 12 to 124.2) in the control cohort.

Results: Of the 39 patients requiring additional procedures, 29 (74%) underwent arthroscopic lysis of adhesions and 15 (38%) revision TKA. Range of motion (ROM) two weeks following MUA was lower in patients who had additional interventions (96.4 versus 107.4°, P < 0.001), as was ROM at one year (103.1 versus 112.9°, P < 0.001). Multivariate analyses found age, cruciate-retaining (CR) implants, and ROM two weeks after MUA as independently associated with failure. There were no differences in preoperative Knee Society Score (KSS) Function, KSS Knee, and Knee Injury and Osteoarthritis Score for Joint Replacement (KOOS JR) scores. At the latest follow-up, patients who failed MUA had inferior KSS Knee (79.1 versus 89.0, P = 0.003), KOOS JR (65.0 versus 80.2, P < 0.01), Forgotten Joint Score (FJS-12) (39.1 versus 62.0, P < 0.01), and Likert satisfaction scores (3.5 versus 4.5, P < 0.01).

Conclusion: This study demonstrated a 17.2% reoperation incidence following MUA. Decreased ROM at two weeks, age, and CR implants were associated with additional intervention. These findings underscore the importance of early ROM recovery following MUA and the need for better understanding the biologic aspects of arthrofibrosis.

Background: Periprosthetic joint infection (PJI) is a serious complication of hip and knee arthroplasty. Although hematogenous seeding is a recognized cause, the contribution of asymptomatic bacteriuria (ASB) remains uncertain. Therefore, we conducted a systematic review and meta-analysis to evaluate this association.

Methods: A systematic search was conducted according to predefined eligibility criteria. There were 16 studies (14 cohorts [n = 48,562 joints] and two randomized controlled trials [n = 1,065 joints] that met inclusion criteria. The primary outcome was PJI rates after hip and knee arthroplasties in patients who had ASB. The secondary outcomes were subgroup analyses by procedure type and culture isolates in urinary and intraoperative cultures. Random-effects meta-analyses used Mantel-Haenszel pooling with Hartung-Knapp-Sidik-Jonkman adjustments.

Results: The ASB cohort showed higher pooled odds of PJI (odds ratio 2.41, 95% confidence interval 1.20 to 4.83; P = 0.02), but subgroup analyses by follow-up and procedure type were not significant. Antibiotic treatment offered no benefit in elective arthroplasty, and ASB in hip fracture hemiarthroplasty showed no increased risk, with or without antibiotics.

Conclusion: The ASB cohort demonstrated a statistically significant, yet modest, increased odds of PJI limited to pooled undifferentiated, arthroplasty. In contrast, procedure- and time-specific analyses, while underpowered, showed no consistent signal to suggest an increased risk of PJI following hip or knee arthroplasty or fracture hemiarthroplasty. Consistent with this, prophylactic antibiotic treatment of ASB was not associated with a protective effect. Taken together, these findings do not support routine preoperative urinalysis to promote antimicrobial stewardship.

Background: Total hip arthroplasty (THA) outcomes are commonly assessed using patient-reported outcome measures (PROMs). As electronic PROMs (ePROMs) gain popularity, it is essential to ensure equivalence to paper-based PROMs (pPROMs). This study aimed to evaluate the interchangeability of ePROMs and pPROMs in patients undergoing THA.

Methods: A prospective cohort analysis of 96 THA patients who completed preoperative ePROMs and pPROMs was conducted. Electronic Oxford Hip Score (OHS) and EuroQol 5-Dimension 5-Level (EQ-5D-5L) were completed zero to 28 weeks prior to surgery, and pPROMs were completed on the day of surgery. Correlations were assessed with Spearman's rank correlation, and agreement and bias were evaluated using intraclass correlation coefficients (ICC) and Bland-Altman analysis. The effect of time between completion of ePROM and pPROM on score difference was assessed.

Results: Electronic scores were lower compared to the paper format (OHS: median 19.0 [interquartile range (IQR) 13.8 to 25.3] versus 19.0 [14.0 to 25.0]; difference -1.5; P = 0.005, EQ-5D-5L: median 0.575 [0.455 to 0.681] versus 0.597 [0.472 to 0.704]; difference -0.028; P = 0.05). These differences were below established minimal clinically important differences (MCIDs). Agreement was good for OHS (ICC 0.873, 95% CI [confidence interval] 0.805 to 0.917) and moderate for EQ-5D-5L (ICC 0.677, 95% CI 0.551 to 0.773). Minimal bias (OHS -1.3, LoA -9.3 to 6.7; EQ-5D-5L -0.025, LoA -0.26 to 0.20) was detected, with 14.6 and 2.1% of scores, respectively, exceeding MCID. The median time interval between ePROM and pPROM administration was six days (IQR 3 to 27 days) and had no effect on differences. However, reduced variability was seen when ePROMs were completed within one week of surgery.

Conclusion: Electronic and paper-based OHS and EQ-5D-5L show good agreement and can generally be used interchangeably. However, caution is required for individual scores near clinically important thresholds. Given their efficiency and scalability, we recommend a full transition to ePROMs.

Background: Certain dressings have been linked to allergic contact dermatitis (ACD), with subsequent exposure resulting in an eczematous skin reaction. The purpose of this study was to compare rates of ACD between patients undergoing arthroplasty who were previously exposed to and who were naïve to a specific silver-impregnated dressing.

Methods: There were 396 patients who underwent 457 primary hip and knee arthroplasties and were prospectively enrolled between August 1, 2023, and December 31, 2024. Patients were classified as "naïve" or "exposed" based on prior dressing exposure. Skin checks were performed on postoperative days seven and 14. The primary outcome was ACD. Multivariable logistic regression analyses were performed to evaluate if prior dressing exposure was an independent risk factor for the development of ACD. Based on documented ACD rates of 1 and 2% in "naïve" and "exposed" patients, respectively, power analysis (80% power, alpha = 0.05, and 1:1 allocation) required 314 patients total (157 per arm) to detect a two-fold difference in ACD rates. There were 177 procedures performed in "exposed" patients and 280 in "naïve" patients. There were no significant differences in age, procedure type, sex, Charlson Comorbidity Index, smoking status, presence of diabetes, or presence of underlying skin conditions between cohorts. Mean body mass index was significantly higher in the "exposed" cohort (34.3 versus 30.6; P < 0.0001).

Results: There was no difference in rates of ACD between "exposed" and "naïve" patients (1.7 versus 1.8%, P = 1.00). Multivariable analyses showed that previous dressing exposure was not associated with increased risk of ACD (odds ratio: 1.16, 95% confidence interval: 0.30 to 4.44, P = 0.831).

Conclusion: Prior exposure to this silver-impregnated dressing was not associated with an increased risk of ACD. Subsequent application of these dressings may be applied with a similar risk profile to the first-time application.

Background: Long-term outcomes of impaction bone grafting (IBG) with a cemented cup in primary total hip arthroplasty (THA), particularly in Asian populations who have prevalent developmental dysplasia of the hip (DDH), remain limited. We evaluated outcomes at ≥ 10 years after primary cemented THA using IBG for severe acetabular defects in osteoarthritis (OA) or rheumatoid arthritis (RA).

Methods: We retrospectively reviewed consecutive primary cemented THAs with IBG and metal-mesh containment (2000 to 2015). The cohort comprised 102 hips (99 patients). Clinical outcomes used the Japanese Orthopaedic Association (JOA) hip score. Radiographs assessed component position, maximum acetabular defect distance, horizontal graft coverage, graft incorporation, and loosening. Kaplan-Meier survivorship used aseptic loosening as the endpoint. The mean follow-up was 12.8 years (range, zero to 23); 66 hips had a follow-up of ≥ 10 years, 33 had ≥ 15 years, and 14 had ≥ 20 years.

Results: In all assessed hips, the JOA hip score improved by ≥ 20 points. No acetabular component showed aseptic loosening or migration ≥ 4 mm. The hip center was restored to a mean of 19.1 mm above the teardrop line, and trabecular continuity between host and graft bone was present in ≥ two zones in 96% at final follow-up. Survivorship was 100% at 10 and 15 years. There was one hip that underwent acetabular revision for deep infection; no cup revisions were performed for aseptic loosening.

Conclusion: An IBG with a cemented cup provided durable fixation and reliable incorporation in complex primary acetabular defects, with no aseptic loosening observed up to 23 years in this Japanese cohort.

Background: While mechanical alignment (MA) is the current gold standard for total knee arthroplasty (TKA), suboptimal patient satisfaction rates have prompted the exploration of alternative alignment strategies. This review examined whether kinematic alignment (KA) improves outcomes following TKA compared to MA.

Methods: There were four databases searched from inception to September 23, 2024, to identify randomized controlled trials (RCTs) investigating TKA using KA compared to MA. Patient demographics, operative techniques, objective outcomes, and patient-reported outcome measures (PROMs) were abstracted. Meta-analyses were performed to compare survivorship, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Knee Score (OKS), and Forgotten Joint Score (FJS). Risk of bias was assessed using the RoB 2 tool for RCTs. There were 11 RCTs and 972 patients included (KA: 484, MA: 488). The mean follow-up was 3.9 years (range, one to 13).

Results: There was no statistically significant difference in all-cause reoperation rate between groups (relative risk (RR): 1.34, 95% confidence interval (CI): 0.71 to 2.52, I² = 0%, P = 0.37). A meta-analysis of two studies with greater than 10-year follow-up found no statistically significant difference in all-cause reoperations (RR: 1.21, 95% CI: 0.6 to 2.47, I² = 0%, P = 0.59) and component revisions (RR: 1.26, 95% CI: 0.38 to 4.14, I² = 0%, P = 0.71) between groups. There was no statistically significant difference in PROMs between groups. In two studies including patients who underwent bilateral TKA (KA versus MA), KA was significantly more likely to be the preferred knee (RR: 2.15, 95% CI: 1.36 to 3.40, I² = 0%, P = 0.00).

Conclusion: There is no significant difference in objective outcomes or PROMs when comparing KA with MA. However, within-subject comparison from bilateral TKA studies indicates patients are more than twice as likely to prefer their KA knee. Future longer-term studies are warranted to better understand the application of varying alignment strategies in TKA, including which populations may benefit most from KA.

Level of evidence: Level I.