Journal of Arthroplasty最新文献

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.

Background: Patient-reported outcome measures (PROMs) are valuable for evaluating treatment success from the patient's perspective. The 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) is a PROM scored from 0 to 100, worst to best, that assesses pain, function, and quality of life (QOL). Interpreting PROMs to determine patient satisfaction with treatment can be challenging. The Patient Acceptable Symptom State (PASS) defines the PROM value beyond which patients consider their condition satisfactory. This study aimed to establish PASS values for the HOOS-12 one year after primary elective total hip arthroplasty (THA) for osteoarthritis.

Methods: Data were drawn from a private Australian joint registry, including adults who underwent THA between January 2020 and December 2022. A single-item satisfaction measure served as the anchor, and participants were categorized as satisfied or dissatisfied. PASS values were estimated using three methods: two predictive modeling methods (one with adjustment for unequal proportions of satisfied/dissatisfied participants and one without) and the receiver operating characteristic (ROC) method. Non-parametric bootstrapping of confidence intervals was performed.

Results: Among 746 participants, 96% reported satisfaction with the surgical outcome. The HOOS-12 PASS values derived from the three methods were lowest for QOL (range, 61.2 to 71.5), followed by pain (70.1 to 77.3), summary score (73.2 to 77), and function (74.7 to 81.8). Predictive modeling adjusted for unequal proportions generated the narrowest confidence interval (CI) (7.7 to 12.2 points) and the highest true positive rates (80 to 93%).

Conclusion: Predictive modeling with adjustment for unequal proportions was the primary method used and generated the following PASS values for the HOOS-12: pain 70.1, function 74.7, QOL 61.2, and summary score 69.9. Establishment of PASS values gives clinicians and researchers a framework on which to interpret HOOS-12 scores in a way that is patient-centered. Future research should validate these findings in independent cohorts.

Introduction: Evidence in support of neuraxial anesthesia in revision total joint arthroplasty (rTJA) is still emerging. The purpose of this study was to demonstrate whether most rTJAs performed at an orthopaedic specialty hospital can be safely completed under neuraxial anesthesia.

Methods: A retrospective cohort study including all patients who underwent revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) between June 3, 2024, and September 17, 2025, at a single institution was performed. Patients were divided by method of anesthesia. The primary outcome was the rate of neuraxial anesthesia utilization. Secondary outcomes included differences in baseline demographics and outcomes between groups. Propensity score matching for neuraxial versus general anesthesia was performed. Univariate analyses were utilized to compare groups. A total of 500 patients underwent rTJA (273 rTKA, 227 rTHA) during the study period. For rTKA and rTHA patients, 219 (80.2%) and 133 (58.6%) received neuraxial anesthesia, respectively.

Results: On matched analysis for rTKA, general anesthesia was associated with higher intraoperative (57.2 versus 21.6 mL, P < 0.001) and total (175.9 versus 119.6 mL, P < 0.001) morphine equivalents administered and readmissions (15.7 versus 1.1%, P = 0.002). For rTHA, general anesthesia was associated with a longer length of stay (83.0 versus 47.4 hours, P < 0.001), increased blood loss (610.0 versus 406.8 mL, P = 0.007), higher rates of transfusion (28.6 versus 11.4%, P = 0.02), and higher readmissions (18.6 versus 1.4%, P = 0.002). Total (144.9 versus 79.5 P < 0.001), intraoperative (59.8 versus 25.4, P < 0.001), and postoperative (85.0 versus 54.0, P = 0.002) morphine equivalents administered were higher in the THA general anesthesia group than the neuraxial anesthesia group.

Conclusion: This study suggests that neuraxial anesthesia is safe and effective in rTJA, including complex cases. Neuraxial anesthetic may be considered more routinely for rTJA.

Purpose: Cruciate-retaining (CR) total knee arthroplasty (TKA) is generally avoided in knees with severe fixed flexion deformity (FFD). The need for additional distal femoral resection, posterior soft-tissue releases, and gap balancing typically favors posterior-stabilized (PS) implants. This study compared CR- and PS-TKA in severe FFD by evaluating clinical and patient-reported outcomes at two years: (1) range of motion (ROM), (2) Knee Society Score (KSS), (3) Oxford Knee Score (OKS), (4) Short-form 36 (SF-36) Physical (PCS) and (5) Mental (MCS) Component Scores.

Methods: Patients who had severe preoperative FFD ≥ 15˚ from our institution's TKA registry were propensity-matched according to age, sex, body mass index, and preoperative scores. A total of 294 knees (147 CR-TKAs and 147 PS-TKAs) were matched and analyzed. Patients were evaluated preoperatively, at six months, and at two years. Postoperative manipulation under anesthesia (MUA) was recorded.

Results: Both groups achieved significant correction of FFD at two years (CR-TKA: 20.8˚ [95% confidence interval (CI), 19.7 to 21.9] to 4.0° [95% CI, 3.1 to 4.9]; PS-TKA: 19.9˚ [95% CI, 19.0 to 20.8] to 3.8° [95% CI, 3.0 to 4.6]; both P < 0.001) with no intergroup differences (P = 0.534). All patient-reported outcomes improved significantly from baseline (P < 0.001) and were comparable between groups. The PS-TKA achieved greater knee flexion and overall ROM (both P < 0.001), but demonstrated more antero-posterior laxity ≥ five mm (P < 0.05). Stair-climbing functions and MUA rates were comparable (P > 0.05).

Conclusion: The CR-TKA achieved outcomes comparable to PS-TKA in knees with severe FFD, with deformity correction maintained at two years. Although PS-TKA provided greater knee ROM, CR-TKA demonstrated lower antero-posterior laxity. These differences did not compromise functional outcomes. Both CR-TKA and PS-TKA remain viable options for patients who have severe FFD when careful intraoperative balancing is attained.

Introduction: Racial differences in total joint arthroplasty (TJA) remain poorly defined. The purpose of this study was to investigate racial/ethnic differences in postoperative clinical and patient-reported functional outcomes between non-Hispanic White, African American, Hispanic, Asian, and Native American populations using the American Joint Replacement Registry (AJRR).

Methods: All primary TJAs from 2012 to 2022 with reported race/ethnicity and a minimum of one-year follow-up data were retrospectively reviewed. Patient-reported outcome measures (PROMs) were evaluated based on identified racial differences. Descriptive statistics were performed using a Chi-square, Fisher exact tests, or analyses of variance (ANOVA). Multivariate regression models were used to assess for predictors of functional outcomes. Statistical significance was set at P < 0.05. There were 896,154 total hip (THAs) and 1,401,359 total knee arthroplasties (TKAs) evaluated. The population of THAs was 88% White and 55% women, and their mean age was 66 years. The population of TKAs was 85% White and 61% women, and their mean age was 68 years.

Results: In the multivariate logistic regression model, Asian patients had a significantly decreased odds of achieving minimal clinically important difference (MCID) after TJA compared to White patients (P = 0.02, THA; P < 0.01, TKA). Overall postoperative functional scores were significantly lower among African American (P < 0.01) and Hispanic (P < 0.01) patients after THA and significantly lower among African Americans (P < 0.01), Asians (P < 0.01), and Hispanics (P < 0.01) after TKA.

Conclusions: Differences in outcomes among racial and ethnic groups are evident in total joint arthroplasty. While all races saw improvement in PROMs preoperatively to postoperatively, Asians may have decreased odds of achieving MCID compared to White patients. Further study is required to identify causes for these differences as well as possible ways to augment the outcomes of minority patients.

Introduction: In periprosthetic joint infection (PJI), prior studies evaluating failed debridement, antibiotics, and implant retention (DAIR) before two-stage exchange arthroplasty report conflicting outcomes and exclude cases that were initially successfully treated with DAIR. This study (1) compared success rates of two-stage exchange arthroplasty with and without a preceding failed DAIR and (2) evaluated overall success rates between these two groups when initial DAIR patients who were initially successful were included in the analysis.

Methods: This multihospital retrospective cohort study evaluated patients diagnosed with PJI ≥ one year after primary total knee arthroplasty (TKA) and who received initial DAIR or two-stage between 2015 and 2022. All patients met Musculoskeletal Infection Society (MSIS) or 2018 International Consensus Meeting (ICM) criteria. We excluded patients who had prior PJI in the same joint or those who underwent more than one DAIR or two-stage exchange arthroplasty. Patients were categorized based on initial treatment: DAIR (n = 94) or two-stage exchange (n = 99). A subset of the DAIR cohort who later required a two-stage exchange due to failure (n = 22) was analyzed separately. Treatment success was defined as no reoperation and an MSIS Tier 1 or 2 outcome. Statistical analyses included t-tests, Chi-squares, Kaplan-Meier survival curves, and Cox proportional hazards models adjusted for key covariates (P < 0.05).

Results: Prior DAIR for acute PJI was not significantly associated with reduced success rates when comparing primary two-stage exchange arthroplasty to two-stage exchange arthroplasty following failed DAIR (P = 0.21), though 24-month survival probability was consistently lower. Similarly, when initial DAIR successes were included in this analysis, there were no statistical differences in survival, although success rates favored two-stage exchange arthroplasty (P = 0.27).

Conclusions: Our results suggest that, when PJI appears acute, DAIR should be completed. While the success rate of DAIR may be low, it does not appear to substantially impact the success of subsequent two-stage exchange arthroplasty.

Background: Patient-reported outcome thresholds add clinical relevance to functional outcome scores. This study aimed to define the patient acceptable symptom state (PASS) and minimum clinically important difference (MCID) for the modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, Hip Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Forgotten Joint Score (FJS) and identify differences in threshold achievement over time.

Methods: Data were retrospectively reviewed for patients who underwent primary total hip arthroplasty between December 2016 and February 2020. A total of 221 hips were included and had complete two- and five-year outcomes with anchor questions for the mHHS, VAS, and HOOS-JR, as well as FJS postoperatively. Receiver operating characteristic (ROC) curves determined PASS threshold values. The MCID was determined using the distribution method for the mHHS and VAS. Rates of threshold achievement were compared between timepoints.

Results: The PASS thresholds and achievement rates at the two-year mark for the mHHS, HOOS-JR, FJS, and VAS were as follows: 88.0 (76%); 71.9 (85.5%); 53.1 (89.1%); and 2.5 (84.6%). The PASS thresholds and rates of achievement at the five-year mark for the mHHS, HOOS-JR, FJS, and VAS were as follows: 75.0 (86.4%), 60.4 (91.0%), 51.0 (86.9%), and 2.3 (83.3%). More patients achieved the PASS at the five-year compared to the two-year timepoint for the mHHS (84.6 versus 76%; P < 0.01). The MCID was achieved at similar rates over the two- and five-year time points for the mHHS (P = 0.76) and VAS (P = 0.22).

Conclusion: Rates of achieving the PASS increased from two- to five-year follow-up. The PASS thresholds also reflected lower functional demands with time. There were no significant differences in rates of achieving the MCID. While overall function may decrease with advancing age, evidenced by lower PASS threshold scores, patient satisfaction increases over time.

Background: Postoperative outcomes after total knee arthroplasty (TKA) are influenced by patient comorbidities. Metabolic syndrome (MetS) combines hypertension, diabetes, obesity, and dyslipidemia, which have been associated with increased short-term surgical complications. However, its independent impact on TKA outcomes beyond the perioperative period (> 90 days) remains unclear. This study compared outcomes following TKA between patients who had and did not have MetS, including a) mechanical complications (mechanical loosening and periprosthetic fracture), b) infectious complications (surgical site infection and periprosthetic joint infection), and c) reoperations (all-cause revision, septic revision, and manipulation under anesthesia), at 90 days, one year, and two years.

Methods: A national all-payer database was queried using International Classification of Diseases, Ninth and Tenth Revision (ICD-9/10) codes to identify 1,255,079 patients who underwent TKA from 2010 to 2023. Among these, 386,813 (30.8%) had MetS. Outcomes were assessed at 90 days, one year, and two years. Student's t-tests and Pearson's Chi-square tests were used for unadjusted comparisons, and multivariable logistic regressions estimated odds ratios (OR) with 95% confidence intervals (CI).

Results: At two years, MetS was associated with increased odds of mechanical loosening (OR [odds ratio] 1.62, 95% CI [confidence interval] 1.43 to 1.83, P < 0.001), periprosthetic fracture (OR 2.84, 95% CI 2.42 to 3.32, P < 0.001), surgical site infection (OR 1.79, 95% CI 1.70 to 1.87, P < 0.001), periprosthetic joint infection (OR 1.53, 95% CI 1.43 to 1.65, P < 0.001), all-cause revision (OR 2.25, 95% CI 2.06 to 2.46, P < 0.001), and septic revision (OR 1.85, 95% CI 1.04 to 3.34, P = 0.040). Among MetS components, hypertension and diabetes were the strongest predictors.

Conclusion: Metabolic syndrome is independently associated with increased risk of mechanical-, infectious-, and revision-related complications following TKA. These findings may help guide perioperative risk stratification, closer medical care coordination, and shared decision-making in this population.

Background: Perioperative vancomycin administration can be difficult to time and can lead to adverse systemic effects. Intraosseous vancomycin (IOV) is becoming increasingly utilized for total knee arthroplasty (TKA) prophylaxis. The primary purpose was to compare the rate of acute kidney injury (AKI) following primary TKA that utilized IOV or intravenous vancomycin (IVV).

Methods: A single-institution retrospective review was conducted on 4,184 primary TKAs from 7/2016 to 11/2024 that received IOV (1,297 cases) or IVV (2,887 cases) as part of antibiotic prophylaxis. All included patients had a basic metabolic panel on postoperative day one. Patients were excluded if they had a solid organ transplant, were on dialysis, or received a blood transfusion following TKA. An AKI was defined as a creatinine increase of 0.3 mg/dL from baseline. Data were analyzed using independent samples t-tests and Chi-square analyses. Logistic regressions were used to identify significant risk factors for AKI.

Results: The rate of AKI was lower in the IOV compared to the IVV group (1.9 versus 3.3%, P = 0.017). Patients who developed AKI had longer hospitalizations (59.9 ± 39.1 hours versus 42.1 ± 33.3, P < 0.001) and a higher likelihood of discharge to skilled nursing facilities (10.1 versus 3.0%, P < 0.001) compared to non-AKI patients. Logistic regression demonstrated that IVV (odds ratio [OR]: 1.87; 95% confidence interval [CI] 1.09 to 3.21), BMI (OR 1.09; 95% CI 1.05 to 1.13), and postoperative blood urea nitrogen (OR 1.29; 95% CI 1.24 to 1.35) were significantly associated with AKI. There were no adverse events observed due to the IO technique.

Conclusion: The use of IOV was associated with a significantly lower rate of AKI following primary TKA when compared to IVV. Administering vancomycin with an IO technique avoids the difficulties of incomplete administration prior to incision and reduces systemic side effects.

Background: Advances in pharmacologic therapy for rheumatoid arthritis (RA), including biologics and Janus kinase inhibitors, have reduced joint damage and the need for surgery. However, total knee arthroplasty (TKA) remains essential in patients who have RA and are generally favorable; most studies emphasize physician-reported outcomes, with limited focus on patient-reported outcome measures (PROMs).

Methods: We retrospectively reviewed 61 patients who have RA (61 knees) who underwent primary TKA between June 2018 and June 2023. Clinical outcomes were assessed using range of motion (ROM), Japanese Orthopaedic Association (JOA) score, and Knee Society Score (KSS). The PROMs included the Knee Injury and Osteoarthritis Outcome Score (KOOS) and a five-grade satisfaction scale. Patients were categorized as satisfied or dissatisfied for subgroup analysis.

Results: The ROM improved significantly from -10.1 to 112.9° preoperatively to -1.8 to 118.3° postoperatively. The JOA scores increased from 50.0 to 65.6, and both KSS knee and functional scores improved significantly (P < 0.01). All KOOS domains improved, with 85.2% of patients reporting satisfaction. In subgroup analysis, physician-reported scores did not differ significantly between satisfied and dissatisfied groups, whereas KOOS ADL and quality of life (QOL) subscales showed greater improvement among satisfied patients.

Conclusion: Total knee arthroplasty in patients who have RA yields significant improvement in physician- and patient-reported outcomes. Improvements in PROMs, particularly in activities of daily living and QOL domains, show a closer association with postoperative satisfaction than clinician-based measures. These findings highlight the importance of routinely incorporating PROMs into outcome evaluation after TKA in RA.