Journal of Arthroplasty最新文献

Background: Increasing femoral head size or using lipped polyethylene acetabular liners both reduce revision risk due to dislocation after total hip arthroplasty (THA). At some cup sizes, surgeons must choose between larger heads or lipped liners. This study compares 32-mm heads with 10° lipped liners against 36-mm heads with neutral liners for stability and revision risk.

Methods: A national registry was queried for primary posterior-approach THAs. A total of 24,921 procedures were included: 17,386 with 32-mm femoral heads and 10° lipped cross-linked polyethylene liners, and 7,535 with 36-mm femoral heads and neutral cross-linked polyethylene liners. Kaplan-Meier analysis, multivariable logistic regressions, and t-tests evaluated 90-day, 2-year, and 8-year revision rates due to dislocation. A subanalysis was performed for patients who had a body mass index ≥ 30. The secondary outcomes included all-cause revision, infection, aseptic loosening, and periprosthetic fracture.

Results: The 90-day, 2-year, and 8-year rates of revision for dislocation were higher in the 32-mm and 10° lipped liner cohort. The Kaplan-Meier curve analyses demonstrated the rate of revision for dislocation was significantly higher in the 32-mm and 10° lipped liner group during the first month following THA (hazard ratio, 5.58; P = 0.019), but was not significant at any later time points. Among obese patients, those who received 32-mm heads and lipped liners had over three times higher odds of revision for persistent dislocation throughout eight years of follow-up hazard ratio, 3.28; P = 0.012).

Conclusions: With a 50-mm acetabular cup, a 36-mm femoral head and a neutral acetabular liner confer greater protection from revision of THA due to dislocation, particularly during the first postoperative month. In obese patients, the elevated dislocation risk with 32-mm heads and lipped liners persists throughout 8-year follow-up, highlighting the sustained clinical benefit of larger head size in this population.

Background: Elevated body mass index (BMI) contributes to osteoarthritis and demand for total knee arthroplasty (TKA). Increased BMI is an established risk factor for complications following primary TKA. However, literature on BMI and outcomes of revision TKA (rTKA) is less conclusive. This study evaluated the association between BMI and outcomes in the early postoperative period following aseptic rTKA. We hypothesized that increasing BMI would be associated with a higher risk of short-term complications.

Methods: A retrospective review of 470 patients who underwent aseptic rTKA within one regional health system from 2017 to 2022 was performed. Revisions were due to infection (39.8%), instability (23.7%), arthrofibrosis (11.8%), and aseptic loosening (11.8%). Patient BMI was obtained from electronic medical records at the time of rTKA. The primary outcome was early reoperation, assessed at 30 and 90 days postoperatively. The secondary outcomes included readmission, major complications, and minor complications at 30 and 90 days postoperatively. Multivariate regression models considering BMI as a continuous variable were used to determine the impact of BMI on outcomes.

Results: Elevated BMI was associated with slightly increased risk of overall reoperation (odds ratio: 1.03, P = 0.036) and 30-day readmission (odds ratio: 1.05, P = 0.029). Rising BMI was also associated with greater length of stay (P = 0.005), supplemental oxygen requirement to at least postoperative day two (P = 0.016), and postoperative hypoxemia beyond 24 hours (P = 0.038). No associations were noted between BMI and 30- or 90-day reoperation, 90-day readmission, or other postoperative complications (all P > 0.05).

Conclusions: This study suggests that failure rates and complications following rTKA remain high compared to primary procedures, with increased risk for overall re-reoperation and early readmission at 30 days. Otherwise, the complication profile was similar across the spectrum of BMI values. Further research is warranted to clarify the role of BMI in operative planning and prognosis.

Background: Population-based data on long-term dislocation risks are currently lacking in literature. Thus, the purpose of this study was to investigate the long-term cumulative incidence of dislocation after total hip arthroplasty (THA) stratified by femoral head size. Furthermore, we investigated the difference in cumulative incidence of dislocation over different time periods.

Methods: We conducted a population-based cohort study using data from the Danish Hip Arthroplasty Register and the Danish National Patient Register. The cohort comprised 56,515 THAs. The study included patients who had a primary THA due to primary osteoarthritis, performed in Denmark from 2000 to 2016. Follow-up was extended until death, implant removal, or December 31, 2021, to ensure a potential minimum 5-year follow-up period. We used a recently validated algorithm to include dislocations that were treated with closed reduction without revision. Cumulative incidence of dislocation was estimated using the Aalen-Johansen estimator with death and implant removal as competing risks. Cumulative incidence of dislocation was stratified by femoral head size and the three time periods: 2000 to 2004, 2005 to 2009, and 2010 to 2016.

Results: The 10-year cumulative incidence of dislocation was 8.8% (95% confidence interval [CI], 8.4 to 9.3) for 28-mm femoral heads, 7.4% (95% CI, 7.0 to 7.9) for 32-mm, and 5.7% (95% CI, 5.4 to 6.0) for 36-mm. Changes over time showed an increase in dislocations for 28- and 32-mm femoral heads, whereas no difference was found for the 36-mm group.

Conclusions: We found that the cumulative incidence of dislocation continued to increase after surgery. It varied from 5.7 to 8.8% after 10 years. The larger femoral heads were associated with lower dislocation rates. Furthermore, we found that 28- and 32-mm femoral heads were associated with a higher cumulative incidence of dislocation in patients who were operated on in more recent years.

Background: Previous research on periprosthetic fractures (PPFs) following total knee arthroplasty (TKA) has primarily addressed late postoperative complications. Evidence concerning intraoperative and early (≤ 90 days) fractures remains limited, particularly within Eastern European and Middle Eastern populations. This study aimed to evaluate the incidence and identify risk factors for such fractures in a large national cohort.

Methods: A retrospective analysis was conducted on 1,243 patients and 1,440 knees who underwent primary TKA between 2014 and 2023. Fractures developed in 35 knees (2.4%) intraoperatively or within 90 days after surgery and constituted the study group. Patients in the fracture group were older, with a mean age of 71 ± 8.8 years compared with 68 ± 7.6 years in the nonfracture group (P = 0.014). Demographic data, comorbidities, preoperative coronal alignment, and characteristics of the implants were compared between the two groups. Univariate and multivariate regression analyses were performed to determine risk factors based on the location of the fracture.

Results: In multivariate regression analyses, independent risk factors for femoral PPF included the use of a constrained condylar insert without a femoral stem (odds ratio (OR): 54, 95% confidence interval (CI): 3.7 to 1,016; P = 0.002), a diagnosis of osteoporosis (OR: 20.5, 95% CI: 5.4 to 77.2; P = 0.001), anterior femoral notching (OR: 11.4, 95% CI: 2.9 to 44.6; P = 0.001), and the use of a posterior-stabilized femoral component (OR: 6.9, 95% CI: 1.8 to 27; P = 0.003). For tibial fractures, preoperative valgus alignment was identified as a risk factor (OR: 11, 95% CI: 2.7 to 45.9; P = 0.001).

Conclusions: Preoperative identification and optimization of osteoporotic patients, careful management of valgus deformities, avoidance of anterior femoral notching, and the use of femoral stems when employing high-constraint inserts may help reduce the risk of PPF.

Background: Although cementless stems are increasingly favored in primary total hip arthroplasty (pTHA), the impact of stem designs on postoperative complications, such as periprosthetic femoral fracture (PFF), remains debated. This study compared PFF rates between cemented and cementless pTHA, focusing on cementless stem geometries.

Methods: We systematically searched PubMed, Embase, Web of Science, Scopus, Google Scholar, and CENTRAL from inception through March 2025. Eligible studies compared cemented and cementless stems in adults undergoing elective pTHAs, reported PFF incidence, and specified cementless stem design. Using a random-effects model, we calculated pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) for primary (PFF) and secondary outcomes (aseptic loosening, dislocation, periprosthetic joint infection, surgical site infection, and all-cause revision). There were 18 studies (55,942 pTHAs) included. Subgroup analyses were performed by cementless stem designs and age. Metaregression was conducted to investigate heterogeneity across the study.

Results: The pooled PFF rate was 1.3% (95% CI: 0.9 to 2.0) for cementless and 0.9% (95% CI: 0.6 to 1.5) for cemented pTHA (OR = 1.38; 95% CI: 0.95 to 2.02; P = 0.089; I² = 45.4%). Quadrangular stems (type B2) significantly reduced PFF risk (OR = 0.78; 95% CI: 0.64 to 0.96, P = 0.033; I² = 0.0%), whereas anatomic fit-and-fill stems (type C2) increased this risk (OR = 2.86; 95% CI = 2.10 to 3.90, P < 0.001; I² = 0.0%) and all-cause revision risk (OR = 1.16; 95% CI = 1.10 to 1.22, P = 0.001; I² = 0.0%). Cementless stems were associated with lower aseptic loosening (OR = 0.36; 95% CI = 0.23 to 0.56; P < 0.001; I² = 50.0%).

Conclusions: Quadrangular stems were protective against PFF, whereas anatomic designs increased PFF and all-cause revision rates. These findings highlight the need for stem-specific considerations in surgical decision making.

Background: Sexual function is an important contributor to quality of life for people undergoing lower limb arthroplasty, yet it is rarely discussed in clinics and inconsistently measured in research. Evidence suggests improvement after surgery, but findings are scattered across hips and knees, instruments vary, and a direct joint-wise comparison is lacking. This review compares sexual outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) across three prespecified domains: return to sexual activity (RTSA), frequency of sexual activity (FSA), and sexual satisfaction (SS) or fulfillment of preoperative expectations.

Methods: A systematic search of major biomedical databases and trial registries was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies reported on sexual function after primary THA or TKA, specifically RTSA, FSA, or SS. There were two independent reviewers who screened, extracted, and assessed the risk of bias. There were 27 studies, including 9,267 patients (5,350 THA and 3,917 TKA), that were eligible.

Results: The RTSA tended to be earlier following TKA compared with THA; however, through exploratory pooling, a greater proportion of THA patients reported higher SS (75.4%, 703 of 932) than TKA patients (69.3%, 843 of 1,216; P = 0.0013) and demonstrated greater increases in FSA (P < 0.001). Study quality was variable, with marked heterogeneity in methodology and outcome measures.

Conclusions: Arthroplasty improves sexual function, but recovery patterns differ: TKA patients return earlier, whereas THA patients achieve greater gains in frequency and satisfaction. These differences have important implications for counseling and expectation setting. Progress in this field requires standardized, validated instruments and high-quality prospective studies.

Level of evidence: III, Systematic Review.

Background: Periprosthetic joint infections (PJIs) of the hip and knee are a devastating outcome of arthroplasty, resulting in profound morbidity. As more arthroplasties are performed, there is a need to monitor the long-term risk and trends of infection.

Methods: A population-based retrospective cohort of all primary hip and knee arthroplasties performed in Ontario from April 1, 2003, until March 31, 2017, was created using linked administrative databases with patients followed postoperatively until March 31, 2018. There were 504,332 primary hip and knee arthroplasties performed, with the number of annual procedures increasing an average of 5.8% annually over the study. The primary outcome was hospital readmission for a PJI. Poisson models were used to determine trends over time.

Results: Overall, 7,331 PJIs were identified. The incidence of a PJI following primary arthroplasty was 0.59 out of 100 (95% confidence interval (CI): 0.57 to 0.61) at 90 days and 1.29 of 100 (95% CI: 1.26 to 1.33) at five years, whereas following revision arthroplasty, it was 1.93 of 100 (95% CI: 1.70 to 2.16) at 90 days and 4.89 of 100 (95% CI: 4.52 to 5.26) at five years. The 1-year incidence of PJI following primary arthroplasty increased from 0.70 of 100 in 2003 to 0.97 of 100 in 2016 (P < 0.001).

Conclusion: The PJIs are increasing, both because of an increase in the numbers of primary arthroplasties and due to an increase in PJIs occurring within 90 days. There is a need to understand the reasons for the rise in PJIs.

Background: Metabolic syndrome (MetS), a cluster of interrelated metabolic abnormalities typically including obesity, dyslipidemia, diabetes, and hypertension, has been linked to surgical complications, but its impact on total hip arthroplasty (THA) beyond 90 days is unclear. This study compared 90-day, one-year, and two-year THA outcomes in patients who had and did not have MetS, and identified which component of MetS (i.e., diabetes, hypertension, obesity, or hypertriglyceridemia) was most strongly associated with each complication. Outcomes included a) infectious (surgical site infection [SSI; 90-day], periprosthetic joint infection [PJI]), b) mechanical (mechanical loosening, periprosthetic fracture [PPFx]), c) all-cause revision [ACR], and d) deep vein thrombosis [DVT; 90-day].

Methods: A nationwide database identified 706,602 THA patients (21.0% MetS) from 2010 to 2023. Outcomes were evaluated at 90 days, one year, and two years. Unadjusted comparisons used Pearson's Chi-square and Student's t-tests; multivariable logistic regressions calculated odds ratios (OR) with 95% confidence intervals.

Results: Higher 90-day SSI (OR 2.41) and PJI at 90 days and at one and two years (OR 1.58, 1.44, and 1.31) were associated with MetS. Obesity was most strongly associated with infection (SSI OR 2.45; PJI OR 1.73 to 1.87), followed by diabetes (SSI OR 1.58; PJI OR 1.47 to 1.60) and hypertension (PJI OR 1.47 to 1.50). Odds of PPFx were higher at all timepoints (OR 3.35, 3.10, and 2.86) most strongly associated with hypertriglyceridemia (OR 1.27 to 1.28) and diabetes (OR 1.21 to 1.25). Odds of ACR increased (OR 2.08, 1.81, and 1.66) and were associated with hypertension (OR 1.35 to 1.41) and obesity at 90 days (OR 1.11). Increased 90-day DVT (OR 3.52) was associated with hypertension, diabetes, and obesity (OR 1.59, 1.34, and 1.31).

Conclusion: Metabolic syndrome was associated with higher odds of infection, PPFx, ACR, and DVT, suggesting that this population may benefit from focused perioperative risk assessment and optimization.

Background: Ambulatory surgery centers (ASCs) are increasingly becoming the preferred setting for elective orthopaedic procedures, including total knee arthroplasty (TKA). The ASC's favorable cost containment, reimbursements, and patient outcomes have driven their growth, but access to the Medicaid population remains an issue. This study aimed to evaluate these barriers for patients seeking TKA at ASCs compared to public hospitals using a cross-sectional survey design.

Methods: All current ASCs registered within the United States were queried, and ASCs offering orthopaedic surgery services were isolated. Trained researchers contacted ASCs and public hospitals using a standardized inquiry script. Key data points included Medicaid acceptance, appointment availability, and out-of-pocket costs. Data were analyzed utilizing chi-square and Student t-tests. A total of 98 ASCs and 98 matched public hospitals were contacted for the study (Vermont and South Dakota had one ASC meeting initial criteria), with 77 ASCs and 94 public hospitals having complete data for analyses.

Results: Public hospitals demonstrated greater Medicaid acceptance compared to ASCs (95 versus 78%, P = 0.002). Both ASCs and public hospitals offered similar appointment availability (14.4 versus 19.1 d, P = 0.258). There were no differences between ASC and hospital out-of-pocket consultation ($470 versus $200, P = 0.483) or procedure costs ($199,167 versus $28,000, P = 0.317); however, only one public hospital and six ASCs provided cost information.

Conclusions: Although ASCs and public hospitals offer comparable appointment availability for elective TKA procedures, ASCs provide much lower Medicaid acceptance rates. Despite the benefits of ASCs, barriers for Medicaid patients persist, highlighting the need for targeted strategies to enhance access to specialized orthopaedic care in the ambulatory setting.

Level of evidence: III.

Background: Total hip arthroplasty (THA) is a highly effective procedure, but outcomes may be influenced by social determinants of health. We investigated the association between neighborhood disadvantage indices, the Social Vulnerability Index (SVI) and Area Deprivation Index (ADI), and postoperative outcomes following THA in a large, multicenter cohort.

Methods: A retrospective review of 9,519 primary THAs performed between 2014 and 2022 was conducted. Patient addresses were geocoded to US Census tracts to assign SVI and ADI scores. We analyzed associations between disadvantage indices and postoperative complications, health care utilization, and patient-reported outcomes using multivariable regression models.

Results: Our analysis found that neighborhood disadvantage was associated with specific postoperative outcomes. Patients who were from higher socioeconomic disadvantage quartiles had an increased risk of periprosthetic fracture (odds ratio = 2.07; 95% confidence interval: 1.21 to 3.54). Conversely, a higher disadvantage in the housing type and transportation domain was associated with a decreased risk of 90-day readmission (odds ratio = 0.72; 95% confidence interval: 0.56 to 0.91). Higher minority status disadvantage was associated with a significant decrease in lengths of hospital stay. There were no significant associations observed for overall SVI or ADI with most outcomes, and long-term improvements in patient-reported outcome measures were similar across all disadvantage levels.

Conclusions: The findings indicate that certain subdomains of neighborhood-level social disadvantage are linked to specific adverse events and health care utilization in THA patients. These associations highlight the need for tailored interventions to mitigate risks in vulnerable populations. While functional outcomes remain consistent, targeted support for patients who have high socioeconomic disadvantage may reduce complications like periprosthetic fractures. Further research is needed to better understand the mechanisms behind these associations and to develop effective, individualized care pathways.