Journal of Arthroplasty最新文献

Background: Contemporary evidence-based indications no longer consider age regarding eligibility for medial unicompartmental knee arthroplasty (mUKA). This has led to more surgical candidates; however, whether patients still have satisfactory outcomes lacks evidence. This study examined the association between age and change in patient-reported outcome measures (PROMs) after mUKA as well as the achievement of Patient Acceptable Symptom State (PASS) and Minimal Important Change (MIC).

Methods: We included 782 mUKAs performed between February 1, 2016, and April 26, 2023. The mean change from preoperative Oxford Knee Score (OKS), Forgotten Joint Score (FJS), and Activity and Participation Questionnaire (APQ) was assessed at three, 12, and 24 months after surgery. The achievement of 12-month PASS (OKS ≥ 30) and MIC (changes in OKS ≥ 8; FJS ≥ 14) was also assessed. Patients were divided into age groups: < 55, 55 to < 65, 65 to < 75 years (reference group), and ≥ 75 years. There were 432 women (55%), patients had a mean age of 67 years (range, 29 to 93) and a mean BMI of 30 (range, 20 to 53).

Results: Median OKS, youngest to eldest, were 34, 35, 36, and 35 (three months); 40, 39, 41, and 43 (12 months); 42, 41, 43, and 42 (24 months). We found no differences in change in OKS between groups. Patients aged 55 to < 65 years had lower changes in FJS at 24 months and APQ at 12 and 24 months. Patients ≥ 75 years had lower 24-month change in APQ. We found no association between age and the fraction achieving either PASS or MIC (youngest to eldest, 90, 90, 94, and 95%).

Conclusion: We found good PROM improvements and satisfactory outcomes after mUKA in all age groups; however, patients aged 55 to < 65 years had worse changes in FJS and APQ. Results support contemporary indications for mUKA, and applying an age cutoff is unwarranted.

Introduction: The increasing incidence of primary total hip (THA) and knee (TKA) arthroplasty has been accompanied by a subsequent rise in revision surgeries. Revision total joint arthroplasty (TJA) is associated with major litigation risk, primarily due to procedural and post-surgical errors. However, the understanding of the causes and outcomes of revision TJA malpractice cases remains unstudied. This study aimed to analyze litigated malpractice claims against orthopaedic surgeons performing revision TJA using a national legal database.

Methods: A database was queried for a nationwide analysis of medical malpractice litigation in revision TJA from 2000 to 2023. Data on the time, duration, and locations of the litigations, allegations of surgical negligence, the damages cited, the outcomes of the trials, and indemnities were collected.

Results: Of 110 TJA malpractice cases identified over two decades, 32 cases involving revision THA and TKA surgeries were included in the final analysis. The cases were equally divided between THA and TKA, spanning 16 states, with the highest proportions in New York, Connecticut, and Louisiana. "Procedural error" (28%; n = 9) was the most frequently cited negligence, followed by "post-surgical error" (25%; n = 8) and "failure to treat" (19%; n = 6). The most common damages were "continued pain/mobility limitations" (28%; n = 9) and "infections" (19%; n = 6). Most cases resulted in a verdict for the defense (63%; n = 20). The average indemnity was $5,713,635, with considerable variability.

Conclusion: This study presents the leading causes of litigated malpractice claims over the past two decades in the United States in revision TJA as perceived procedural and post-surgical errors, with the most common damages reported being "persistent pain/mobility limitations" and "infections." Given the rising incidence of revision TJA, orthopaedic surgeons may utilize these trends to better inform patients about the potential risks and outcomes of surgery and mitigate litigation risks.

Background: The relationship between surgeon and hospital case volumes and postoperative risk following total hip arthroplasty and total knee arthroplasty (THA and TKA) has been described independently. This study aimed to assess the risk of periprosthetic joint infection (PJI) following primary TKA and THA to determine if lower volume surgeons operating at higher volume centers would have lower rates of complications compared to lower volume surgeons operating at lower volume hospitals.

Methods: A health care database was used to retrospectively identify all primary and elective total joint arthroplasties from October 2015 to December 2021. Using restricted cubic splines, high-volume hospitals were defined using Markov chain Monte Carlo simulation, which identified a volume beyond which PJI rates no longer decreased significantly with increasing hospital volume. A similar methodology was used to identify low-volume surgeons operating in high- and low-volume hospitals. There were 605,254 patients who underwent total joint arthroplasty (THA: 37.71%; TKA: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high- and low-volume hospital cohorts. High-volume hospitals were defined as > 508 THA and > 812 TKAs per year, and low-volume hospitals were defined as < 145 THAs and < 243 TKAs per year. Multivariable models accounting for potential confounding covariates were created to determine the odds of PJI between cohorts.

Results: After taking confounding variables into account, low-volume surgeons at high-volume hospitals had lower rates of PJI relative to their counterparts at low-volume hospitals (THA 0.67 versus 0.80%, adjusted odds ratio = 0.69 [95% confidence interval = 0.54 to 0.88], P = 0.002; TKA 0.51 versus 0.69%, adjusted odds ratio = 0.73, [95% confidence interval = 0.61 to 0.87], P = 0.007).

Conclusions: Increasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume.

Background: Patients who have the autoinflammatory bowel disease ulcerative colitis (UC) may become candidates for total hip arthroplasty (THA). Having UC may predispose patients to postoperative adverse events, but it remains unclear if these events are related more to the disease process itself or perhaps related to the medications used to treat the condition.

Methods: Patients undergoing THA were identified from a large administrative dataset. Those who did not have and those who had UC were matched 4:1 based on patient age, sex, and the Elixhauser Comorbidity Index (ECI). Matched THA patients who did not have UC (n = 19,482) and those who had UC (n = 4,874) were identified. The matched groups were compared regarding 90-day adverse and five-year survival. Further analyses were performed based on classes of medications.

Results: Controlling for patient age, sex, and ECI, UC patients were at significantly higher odds of 90-day adverse events: any (odds ratio [OR] 1.59), severe (OR 1.72), and minor (OR 1.63) (all P < 0.001). Despite this, no differences in 5-year survival were identified. Relative to those who did not have UC, there were increasing odds of any adverse event based on the potency of related medications: no corticosteroids /immunomodulators/5-aminosalicylic acid (5-ASA) (OR 1.42), corticosteroids only (OR 1.58), 5-ASA ± corticosteroids OR (1.72), and immunomodulators ± corticosteroids (OR 1.74, all P < 0.001).

Conclusions: Total hip arthroplasty patients who have UC were at higher odds for 90-day postoperative adverse events relative to those who did not have UC, and this risk was even greater for those on defined classes of medications. Total hip arthroplasty patients who have UC bear specific considerations, and surgeons must carefully consider and manage the patient's medication regimen in the perioperative period of the THA.

Introduction: In recent years, there has been an increased utilization of dual mobility (DM) implants in primary total hip arthroplasty (THA) to mitigate the risk of postoperative hip instability. This study aimed to present midterm outcomes of DM bearings in primary THA using data from the American Joint Replacement Registry (AJRR).

Methods: Screening was conducted on patients aged ≥ 65 years who underwent primary THA between 2012 and 2018. Patients were categorized into three groups: (1) DM articulation, (2) ≤ 32 mm femoral head, and (3) ≥ 36 mm femoral head. Multivariable statistical modeling was employed to analyze patient and hospital characteristics, minimizing potential confounding variables and identifying independent associations with revision. Cox proportional hazards regression analyses were used to assess all-cause revision and revision specifically for instability.

Results: A total of 207,526 primary total hip arthroplasties (THAs) were identified. Among them, 13,896 (6.7%) utilized dual mobility (DM) articulation, 60,358 (29.1%) had a femoral head size of ≤ 32 mm and 133,272 (64.2%) had a femoral head size of ≥ 36 mm. At the eight-year follow-up, the all-cause revision rate was higher in the DM group (3.5%, 95% confidence interval [CI] 3.1 to 4.1) compared to the ≤ 32 mm (2.6%, 95% CI 2.5 to 2.8) and ≥ 36 mm (2.7%, 95% CI 2.5 to 2.9) groups. However, the revision rate for instability was comparable among the DM (0.4%, 95% CI 0.2 to 0.5), ≤ 32 mm (0.5%, 95% CI 0.4 to 0.5), and ≥ 36 mm (0.3%, 95% CI 0.3 to 0.4) groups at eight-year follow-up.

Conclusion: The utilization of DM was associated with higher overall revision rates. However, no significant differences in rates of revision for instability were observed among any of the bearing surface groups. These findings may be attributed to surgeons selectively utilizing DM articulations in higher-risk patients.

Introduction: While total knee arthroplasty (TKA) is a generally successful procedure, 10 to 30% of patients still report suboptimal outcomes after surgery. Prehabilitation may offer potential benefits to improve poorer outcomes, although its effectiveness remains uncertain. Our study aimed to assess the efficacy of prehabilitation interventions on patients at risk of poor outcomes following TKA.

Method: There were six electronic databases searched up until December 2023. All randomized controlled trials (RCTs) comparing prehabilitation versus usual care in adult patients with osteoarthritis undergoing primary TKA and at risk of poorer outcomes were included. There were four reviewers who independently extracted data and assessed the risk of bias for each study.

Results: The 13 included studies assessed prehabilitation among patients at risk of poor outcomes, identified with various factors including range of motion deficit, functional limitations, high body mass index, psychological factors, frailty, older age, central sensitization, and high risk of discharge to inpatient rehabilitation. The interventions were initiated across a wide range, from four to 277 days before surgery. The efficacy of exercise therapy and multidisciplinary rehabilitation remains inconclusive due to limited, low-quality evidence. The results failed to indicate that various forms of non-exercise therapy, including education, psychological intervention, and weight loss therapy, were effective in improving outcomes after TKA. The included studies have major limitations such as small sample size, inappropriate comparators, substantial clinical heterogeneity in intervention characteristics, inadequate blinding for providers and participants, a lack of justification for identifying patients at risk of poor recovery, and a lack of appropriate interventions for managing modifiable factors.

Conclusion: While our finding fails to show that non-exercise therapy is effective, results of exercise therapy and multidisciplinary rehabilitation remain inconclusive. Further high-quality research is warranted to establish evidence on modifiable factors predictive of poorer postoperative outcomes and investigate how they can be effectively managed.

Background: Sex diversity remains limited in the United States arthroplasty workforce. This study evaluates fellowship program characteristics associated with increased sex diversity in US-based fellowship programs and the pipeline of women trainees before arthroplasty fellowship.

Methods: Demographic data from 233,981 allopathic medical school graduates, 11,364 orthopaedic surgery residents, and 1,501 arthroplasty fellows were analyzed. Women trainee representation was calculated among allopathic medical students, orthopaedic surgery residents, and arthroplasty fellows (2012 to 2022). Fellowship program characteristics associated with increased sex diversity among arthroplasty fellows were evaluated with Chi-square tests.

Results: Female representation in arthroplasty fellowship training (5.9%) was less than that in orthopaedic surgery residency (15.1%) and allopathic medical school (47.6%) training (P < 0.001). Sex diversity in arthroplasty fellowship training increased over the study period (2.4 to 9.9%, P < 0.001). The presence of women faculty, geographic region, accreditation status, annual number of fellows, and total number of faculty were not associated with increased sex diversity of arthroplasty fellows (P > 0.05).

Conclusions: Sex diversity in arthroplasty fellowship training has improved over the past decade. Yet, women trainees remain under-represented relative to the trainee pipeline. Increased efforts to recruit female medical students and orthopaedic residents may help promote workforce diversity in arthroplasty.