Arthroplasty最新文献

Background: Implant impingement and soft tissue tension are factors involved in dislocation after total hip arthroplasty (THA). Combined anteversion (CA) has been used as an indicator for implant placement. However, optimal implant placement remains a challenge. Moreover, the effect of changes in offset on dislocation is still unclear. In this study, we aimed to clarify the effects of postoperative CA and pre- and postoperative changes in offset on dislocation.

Methods: Included were patients who underwent primary cementless THA between 2013 and 2020. The mean values of CA and offset in the dislocation and non-dislocation groups were compared. The CA values within ± 10% of the recommended values were defined as good CA, and those outside the range were rated as poor CA. The dislocation rates were compared between the good and poor CA groups and between the groups with and without increased offset.

Results: A total of 283 hips were included. The mean values of CA in the dislocation and non-dislocation groups were significantly different (P < 0.05). The dislocation rate was significantly lower in the good CA group (P < 0.05). The dislocation rates in the groups with and without increased total offset were 0.5% and 4.3%, respectively (P = 0.004). There were no dislocations in patients with good CA and increased offset.

Conclusions: The dislocation rate was significantly lower when implants were placed within ± 10% of the recommended CA value. Our results suggest that dislocation can be avoided by placing the implant in the good CA range and considering the increase in total offset on the operative side.

Background: Artificial intelligence (AI) uses computer systems to simulate cognitive capacities to accomplish goals like problem-solving and decision-making. Machine learning (ML), a branch of AI, makes algorithms find connections between preset variables, thereby producing prediction models. ML can aid shoulder surgeons in determining which patients may be susceptible to worse outcomes and complications following shoulder arthroplasty (SA) and align patient expectations following SA. However, limited literature is available on ML utilization in total shoulder arthroplasty (TSA) and reverse TSA.

Methods: A systematic literature review in accordance with PRISMA guidelines was performed to identify primary research articles evaluating ML's ability to predict SA outcomes. With duplicates removed, the initial query yielded 327 articles, and after applying inclusion and exclusion criteria, 12 articles that had at least 1 month follow-up time were included.

Results: ML can predict 30-day postoperative complications with a 90% accuracy, postoperative range of motion with a higher-than-85% accuracy, and clinical improvement in patient-reported outcome measures above minimal clinically important differences with a 93%-99% accuracy. ML can predict length of stay, operative time, discharge disposition, and hospitalization costs.

Conclusion: ML can accurately predict outcomes and complications following SA and healthcare utilization. Outcomes are highly dependent on the type of algorithms used, data input, and features selected for the model.

Level of evidence: III.

Background: Controversy remains over whether different surgical approaches exert an impact on the component positioning in total hip arthroplasty. We conducted a retrospective study to reveal the long-term position of prostheses in the first group of patients in China who underwent direct anterior hip arthroplasty.

Methods: Collected were data from 350 patients who underwent direct anterior hip arthroplasty between 2008 and 2013, including demographic information, imaging data, Harris hip scores, and surgical complications. Variables, measured radiographically or by CT, included hip offset, leg length discrepancy, component position, and stability within one week after surgery and at the last follow-up. The data were subjected to statistical analysis by using paired t-tests and Pearson chi-square tests.

Results: Data were harvested by follow-up and self-reported questionnaires. The postoperative follow-up lasted for 13.1 years on average (minimum, 10 years; maximum, 15 years), and the overall survival rate of hip prostheses was 96.3%. The mean Harris score at the final follow-up was 91.8 points. After excluding patients with significant preoperative hip deformities, the incidence of postoperative limb inequality (> 5 mm) was 4.9% at the last follow-up, and the incidence of hip offset discrepancy (> 5 mm) was 14.6%. The overall proportion of the acetabular components located in the Lewinnek safe zone was 77.7%, whereas the proportion of femoral prostheses in the safe zone (< 3° inclination) was 94.0%. Based on the revised data and the last follow-up imaging, the total proportion of acetabular and femoral prostheses with a radiolucence of > 2 mm was 5.1%.

Conclusion: Direct anterior approach hip arthroplasty could achieve excellent component positioning and long-term prosthesis survival in patients without severe hip deformities.

Background: Unicompartmental knee replacement (UKR) is one of the effective interventions for the treatment of symptomatic knee osteoarthritis. Moreover, it has multiple advantages over total knee arthroplasty (TKA), including reduced intraoperative blood loss, decreased risk of transfusion, and faster recovery. This study aimed to discuss critical technical considerations regarding UKR and some of the controversies and updates.

Methods: We conducted a review to provide an overview of the controversies and technical considerations about UKR in several aspects. Only peer-reviewed articles were included, up to December 2023 using PubMed, Google Scholar, ERIC, and Cochrane database for systematic reviews databases.

Result: UKR is associated with superior patient-reported clinical and functional outcomes, as well as shorter hospital stays, fewer postoperative complications, and revealed favorable outcomes in patients' return to sport. The choice between mobile- and fixed-bearing prostheses depends, in part, on the surgeon's preference. The mobile-bearing UKR is a less constrained prosthesis and can potentially result in less wear, but it is more technically demanding. While no significant difference between mobile-bearing versus fixed-bearing prostheses, cementless is superior to cemented design. Furthermore, UKR can be a good alternative for high tibial osteotomy (HTO) and still can be considered after a failed HTO. Lastly, recent reviews have shown a revision rate comparable to that of TKA. This is probably influenced by Improved comprehension of the best indications, patient selection criteria, as well as of the design, materials, and technological advances.

Conclusion: UKR treatment for unicompartmental knee osteoarthritis is secure and effective. Based on clinical and functional outcomes, decreased morbidity and mortality, and cost-effectiveness, long-term studies suggest that UKR is superior to TKA. Further investigation in this area is warranted.

Background: Obesity adversely impacts outcomes of total hip arthroplasty (THA), leading surgeons to impose body mass index cutoffs for patient eligibility and encourage preoperative weight loss. This study aimed to determine if preoperative weight loss impacts outcomes of THA in the general patient population and if it mitigates poor outcomes in obese patients.

Methods: Patients who underwent THA from 2013-2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by weight loss of >10% of body weight over the preceding 6 months. We used multivariable linear and logistic regression models, adjusted for age, sex, race/ethnicity, and comorbidities, to examine the effect of significant preoperative weight loss on 30-day outcomes after THA in the general and obese patient populations.

Results: In the overall population, patients who lost significant weight preoperatively had significantly increased length of stay, were more likely to have a non-home discharge, return to the operating room, or be readmitted, and were more likely to experience numerous medical complications. In the obese population, patients who lost significant weight preoperatively had significantly increased length of stay and were more likely to require a transfusion or experience any medical complication.

Discussion: Rapid significant preoperative weight loss is not associated with improved postoperative outcomes after THA in the obese population and is associated with worse outcomes in the general population. Arthroplasty surgeons should balance these risks with the risks of obesity when advising patients about preoperative weight loss prior to THA.

Level of evidence: III.

Purpose: This study aimed to analyze the epidemiological characteristics of hip fracture in all age groups in Shanghai, and to evaluate the hospitalization cost of patients with hip fracture.

Methods: A total of 1,332 hip fracture patients admitted to a tertiary general hospital between January 2015 and May 2020 in Shanghai were included. Age, sex, diagnosis, cause of injury and site, fracture type, comorbidities, length of stay, treatment, outcomes (at discharge) and hospitalization expenses were recorded. The epidemiological characteristics of hip fracture were analyzed by using SPSS 26.0 software.

Results: The average age of hip fracture was 77.24 ± 12.66 years, and 69.0% of the patients were female. Overall, 886 patients had femoral neck fracture, and 446 patients suffered from intertrochanteric fracture. Most of the fractures caused by falls at the same level and falls from a height occurred in those aged 81-90 years; and traffic accident injuries mostly took place in patients aged 50-60. Among the 1,302 hip fracture patients who underwent surgical treatment, hip replacement was the major choice for femoral neck fracture, accounting for 49.2%. Internal fixation was the main treatment choice for intertrochanteric fracture, making up 97.8%. The median length of hospital stay lasted 8 days and at cost of hospitalization was ¥49,138.18 RMB.

Conclusion: This epidemiological study found that patients with hip fracture had certain distribution characteristics in age, sex, type of fracture, injury season, cause of injury, mode of operation, length of stay, cost, and so on. Proper medical management, social preventive measures, and prevention of falls are needed to reduce the risk of hip fracture and the socioeconomic burden.

Purpose: The gold standard to decrease total joint arthroplasty (TJA) periprosthetic joint infection (PJI) is preoperative antibiotic prophylaxis. Despite substantial prevention efforts, rates of PJIs are increasing. While cefazolin is the drug of choice for preoperative prophylaxis, adjunctive vancomycin therapy has been used in methicillin-resistant Staphylococcus aureus (MRSA) endemic areas. However, studies examining these combinations are lacking. Therefore, we sought to examine complications among vancomycin plus cefazolin and cefazolin-only recipients prior to primary TJA in a single institutional sample and specifically assessed: (1) microbiological aspects, including periprosthetic joint and surgical site infections, microbes cultured from the infection, and frequency of microbes cultured from nasal swab screening; (2) 30-day emergency department (ED) visits and re-admissions; as well as (3) associated risk factors for infection.

Methods: A total of 2,907 patients (1,437 receiving both cefazolin and vancomycin and 1,470 given cefazolin only) who underwent primary TJA between 1 January 2014 and 31 May 2021 were identified. SSI and PJI as well as rates of cultured microbes rates were obtained through one year, those with prior nasal swab screening and 30-day re-admission were identified. Subsequently, multiple regression analyses were performed to investigate potential independent risk factors for PJIs.

Results: There was no significant difference in the rates of SSI (P = 0.089) and PJI (P = 0.279) between the groups at one year after operation. Commonly identified organisms included Staphylococcus and Streptococcus species. The VC cohort did have a greater reduction of MRSA in the previously nasal swab-screened subset of patients. Multiple regression analyses demonstrated emergency as well as inpatient admissions as risk factors for PJI.

Conclusions: Adjunctive vancomycin therapy offers increased protection against MRSA in previously screened individuals. However, those negative for MRSA screening do not require vancomycin and have similar protection to infection compared to recipients of cefazolin only in a high-powered single institution analysis in an MRSA endemic area.

Background: Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively.

Purpose: This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery.

Methods: A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy.

Results: Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R² = 0.06) CONCLUSION: In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery.

Background: Body mass index (BMI) has been shown to influence risk for revision total hip arthroplasty (rTHA), but few studies have specifically examined which causes of rTHA are most likely in different BMI classes. We hypothesized that patients in different BMI classes would undergo rTHA for disparate reasons.

Methods: Ninety-eight thousand six hundred seventy patients undergoing rTHA over 2006-2020 were identified in the National Inpatient Sample. Patients were classified as underweight, normal-weight, overweight/obese, or morbidly obese. Multivariable logistic regression was used to analyze the impact of BMI on rTHA for periprosthetic joint infection (PJI), dislocation, periprosthetic fracture (PPF), aseptic loosening, or mechanical complications. Analyses were adjusted for age, sex, race/ethnicity, socioeconomic status, insurance, geographic region, and comorbidities.

Results: Compared to normal-weight patients, underweight patients were 131% more likely to have a revision due to dislocation and 63% more likely due to PPF. Overweight/obese patients were 19% less likely to have a revision due to dislocation and 10% more likely due to PJI. Cause for revision in morbidly obese patients was 4s1% less likely to be due to dislocation, 8% less likely due to mechanical complications, and 90% more likely due to PJI.

Conclusions: Overweight/obese and morbidly obese patients were more likely to undergo rTHA for PJI and less likely for mechanical reasons compared to normal weight patients. Underweight patients were more likely to undergo rTHA for dislocation or PPF. Understanding the differences in cause for rTHA among the BMI classes can aid in patient-specific optimization and management to reduce postoperative complications.

Level of evidence: III.

Background: The coronal plane alignment of the knee (CPAK) classification was first developed using long leg radiographs (LLR) and has since been reported using image-based and imageless robotic total knee arthroplasty (TKA) systems. However, the correspondence between imageless robotics and LLR-derived CPAK parameters has yet to be investigated. This study therefore examined the differences in CPAK parameters determined with LLR and imageless robotic navigation using either generic or optimized cartilage wear assumptions.

Methods: Medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) were determined from the intraoperative registration data of 61 imageless robotic TKAs using either a generic 2 mm literature-based wear assumption (Nav_lit) or an optimized wear assumption (Nav_opt) found using an error minimization algorithm. MPTA and LDFA were also measured from preoperative LLR by two observers and intraclass correlation coefficients (ICCs) were calculated. MPTA, LDFA, joint line obliquity (JLO), and arithmetic hip-knee-ankle angle (aHKA) were compared between the robotic and the average LLR measurements over the two observers.

Results: ICCs between observers for LLR were over 0.95 for MPTA, LDFA, JLO, and aHKA, indicating excellent agreement. Mean CPAK differences were not significant between LLR and Nav_lit (all differences within 0.6°, P > 0.1) or Nav_opt (all within 0.1°, P > 0.83). Mean absolute errors (MAE) between LLR and Nav_lit were: LDFA = 1.4°, MPTA = 2.0°, JLO = 2.1°, and aHKA = 2.7°. Compared to LLR, the generic wear classified 88% and the optimized wear classified 94% of knees within one CPAK group. Bland-Altman comparisons reported good agreement for LLR vs. Nav_lit and Nav_opt, with > 95% and > 91.8% of measurements within the limits of agreement across all CPAK parameters, respectively.

Conclusions: Imageless robotic navigation data can be used to calculate CPAK parameters for arthritic knees undergoing TKA with good agreement to LLR. Generic wear assumptions determined MPTA and LDFA with MAE within 2° and optimizing wear assumptions showed negligible improvement.