Arthroplasty最新文献

Background: Despite recent developments in THA, a more objective method is needed to assist orthopedic surgeons in identifying the insertion endpoint of the broaching procedure. Therefore, this systematic review evaluated the in-vivo efficacy of various acoustic and vibration analyses in detecting proper implant seating, identifying intraoperative complications, and quantifying the accuracy of predictive modeling using acoustics.

Methods: Four electronic databases were searched on July 23rd, 2023, to retrieve articles evaluating the use of acoustic analysis during THA. The search identified 835 unique articles, which were subsequently screened by two independent reviewers as per our inclusion and exclusion criteria. In total, 12 studies evaluating 580 THAs were found to satisfy our criteria and were included in this review.

Results: Methodologically, analyses have suggested stopping broaching when consecutive blows emit similar acoustic profiles (maximum peak frequency ± 0.5 kHz), which indicates proper implant seating in terms of stability and mitigates subsidence. Also, abrupt large deviations from the typical progression of acoustic signals while broaching are indicative of an intraoperative fracture. Since height, weight, femoral morphological parameters, and implant type have been shown to alter acoustic emissions while hammering, incorporating these factors into models to predict subsidence or intraoperative fracture yielded virtually 100% accuracy in identifying these adverse events.

Conclusion: These findings support that acoustic analyses during THA show promise as an accurate, objective, and non-invasive method to predict and detect proper implant fixation as well as to identify intraoperative fractures.

Trial registration: PROSPERO registration of the study protocol: CRD42023447889, 23 July 2023.

Background: While the benefits of sonication for improving periprosthetic joint infection (PJI) are well-documented, its potential therapeutic effect against bacterial biofilm remains unstudied. This study aimed to investigate the safety and efficacy of a novel nanoparticle ultrasonication process on methicillin-resistant Staphylococcus aureus (MRSA) bacterial biofilm formation in a PJI rat model.

Methods: This novel ultrasonication process was designed to remove attached bacterial biofilm from implant and peri-articular tissues, without damaging native tissues or compromising implant integrity. Twenty-five adult Sprague-Dawley rats underwent a surgical procedure and were colonized with intra-articular MRSA, followed by the insertion of a titanium screw. Three weeks after the index surgery, the animals received a second procedure during which the screws were explanted, and soft tissue was sampled. The intraoperative use of the nanoparticle sonication treatment was employed to assess the device's safety, while ex vivo treatment on the retrieved tissue and implants was used to evaluate its efficacy.

Results: Clinical and histological assessments did not indicate any macro- or micro-damage to the host tissue. Sonication of the retrieved tissues demonstrated an average bacterial removal of 2 × 10³ CFU/mL and 1 × 10⁴ CFU/gram of tissue. Compared to the standard-of-care group (n = 10), implants treated with sonication (n = 15) had significantly lower remaining bacteria, as indicated by crystal violet absorbance measurements (P = 0.012).

Conclusions: This study suggests that nanoparticle sonication technology can successfully remove attached bacterial biofilms from explanted orthopedic hardware and the joint capsule, without negatively affecting native tissue. The study provides initial results supporting the potential of nanoparticle sonication as an adjuvant treatment option during a DAIR (debridement, antibiotics, and implant retention) procedure for PJI, paving the way for future clinical trials.

Purpose: Although many factors were suggested to affect acetabular cup positioning during primary total hip arthroplasty, the effect of surgeon handedness was rarely evaluated. We aimed primarily to assess the difference in cup positioning (inclination and anteversion) between the right and left sides during primary THA. Secondly, to check the difference in the percentages of cups positioned in the safe zone for inclination and anteversion and if there will be a difference in cup positioning according to the type of cup fixation (cemented vs. cementless).

Methods: Cup inclination and anteversion of 420 THAs were radiographically evaluated retrospectively. THAs were performed by a senior right-handed surgeon, who operated through a direct lateral approach in a lateral decubitus position using manual instruments and freehand technique for cup placement. Patients were assigned to two groups: Group A (right, or dominant side), and Group B (left, or non-dominant side), with equal cases of THAs (n = 210) in each group.

Results: No difference was found in patients' basic characteristics, preoperative diagnosis, and cup fixation (54.3% cemented and 45.7% cementless) between the two groups. There was a significant difference in cup inclination between Groups A and Group B (40.1° ± 6.3° vs. 38.2° ± 6.1°) (P = 0.002). No significant difference was revealed in anteversion between the two groups (11.7° ± 4.4° vs. 11.8° ± 4.7°) (P = 0.95). The percentage of cups located within the safe zone in terms of both inclination and anteversion was 85.2% vs. 83.8% and 69% vs. 73.3% for Group A and Group B, according to Lewinnek and Callahan's safe zones, respectively. There existed a significant difference in the cemented cup inclination between Group A and Group B (40.8° ± 6.4° vs. 38.3° ± 6.3°) (P = 0.004).

Conclusion: Cup inclination is affected by the surgeon's handedness when operating through a direct lateral approach and using a freehand technique, while anteversion is less affected. Furthermore, the difference is greater with cemented cups.

Purpose: In total knee arthroplasty (TKA), asymmetric tibial components have been developed alongside symmetric tibial components to enhance bony coverage at the tibia. In primary TKA and revision TKA for patients with significant bone defects, augmentation is employed to fill the bone defect. However, there have been no reports on bony coverage of the tibial component of the revision system in the cases of bone defects. Therefore, we simulated bone defects using CT and compared the bony coverage of asymmetric and symmetric tibial components in the revision TKA system.

Methods: This study included 45 patients (50 knees involved) with medial osteoarthritis. Preoperative CT scans were used to simulate placement using ZedKnee. Three models were evaluated: Persona Revision PCCK (Zimmer) for the asymmetric component, NexGen LCCK (Zimmer) for the symmetric component, and the ATTUNE revision system (Depuy-Synthes). A 130-mm stem extension was utilized. Augmentations of each thickness were placed to simulate bone defects of 5, 10, and 15 mm. The coverage, overhang, and underhang rates were measured for each slice and compared among the models.

Results: In terms of coverage, the rate was greater for PCCK at 0 mm, and only ATTUNE exhibited a significantly lower coverage at 5 and 10 mm. There was no significant difference in coverage at 15 mm. At 0 mm, PCCK demonstrated less posterior underhangs. At 5 and 10 mm, PCCK showed less anterior overhang but more anterior underhang. At 15 mm, PCCK had a less anterior overhang, with an overhang in the posterior region but less underhang. When overhang and underhang were combined and compared, the asymmetric component generally yielded superior results.

Conclusion: In the cases of bone defects, asymmetric components demonstrated reduced anterior overhang and decreased posterior underhang, resulting in greater bone coverage. This may contribute to improved long-term outcomes in the revision TKA system.

Background: Total joint arthroplasty (TJA) is an effective treatment for end-stage osteoarthritis, but postoperative pain has been poorly managed. The purpose of this study was to (1) assess how much narcotic medication was prescribed after TJA; (2) assess if patients were satisfied with their pain management; (3) compare these same data between total hip arthroplasty (THA)/total knee arthroplasty (TKA); (4) compare these same data between preoperative opioid users/opioid-naïve patients.

Methods: An IRB-approved prospective study was conducted at a US academic joint replacement practice. Patients were evaluated by an independent observer at three weeks, three months, and six months postoperatively using the Detroit Interventional Pain Assessment (DIPA) scale. Patients verbally rated their pain with their current medication regimen as 0 (no pain), 1 (tolerable pain), or 2 (intolerable pain) on the DIPA scale. Narcotic usage was verified by the Michigan Automated Prescription System (MAPS). Patients were divided into THA, TKA, previously on opioids, and opioid-naïve groups. Provider efficiency scores reflected pain management satisfaction and were calculated as the percentage of patients reporting no pain or tolerable pain.

Results: Out of 200 patients, the percentage of patients using narcotics and their daily usage (MMEs) significantly decreased from 75.5% (27.5 MMEs) at three weeks to 42.9% (5.3 MMEs) at six months (P < 0.001). In 80% of patients, narcotics taken at six months were prescribed by outside providers. Significantly fewer patients used narcotics at six months for THA (15.4%) compared to TKA (52.7%) (P < 0.021). There was a significant difference in daily narcotic usage between patients who took narcotics preoperatively (22.9 MMEs) and opioid-naïve ones (13.4 MMEs) (P < 0.001). Provider efficiency scores were best at three weeks (76.6%) and three months (70%) but declined at six months (57.2%).

Conclusions: Narcotic tapering practices were observed as postoperative daily narcotic intake decreased across six months. However, outside providers prescribed 80% of narcotics at six months, necessitating a better-coordinated practice with surgeons. Patients taking preoperative narcotics experienced higher daily MME requirements than their opioid-naïve counterparts. In terms of the percentage of patients on narcotics, THA is a better procedure for tapering patients off narcotics by six months.

Background: Indications for total hip arthroplasty (THA) have evolved over recent decades, with a growing trend toward operating on younger and more active patients. With this shift in patient demographics, there has been a change in femoral stem designs and proximal femoral morphology encountered. This study aimed to evaluate the potential correlation between femoral stem osteointegration and proximal femoral morphology using the Dorr and Noble classifications.

Materials and methods: We conducted a retrospective review of 122 uncemented femoral stems (AMIstem Medacta, triple tapered). The demographic data analyzed included sex, age, stem size, and surgical indications. Preoperative radiographs were reviewed to determine the Dorr classification as well as the canal-to-calcar isthmus ratio, cortical index, and canal flare index. Postoperative radiographs were carefully reviewed to identify the presence of potential postoperative radiolucencies. Inter- and intra-observer agreements for these parameters were also analyzed.

Results: Significant radiolucencies (> 2 mm) were found in 19.5% of the patients. Of all the variables analyzed, the cortical index was the only parameter significantly associated with the appearance of clinically significant radiolucency, with a threshold value of 0.62.

Conclusions: The appearance of radiolucencies is multi-factorial. Nevertheless, in this study, a high cortical index (> 0.62), representing the champagne flute morphology, was found to be associated with the development of significant radiolucencies.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed orthopedic procedures. This study aimed to evaluate the impact of COVID-19 status on postoperative complications and mortality in patients undergoing THA and TKA.

Methods: A total of 110,186 underwent either THA or TKA. Patients were grouped based on their COVID-19 status, gathered from the National COVID-19 Cohort Collaborative (N3C) in the 12 weeks preceding surgery and compared for various variables, including age, sex, BMI, and Charlson Comorbidity Index (CCI) scores. COVID-19 status was defined as a positive test result that was closest to the date of surgery regardless of testing positive previously. Postoperative complications such as venous thromboembolism (VTE), sepsis, surgical site infection, bleeding, acute kidney injury (AKI), 30-day, and 1-year all-cause mortality were examined. To compare the variables, an odds ratio with a 95% confidence interval was calculated with a significant level set at P < 0.05. Logistic regression using R programming was utilized for these calculations.

Results: Univariate analysis was performed and rates of VTE (1.02% vs. 3.35%), 30-day mortality (0.25% vs. less than 5%), and 1-year mortality (1.42% vs. 5.43%) were higher in the COVID-19-positive group for THA patients (P < 0.001). For TKA patients, only 30-day mortality was significantly higher in the COVID-19-positive group (P = 0.034). Multivariate logistic regression revealed that a positive COVID-19 diagnosis within two weeks of surgery and a CCI score > 3 were significant predictors of postoperative complications and mortality for both TKA and THA.

Conclusions: Patients with a positive COVID-19 diagnosis within 12 weeks of THA or TKA carried a significantly higher risk for postoperative complications and mortality. In addition, a CCI score > 3 is also a significant risk factor. These findings emphasize the importance of vigilant preoperative screening and risk stratification in the era of COVID-19.

Patients undergoing knee replacement, which is mainly indicated in severe osteoarthritis, are frequently co-affected by osteoporosis and osteopenia. With a prevalence standing at around 20% in patients receiving knee arthroplasty, osteoporosis could lead to poor outcomes postoperatively. Some of these complications include periprosthetic fractures and an increased revision rate. Antiresorptive medications have been shown to be beneficial postoperatively. However, no studies have been conducted on whether they had any benefits if given preoperatively. Surgical management may also be beneficial, but this area remains full of controversy.

Background: Surgical site infection (SSI) is a major problem following total hip arthroplasty (THA). This study investigated the impact of a standard intraoperative routine where the surgical team wears full-body exhaust suits (space suits) within a laminar airflow (LAF)-ventilated operating room (OR) on environmental contamination. Our primary objective was to identify potential modifiable intraoperative factors that could be better controlled to minimize SSI risk.

Methods: We implemented an approach involving simultaneous and continuous air sampling throughout actual primary cementless THA procedures. This method concurrently monitored both airborne particle and microbial contamination levels from the time the patient entered the OR for surgery until extubation.

Results: Airborne particulate and microbial contamination significantly increased during the first and second patient repositionings (postural changes) when the surgical team was not wearing space suits. However, their concentration exhibited inconsistent changes during the core surgical procedures, between incision and suturing, when the surgeons wore space suits. The microbial biosensor detected zero median microbes from draping to suturing. In contrast, the particle counter indicated a significant level of airborne particles during head resection and cup press-fitting, suggesting these procedures might generate more non-viable particles.

Conclusions: This study identified a significant portion of airborne particles during the core surgical procedures as non-viable, suggesting that monitoring solely for particle counts might not suffice to estimate SSI risk. Our findings strongly support the use of space suits for surgeons to minimize intraoperative microbial contamination within LAF-ventilated ORs. Therefore, minimizing unnecessary traffic and movement of unsterile personnel is crucial. Additionally, since our data suggest increased contamination during patient repositioning, effectively controlling contamination during the first postural change plays a key role in maintaining low microbial contamination levels throughout the surgery. The use of sterile gowns during this initial maneuver might further reduce SSIs. Further research is warranted to investigate the impact of sterile attire on SSIs.

Background: With advancements in perioperative care, joint replacement (JR) surgery is undergoing a transition from opacified in-patient institutions to nimble out-patient Ambulatory Surgical Centers (ASC). The goal of JR in ASC setting is safe patient discharge with subsequent rehabilitation without readmission. Multi-modal preoperative rehabilitation (MMPR) is a novel field of perioperative care, encompassing comprehensive parameters to ensure smooth transition from fitness for surgery to JR in outpatient setting. At present, there are no open-access schemes for selecting patients qualified for JR in the ASC setting. In this article, we propose an evidence-based, 10-point systematic evaluation of patients with target endpoints for MMPR to qualify patients for JR as an outpatient procedure. This checklist is a non-proprietary scheme serving as an initial framework for surgeons exploring surgery in the ASC setting. BODY: We introduce factors for a prehabilitation scheme, called Checklist Outpatient-Joint Replacement (CO-JR) to qualify patients for outpatient JR surgery. These factors have been developed based on an extensive literature review and the significant experience of authors to incorporate variables that drive a successful outpatient JR procedure. The factors include patient education, psychiatric & cognitive ability, medical fitness, musculoskeletal capability, financial ability, transportation access, patient motivation, information technology (IT) capabilities, along with ability to recover independently at home postoperatively. The CO-JR scheme is under the process of validation at multiple institutions. We introduce this as a starting point for collaborative development of an open-access scheme for all surgeons to learn and adapt as needed for their respective global region.

Conclusion: We established a non-proprietary 10-point CO-JR scheme, serving as a framework for surgeons to successfully select patients for JR surgery in the ASC setting. We encourage concomitant validation of this scheme globally. Our goal is to reach an international consensus on an open-access scheme, available for all surgeons to enrol patients for JR in the ASC setting, but modifiable to accommodate regional needs.