Faculty Bibliography

PURPOSE/UNASSIGNED:The impact of altering a patient's hip offset during total hip arthroplasty (THA) on periprosthetic fracture risk is unknown. The purpose of this study was to compare periprosthetic fracture risk in patients where THA offset was "matched" to their contralateral native hip versus those where offset was mismatched. MATERIALS AND METHODS/UNASSIGNED:-tests and chi square analyses were used for data comparison. Relative risk (RR) with a 95% confidence interval (CI) was then calculated. RESULTS/UNASSIGNED:=0.015). CONCLUSION/UNASSIGNED:Failure to restore a patient's offset during THA is associated with increased rates of periprosthetic fracture. Although restoration of native hip anatomy is an important technical consideration of this procedure, alterations in the hip lever arm may predispose patients to periprosthetic fracture.

BACKGROUND:Hip resurfacing arthroplasty (HRA) is a femoral bone-preserving alternative to total hip arthroplasty (THA) for younger, active patients. However, complications such as fractures, loosening, and metal wear can require conversion to THA. In some cases, revision of both the acetabular and femoral components is required. METHODS:We conducted a retrospective review of 15 patients who underwent conversion of HRA to THA at a single, academic tertiary care centre between January 2011 and April 2024. Demographic data, surgical details, implant characteristics, and indications for conversion were collected. Postoperative outcomes including complications, reoperations, and revisions were investigated. Revision-free survival was estimated using Kaplan-Meier analysis. RESULTS: = 3). Dual-mobility (DM) constructs were used in 11 cases (73.3%). There were no dislocations. There was 1 90-day readmission due to persistent wound drainage which underwent debridement, antibiotics, and implant retention (DAIR) 14 days post-conversion. The average follow-up duration after the conversion procedure was 6.1 years. Kaplan-Meier analysis demonstrated 93% revision-free survival at one-year, which remained stable through 13 years. CONCLUSIONS:In this study of 15 both-component HRA conversions, we observed 93% revision-free survivorship at mid-term follow-up. While the small cohort size limits definitive conclusions, our findings suggest that revision of the acetabulum during conversion, particularly with dual-mobility constructs, may be an effective strategy to mitigate instability and manage metal-on-metal failure in appropriate patients. Further research with larger cohorts is warranted to confirm our findings.

PURPOSE/OBJECTIVE:Nonsteroidal anti-inflammatory drugs (NSAIDs) increase fluid retention and the risk of heart failure (HF). The NSAIDs are commonly used in total hip arthroplasty (THA) as part of a modern multimodal pain protocol, but the risk of selective cyclooxygenase-2 (COX-2)-preferential NSAIDs in THA for Type 2 diabetes mellitus (T2DM) patients, who have an increased risk for cardiac disease, is not well understood. This study aimed to compare rates of new-onset HF following THA in T2DM patients receiving perioperative meloxicam or celecoxib. METHODS:A retrospective review was conducted of 18,142 patients who underwent primary elective THA. Data included demographics, perioperative aspirin, meloxicam and celecoxib use, T2DM diagnosis, and development of new-onset postoperative HF. Cohorts were separated based on the presence of a T2DM diagnosis and use of meloxicam or celecoxib. Propensity-matching controlled for age, American Society of Anesthesiologists score, and perioperative aspirin use. Rates of HF within T2DM patients who utilized peri-THA meloxicam versus celecoxib were compared. RESULTS:Of patients who utilized meloxicam or celecoxib, T2DM patients experience new-onset postoperative HF at higher rates than non-diabetics (6.1 [T2DM] versus 2.8% [non-T2DM], P < 0.001). Within the T2DM patients, the patients who utilized celecoxib developed HF at higher rates than T2DM patients who utilized meloxicam (4.0 [meloxicam] versus 7.1% [celecoxib], P = 0.013). CONCLUSIONS:Patients who have T2DM experience a higher incidence of new-onset postoperative HF compared to non-diabetics following perioperative selective NSAID use for THA. Additionally, T2DM patients developed HF at a greater rate when treated with perioperative celecoxib versus meloxicam. Given that both agents were associated with HF events in this high-risk population, caution is warranted when prescribing selective NSAIDs in T2DM patients undergoing THA. Risk-benefit considerations and individualized perioperative pain management strategies should be carefully considered.

BACKGROUND:Nonmodular dual mobility (DM) articulations in total hip arthroplasty (THA) aim to reduce dislocations through a large outer bearing diameter while minimizing wear via a smaller inner bearing where most motion occurs. Although routine use remains uncommon in the United States, this construct may protect against dislocation. This study aimed to evaluate clinical outcomes of a cementless, nonmodular DM acetabular cup at a mean follow-up of two years. METHODS:We conducted a single-arm retrospective review of 604 primary, elective THAs using a cementless nonmodular DM acetabular cup between April 2017 and August 2024 at a single health system with at least 90 days of follow-up. All surgeries were performed by a single hip surgeon via posterior approach. Cases were planned using digital templating and performed with manual instruments without enabling technology. Clinical outcomes were collected, including 90-days readmission and revision rates, reasons for readmission and revision, and dislocation rates. RESULTS:At a mean follow-up of 2.0 years (range, 0.25 to 8.0), all-cause and aseptic acetabular cup implant survivorship was 99.8%. There were six revisions during the study period. There was one acetabular component (0.2%) that was revised due to cup dissociation from the pelvis. The remaining revisions included two for periprosthetic femoral fracture (0.3%), one for femoral loosening (0.2%), and two for acute periprosthetic joint infection (0.3%), none of which involved revision of the acetabular cup. There were no dislocations observed, and no patients required revision for instability. CONCLUSIONS:Cementless nonmodular DM acetabular cups offered excellent clinical outcomes in primary THA at a mean follow-up of 2.0 years, with no observed dislocations in 604 cases and high implant survivorship. These findings support the use of nonmodular DM implants as a viable option to achieve THA implant stability and durable fixation even when using a posterior approach without enabling technology.

BACKGROUND:Complications of hip resurfacing arthroplasty (HRA) may require conversion to total hip arthroplasty (THA). While well-fixed acetabular components are often retained during conversion, data on implant survival and associated risks are limited. This study evaluated implant-related outcomes, survivorships, and complications in patients who undergo HRA to THA conversion with acetabular component retention. METHODS:A retrospective review of 40 patients having undergone conversion from HRA to THA was conducted. Patients were included if the original HRA acetabular component was retained, provided they had at least one year of clinical follow-up. Demographics, perioperative variables, implant characteristics, and clinical outcomes were collected via chart review. The mean time to conversion was 8.2 years (range, 0.1 to 14.2) with an average of 4.1-years of follow-up (range, 1.0 to 10.9). Common indications for conversion included metallosis (40.0%), mechanical loosening (32.5%), and periprosthetic fracture (22.5%). Most cases (97.5%) were converted to dual-mobility constructs. RESULTS:There were six patients (15.0%) who underwent subsequent reoperation following conversion, including three for infection, one for dislocation, and two for aseptic stem loosening. Kaplan-Meier analysis demonstrated an all-cause revision-free survivorship of 90.0% at one year and 81.2% at 10 years, with aseptic survivorship of 88.5% and acetabular component survivorship of 100% through final follow-up. CONCLUSION/CONCLUSIONS:Conversion of HRA to THA with retention of a well-fixed acetabular component and conversion to a dual-mobility construct provides durable survivorship up to 10 years (mean follow-up: 4.1 years). However, the rates of periprosthetic joint infection (PJI) and reoperation are more aligned with those seen in revision THA than primary THA, emphasizing the need for careful patient selection and transparent preoperative counseling. These findings highlight that while this approach can be an effective option for failed hip resurfacing, appropriate caution is warranted to mitigate the elevated risks of infection and reoperation in this cohort.

BACKGROUND:Tranexamic acid (TXA) has reduced, but not eliminated, blood transfusions surrounding total knee arthroplasty (TKA). Identifying risk factors for transfusion remains important for risk reduction and type and screen (T and S) optimization. METHODS:We retrospectively reviewed 7,254 patients who underwent primary, unilateral TKA and 307 patients who underwent primary bilateral TKA between January 2014 and January 2023, who received perioperative TXA and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline Hgb levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regressions and receiver operating characteristic (ROC) analyses. A total of 172 unilateral TKA patients (2.4%) received perioperative transfusions, with 170 (2.3%) receiving postoperative transfusions and two (0.03%) receiving intraoperative transfusions. There were 26 bilateral TKA patients (8.5%) who received postoperative transfusions with no documented intraoperative transfusions. RESULTS:For unilateral TKA, the risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index (BMI), and a direct correlation with American Society of Anesthesiologists (ASA) class and estimated blood loss (EBL) on multivariate testing. The ROC analyses demonstrated an optimal Hgb cutoff of 12.1 g/dL for predicting transfusion. The transfusion rate below Hgb of 12.1 g/dL was 6.6%, compared to a rate of 1.4% above this Hgb threshold. Below Hgb of 11 g/dL, the transfusion rate was 11.1%, while for Hgb between 11 and 12 g/dL, the transfusion rate was 4.6%. CONCLUSION/CONCLUSIONS:Transfusion is rare in unilateral TKA when TXA is used and preoperative Hgb is ≥ 12.1 g/dL, challenging universal T and S. Patients who have Hgb less than 11.0 g/dL and bilateral TKA patients remain at higher risk. Risk factors such as Hgb between 11 and 12 g/dL, BMI, ASA and EBL may predict transfusion risk and need for T and S.

PURPOSE/OBJECTIVE:To evaluate the safety and efficacy of genicular artery embolization and its longitudinal effects on biomarkers implicated in knee osteoarthritis (KOA) pathogenesis.. MATERIALS AND METHODS/METHODS:This is a prospective, single-arm clinical trial of patients with symptomatic KOA resistant to conservative therapy for greater than 3 months. Twenty-five patients who underwent GAE using 250-μm microspheres were included. Patient reported outcome measures were evaluated at baseline and 1-, 3-, and 12-months following GAE. Blood samples were collected for biomarker analysis. Magnetic resonance imaging was obtained at baseline and 3 months post GAE. The primary endpoint was the clinical success rate at 12 months. Baseline and follow-up outcomes were analyzed using the Wilcoxon matched-pairs signed-rank test. RESULTS:The technical success was 100%, with no significant adverse events. The clinical success rate was 62%. The mean VAS pain score for the target knee decreased by 48.5% at 1 month, 50.8% at 3 months, and 55.4% at 12 months (p < .001). WOMAC pain scores improved by 39.6% at 1 month, 50.1% at 3 months, and 43.7% at 12 months (p < .001). There was a statistically significant decrease in the serum levels of vascular endothelial growth factor (VEGF) and Interleukin-1 receptor antagonist (IL-1Ra) at 12 months. The remaining biomarkers showed no significant change. CONCLUSIONS:GAE is a safe treatment for symptomatic KOA, providing clinically significant pain relief for a subset of patients. The observed reductions in serum VEGF and IL-1Ra levels following GAE may contribute to local pain relief and decreased inflammation in the knee joints.

BACKGROUND:Sleep impairment following total hip arthroplasty (THA) is common and may decrease patient satisfaction and early recovery. Standardized postoperative recommendations for sleep disturbance have not been established. We aimed to assess whether melatonin use improves sleep quality and quantity in the acute period following THA. METHODS:Patients undergoing primary, elective THA between July 2021 and March 2024 were prospectively enrolled and randomized to receive either five mg of melatonin or a placebo nightly for 14 days postoperatively. Participants recorded nightly pain scores on the visual analog scale (VAS), the number of hours slept, and the number of nighttime awakenings in a sleep diary. Sleep disturbance was assessed preoperatively and on postoperative day (POD) 14 using the patient-reported outcome measurement information system sleep disturbance (PROMIS-SD) form. Epworth Sleepiness Scores (ESS) were collected to assess sleep quality and were the primary outcome of this study. Of the 139 patients who completed the study protocol, there were 64 patients in the placebo group and 75 patients in the melatonin group. RESULTS:Both groups demonstrated comparable postoperative ESS (melatonin: 6.0 ± 4.0; placebo: 6.8 ± 4.5, P = 0.35). Melatonin patients experienced significantly more hours slept on POD2 (6.5 ± 1.7; 5.7 ± 2.4, P = 0.017) and averaged over POD one to three (6.1 ± 1.6; 5.7 ± 2.0, P = 0.14), although this was not statistically significant. Fewer nighttime awakenings in the melatonin group were observed on POD two (2.7 ± 1.5; 3.1 ± 2.0, P = 0.28), although this was not statistically significant. The melatonin group demonstrated significantly lower postoperative PROMIS-SD scores (52.5 ± 9.3; 56.3 ± 9.2, P = 0.040). CONCLUSION/CONCLUSIONS:Melatonin may not improve overall postoperative sleep quality following THA as measured by the ESS. Melatonin may promote sleep duration in the POD one to three period, although potential benefits wane after POD three. Melatonin is safe and can be considered for THA patients experiencing early postoperative sleep disturbance.

BACKGROUND:Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase fluid retention and the risk of heart failure (HF). Type 2 diabetes mellitus (T2DM) is known to increase the risk of cardiac disease, including HF. As part of a modern multimodal pain protocol, NSAIDs are commonly used in total knee arthroplasty (TKA), but the risk of NSAID use in TKA for T2DM patients is not well understood. The purpose of this study was to compare rates of new-onset HF following TKA in Type 2 diabetics with varying NSAID use. METHODS:We reviewed 3,906 patients who underwent primary TKA from 2015 to 2023 at a single academic institution. Data collected included demographics, preoperative diagnosis of T2DM, postoperative development of new-onset HF, NSAIDs taken perioperatively, and aspirin use for deep vein thrombosis (DVT) prophylaxis. Propensity matching was conducted to control for age, American Society of Anesthesiologists (ASA) Score, and aspirin use. Rates of postoperative HF within T2DM patients who took meloxicam versus celecoxib were compared using Chi-square analyses. RESULTS:Among patients who took meloxicam or celecoxib perioperatively, a preoperative diagnosis of T2DM was disproportionately associated with postoperative HF (P = 0.006). When comparing peri-TKA use of meloxicam versus celecoxib in T2DM patients, the use of celecoxib was disproportionately associated with the development of postoperative HF (2.2% [meloxicam], 4.8% [celecoxib], P = 0.002). CONCLUSIONS:We found patients who had T2DM developed postoperative HF at higher rates compared to non-diabetics following peri-TKA NSAID use and that T2DM patients developed new-onset HF at higher rates when utilizing celecoxib than meloxicam in the peri-TKA period. Along with the many other factors that contribute to an orthopaedic surgeon's decision on which NSAID to use postoperatively, we advocate for consideration of the risk of new-onset HF in T2DM patients when prescribing meloxicam and celecoxib in the post-TKA period.