Faculty Bibliography

BACKGROUND:Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing. METHODS:We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received 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 regression and receiver operating characteristic curve analysis. RESULTS:The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index, and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The receiver operating characteristic analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively. CONCLUSIONS:In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is >12 g/dL, challenging the need for universal type and screening. Conversely, patients who have Hgb < 11.0 g/dL, remain at substantial risk for transfusion. Between Hgb 11 and 12 g/dL, patient age, sex, body mass index, American Society of Anesthesiologists classification, anticipated estimated blood loss, and surgical time may help predict transfusion risk and the need for a perioperative type and screen. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Cement fixation for total hip arthroplasty (THA) remains a controversial topic. While cemented stems are associated with lower risk of periprosthetic fractures (PPF), cementless stems may offer superior biological fixation. This study analyzed peri-operative and short-term outcomes of cemented vs. cementless stem fixation in THA. METHODS:A retrospective review was conducted on 15,012 patients who underwent primary elective THA at an academic medical center from 2011 to 2021. Of these patients, 429 were cemented. Patients were stratified into 3 age cohorts (25-69, 70-79 and ≥ 80 years). Cemented stem patients were 1:1 propensity-score matched to cementless stem patients for baseline characteristics. Perioperative and short-term outcomes were compared. RESULTS:The mean operative time for cemented cases was significantly longer across all age cohorts (25-69, P = 0.005; 70-79, P < 0.001; ≥80, P < 0.001). In the 70-79 and ≥ 80 cohorts, cemented patients demonstrated a significantly shorter length of stay (LOS) compared to cementless patients (2.2 vs. 2.6 days, P = 0.017; 3.0 vs. 3.4, P = 0.041, respectively). In the 70-79 and ≥ 80 cohorts, cemented patients were significantly more likely to be discharged home when compared to cementless patients (88.2 vs. 80.5%, P = 0.031; 64.0 vs. 54.2%, P = 0.046, respectively). Across age cohorts, there were no differences in all-cause revision rates (Cohort 1: 5.4% vs. 1.1%, P = 0.108; Cohort 2: 3.0% vs. 1.8%, P = 0.362; Cohort 3: 1.8% vs. 1.2%, P = 0.714). The ≥ 80 cohort demonstrated increased rates of PPF in the cementless cohort compared to cemented (1.2 vs. 0%, P = 0.082, respectively), but it did not reach significance. CONCLUSION/CONCLUSIONS:Patient age has a substantial impact on perioperative outcomes following cemented versus cementless stem THA. Patients > 70 with a cemented femoral stem had improved perioperative outcomes such as shorter LOS, increased discharge to home and reduced rates of PPF compared to their cementless stem counterparts. Patient age should be considered prior to selecting a stem fixation strategy. LEVEL OF EVIDENCE/METHODS:III, Therapeutic Study.

BACKGROUND:Sleep impairment following total knee arthroplasty (TKA) is common and may decrease patient satisfaction and recovery. Standardized postoperative recommendations for sleep disturbances have not been established. We aimed to assess whether melatonin use could promote healthy sleep and reduce sleep disturbance in the acute period following TKA. METHODS:Patients undergoing primary, elective TKA between July 19, 2021 and January 4, 2024 were prospectively enrolled and randomized to receive either 5 mg of melatonin nightly or placebo for 14 days postoperatively. Participants recorded their nightly pain on the visual analog scale, the number of hours slept, and the number of nighttime awakenings in a sleep diary starting the night of surgery (postoperative day [POD] 0). Sleep disturbance was assessed preoperatively and on POD 14 using the patient-reported outcome measurement information system sleep disturbance form. Epworth Sleepiness Scores were collected on POD 14 to assess sleep quality. RESULTS:Of the 138 patients enrolled, 128 patients successfully completed the study protocol, with 64 patients in each group. Melatonin patients trended towards more hours of sleep on POD 2 (placebo: 5.0 ± 2.4, melatonin: 5.8 ± 2.0, P = 0.084), POD 3 (placebo: 5.6 ± 2.2, melatonin: 6.3 ± 2.0, P = 0.075), and averaged over POD 1 to 3 (placebo: 4.9 ± 2.0, melatonin: 5.6 ± 1.8, P = 0.073), though no differences were observed on POD 4 or after. Fewer nighttime awakenings in the melatonin group were observed on POD 1 (placebo: 4.4 ± 3.9, melatonin: 3.6 ± 2.4, P = 0.197), although this was not statistically significant. Preoperative and postoperative Patient-Reported Outcomes Measurement Information System Sleep Disturbance (PROMIS-SD) score increases were comparable for both groups (placebo: 4.0 ± 8.4, melatonin: 4.6 ± 8.2, P = 0.894). The melatonin (65.4%) and placebo (65%) groups demonstrated similar rates of increased sleep disturbance. CONCLUSION/CONCLUSIONS:Melatonin may promote longer sleep in the immediate postoperative period after TKA, though these benefits wane after POD 3. Disturbances in sleep should be expected for most patients, though melatonin may have an attenuating effect. Melatonin is safe and can be considered for TKA patients experiencing early sleep disturbances postoperatively.

BACKGROUND:Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS:Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS:There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS:In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

INTRODUCTION/BACKGROUND:Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS:We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS:In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION/CONCLUSIONS:More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE/METHODS:III, Retrospective Review.

Genicular artery embolization is increasingly recognized as a safe and effective treatment option for symptomatic knee osteoarthritis and recurrent hemarthrosis following total knee arthroplasty. Genicular arteries are an essential vascular supply for the knee joint and demonstrate considerable variability. Familiarity with the anatomy and common variations is critical for pre-procedural planning, accurate target selection, and minimizing adverse events in trans-arterial embolization procedures. This review aims to provide a detailed discussion of the genicular artery anatomy that is relevant to interventional radiologists performing genicular artery embolization.

PURPOSE/OBJECTIVE:To characterize the safety, efficacy, and potential role of genicular artery embolization (GAE) as a disease-modifying treatment for symptomatic knee osteoarthritis (OA). MATERIALS AND METHODS/METHODS:This is an interim analysis of a prospective, single-arm clinical trial of patients with symptomatic knee OA who failed conservative therapy for greater than 3 months. Sixteen patients who underwent GAE using 250-μm microspheres and had at least 1 month of follow-up were included. Six patients completed the 12-month follow-up, and 10 patients remain enrolled. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was evaluated at baseline and at 1, 3, and 12 months. Serum and plasma samples were collected for biomarker analysis. The primary end point was the percentage of patients who achieved the minimal clinically important difference (MCID) for WOMAC pain score at 12 months. Baseline and follow-up outcomes were analyzed using the Wilcoxon matched-pairs signed-rank test. RESULTS:Technical success of the procedure was 100%, with no major adverse events. The MCID was achieved in 5 of the 6 (83%) patients at 12 months. The mean WOMAC pain score decreased from 8.6 ± 2.7 at baseline to 4.9 ± 2.7 (P = .001), 4.4 ± 2.8 (P < .001), and 4.7 ± 2.7 (P = .094) at 1, 3, and 12 months, respectively. There was a statistically significant decrease in nerve growth factor (NGF) levels at 12 months. The remaining 8 biomarkers showed no significant change at 12 months. CONCLUSIONS:GAE is a safe and efficacious treatment for symptomatic knee OA. Decreased NGF levels after GAE may contribute to pain reduction and slowing of cartilage degeneration.

BACKGROUND:Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively. METHODS:We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion. RESULTS:Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion. CONCLUSION:Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.

INTRODUCTION/BACKGROUND:Selective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. METHODS:We retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 FB and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had fixed-bearing (FB) and DM implants. Cases were then stratified into three groups based on the attending surgeon's rate of DM utilization (≤1, 1 to 10, or >10%) and outcomes were compared. RESULTS:There were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0 to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1 to 10% of cases, and 7 (10%) in >10% of cases. The 90-day rates of readmission (7.3 vs 7.6 vs 7.2%, P=0.7) and reoperation (3.4 vs 3.9 vs 3.8%, P=0.3), as well as readmission for instability (0.5 vs 0.6 vs 0.8%, P=0.2) and reoperation for instability (0.5 vs 0.5 vs 0.8%, P=0.6), did not statistically differ between cohorts. CONCLUSION/CONCLUSIONS:Selective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (i.e., surgical approach, computer navigation, robotic assistance, and large diameter fixed-bearings) may have masked any benefits of selective DM use.