Faculty Bibliography

BACKGROUND:Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are widely used as screening tools for periprosthetic joint infection (PJI) following total knee and hip arthroplasty (TKA and THA, respectively). However, the significance of an isolated elevated ESR with a normal CRP, especially in cases with low clinical suspicion, remains unclear. METHODS:We retrospectively reviewed 19,872 primary TKAs and 12,143 primary THAs performed between March 2012 and March 2023 at a high-volume academic orthopaedic hospital. Of these, 656 TKA and 253 THA patients ≥ 18 years old who underwent elective TJA for osteoarthritis had an elevated ESR (higher than 30 millimeters/hour) and a normal CRP (less than or equal to 10 milligrams/liter) at least 90 days postoperatively. These cutoffs were chosen in concordance with the International Consensus Meeting (ICM) 2018 diagnostic criteria for PJI. Patients who were already undergoing PJI treatment were excluded, as it was inferred the serum biomarkers were not drawn for screening purposes. The final cohorts consisted of 641 TKA and 252 THA patients. Data collected through manual chart review of clinical progress notes included presenting symptoms, inflammatory markers, and PJI diagnoses. We calculated the incidence of PJI within the cohort of patients who had an isolated, elevated ESR. RESULTS:Of the 641 TKA patients who had an isolated, elevated ESR, seven (1.1%) were subsequently diagnosed with PJI. Of the 252 THA patients who had an isolated, elevated ESR, three (1.2%) were subsequently diagnosed with PJI. Of the seven TKA and three THA patients subsequently diagnosed with PJI, three (0.5%) TKA and two (0.8%) THA patients had clinical findings highly suspicious for PJI, such as a large effusion and severe, sudden-onset swelling. These patients did not represent cases where a surgeon would encounter true uncertainty regarding whether to pursue further workup and testing. This left four TKA (0.5%) and one THA (0.4%) patient who had an isolated, elevated ESR who were eventually diagnosed with PJI despite limited clinical concern beyond nonspecific pain. The positive predictive value (PPV) of an isolated, elevated ESR for the diagnosis of PJI was 1.1% in the TKA cohort and 1.2% in the THA cohort. CONCLUSION/CONCLUSIONS:Isolated, elevated ESR with a normal CRP should not automatically trigger a full PJI workup. The risk of PJI is low in this specific patient population, especially when only accompanied by nonspecific symptoms. Most PJI cases in this cohort were found in patients who also had relevant clinical symptoms like sudden-onset swelling or large effusions, suggesting that important weight should be given to the presence or absence of additional PJI symptoms when deciding whether to pursue further testing after an isolated, elevated ESR.

BACKGROUND:Vancouver B2 and B3 periprosthetic femur fractures (PPFF) have posed significant treatment challenges due to stem instability and lack of adequate femoral bone stock. This study investigated subsidence, survivorship, and outcomes of Vancouver B2 and B3 fractures, based on the order in which revision stem placement and fracture reduction occurred during revision total hip arthroplasty (rTHA). METHODS:This retrospective, cohort study included 46 rTHAs between June 2011 and April 2023. Included patients underwent rTHA for Vancouver B2 or B3 PPFF with minimum one-year radiographic and two-year clinical follow-up. All patients were treated with diaphyseal-engaging tapered fluted titanium stems and stem modularity decisions were based on surgeon preference. Cohorts were separated based on if stem placement (SF, n = 19), or fracture reduction (RF, n = 27) occurred first. Patient demographics, intraoperative information, and clinical and radiographic outcomes were collected. RESULTS:The SF and RF cohort showed no statistically significant differences in rate of subsidence ≥5 mm [26.3%[SF], 22.2%[RF], P = 0.749), rate of subsidence ≥ 10 mm (15.8%[SF], 14.8%[RF], P = 0.928), nor average subsidence (4.1 mm[SF], 4.4 mm[RF], P = 0.861). We found no statistically significant differences in surgery-related clinical outcomes or all-cause revision rates within a two-year follow-up period. The groups demonstrated comparable rates of procedure-related 90-day emergency department visits(P = 0.370) and readmissions(P = 0.712). The SF group underwent four revisions for three PJIs and one acetabular component aseptic loosening. The RF cohort underwent four revisions for one acetabular component aseptic loosening, one dislocation, one PPFF, and one PJI. Rates of all-cause revision were comparable(P = 0.583). There was one case within the RF cohort to explant the trochanteric plate with no revision of arthroplasty components. CONCLUSIONS:The present analysis suggests the order in which intraoperative femoral stem implantation and fracture reduction occurs does not affect short-term clinical and radiographic outcomes. This intraoperative decision should be based upon patient anatomy, fracture patterns, and surgeon discretion.

BACKGROUND:Solid organ transplant (SOT) patients undergoing total joint arthroplasty (TJA) may be at higher risk for complications due to complex medical and surgical histories, chronic immunosuppressive medications, and significant ongoing comorbidities. This study aimed to evaluate postoperative outcomes following primary, elective TJA in patients with a history of SOT. METHODS:We retrospectively reviewed 53,043 primary, elective TJA patients from 2011 to 2025. Patients were screened for SOT history prior to TJA. All SOT patients were taking some form of immunosuppressive medication following their transplantation. Demographics, SOT details, and surgical data were obtained. SOT patients (n = 70) underwent a nearest-neighbor 1:3 propensity-score matching to non-SOT (NSOT) controls (n = 210) based on age, sex, smoking, Charlson Comorbidity Index, body-mass index, and TJA indication. Kidney transplants were most common (61.4%), followed by liver (24.3%), and heart (8.6%). Differences in surgical outcomes and postoperative complications between the patients were investigated using Chi-squared tests, independent t-tests and effect size (ES) estimates. Baseline characteristics did not differ between the groups (P > 0.05). RESULTS:SOT patients had significantly longer hospital stays (92 vs. 51 h, P < 0.001, ES = 0.82), higher rates of discharge to skilled nursing facilities (SNF) (15.7% vs. 5.7%, P = 0.014, ES = 0.17) and all-cause 90 day readmissions (15.7% vs. 6.7%, P = 0.040, ES = 0.12), primarily driven by non-surgical reasons (14.3% vs. 4.3%, P = 0.010, ES = 0.16) compared to NSOT patients. All-cause revision rates were comparable between SOT and NSOT patients (4.3% vs. 3.8%, P = 0.999), including aseptic (2.9% vs. 1.9%, P = 0.642) and septic causes (1.4% vs. 1.9%, P = 0.999). CONCLUSIONS:Despite higher rates of SNF discharge and non-surgical 90 day readmissions, SOT patients achieved similar all-cause, septic, and aseptic revision rates, compared to NSOT patients. These findings suggest that compared to well-matched comorbid controls, SOT patients can safely undergo elective TJA with comparable revision risk. Enhanced perioperative care may help reduce readmission risks in this complex population.

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.

INTRODUCTION/BACKGROUND:As the number of total hip arthroscopies performed rises, further research is needed on the impact hip arthroscopy (HA) may have on total hip arthroplasty (THA). This study aimed to compare clinical and patient-reported outcomes of THA in patients with and without a history of HA. METHODS:= 448) based on age, sex, race, smoking status, American Society of Anesthesiologists score, body mass index, and Charlson Comorbidity Index. Perioperative data, rates of complications and reoperation/revisions, Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected. Logistic regression was used to assess if the likelihood of reoperation was related to prior HA and surgical approach. RESULTS:= 0.009). Surgical approach for THA was not associated with postoperative dislocation rate. Patient-reported outcomes were not different among the 2 cohorts. CONCLUSIONS:In our study, THA patients with history of HA experienced increased rates of dislocation and return to operation room. These findings highlight a need for increased clinical awareness. These findings may inform intraoperative and postoperative modifications to increase prosthetic hip stability. Additionally, this knowledge can have implications for insurance billing and payments, as these cases are coded as primary THA but may present with more complexity or worse outcomes.

BACKGROUND/UNASSIGNED:Arthrofibrosis represents a source of patient dissatisfaction following total knee arthroplasty (TKA). The purpose of this systematic review and meta-analysis was to evaluate the efficacy of perioperative angiotensin II receptor blockers (ARBs) as anti-fibrotic agents in patients undergoing total knee arthroplasty (TKA). METHODS/UNASSIGNED:The Medline, Embase and Cochrane library databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The outcome measures of interest were postoperative knee range of motion (ROM), rates of manipulation under anesthesia (MUA) and revision rates. RESULTS/UNASSIGNED: = 0.3349). CONCLUSION/UNASSIGNED:This systematic review and meta-analysis found that the utilization of perioperative ARBs were not associated with superior postoperative knee ROM nor lower rates of MUA in patients undergoing TKA. Additionally, no difference in revision TKA rates existed between patients in the ARB cohort compared to the control cohort. Based on the current available data, it is the author's current recommendation that perioperative ARB usage is not indicated in the setting of TKA for the prevention of arthrofibrosis. However, this analysis should be interpreted in light of the low level of evidence and under-reporting of data of the included studies. Thus, higher-level evidence, prospective, comparative studies should be conducted to definitively identify if perioperative ARBs can be utilized as effective anti-fibrotic agents in the setting of TKA.

BACKGROUND:Severe obesity and its association with advanced knee osteoarthritis are established risk factors for surgical complications and associated costs of total knee arthroplasty (TKA). This clinical trial examines the functional knee outcomes of severely obese patients who have severe knee osteoarthritis undergoing bariatric surgery versus immediate TKA and examines the impact of surgical weight loss on the pursuit of TKA. METHODS:The SWIFT Trial (Surgical Weight-loss to improve Functional status Trajectories) following total knee arthroplasty was a multicenter, prospective trial examining outcomes of weight loss surgery and TKA in patients who have severe obesity (body mass index ≥ 40 or greater than 35 who have comorbidities) and symptomatic Kellgren-Lawrence grades 3 or 4 radiographic knee osteoarthritis. Study patients were recruited prospectively from November 2015, to October 2024 and divided into two groups: the bariatric arm (patients undergoing bariatric surgery) and the TKA arm (patients undergoing TKA). Each study arm underwent a comprehensive battery of knee functional assessments at baseline, six, 12, and 24 months, as well as re-evaluations in the bariatric surgery arm to assess the need for delaying or proceeding with TKA at 12 and 24 months. There were 232 study subjects who completed surgery and knee evaluation (n = 159: immediate TKA versus n = 73: bariatric surgery). The study groups had comparable degrees of knee disability at study initiation. RESULTS:Longitudinal functional analysis demonstrated major improvement extending to two years in patient-reported outcomes and performance-based functional assessments in both study arms, with a slight superiority in the TKA arm. Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.0001). Bariatric surgery resulted in 45 and 36% delays in TKA at 12 and 24 months, respectively, due to improved knee status. CONCLUSION/CONCLUSIONS:Knee function and mobility improved significantly in both study arms, with superiority in the Knee Injury and Osteoarthritis Outcome and Western Ontario and McMaster Universities Osteoarthritis Index scores in the TKA group. Improved knee function with surgical weight loss can be associated with up to a two-year delay in the need for TKA.

Young adults with hip pathology present a therapeutic challenge requiring careful consideration of treatment options that will affect decades of future function. Historically, the orthopedic community has maintained a strong preservation bias, often pursuing multiple preservation attempts before considering arthroplasty because of concerns about implant longevity. This narrative review critically examines current evidence regarding hip preservation surgery and total hip arthroplasty in young adults to inform evidence-based decision making. The literature reveals that successful hip preservation requires a narrow therapeutic window defined by preserved articular cartilage, accurate structural diagnosis, and appropriate patient selection. Clinical and imaging predictors, including joint space narrowing below 2 mm, Tönnis grade 2 or higher osteoarthritis, bipolar chondral damage, and mechanical symptoms, reliably identify patients unlikely to benefit from preservation. Concurrently, advances in bearing surfaces-particularly highly cross-linked polyethylene and ceramics-have dramatically improved arthroplasty outcomes, with contemporary data demonstrating 10-year survivorship exceeding 90% in patients younger than 55 years. Modern total hip arthroplasty delivers consistent pain relief and functional improvement that often exceeds preservation outcomes in appropriately indicated patients. This review proposes a decision-making framework emphasizing that treatment selection should be guided by objective disease characteristics rather than age-based algorithms, optimizing long-term outcomes while minimizing unnecessary morbidity.

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.

INTRODUCTION/BACKGROUND:Use of the direct anterior approach (DAA) in total hip arthroplasty (THA) has increased, with suggested benefits of faster recovery and less pain. However, consensus regarding the optimal approach is lacking. This study compared post-operative pain, functional recovery, and opioid use between DAA and posterior approach (PA) THA. METHODS:-tests. RESULTS: 0.001), but these small differences do not reflect clinical significance. MME comparison showed a trend towards decreased opioid consumption within the DAA cohort, but the clinical relevance of these differences is unknown. CONCLUSIONS:Pain, function, and opioid use were largely comparable between DAA and PA, with minor statistical differences unlikely to be clinically meaningful.