Faculty Bibliography

BACKGROUND/UNASSIGNED:Periprosthetic joint infections (PJIs) following primary and revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) have been studied, but a contemporary large-scale analysis of incidence has not been performed. This study assessed PJI incidence and trends for TKA, THA, rTKA, and rTHA using a contemporary database. METHODS/UNASSIGNED:Epic Cosmos database was retrospectively queried (2015-2023). Current procedureal terminology codes identified patients: 27447 (TKA), 27130 (THA), 27486 (rTKA one component), 27487 (rTKA both components), 27134 (rTHA both components), 27137 (rTHA acetabular component), and 27138 (rTHA femoral component). PJI rates were identified using International Classification of Diseases 9/10 codes and analyzed using linear regression. RESULTS/UNASSIGNED:= .08). CONCLUSIONS/UNASSIGNED:Significant PJI reduction after primary TKA and THA was observed over the last decade, but infection rates remained stable in revision cohorts. Further investigations are required to assess underlying reasons for observed PJI rate reductions following primary arthroplasty.

BACKGROUND:Management of severe acetabular bone loss during revision total hip arthroplasty (rTHA) remains challenging. Cup-cage constructs and custom triflange acetabular components are commonly used, but comparative outcomes remain poorly defined. METHODS:This meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were four electronic databases searched for studies published from 2015 to 2025 that reported outcomes of cup-cage or custom triflange reconstruction in patients who had Paprosky 2 to 3B acetabular defects. Indications for cup-cage and triflange constructs were recorded. Re-revision, periprosthetic joint infection (PJI), instability, and aseptic loosening were pooled using fixed- and random-effects models. Meta-regression was performed to adjust for acetabular defect severity. RESULTS:There were 18 studies comprising 808 revision THAs (293 cup-cage and 515 custom triflange) included. Across both reconstruction strategies, the most common indications were aseptic loosening and conversion after periprosthetic joint infection. The weighted mean follow-up was 5.8 years for cup-cage and 6.2 years for triflange reconstructions (P = 0.071). The cup-cage cohort had a higher proportion of Paprosky 3B defects than the triflange cohort (79.2 versus 71.8%, P < 0.001). After adjustment for acetabular defect severity, no differences in re-revision rates were observed between cup-cage and triflange constructs. Likewise, there were no differences in PJI, instability, or aseptic loosening between groups. CONCLUSIONS:Among patients undergoing rTHA with cup-cage or custom triflange reconstruction for Paprosky 2 to 3B defects, outcomes were equivalent across major failure modes after adjustment for bone loss severity. Neither construct demonstrated superior survivorship; therefore, implant selection should be individualized according to defect pattern, available resources, surgical goals, and surgeon preference rather than an expectation of differential clinical performance.

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.

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.

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.

BACKGROUND:Robotic and navigation-assisted total knee arthroplasty (TKA) systems aim to optimize surgical performance; however, their influence on the speed of functional recovery remains unclear. This study compared the time to achieve a minimal clinically important difference (MCID) among patients undergoing robotic-assisted (RA), navigation-assisted (NA), and conventional TKA using Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) questionnaires. METHODS:This retrospective cohort study included patients undergoing primary TKA for osteoarthritis at a tertiary academic center from July 2017 to July 2024. Inclusion required preoperative and postoperative KOOS-JR scores within 12 months of surgery. Exclusion criteria were non-osteoarthritis indications, bilateral procedures, or revision within one year. The MCID was defined using both anchor-based and distribution-based methods. The time to MCID was analyzed using multivariable interval-censored accelerated failure time models, accounting for clinical and demographic variables and the operating surgeon. A total of 2,002 patients met the inclusion criteria: 433 (21.6%) underwent RA-TKA, 713 (35.6%) NA-TKA, and 856 (42.8%) conventional TKA. RESULTS:Both technology-assisted approaches were associated with faster MCID achievement compared to conventional TKA. Using distribution-based thresholds, NA-TKA achieved MCID 29% faster (time ratio [TR] = 0.71, 95% confidence interval (CI): 0.58 to 0.88, P = 0.002) and RA-TKA 26% faster (TR = 0.74, 95% CI: 0.57 to 0.95, P = 0.018), with covariate-standardized estimated median times of 19.9, 20.7, and 28.0 days, respectively. Using anchor-based thresholds, NA-TKA achieved MCID 27% faster (TR = 0.73, 95% CI: 0.57 to 0.95, P = 0.017) and RA-TKA 26% faster (TR = 0.74, 95% CI: 0.55 to 1.00, P = 0.050), with corresponding median times of 52.8, 53.5, and 71.9 days. The one-year MCID attainment rates were similar across all techniques (P > 0.6 for both definitions). CONCLUSIONS:Both RA-TKA and NA-TKA were associated with 26 to 29% faster achievement of clinically meaningful improvement compared with conventional TKA, corresponding to approximately seven to 19 fewer days to reach MCID, despite similar one-year attainment rates. Prospective multicenter studies are needed to validate these results and determine whether accelerated recovery translates to advantages in quality of life, healthcare utilization, and patient satisfaction.

INTRODUCTION/BACKGROUND:An extended trochanteric osteotomy (ETO) is used in complex cases to enhance access to the femoral canal and aid implant and cement removal during revision total hip arthroplasty (RTHA). However, there is no consensus regarding postoperative rehabilitation protocols. The aim of this study was to assess the efficacy and safety of immediate weight-bearing (WB) protocols in patients undergoing ETO during RTHA. METHODS:A multicenter retrospective review was conducted at two academic medical centers between 2014 and 2021 to identify patients undergoing an ETO during RTHA with a minimum 1-year follow-up. Thirty-nine patients underwent an immediate WB protocol postoperatively. Union rates, ambulatory status, 90-day orthopaedic-related complications, revision surgeries, revisions, and Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) scores were collected. RESULTS:Fifty-three patients were included in the final analysis. The average follow-up time was 15.8 ± 20.4 months, with a mean age of 63.7 ± 11.5 years. Bony union was achieved in 46 patients (86.8%). The mean earliest time to union was 4.2 ± 5.4 months. Average HOOS JR scores significantly improved from preoperative to 1-year follow-up (mean 16.4 ± 4.1 vs 3.5 ± 4.2), P ≤ 0.000001). At the final follow-up, ambulatory status improved, with fewer patients kept as non-weight bearing (11 (21.6%) versus 7 (15.2%)). Two complications (3.8%) due to deep infection, 5 revision surgeries (9.4%), and 6 revisions (11.0%) were observed within 90 days. CONCLUSION/CONCLUSIONS:Most patients who underwent ETO during RTHA and were placed on an immediate WB protocol achieved union at 4.2 months on average. HOOS JR scores improved as early as 2 weeks. More importantly, a greater proportion of patients experienced an improved ambulatory status at the final follow-up. These findings suggest that an immediate WB protocol-particularly WBAT-may be effective and safely implemented in patients undergoing an ETO during RTHA. LEVEL OF EVIDENCE/METHODS:Level III retrospective cohort comparison study.

BACKGROUND:The impact of body mass index (BMI) on outcomes after total knee arthroplasty (TKA) is a highly debated topic. Our study aims to investigate the implications of BMI changes from the day of surgical booking to the surgery date on perioperative and postoperative outcomes. METHODS:We retrospectively reviewed patients who underwent elective, primary, unilateral TKA at an urban academic institution from 2015-2024 with a minimum 90-day follow-up. The cohort was classified into three groups by percent BMI change from surgical booking date to TKA date: Group 1, decrease in BMI; Group 2, 0-5% increase in BMI; and Group 3, > 5% increase in BMI. Propensity-score matching (1:1:1) based on age, gender, BMI at surgical booking, and smoking status was performed; perioperative and postoperative outcomes were compared. Multivariate regression analysis evaluated risk factors for interval change in BMI. RESULTS:Before matching, 12,990 patients were included, with 39.6% in Group 1, 41.2% in Group 2, and the remaining 19.2% in Group 3. Notably, Group 3 had the longest length of stay (50.3 h vs. 48.6 [1] & 47.1 [2]; P = 0.002) and the lowest discharge-to-home rates (88.7% vs. 89.8% [1] & 91.7% [2]; P = 0.014). No significant difference was seen in 90-day ED visits, 90-day readmissions, or revision rates. Logistic regression of the pre-match cohort found that prolonged surgical booking delays were associated with decreased all-cause revisions (OR = 0.98; P = 0.038), while percent BMI change in this period did not impact revision incidence. Duration of surgical booking delay had no impact on BMI changes in obese patients. CONCLUSION/CONCLUSIONS:Our study evaluated preoperative BMI change between surgical booking and TKA, finding that most patients (60.4%) gain weight during this time. While patients with significant BMI increases (> 5%) had longer hospital stays and lower discharge-to-home rates, Percent BMI change during this period did not impact all-cause or septic revision incidence.

The use of technology in adult reconstruction (AR) reflects a balance of perceived utility, workflow considerations, and training exposure. This study evaluated whether exposure to technology during residency and fellowship training influences early-career AR surgeons’ utilization of and attitudes towards technology in total joint arthroplasty (TJA). An online survey was distributed to a nationwide cohort of 51 AR surgeons who completed fellowship between 2011 and 2022 at 13 U.S. programs. Survey items assessed exposure to technology during training, utilization, and perceived impact of technology on clinical practice. 36 surgeons (71%) reported using technology in fewer than half their training cases (< 50% group), while 15 (29%) reported use in the majority of cases (> 50% group). Most surgeons (88%) reported access to technology in their current practice, with no statistically significant difference between training exposure groups (p = 0.999). Similarly, among those with access, most surgeons (78%) reported using technology in their current practice, with no statistically significant difference between training groups (p = 0.238). However, surgeons with greater exposure rated the importance of technology in TJA and its impact on patient outcomes significantly higher (p = 0.003 for both). Greater exposure to technology during training was thus associated with higher perceived value, though no significant differences in access or utilization in early practice were observed.