Faculty Bibliography

Bone loss often complicates revision total knee arthroplasty (TKA). Management of metaphyseal defects varies, with no clearly superior technique. Two commonly utilized options for metaphyseal defect management include porous-coated metaphyseal sleeves and tantalum cones. A systematic review was conducted according to the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We combined search terms "Total knee arthroplasty" AND/OR "Sleeve," "Cone" as either keywords or medical subject heading (MeSH) terms in multiple databases according to PRISMA recommendations. All retrieved articles were reviewed and assessed using defined inclusion and exclusion criteria. A total of 27 studies (12 sleeves and 15 cones) of revision TKAs were included. In the 12 studies on sleeve implantation in revision TKAs, 1,617 sleeves were implanted in 1,133 revision TKAs in 1,025 patients. The overall rate of reoperation was 110/1,133 (9.7%) and the total rate of aseptic loosening per sleeve was 13/1,617 (0.8%). In the 15 studies on tantalum cone implantation in revision TKAs, 701 cones were implanted into 620 revision TKAs in 612 patients. The overall rate of reoperation was 116/620 (18.7%), and the overall rate of aseptic loosening per cone was 12/701 (1.7%). Rates of aseptic loosening of the two implants were found to be similar, while the rate of reoperation was nearly double in revision TKAs utilizing tantalum cones. Variability in the selected studies and the likely multifactorial nature of failure do not allow for any definitive conclusions to be made. This review elucidates the necessity for additional literature examining revision TKA implants.

Cementless fixation in total knee arthroplasty (TKA) offers the potential for biologically active osseointegration and the potential for life-long fixation. With early cementless TKA designs, several design issues were identified related to early failure, particularly with the tibial and patellar components. However, in the recent two decades, with improvements upon the early designs, particularly in porous metal technology as well as improved early biomechanical stability, interest was re-established in cementless TKA. The surgical technique for cementless TKA is more exacting than cemented technique, with an important emphasis on indications, accurate resections, and component alignment. Modern cementless TKA designs have demonstrated excellent early- and mid-term survivorship equivalent to cemented TKA. More long-term studies are needed to study this comparison. While implant cost maybe higher with cementless designs, there is emerging evidence that there may be an overall cost saving with the use of cementless components given the shorter operative time and the savings in the cost of supplies associated with the use of cement. As the population undergoing TKA is becoming younger and more active, interest in the use of cementless implants will likely increase.

Osteoarthritis of the hip and knee is known to affect sexual activity. For patients with osteoarthritis, pain during sexual activity can lead to decreased quality of life and other associated health issues. The authors designed a prospective study to evaluate the effect of total hip arthroplasty and total knee arthroplasty on the psychosocial and physical aspects of sexuality pre- and postoperatively. Between April 2009 and December 2011, patients received questionnaires in the mail preoperatively. They were asked to return the pre-operative questionnaire before surgery and the postoperative questionnaire 6 months after surgery. Data were analyzed to evaluate the psychosocial and physical aspects of sexuality and participants' subjective assessment of their appearance. Preoperatively, 91% and 67% of patients reported psychosocial and physical issues, respectively. After the arthroplasty procedure, 84% (P<.001) and 47% (P<.001) of patients reported improvement psychosocially and physically, respectively. Of the patients, 16% reported that arthroplasty adversely affected sexual function, with their predominant fear being joint damage (63%). A greater number of women and patients undergoing hip procedures reported improvement in sexual activity after surgery compared with men (P=.02) and patients undergoing knee procedures (P=.002). Both hip and knee osteoarthritis and arthroplasty had a significant effect on overall sexual function-psychosocially, physically, and in terms of patients' assessment of their external appearance-with higher rates of improvement seen after hip arthroplasty. Because of the effect of osteoarthritis and arthroplasty on sexual function, this topic should be addressed both pre- and postoperatively. [Orthopedics. 2021;44(x):xx-xx.].

PURPOSE/OBJECTIVE:There has been an increase in the use of unlinked constrained condylar knee (CCK) prostheses in primary total knee arthroplasty (TKA) for cases with significant deformities that cannot be adequately balanced in flexion and extension. However, the literature on its outcomes is limited. The goal of this study is to evaluate whether there are any clinic or radiographic outcome differences for a primary, non-stemmed, unlinked constrained TKA as compared to a control group of posterior-stabilized (PS) TKA using the same implant design. METHODS:Clinical and radiographic outcome measures for 404 cemented, non-stemmed, primary TKAs performed by two surgeons at the same institution were retrospectively reviewed. All patients underwent primary, non-stemmed components; 241 used CCK inserts and 163 used PS inserts. Preoperative deformity, knee society scores (KSS), range-of-motion (ROM), radiographic data and revision rates were compared between the CCK and PS groups. RESULTS:Both groups had comparable demographics and preoperative ROM and KSS. At similar mean follow-up times (6.1 ± 1.0 years for the CCK group and 6.3 ± 1.2 years for the PS group), no significant difference was found in ROM, KSS or radiographic outcomes. Revision rates were higher for the CCK group (2%) as compared to the HF-PS (0.6%) group (n.s). CONCLUSIONS:The particular design of cemented, primary, non-stemmed, unlinked CCK-TKA examined in this study provided similar clinical and radiographic outcomes to that of PS-TKA at midterm follow-up. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:The ideal femoral component in revision total hip arthroplasty (rTHA) remains undetermined; however, tapered, fluted, titanium (TFT) stems are now widely used with favorable results in all types of revision scenarios. With both modular and monoblock TFT stem options, neither has been proven to be superior. Femoral stem subsidence has been linked to aseptic loosening, instability, and leg length discrepancy. This study aims to assess stem subsidence of modular and monoblock TFT stems at a single urban orthopedic specialty hospital within a tertiary academic medical center. METHODS:Electronic medical records of rTHAs performed between January 2013 and March 2018 utilizing modular and monoblock TFT stems were examined. Data collected included baseline demographics, surgical indication, femoral Paprosky classification, and stem subsidence at most recent follow up (3 months to 3 years). Two-sample t-tests and chi-squared tests were used for statistical analysis. RESULTS:A total of 186 patients (106 modular, 80 monoblock) were included in the analysis. Modular stems underwent significantly greater subsidence than monoblock stems at latest radiographic follow-up (3.9 ± 2.6 vs 2.3 ± 2.5 mm, P < .001). A significantly greater proportion of modular stems underwent >5 mm of subsidence at latest follow-up (29.2% vs 11.3%, P < .001). CONCLUSION/CONCLUSIONS:Monoblock TFT stems have displayed promising clinical results in prior studies, and now have been shown to decrease the incidence of postoperative subsidence. With the potential for stem subsidence to lead to aseptic loosening, limb length discrepancy, and instability, the orthopedic surgeon should weigh the risks and benefits of utilizing modular vs monoblock TFT stems in rTHA.

INTRODUCTION/UNASSIGNED:Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component. METHODS/UNASSIGNED:We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries. RESULTS/UNASSIGNED: 0.03) and FNS was inversely associated with postoperative HOOS scores. CONCLUSIONS/UNASSIGNED:Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

Introduction/UNASSIGNED:The epidemiology of re-revision total hip arthroplasty (THA) is not yet well-understood. We aim to investigate the epidemiology and risk-factors that are associated with re-revision THA. Methods/UNASSIGNED:288 revision THA were analyzed between 1/2012 and 12/2013. Patients who underwent two or greater revision THA were included. Hips with first-revision due to periprosthetic joint infection (PJI) were excluded. Failure was defined as reoperation. Results/UNASSIGNED:51 re-revision patients were available. Mean age was 59.6 (±14.2 years), 32 (67%) females, average BMI of 28.8 (±5.4), and median ASA 2 (23; 55%). The most common re-revision indications were acetabular component loosening (15; 29%), PJI (13; 25%) and instability (9; 18%). The most common indications for first revision in the re-revision population were acetabular component loosening (11; 27%), polyethylene wear (8; 19%) and instability (8; 19%). There was an increased risk of re-revision failure if the re-revision involved exchanging only the head and polyethylene liner (RR = 1.792; p = 0.017), instability was the first-revision indication (RR = 3.000; p < 0.001), and instability was the re-revision indication (RR = 1.867; p = 0.038). If isolated femoral component revision was indicated during the re-revision, there was a decreased risk of failure (RR = 0.268, p = 0.046). 1-year re-revision survival was 54% (23/43). Discussion/UNASSIGNED:Acetabular component loosening, instability, and PJI were the most common indications for re-revision. Revision due to instability is a recurrent problem that leads to re-revision failure. There was a higher infection rate in the re-revision population compared to published revision PJI. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population.

BACKGROUND:Nonmodular and modular femoral stems have been associated with complications after revision total hip arthroplasty (rTHA). As such, the ideal femoral component for rTHA remains undecided. This study aims to report outcomes of titanium, tapered-fluted, modular and nonmodular femoral components in rTHA. METHODS:From January 1, 2013 to September 30, 2017, all rTHAs using modular or nonmodular femoral stems were identified. Demographic data including age, gender, and American Society of Anesthesiologists scores were collected. Surgical details including operative time and implant cost were also collected. Clinical outcomes including length of stay, dislocation, infection, fracture, reoperation, and re-revision were collected. Statistical analysis was performed using chi-square test and Student's t-test for all categorical and continuous variables, respectively. RESULTS:One hundred forty-six rTHA cases (103 modular and 43 nonmodular) were identified with an average follow-up of 29 months (range 3-59 months). Nonmodular stems had a significantly lower cost when compared to modular implants (modular stems 120.8% higher cost; P < .001). The surgical time of nonmodular components was significantly greater (193 minutes vs 163 minutes; P = .029). There were no differences observed in any other surgical details or clinical outcomes assessed, including length of stay (P = .323), rate of re-revision of the femoral implant (P = .389), rate of re-operation (P = .383), and postop complications (P = .241), including infection (P = .095), dislocation (P = .778), and fracture (P = .959). CONCLUSIONS:Nonmodular components provide encouraging clinical results with significantly lower costs compared to modular implants in rTHA. The use of titanium, tapered-fluted, nonmodular components may offer a more cost-effective approach to rTHA compared to their modular counterparts.

A comprehensive strategy is important for ensuring reproducible and safe acetabular component sizing and positioning. Presented here is our approach for anatomic acetabular component positioning in direct anterior total hip arthroplasty. This strategy has evolved with our understanding of the ramifications of socket sizing and positioning on instability and impingement. Data collected by a single surgeon (J.A.R.) between 2009 and 2011 influenced our current paradigm. We compare the sizing and positioning parameters of the anterior and posterior approach, thus demonstrating how the 2 are different. By highlighting these differences, we hope to provide a clear, defined approach to acetabular placement and sizing for direct anterior-approach total hip arthroplasty.