Faculty Bibliography

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.

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: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.

BACKGROUND:Postoperative improvement in patient-reported outcomes is a key measure of total hip arthroplasty success. The Minimum Clinically Important Difference (MCID) represents the smallest improvement perceived as beneficial. Distribution-based MCIDs have been criticized for producing thresholds smaller than anchor-based values, questioning their clinical relevance. We hypothesized they may capture early biological recovery signals associated with subsequent patient-reported outcomes and aimed to determine whether failure to achieve an early distribution-based MCID (seven to 31 days) was associated with failure to achieve a late anchor-based MCID (90 to 365 days). METHODS:This retrospective cohort study included patients undergoing primary unilateral total hip arthroplasty for osteoarthritis from January 1, 2021, to January 1, 2025, comprising 844 patients. Patients were included if they completed 'Hip disability and Osteoarthritis Outcome Score, Joint Replacement' questionnaires preoperatively, at seven to 31 days, and at 90 to 365 days. Distribution-based MCID was defined as a ≥ 7.8-point improvement, and anchor-based MCID as ≥ 23 points. Multivariable regression assessed associations between early distribution-based and late anchor-based MCID failure, adjusting for demographics and clinical factors. RESULTS:In the early period (seven to 31 days), 565 patients (67.0%) achieved the distribution-based MCID, whereas 573 (67.9%) achieved the late anchor-based MCID (90 to 365 days). Among patients who failed to attain an early distribution-based MCID, 54.1% (151 of 279) also failed the late anchor-based MCID, compared with 21.2% (120 of 565) among early achievers (P < 0.001). Early distribution-based MCID failure was a strong independent predictor of late anchor-based MCID failure (odds ratio: 2.61; 95% confidence interval: 1.85 to 3.68; P < 0.001). Higher baseline Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores and facility-based discharge were also independently associated with late failure (P < 0.05). CONCLUSIONS:Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year. Early distribution-based MCID attainment may represent an important prognostic marker, enabling timely clinical intervention.

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.

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: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.

BACKGROUND:The impact of postoperative antithrombotic therapy (ATT) on complications such as periprosthetic joint infection (PJI) after total knee and hip arthroplasty (TKA and THA, respectively) remains understudied. We aimed to evaluate temporal trends in ATT use and the association between ATT type and PJI following primary TKA and THA. METHODS:We retrospectively reviewed 20,376 TKA and 16,076 THA patients receiving postoperative ATT between 2013 and 2025. Trends in ATT use were analyzed for all patients, but PJI incidence (2018 International Consensus Meeting definition) was assessed only in patients who had a minimum 90-day follow-up (14,663 TKA; 11,445 THA). Of these, 0.8% and 1.3% developed a PJI, respectively. Multivariate logistic regressions adjusted for age, sex, body mass index, smoking, and the Charlson Comorbidity Index were applied to assess the association between ATT and PJI. RESULTS:From 2013 to 2025, aspirin monotherapy increased to account for the majority of prophylaxis (TKA: 2.0 to 59.4%; THA: 3.1 to 82.2%). In contrast, the use of low-molecular-weight heparin (LMWH) declined (TKA: 87.6 to 0.8%; THA: 86.7 to 2.3%), as did warfarin (TKA: 4.1 to 0.3%; THA: 3.4 to 0.9%) and rivaroxaban (TKA: 6.8 to 4.2%; THA: 8.9 to 2.8%). During the same period, apixaban use increased (TKA: 0 to 10.0%; THA: 0 to 12.7%). Aspirin monotherapy was associated with lower odds of PJI compared to non-aspirin regimens (adjusted odds ratio [OR] 0.60, 95% confidence interval [CI] 0.45 to 0.81, P = 0.001). Conversely, warfarin (OR 8.01, 95% CI 3.41 to 18.88, P < 0.001) and LMWH (OR 1.89, 95% CI 1.35 to 2.64, P < 0.001) were independently associated with increased PJI risk in THA. CONCLUSION/CONCLUSIONS:Aspirin has become the dominant postoperative ATT agent. In THA, aspirin is associated with a significantly decreased risk of PJI compared to potent anticoagulants like warfarin and LMWH, while no such association was found in the TKA cohort. Surgeons should prioritize aspirin to minimize postoperative infection risk.

BACKGROUND:Weight management strategies before total hip arthroplasty (THA) include bariatric surgery and Glucagon-like peptide-1 receptor agonists, including semaglutide. Previous studies have reported higher THA implant failure in patients who had prior bariatric surgery. This study aimed to evaluate semaglutide as a weight management alternative for patients undergoing THA and any effects on perioperative outcomes. METHODS:A retrospective review of primary, elective THAs performed between 2012 and 2024 was conducted at a single, urban, academic center. The study identified 224 patients who had a history of bariatric surgery, 202 patients who had perioperative semaglutide use, and a control group of 2,991 patients who had a body mass index (BMI) > 35. Demographic variables and clinical outcomes were compared between cohorts. RESULTS:The bariatric patients were younger (57 versus 61, P = 0.012) and more often women (65.6 versus 57.4 versus 55.4%, P < 0.001) than semaglutide and control patients. Preoperative hemoglobin A1c was lowest in semaglutide patients (6.2 versus 5.7 versus 5.8%, P < 0.001). The changes in BMI varied across groups one year before and after THA (P < 0.001). The bariatric and semaglutide groups decreased their BMI by 1.4 and 0.8, respectively, and control patients increased by 0.4. Implant survivorship was 95.5% at 10 years. There was no correlation found between any cohort and 90-day emergency department visits, readmissions, and all-time revision. Higher American Society of Anesthesiologists class and Charlson Comorbidity Index ≥ 5 conferred increased complications. CONCLUSIONS:Semaglutide appears to be a safe alternative to bariatric surgery for weight management before THA, with similar implant survival and postoperative complication rates. Further studies are warranted to understand outcomes for THA patients who use semaglutide.