Faculty Bibliography

INTRODUCTION/BACKGROUND:A two-stage revision has long been the gold standard for chronic periprosthetic joint infections (PJI), with real-component articulating spacers becoming overwhelmingly popular. While several studies have evaluated the success of these spacers in revision total knee arthroplasty (rTKA), to our knowledge, this is the first to specifically compare outcomes of spacers stratified by the level of liner constraint. METHODS:This retrospective analysis reviewed 135 patients who were indicated for two-stage rTKA due to PJI between 2011 and 2023 at a single specialty urban academic institution. Patients were categorized into three groups based on the polyethylene liner constraint used during the first stage: cruciate retaining (CR), posterior stabilized (PS), and varus-valgus constrained (VVC). Of these 135 patients, 60 (44%) were categorized in the CR group, 47 (35%) were in the PS group, and 28 (21%) were in the VVC group. These groups were compared after each stage for peri- and postoperative outcomes such as operative time, length of stay (LOS), discharge disposition, knee range of motion (ROM), as well as incidence of re-revision and reinfection. RESULTS:The mean postoperative LOS was not different among cohorts for both stages. Operative time was significantly longer in the VVC group after the second stage (P = 0.007), while there was no difference after the first stage (P = 0.085). There were no differences in ROM after both stages. The mean ROM after the first stage was 92° in the CR group, 90° in the PS group, and 85° in the VVC group (P = 0.46). After the second stage, ROM was 101° in both the CR and VVC groups and 107° in the PS group (P = 0.28). There were no differences in the risk of re-revision due to re-infection across the groups after the first or second stage procedures. The re-infection incidence after the first stage was 14% in the VVC group, compared to 5% in the CR group and 4% in the PS group (P = 0.14). After the second stage, the reinfection risk was 21% in the VVC group, 8% in the CR group, and 13% in the PS group (P = 0.21). CONCLUSION/CONCLUSIONS:No significant differences were observed in the risk of complications such as re-infection, re-revisions, and postoperative ROM, suggesting that the choice of liner constraint in two-stage revision can be left up to surgeon's discretion.

Total hip arthroplasty (THA) is one of the most common and successful procedures for the treatment of end-stage hip arthritis. However, in certain complex scenarios, THA can present important and unique challenges, specifically following acetabular fractures in adolescent patients, following failed fixation of proximal femoral fractures, and in developmental dysplasia of the hip (DDH). As these cases involve distorted anatomy, poor bone quality, retained hardware, and previous surgeries, detailed planning, specialized instrumentation and implants, and novel surgical techniques are required. This narrative review examines the challenges, surgical considerations, outcomes, and complications in complex THA management.

BACKGROUND:Periprosthetic joint infection (PJI) is a high-cost and extremely morbid complication following total joint arthroplasty (TJA); thus, developing a better understanding of perioperative infection prevention strategies is prudent. Literature is mixed regarding the efficacy of vancomycin powder and dilute povidone-iodine lavage, and limited on the combination thereof. To our knowledge, no prospective orthopaedic clinical trials to date have evaluated the efficacy of local vancomycin powder, dilute povidone-iodine lavage, or a combination vancomycin-povidone-iodine-protocol (VPIP) against normal saline irrigation. METHODS:In a large, prospective, multi-center, randomized-controlled study, four distinct infection prevention strategies were implemented in high-risk TJA patients. Local vancomycin powder, dilute povidone-iodine solution, combined VPIP, and saline control were used. Primary outcomes included PJI, wound complications, revisions, emergency department (ED) visits, readmissions, and serious adverse events within three months of index surgery. Chi-square tests were used to compare incidence rates. The criteria used for the diagnosis of PJI were the International Consensus Meeting (ICM) guidelines. RESULTS:There were 821 total hip arthroplasty (THA) and 1,080 total knee arthroplasty (TKA) patients randomized into well-balanced study groups. In the THA and TKA cohorts, respectively, there were no statistically significant differences in rates of persistent wound drainage or dehiscence (P = 0.98, P = 0.95), cellulitis or abscess (P = 0.81, P = 0.51), 3-month infection rates (P = 0.14, P = 0.13), type of septic revisions performed (P = 0.51, P = 0.80), aseptic revision rates (P = 0.07, P = 0.90), ED visits (P = 0.61, P = 0.46), or readmissions (P = 0.78, P = 0.87) between the four treatment groups. CONCLUSIONS:There were no statistically significant differences in PJI or other surgical outcomes following THA or TKA among the study groups. Therefore, the use of such prophylactic measures, including povidone-iodine and vancomycin powder in high-risk patients, can be left up to the surgeon or hospital discretion.

INTRODUCTION/BACKGROUND:The subset of patients admitted to the intensive care unit (ICU) following total joint arthroplasty (TJA) has yet to be studied in detail. Specifically, there is little data on the effects of vasopressor administration in patients who require critical care after TJA. We sought to characterize patient outcomes and mortality by vasopressor administration in the ICU following primary TJA. METHODS:We retrospectively reviewed 187 patients who required admission to the ICU within 14 days following primary, unilateral TJA from 2012 to 2024, out of 47,083 patients who underwent TJA during this time (0.40%). Exclusion criteria included TJA for trauma, acute fracture, and revision or conversion TJA. Patients were classified by whether they received any vasopressor (i.e., norepinephrine, phenylephrine, or vasopressin) medication at any point during their ICU stay. Limited intraoperative use of vasopressor did not qualify. Demographic and surgical data were collected and compared. Primary outcomes included complications, revisions/reoperations. RESULTS:Of the 187 patients requiring ICU admission following primary TJA, 20 received vasopressors during their stay. No significant demographic differences were found between cohorts. Hypotension (26%) was the most common indication for ICU admission. Vasopressor use was not associated with a significant increase in 30-day or one-year mortality (5.0 vs. 0.6%, P=0.07; 5.0 vs. 1.2%, P=0.20, respectively), but was associated with a significant increase in revisions/reoperations 25.0 vs 6.0%, P=0.005). No significant differences were observed for 90-day VTE events (P=0.62). Dislocations were significantly more common in patients who received vasopressors (14.3 vs. 1.0%, P=0.047). CONCLUSION/CONCLUSIONS:Patients who received vasopressors in the ICU following TJA had significantly higher rates of revisions, reoperations, and dislocation. There were no differences in mortality rates or VTE rates between groups. Further investigation is required to better characterize outcomes following vasopressor requirement in the total joint arthroplasty population.

BACKGROUND:10 years after changing our institution's total hip arthroplasty (THA) preoperative antibiotic prophylactic protocol by adding gram-negative (GN) coverage, this study aimed to assess the impact of adding GN specific coverage (GNSC) prior to THA on periprosthetic joint infection (PJI) rates. METHODS:This was a retrospective case-control study of 14,598 patients who underwent primary, elective THA between July 2012 and January 2022, with minimum 1-year follow-up. All patients were under perioperative antibiotic protocol that included GNSC with either weight-based gentamicin or aztreonam (+GNSC) and were compared to a historical control group of patients for which the antibiotic prophylactic protocol did not include GNSC (-GNSC). PJI and nephrotoxicity rates, as well as the severity of nephrotoxicity according to the RIFLE criteria, were compared between the study populations and 4122 controls. RESULTS: = 0.567), which are the two more severe forms of nephrotoxicity, were comparable between the groups. CONCLUSIONS:The addition of gentamicin or aztreonam prior to THA reduces the incidence of GN-related PJIs. Increased nephrotoxicity rates were limited to the mildest form, usually associated with reversibility and favourable outcomes.

BACKGROUND:Corticosteroid injections following total hip arthroplasty (THA) are commonly utilized to address soft-tissue pathology such as bursitis and tendinitis. The THA surgical approaches differ in the extent of muscle and soft-tissue dissection. The aim of this study was to compare the impact of surgical approach on postoperative corticosteroid injection requirements when controlling for multiple covariates. A secondary aim was to identify risk factors associated with the various injection types. METHODS:This was a propensity-matched retrospective study of 10,907 THA patients from June 2016 to December 2022 at a single, urban, academic health center. Patients were stratified into cohorts based on surgical approach: anterior (n = 4,287) and posterior (n = 6,620), then propensity-matched 1:1 with nearest-neighbor matching to form two cohorts of 4,287 patients. Baseline characteristics and corticosteroid injection data for soft-tissue pathology were obtained and analyzed. Chi-square and multivariate logistic regression analyses were used to assess the impact of patient and surgical factors on receiving postoperative steroid injections. RESULTS:A posterior approach conferred increased risk of postoperative injections (aOR [adjusted odds ratio] 1.242, P = 0.001) after controlling for multiple covariates. The posterior approach also had higher total rates of greater trochanter (GT) bursitis injections postoperatively compared to the anterior group (11.5 versus 7.3%, P < 0.001). Both surgical approaches demonstrated comparable rates of iliopsoas bursitis injections (P = 0.39), gluteus medius tendinosis injections (P = 0.09), and lateral femoral cutaneous nerve injections (P = 0.27). The strongest predictor of postoperative injections was a history of preoperative injection (aOR 3.772, P < 0.001). CONCLUSION/CONCLUSIONS:Posterior approach, women, and history of preoperative corticosteroid injection were identified as the strongest risk factors for postoperative GT bursitis injection or postoperative soft-tissue injection. These factors should be considered when counseling patients on expected postoperative outcomes and the likelihood of corticosteroid injections following THA.

PURPOSE/OBJECTIVE:mapping technique for imaging of body parts containing metal hardware, based on magnitude images acquired with turbo spin echo (TSE) pulse sequences. THEORY AND METHODS/METHODS:values were validated against gradient-recalled and spin echo dual angle methods, as well as a vendor-provided TurboFLASH-based mapping sequence, in gel phantoms and human subjects without and with metal implants. RESULTS:shimming. CONCLUSION/CONCLUSIONS:values in regions near metal hardware, overcoming susceptibility-related and narrow-range limitations of standard mapping techniques.

INTRODUCTION/BACKGROUND:To our knowledge, outcomes of patients undergoing staged, bilateral total hip arthroplasty (THA) via dissimilar surgical approaches have not yet been investigated. This study examined demographics, implant selection, technology utilization, and component positioning between hips in patients who underwent one THA via posterior and one via direct anterior approach and secondarily evaluated patient-reported outcomes. METHODS:There were 36 patients (72 hips) who underwent staged, bilateral, primary, elective THAs via different approaches from January 2012 to December 2023. Patient demographics, intraoperative technology utilization, implants used, and pre- and postoperative Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR) scores were recorded. The hip center of rotation, acetabular height and anteversion, and metaphyseal canal fill were measured on postoperative radiographs. Femoral stem coronal and sagittal plane angulation following both approaches were also compared on postoperative radiographs. RESULTS:There were 15 (41.7%) patients who underwent posterior THA first. The mean time between operations was five years (range, 0.93 to 10.2). Intraoperative technology utilization was more common for the anterior THA (P = 0.002). There were no significant differences in hip center of rotation (P = 0.292), acetabular anteversion (P = 0.428), or acetabular height (P = 0.935) between patients' anterior and posterior approach THAs. The proportion of patients who had posterior stem angulation was significantly greater following anterior THA; neutral stem angulation was seen more frequently following posterior THA (P = 0.005). Lipped liners (P < 0.001), high offset femoral stems (P = 0.007), and dual or triple-taper stems (P < 0.001) were more commonly utilized in posterior THAs. For patients who had pre- and postoperative HOOS-JR for each hip, there was no significant difference in postoperative score improvement between anterior and posterior THAs (P = 0.697), with a mean follow-up time of 2.4 years (range, 0.3 to 9.28) for posterior and 6.1 years (range, 2.8 to 10.3) for anterior THAs (P = 0.249). CONCLUSIONS:Patients undergoing staged, bilateral THAs via different surgical approaches exhibit radiographic characteristics likely attributable to technical challenges for each approach. However, these differences related to approach do not seem to impact short-term clinical and patient-reported outcomes.

BACKGROUND:With the increased rates of revision total hip (rTHA) and total knee arthroplasty (rTKA), the financial burden of these procedures is at risk of straining the healthcare system. Our study sought to create a model to evaluate the cost-effectiveness of rTKA and rTHA performed by high-volume (HV) and low-volume (LV) surgeons. METHODS:percentile in annual volume were classified as HV surgeons and the remainder were classified as LV surgeons. Previously published cost estimates were utilised for operative time, hospital length of stay (LOS), discharge disposition, 90-day readmission, and 1-year re-revision. RESULTS: < 0.001). Both groups had equivalent discharge disposition, 90-day readmission, and 1-year re-revision. HV surgeons had lower estimated mean costs for rTHA ($22,027.81 vs. $24,617.39) and rTKA ($20,343.23 vs. $18,554.67). CONCLUSIONS:HV surgeons have a lower estimated mean cost for both rTHA and rTKA. Healthcare systems may benefit from having rTHA and rTKA procedures performed by HV surgeons who are able to perform these revision procedures for a lower cost without negatively impacting patient outcomes.

INTRODUCTION/BACKGROUND:Technology is increasingly incorporated into unicompartmental knee arthroplasty (UKA) through computer-assisted navigation (N-UKA) and robot-assisted surgery (R-UKA) to improve alignment, implant positioning, and gap balancing. Whether intraoperative technology helps achieve the minimal clinically important difference (MCID) in patient-reported outcomes (PROMs) compared to conventional UKA (C-UKA) remains unclear. This systematic review aimed to assess whether differences in PROMs between C-UKA and technology-assisted UKA reached MCID values. MATERIALS AND METHODS/METHODS:PubMed/MEDLINE/Cochrane Library were reviewed for studies comparing PROMs between primary C-UKA (control group) and N-UKA or R-UKA. Delta improvements were compared to established MCID values. Additional radiographic and clinical differences were assessed. The review yielded four (N=328) N-UKA and seven (N=526) R-UKA studies with C-UKA cohorts as controls. RESULTS:Differences in preoperative and postoperative PROMs were reported as statistically significant in three of four studies (75%) comparing N-UKA and C-UKA; however, none of the studies reported values that reached the MCID. Differences in preoperative and postoperative PROMs were reported as statistically significant in four of seven studies (57.1%) comparing R-UKA and C-UKA; however, only three of the studies (42.9%) reported values that reached the MCID. Improved radiographic outcomes for N-UKA and R-UKA were reported in 75% and 57.1% of studies, respectively. Only one study reported improved revision rates with R-UKA compared to C-UKA. CONCLUSION/CONCLUSIONS:Though studies may report better improvements in PROMs in N-UKA and R-UKA compared to C-UKA, these often may not achieve clinical significance. Future studies should present outcome differences in the context of validated MCID as well as other metrics such as revision rates and radiographic outliers as the impetus for technology-assisted UKA.