Faculty Bibliography

BACKGROUND:Traveling fellowships, such as the Hip Society Rothman-Ranawat fellowship, offer orthopaedic surgeons the opportunity to enhance their skills, conduct research, and gain mentorship at top orthopaedic centers. This study aimed to assess the impact of the Hip Society Rothman-Ranawat traveling fellowship on an adult reconstruction surgeon's career. METHODS:A non-incentivized online survey was distributed to the 40 past recipients of the Hip Society Rothman-Ranawat traveling fellowship spanning from 2013 to 2023. The survey comprised short-answer questions and multiple-choice questions to evaluate the impact of the traveling fellowship. Surgeon publication counts and h-indexes were extracted from the Scopus database before the fellowship and at intervals of three years, five years, and the present post fellowship. Quantitative metrics were adjusted based on the time elapsed since the surgeon completed the fellowship and compared using paired-sample t-tests. RESULTS:This study had a 95% response rate (n = 38). Following the completion of the fellowship, we observed an increase in publication count and h-index at various intervals compared to the time before the fellowship. The mean annual percentage increase in publication count was 25.6% at the 3-year mark, 37.6% at the 5-year mark, and 29.4% at the present time, all relative to the publication count before the fellowship. Similarly, the mean annual percentage increase in the h-index was 9.7% at the 3-year mark, 9.6% at the 5-year mark, and 4.1% at the present time, all compared to the h-index before the fellowship. Qualitative measures showed previous fellows endorsed that the fellowship positively changed their clinical practice (84% agreement), expanded their network (97% agreement), increased research productivity (82% agreement), and improved surgical technique (74% agreement). CONCLUSION/CONCLUSIONS:Responses from past Hip Society Rothman-Ranawat traveling fellows suggest that participating in the fellowship positively influenced their career trajectories.

BACKGROUND:Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase fluid retention and the risk of heart failure (HF). Type 2 diabetes mellitus (T2DM) is known to increase the risk of cardiac disease, including HF. As part of a modern multimodal pain protocol, NSAIDs are commonly used in total knee arthroplasty (TKA), but the risk of NSAID use in TKA for T2DM patients is not well understood. The purpose of this study was to compare rates of new-onset HF following TKA in Type 2 diabetics with varying NSAID use. METHODS:We reviewed 3,906 patients who underwent primary TKA from 2015 to 2023 at a single academic institution. Data collected included demographics, preoperative diagnosis of T2DM, postoperative development of new-onset HF, NSAIDs taken perioperatively, and aspirin use for deep vein thrombosis (DVT) prophylaxis. Propensity matching was conducted to control for age, American Society of Anesthesiologists (ASA) Score, and aspirin use. Rates of postoperative HF within T2DM patients who took meloxicam versus celecoxib were compared using Chi-square analyses. RESULTS:Among patients who took meloxicam or celecoxib perioperatively, a preoperative diagnosis of T2DM was disproportionately associated with postoperative HF (P = 0.006). When comparing peri-TKA use of meloxicam versus celecoxib in T2DM patients, the use of celecoxib was disproportionately associated with the development of postoperative HF (2.2% [meloxicam], 4.8% [celecoxib], P = 0.002). CONCLUSIONS:We found patients who had T2DM developed postoperative HF at higher rates compared to non-diabetics following peri-TKA NSAID use and that T2DM patients developed new-onset HF at higher rates when utilizing celecoxib than meloxicam in the peri-TKA period. Along with the many other factors that contribute to an orthopaedic surgeon's decision on which NSAID to use postoperatively, we advocate for consideration of the risk of new-onset HF in T2DM patients when prescribing meloxicam and celecoxib in the post-TKA period.

BACKGROUND:The cementation technique is crucial for achieving adequate fixation and optimal survivorship in total knee arthroplasty (TKA). The thickness of the cement at the tibial bone-implant surface may be related to aseptic tibial loosening. However, to date, no studies have demonstrated a direct association between cement thickness and rates of aseptic tibial loosening. METHODS:We performed a retrospective review to identify 28,327 primary cemented TKAs with at least 2 years of follow-up at an academic health system from 2013 to 2021. A total of 115 cases underwent revision surgery for aseptic tibial loosening. Cases where the implant was recalled specifically for loosening (n = 23) were excluded. The remaining 92 aseptic tibial loosening cases were 2:1 propensity score matched and implant matched to control patients who did not have tibial loosening. There were two independent reviewers who then measured the thickness of the cement interface in 10 locations along the bone-implant interface from initial postoperative radiographs. The averages of the reviewers' measurements were calculated and then compared using independent t-tests. RESULTS:Aseptic tibial loosening cases involving implant A tibial baseplate (n = 75) had significantly thinner cement interfaces than matched controls at all the 10 locations measured. Aseptic loosening cases involving implant B (n = 17) also displayed a thinner cement interface than matched controls in all locations, but this result was only statistically significant at the medial baseplate, medial keel, lateral keel, anterior keel, and posterior baseplate. CONCLUSIONS:In two widely used TKA systems, tibial aseptic loosening was associated with significantly thinner cement interfaces when compared to propensity-matched controls in two different implant types. Further prospective studies are needed to identify the optimal keel preparation and design as well as minimal cement interface thickness to avoid implant loosening. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:A tourniquet is commonly used during total knee arthroplasty (TKA) to improve surgical field visibility and minimize blood loss. While the short-term effects of tourniquet use on postoperative outcomes have been studied extensively and found to be minimal, its influence on longer-term outcomes remains underexplored. This study examined tourniquet use in TKA with up to five-year follow-up. METHODS:In this post hoc analysis of a randomized controlled trial, 227 patients who underwent primary TKA in the tourniquet (T) group (n = 112) or no tourniquet (NT) group (n = 115) were evaluated. Clinical outcomes and patient-reported outcome measures (PROMs) were compared between the two groups. RESULTS:The T group had non-significant trends toward reduced blood loss (131.8 versus 116.7 ml, P = 0.098) and shorter operative time (97.8 versus 95.7 minutes, P = 0.264), with slightly higher postoperative day-one Visual Analog Scale (VAS) pain scores (3.1 versus 3.6, P = 0.197). Length of stay (2.0 versus 2.1 days, P = 0.837) and home discharge rate (88.7 versus 92.0%, P = 0.340) were comparable. The NT group had three 90-day readmissions, while none occurred in the T group (2.7 versus 0%, P = 0.081). The active range of motion at the final follow-up was similar between groups (108.3 versus 106.5 degrees, P = 0.457). All-cause revision rates at five years were comparable between the NT and T groups (5.2 versus 3.6%, P = 0.546). Kaplan-Meier survivorship analysis revealed comparable aseptic implant survival at five years (P = 0.769). There were no significant differences in Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, PROMIS pain interference, or PROMIS physical health scores at three months, one year, and five years postoperatively. CONCLUSION/CONCLUSIONS:Using a tourniquet during primary TKA was not associated with differences in clinical or patient-reported outcomes at up to five-year follow-up. These findings suggest that tourniquet use in TKA can be left to the surgeon's discretion.

BACKGROUND:The relationship between total hip arthroplasty (THA) surgeon volume and outcomes is informative in this era of health care value optimisation. The purpose of this study was to evaluate outcomes based on modern-day surgeon practice volumes. METHODS:The SPARCS database was queried for patients undergoing primary THA from 2010 to 2020. Annual case volume thresholds were 30 and 150, differentiating high-volume (HV), intermediate-volume (IV), and low-volume (LV) groups. Perioperative outcomes and all-cause cumulative revision rates were evaluated. RESULTS: 0.001). While controlling for confounders, multivariate regression revealed increased odds of PJI for IV (1.5) and LV (1.87) and increased all-cause revision hazard ratio for IV (1.1) and LV (1.3). Cumulative revision rates were lower for HV at 1 and 2 years, but rates converged with IV group at 9 years. CONCLUSIONS:HV surgeons have the most favourable short-term outcomes. However, in the long-term the difference in all-cause revision event rates becomes less apparent.

BACKGROUND:Despite theoretical risks of fatigue wear, there is little empirical evidence correlating postoperative impact level from physical activity with failure rates following total hip and knee arthroplasty (THA and TKA). This study aimed to assess the relationship between the impact level from self-reported sports and physical activity participation and revision rates following primary arthroplasty. METHODS:A survey was conducted on recreational sports participation among primary elective THA and TKA patients from an urban, academic health system between June 1, 2011, and January 31, 2022. A total of 1,622 THA and 1,388 TKA respondents were included in the study. The survey was administered cross-sectionally at various time points, with a minimum follow-up of at least one year required for inclusion (THA, 5.3 years; TKA, 4.8 years postoperation on average). Patients were divided into four cohorts based on participation and intensity of the sport: no sports, low-impact sports, intermediate-impact sports, and high-impact sports. Descriptive comparisons were made to evaluate revision rates and mean time to follow-up among these groups in THA and TKA patients. The Kaplan-Meier method was utilized to assess 10-year implant survivability. RESULTS:Healthier and younger patients who underwent THA or TKA were significantly more likely to participate in intermediate- to high-impact sports and were found to have noninferior revision rates than those who engaged in no sports or low-impact sports: THA (2.9 [no sports] versus 1.9 [low impact] versus 1.6% [intermediate/high impact]), TKA (3.0 versus 1.6 versus 0.0%). When analyzing aseptic versus septic revisions separately, no notable patterns or differences were observed. CONCLUSIONS:At a mean 5-year follow-up, healthier and younger patients who participated in intermediate- and high-impact physical activities had noninferior revision rates as than patients who were less active. These findings offer guidance for clinicians when advising patients on the safe resumption of sports activities following total joint arthroplasty.

BACKGROUND:Patients' satisfaction and job limitations after primary total hip arthroplasty (THA) based on occupation intensity have not been evaluated. This study aimed to assess patients' ability and satisfaction with their return to work following primary THA depending on intensity of their occupation. METHODS:This retrospective review surveyed patients undergoing primary THA between June 2011 and January 2022, with at least one year of follow-up, on return to work rates. Of 1,713 participants, 1,176 (68.7%) reported working prior to THA and were stratified into high intensity (HI) (i.e. laborer, construction), standard intensity (SI) (i.e. walking, climbing stairs), and low intensity (LI) (i.e. desk jobs) groups. Baseline demographics and survey responses were compared. Among patients who worked preoperatively, 66 (5.6%), 450 (38.3%), and 660 (56.1%) were in the HI, SI, and LI groups, respectively. RESULTS:High rates of workers across all groups reported improvements in their ability to work following THA, with 74.8% of SI, 68.8% of LI workers and 63.6% of HI workers reporting "remarkable" or "modest improvement." The HI group was more likely male, younger, and a current smoker compared to the SI and LI groups. Among LI workers, 47.2% returned within the first month and83.6% returned within two months. SI workers showed a similar pattern, with 36.2% returning in less than a month and 79.7% returning within two months. HI workers had a comparatively lower return rate, with 12.3% returning within the first month and 52.6% returning within two months. CONCLUSION/CONCLUSIONS:Across all intensity levels, THA enables improvements in perceived work function and satisfaction. However, higher-intensity work requires more time, is more difficult, and yields lower return-to-work satisfaction compared to low-intensity work.

INTRODUCTION/BACKGROUND:Obtaining an accurate preoperative diagnosis of periprosthetic joint infections (PJI) is challenging, making differentiating between septic and aseptic failures difficult. We sought to identify the value of common serum biomarkers and evaluate the accuracy of three ratios in the diagnosis of PJI after primary total knee arthroplasty (TKA): albumin-globulin ratio (AGR), C-reactive protein-albumin ratio (CAR), and C-reactive protein-AGR ratio (CAGR). METHODS:Patients undergoing PJI and aseptic revisions after TKA between 2011 and 2021 were retrospectively reviewed at a single institution. Only patients who had reported serum white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin (Alb), and total protein (TP) were included. Areas under the curve (AUCs), which optimize diagnostic performance by balancing sensitivity and specificity at a specific cutoff, were calculated for each individual biomarker and the three ratio groups: AGR = Alb / [TP - Alb], CAR = CRP / Alb, and CAGR = CRP / AGR). Higher AUCs indicate improved identification of PJI while reducing misclassification. RESULTS:Out of the 126 included cases, 89 were confirmed PJIs and 37 were aseptic revisions. Among the single and combination serum biomarkers, the AUCs were as follows: CRP (0.85), ESR (0.76), Alb (0.81), AGR (0.78), CAR (0.87), and CAGR (0.87). The CAR demonstrated excellent accuracy at a cutoff of 2.46, with a sensitivity of 0.74 and specificity of 0.84. CAGR also demonstrated excellent accuracy at a cutoff of 7.09, with a sensitivity of 0.80 and specificity of 0.78. CONCLUSION/CONCLUSIONS:The CRP, CAR, and CAGR showed an excellent diagnostic accuracy as markers for PJI. In patients undergoing revision TKA, common serum biomarkers such as Alb, TP, CRP, and ESR can be obtained, and CAR or CAGR ratios can be calculated to aid in the diagnosis of PJI, especially in cases where synovial analysis is inconclusive, allowing for better clinical decision-making.

BACKGROUND:Recovery after total knee arthroplasty (TKA) shows considerable variability in both pain relief and functional improvement. The Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) is a widely used measure for evaluating these outcomes. This study aimed to identify distinct latent recovery trajectories, which represent underlying, unobserved patterns of postoperative recovery inferred from KOOS-JR scores, and to explore patient characteristics associated with these trajectories. METHODS:This retrospective cohort study analyzed patients who underwent primary TKA for osteoarthritis at a tertiary academic center from January 2020 to March 2023. Inclusion criteria required patients to have completed a preoperative KOOS-JR questionnaire and at least two postoperative follow-ups at 1, 3, 6, or 12 months. Exclusion criteria included bilateral or revision procedures. Collected characteristics included age, sex, Body Mass Index, American Society of Anesthesiologists physical status classification, race, smoking status, procedure type, anesthesia type, length of hospital stay, and discharge disposition. Growth mixture modeling was used to model recovery trajectories, with associations evaluated using the "three-step approach." Model fit was assessed using the Akaike and Bayesian Information Criteria, Vuong-Lo-Mendell-Rubin likelihood ratio, posterior probabilities, and entropy values. RESULTS:Of 700 eligible patients, growth mixture modeling identified two recovery trajectories: 95.4% of patients (trajectory 1 [T1]) demonstrated steady improvement, while 4.6% (trajectory 2 [T2]) began with lower KOOS-JR scores (mean 9.7 vs. 47.9 for T1) but recovered to near T1 levels by 1 month. Trajectory 2 patients were markedly younger (mean 64 vs. 67 years), had higher Body Mass Index (36 vs. 31), included more Black or African American individuals (38% vs. 20%), and were more frequently discharged to rehabilitation facilities (16% vs. 3.3%; all P < 0.05). Each additional year of age reduced the likelihood of following T2 by 4% (odds ratio = 0.96, 95% confidence interval, 0.92 to 0.99; P = 0.016), while discharge to rehabilitation increased the likelihood 6-fold (odds ratio = 6.22, 95% confidence interval, 1.89 to 17.8; P = 0.001). CONCLUSION/CONCLUSIONS:This study identified two distinct recovery trajectories after TKA, with notably no trajectory emerging showing decline or stagnation from preoperative levels. Despite lower baseline scores, patients in T2 achieved substantial recovery, suggesting TKA provides meaningful improvement even for those with substantially compromised function. The findings also highlight the need to explore whether rehabilitation discharge directly influences the observed postoperative gains.

BACKGROUND:Social determinants strongly influence overall health, including recovery after total joint arthroplasty (TJA). The modern electronic health record includes a list of individuals identified by patients as their primary contacts. We aimed to assess whether the relationship between patients and their documented primary contacts was associated with outcomes after TJA. METHODS:We retrospectively reviewed primary, elective total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) at a single institution from June 2011 to December 2022, and stratified patients into two groups: family (F) [familial relationships to include spouse, first, or second degree relative] or non-family (NF) [nonfamilial relationships, such as friend or neighbor] based on patient relationship to their primary emergency contact. Baseline characteristics and postoperative outcomes were compared. Binary logistic regression was utilized to assess variables associated with all-cause revision. In total, 17,520 THAs were included as follows: 16,123 (92.0%) in the F group and 1,397 (8.0%) in the NF group. Additionally, 20,397 TKAs were included as follows: 18,819 (92.3%) in the F group and 1,578 (7.7%) in the NF group. RESULTS:For both THA and TKA patients, having a NF primary contact was independently associated with a higher risk of all-cause revision at the latest follow-up (OR [odds ratio]: 1.48 [95% CI (confidence interval): 1.05 to 2.08], P = 0.025) and (OR: 1.62 [95% CI: 1.10 to 2.38], P = 0.014), respectively. In both THA and TKA, the F group had shorter lengths of stay (P < 0.001) and was more likely to be discharged home (P < 0.001) compared to the NF group. CONCLUSIONS:TJA patients who have a familial primary contact demonstrate better postoperative outcomes compared to those who do not have a familial contact. Awareness of social support and additional postoperative support for patients who have NF primary contacts may be warranted following TJA.