Faculty Bibliography

BACKGROUND:Two-stage revisions for chronic periprosthetic joint infections (PJIs) often include antibiotic-loaded cement spacers to control for infection and preserve function. While studies have reported on complications (dislocations, readmissions, and reoperations) after static versus articulating spacer types, there is a paucity of evidence about whether the degree of spacer constraint in articulating spacers affects these complications. This study aims to address a key gap in understanding as to whether the level of spacer constraint affects complications in two-stage revision THA utilizing articulating spacers. QUESTIONS/PURPOSES/OBJECTIVE:(1) Among patients receiving nonconstrained versus constrained articulating antibiotic spacers during first-stage revision THA for PJI, are there differences in major complications, such as dislocation, loosening, periprosthetic fracture, reinfection, and unplanned revisions? (2) After second-stage reimplantation, do patients who received a nonconstrained versus constrained liner during the first stage show differences in the risk of complications, reoperations, and readmissions? METHODS:This is a retrospective review of 539 patients who underwent two-stage revision THA for PJI at a single-specialty, urban academic referral center between July 2011 and March 2023. Of these 539 patients, 72% (388) were excluded for undergoing a full component revision (femoral or acetabular) for any reason before their first stage, 3% (15) for receiving static spacers, and 6% (35) for receiving prefabricated femoral mono-block stems as part of their first stage. Those who underwent only liner exchange were not excluded. The remaining 19% (101 of 539) of patients were included in the final analysis and categorized by degree of liner constraint: 32 were in the nonconstrained group and 69 were in the constrained group. All surgeons included in this study specialize in adult reconstruction and are fellowship trained, and the selected level of constraint was solely based on their routine practice for articulating spacer construct. Baseline characteristics and clinical data, including age, self-reported gender, race, BMI, American Society of Anesthesiologists score, smoking status, surgical history, and perioperative details, were collected. There were no differences in baseline characteristics between the groups except for smoking status. A priori power analysis determined that 150 patients (75 per group) would be needed to detect a statistical difference in the risk of dislocation between groups, assuming a 20% dislocation risk for the constrained group, at a 0.05 alpha level, and 80% power. RESULTS:Between patients receiving nonconstrained versus constrained liners, there were no differences in complications after the first stage of revision. Three percent (1 of 32) of the nonconstrained liners developed dislocations compared with 3% (2 of 69) in the constrained group (relative risk [RR] 1.1 [95% confidence interval (CI) 0.09 to 12.3]; p > 0.99). Three percent (1 of 32) of the nonconstrained group developed periprosthetic fractures compared with 7% (5 of 69) in the constrained group (RR 0.4 [95% CI 0.05 to 3.69]; p = 0.72). Similarly, 3% (1 of 32) versus 7% (5 of 69) had persistent infection (RR 0.4 [95% CI 0.05 to 3.69]; p = 0.72). One incident of loosening occurred in the constrained group. There were also no differences in spacer revision incidence: 10% (3 of 32) of the nonconstrained group and 10% (7 of 69) of the constrained group underwent an unplanned revision after the first stage (RR 1.0 [95% CI 0.29 to 3.91]; p = 0.91). For the second stage, dislocation was 14% (3 of 21) in the nonconstrained group and 10% (5 of 52) in the constrained group (RR 1.1 [95% CI 0.2 to 5.9]; p > 0.99). When comparing periprosthetic fractures, 10% (2 of 21) of the nonconstrained group developed periprosthetic fractures compared with 4% (2 of 52) in the constrained group (RR 2.2 [95% CI 0.3 to 16.6]; p = 0.78). Nineteen percent (4 of 21) in the nonconstrained group had persistent infection compared with 12% (6 of 52) in the constrained group (RR 1.5 [95% CI 0.39 to 5.74]; p = 0.81). The occurrence of readmission after the second stage was 19% (4 of 21) in the nonconstrained group compared with 15% (8 of 52) in the constrained group (RR 1.1 [95% CI 0.3 to 3.9]; p > 0.99). Twenty-four percent (5 of 21) of patients in the nonconstrained group required a surgery-related emergency department visit compared with 13% (7 of 52) in the constrained group (RR 1.6 [95% CI 0.4 to 5.6]; p = 0.64). The incidence of reoperation was 14% (3 of 21) in the nonconstrained group and 13% (7 of 52) in the constrained group (RR 0.9 [95% CI 0.2 to 3.8]; p > 0.99). CONCLUSION/CONCLUSIONS:Our results indicated no differences in the risk of dislocations, reinfections, reoperations, and readmissions between patients undergoing constrained versus nonconstrained articulating spacers for two-stage revision THA. Because constrained liners are typically preferred in patients at higher risk of instability, our findings suggest that their use does not necessarily increase the risk of complications. However, because of the small sample size, larger studies are needed to demonstrate whether there is superiority of liner constraint in this patient population. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.

OBJECTIVE:This study assesses the impact of a structured summer externship program (SEP) in orthopedic surgery on participants' career trajectories and diversity within the field. Specifically, we evaluated the proportion of SEP participants who chose a career in orthopedic surgery and analyzed trends in gender and racial/ethnic diversity among the cohort over a 20-year period. DESIGN/METHODS:A retrospective cohort analysis was conducted using data from participants in 1 academic department's SEP between 2004 and 2023. Participant demographic data, ultimate specialty match information, and residency outcomes were collected and statistically analyzed to assess trends in specialty selection, gender, and racial/ethnic diversity among the SEP alumni. SETTING/METHODS:This study took place in the Department of Orthopedic Surgery at a large academic tertiary medical center. PARTICIPANTS/METHODS:The study included 564 medical students who participated in the SEP between 2004 and 2023. Of these, 441 (78.2%) have graduated from medical school to date, 114 (20.2%) are still enrolled, and 5 (0.89%) have left medicine for careers in other sectors. Data for 9 participants (1.6%) was unavailable. RESULTS:Among the 436 graduates, 161 (36.9%) eventually matched into orthopedic surgery. An additional 13.5% entered internal medicine, 7.3% matched into radiology, 6.6% into emergency medicine, 5.5% into anesthesiology, and 30.3% into various other specialties. Female representation in the SEP increased from 16.6% in 2004 to 51.1% in 2023 (χ² = 4.95, p = 0.026), while non-white participant representation grew from 16.6% to 45% over the same period (χ² =3.18, p = 0.075). CONCLUSIONS:The SEP is one way of providing resources and opportunity for engagement for students interested in orthopedic surgery careers while promoting diversity within the field. This program serves as a valuable pathway, offering early exposure to orthopedic surgery, research opportunities, and professional networking, all of which may play an increasingly critical role as residency selection criteria evolve. The SEP's advantages to participants underscore the importance of targeted programs in fostering opportunity for previously underrepresented groups in the field of orthopedic surgery.

BACKGROUND:Methylene blue (MB), a phenothiazine dye with antimicrobial activity, is used to stain soft tissues and guide thoroughness of debridement during revision total knee arthroplasty (rTKA) for periprosthetic joint infection (PJI). The purpose of this study was to determine if instillation of MB prior to arthrotomy impacts culture yield in TKA PJI. METHODS:We retrospectively reviewed 266 patients diagnosed with TKA PJIs according to the 2018 International Consensus Meeting (ICM) criteria from January 2018 - March 2023 at a single academic hospital. Demographics, perioperative outcomes, and preoperative and intraoperative culture positivity were compared between patients who received intraoperative MB (MB group; n = 26) and those who did not (nMB group; n = 241). A record of detected organisms was included in the analysis. RESULTS:There was no difference in preoperative aspiration culture positivity between groups. However, the MB group had a higher percentage of preoperative to intraoperative culture concordance (89.5 vs. 69.9%; P = 0.04). Although the overall rate of intraoperative culture positivity did not differ significantly between groups, the MB group had more intraoperative cultures obtained per patient (4.9 vs. 4.5; P = 0.02) and higher numbers of positive intraoperative cultures per patient. Concordance rates for patients in both groups with positive preoperative and negative intraoperative cultures were similar (10.5 vs. 16.5%, P = 0.50). Among patients with negative preoperative cultures, intraoperative culture positivity was more discordant in the MB group (0 vs. 18.8%; P = 0.03). There was no difference in the number of patients that received antibiotics following aspiration (68.4 vs. 49.6%; P = 0.12). CONCLUSION/CONCLUSIONS:While MB use did not affect overall culture positivity, it could interfere with intraoperative pathogen detection in patients with negative preoperative cultures. In these cases, MB should be avoided to decrease inaccuracies in intraoperative culture yield. If preoperative cultures are positive, MB may improve surgical debridement and likelihood of infection eradication.

INTRODUCTION/BACKGROUND:The role of advanced imaging in diagnosing aseptic implant loosening following total hip arthroplasty (THA) remains unclear. This study aimed to assess the diagnostic value of magnetic resonance imaging (MRI) in detecting aseptic loosening. METHODS:This was a retrospective review of 342 consecutive patients who underwent revision THA between July 2011 and April 2023 and had a pelvis MRI as part of the preoperative diagnostic evaluation. Among them, 62 patients had an intraoperative diagnosis of aseptic loosening of either the femoral or acetabular component. Patients were stratified based on the concordance between their MRI and radiographs findings. RESULTS:Preoperative MRI showed signs of aseptic loosening in 25/62 patients (sensitivity = 40.3%). Similarly, preoperative radiographs demonstrated signs of aseptic loosening in 27 patients (43.5%). Twelve patients (19.4%) had both MRI and radiographs predictive of aseptic loosening, 22 patients (35.5%) did not show signs of aseptic loosening in either MRI or radiographs, and for 28 patients (45.2%), the results were discordant. Among the patients with a negative radiograph for aseptic loosening (n = 35), 13 patients (37.1%) showed signs of aseptic loosening on MRI. CONCLUSION/CONCLUSIONS:Aseptic loosening remains an elusive diagnosis, and the findings of this study suggest that the utility of MRI and radiographs as part of the diagnostic process is limited. However, in cases of presumed aseptic loosening with inconclusive radiographs findings, MRI may play a role in improving the diagnostic process. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:Debridement, antibiotics, and implant retention (DAIR) are the mainstays surgical treatment for acute periprosthetic joint infection (PJI). However, re-operation following DAIR is common, and the risk factors for DAIR failure remain unclear. This study aimed to assess the perioperative characteristics of patients who failed initial DAIR treatment. METHODS:A retrospective review was conducted on 83 patients who underwent DAIR for acute PJI within three months following index surgery from 2011 to 2022, with a minimum one-year follow-up. Surgical outcomes were categorized using the Musculoskeletal Infection Society (MSIS) outcome reporting tool (Tiers 1 to 4). Patient demographics, laboratory data, and perioperative outcomes were compared between patients who had failed (Tiers 3 and 4) (n = 32) and successful (Tiers 1 and 2) (n = 51) DAIR treatment. Logistic regression was also performed. RESULTS:After logistic regression, Charlson Comorbidity Index (CCI) (odds ratio (OR): 1.57; P = 0.003), preoperative C-reactive protein (CRP) (OR: 1.06; P = 0.014), synovial white blood cell (WBC) (OR: 1.14; P = 0.008), and polymorphonuclear cell (PMN%) counts (OR: 1.05; P = 0.015) were independently associated with failed DAIR. Compared with total hip arthroplasty (THA), total knee arthroplasty (TKA) patients (OR: 6.08; P = 0.001) were at increased risk of DAIR failure. The type of organism and time from primary surgery were not correlated with DAIR failure. CONCLUSION/CONCLUSIONS:Patients who had failed initial DAIR tended to have significantly higher CCI, CRP, synovial WBC, and PMN%. The TKA DAIRs were more likely to fail than the THA DAIRs. These characteristics should be considered when planning acute PJI management, as certain patients may be at higher risk for DAIR failure and may benefit from other surgical treatments.

BACKGROUND:Current data evaluating the clinical value and cost-effectiveness of advanced diagnostic tests for periprosthetic joint infection (PJI) diagnosis, including alpha-defensin and synovial C-reactive protein (CRP), is conflicting. This study aimed to evaluate the adequacy of preoperative and intraoperative PJI workups without utilizing these tests. METHODS:This retrospective analysis identified all patients who underwent revision total knee or hip arthroplasty (rTKA and rTHA, respectively) for suspected PJI between 2018 and 2020 and had a minimum follow-up of two years. Perioperative data and lab results were collected, and cases were dichotomized based on whether they met the 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI. In total, 204 rTKA and 158 rTHA cases suspected of PJI were reviewed. RESULTS:Nearly 100% of the cases were categorized as "infected" for meeting the 2018 MSIS criteria without utilization of alpha-defensin or synovial CRP (rTKA: n = 193, 94.6%; rTHA: n = 156, 98.7%). Most cases were classified as PJI preoperatively by meeting either the major MSIS or the combinational minor MSIS criteria of traditional lab tests (rTKA: n = 177, 86.8%; rTHA: n = 143, 90.5%). A subset of cases was classified as PJI by meeting combinational preoperative and intraoperative MSIS criteria (rTKA: 16, 7.8%; rTHA: 13, 8.2%). Only 3.6% of all cases were considered "inconclusive" using preoperative and intraoperative data. CONCLUSION/CONCLUSIONS:Given the high rate of cases satisfying PJI criteria during preoperative workup using our available tests, the synovial alpha-defensin and synovial CRP tests may not be necessary in the routine diagnostic workup of PJI. We suggest that the primary PJI workup process should be based on a stepwise algorithmic approach with the most economical testing necessary to determine a diagnosis first. The use of advanced, commercialized, and costly biomarkers should be utilized only when traditional testing is indeterminate.

BACKGROUND:Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF. METHODS:We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk. RESULTS:There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095). CONCLUSIONS:The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.

Culture-positive (CP) and culture-negative (CN) periprosthetic joint infections (PJI) remain a crucial area of research; however, current studies comparing these infections rely on unstandardized outcome reporting tools. Our study aimed to compare the outcomes of two-stage revision of CP and CN PJI using the standardized Musculoskeletal Infection Society (MSIS) outcome reporting tool. We retrospectively reviewed 138 patients who were diagnosed with PJI and indicated for two-stage revision total knee arthroplasty (rTKA). The majority of patients in both CP and CN cohorts achieved infection control without the need for reoperation (54.1% and 62.5%, respectively). There was a significant difference in the overall distribution of MSIS outcomes (p = 0.043), with a significantly greater rate of CN patients falling into Tier 1 (infection control without the use of suppressive antibiotics) (52.5% versus 29.6%, p = 0.011). There was also a significant difference in the distribution of septic versus aseptic reoperations after 2nd stage (p = 0.013), with more CP reoperations being septic and more CN reoperations being aseptic. The duration from first to second stage was significantly shorter in the CN cohort (p = 0.002). While overall infection control was similar between cohorts, these data suggest that the outcomes of two-stage rTKA are favorable in cases of CN PJI.

INTRODUCTION/BACKGROUND:The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS:An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS:Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION/CONCLUSIONS:Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.