Faculty Bibliography

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.

BACKGROUND:High body mass index (BMI) is a risk factor for tibial baseplate loosening following total knee arthroplasty (TKA) but may not adequately correlate with stresses at the tibial baseplate. In this study, we aimed to determine an optimal cutoff of a weight-to-tibial baseplate surface-area ratio (weight/SA) for predicting aseptic tibial baseplate loosening. We further examined whether tibial stem extensions have a protective effect. METHODS:We identified 16,368 patients who underwent primary, elective TKA from June 2011 to March 2023. Patient demographics, including age, sex, and race, implants used, and revision surgeries were extracted. Revisions were manually reviewed to confirm revision indications. The exact surface areas of tibial baseplates were obtained from manufacturers. Receiver operating characteristic (ROC) analysis of patients without tibial stem extensions was utilized to examine the utility of BMI and weight/SA for predicting aseptic tibial baseplate loosening. Optimal weight/SA and BMI cutoffs for predicting loosening were determined. The effect of tibial stem extensions on loosening was then examined in patients at or above (n = 7,698; 3.7% with stem extension) and below (n = 8,670; 1.3% with stem extension) the determined weight/SA cutoff. RESULTS:There were 16,368 patients in the final sample (median age, 67 years; 68.9% female; 54.1% White). Weight/SA (area under the curve [AUC] = 0.653; p < 0.001) was a better predictor of aseptic tibial baseplate loosening requiring revision compared with patient BMI (AUC = 0.624; p < 0.001). The optimal weight/SA cutoff for predicting loosening was 0.0162 kg/mm2 (sensitivity = 0.747, specificity = 0.537). Multivariable logistic regression demonstrated that being at or above the weight/SA cutoff (odds ratio [OR] = 3.17; p < 0.001) but not the BMI cutoff (p = 0.911) was a significant predictor of revision for tibial baseplate loosening in patients without stem extensions. No cases of revision for aseptic tibial baseplate loosening in patients with stem extensions occurred either at or above or below the cutoff. The rate of revision for aseptic tibial baseplate loosening in patients without stem extensions was 0.3% for patients below and 1.0% for patients at or above the weight/SA cutoff. CONCLUSIONS:The ratio of weight-to-tibial baseplate surface area was more predictive of revision for aseptic tibial baseplate loosening following TKA compared with BMI alone. For patients with obesity with small tibial baseplate sizes, utilization of a tibial stem extension may protect against tibial loosening. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Changing from standing to sitting positions requires rotation of the femur from an almost vertical plane to the horizontal plane. Osteoarthritis of the hip limits hip extension, resulting in less ability to recruit spinopelvic tilt (SPT) while standing and requiring increased SPT while sitting to compensate for the loss of hip range of motion. To date, the effect of total hip arthroplasty (THA) on spinopelvic sitting and standing mechanics has not been reported, particularly in the setting of patients with coexistent sagittal plane spinal deformity. METHODS:A retrospective review was performed of patients ≥18 years of age undergoing unilateral THA for hip osteoarthritis with sitting and standing radiographs made before and after THA. Alignment was analyzed at baseline and follow-up after THA in both standing and sitting positions in a relaxed posture with the fingers resting on top of the clavicles. Patients were grouped according to the presence or absence of sagittal plane deformity preoperatively into 3 groups: no sagittal plane deformity (normal), thoracolumbar (TL) deformity (pelvic incidence-lumbar lordosis [PI-LL] mismatch > 10° and/or T1-pelvic angle [TPA] > 20°), or apparent deformity (PI-LL ≤ 10° and TPA ≤ 20°, but sagittal vertical axis [SVA] > 50 mm). RESULTS:In this study, 192 patients were assessed: 64 had TL deformity, 39 had apparent deformity, and 89 had normal alignment. Overall, patients demonstrated a reduction in standing SVA (45 to 34.1 mm; p < 0.001) and an increase in SPT (14.6° to 15.7°; p = 0.03) after THA. There was a greater change in standing SVA (p < 0.001) among patients with apparent deformity (-29.0 mm) compared with patients with normal alignment (0.9 mm) and patients with TL deformity (-16.3 mm). Those with apparent deformity also experienced the greatest difference (p = 0.03) in postural SPT change (moving from standing to sitting) (-10.1°) from before to after THA when compared with those with normal alignment (-3.6°) and TL deformity (-1.2°). The difference in postural SVA change from before to after THA was also greatest (p < 0.001) in those with apparent deformity (32.1 mm) compared with those with normal alignment (6.5 mm) and TL deformity (17.3 mm). CONCLUSIONS:Postural changes in spinopelvic alignment vary after THA depending on the presence of TL deformity or apparent deformity due to hip flexion contracture. Patients with apparent deformity had larger changes in standing and sitting alignment than patients with TL deformity or patients with normal alignment. The assessment of global sagittal alignment findings can be used to predict the likelihood of improvement in sagittal alignment after THA. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

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:Same-day cancellations of elective surgeries present challenges to patients, providers, and healthcare institutions. This study aimed to investigate the frequency and predictors of same-day cancellations for elective total joint arthroplasty (TJA). METHODS:A retrospective review was conducted on 13,744 scheduled primary, elective TJAs at an urban academic center from September 2017 to August 2023. Cases that experienced same-day cancellations were grouped based on the reasoning for cancellation into one of two categories - operative concern (e.g., acute health issues, medication non-compliance) or a nonoperative concern (e.g., financial clearance, transportation issues). Patient demographics were compared between the cancellation and surgery cohorts and between the categorical reasons for cancellation. RESULTS:Out of the 38,849 scheduled TJAs, 362 cases (0.9%) were canceled on the day of surgery. Higher patient body mass index (BMI) was the singular patient factor predictive of same-day cancellation across all TJAs. Non-white race, men, and higher Charlson Comorbidity Index (CCI) were additional significant predictors for THA, but not TKA cancellation. Operative concerns accounted for 74.9% of the cancellations, and nonoperative concerns accounted for 25.1%. Increased patient BMI was predictive of TJAs canceled due to operative concerns, whereas younger patient age was predictive of TJAs canceled due to nonoperative concerns. Of all same-day cancellations, 81.8% were ultimately rescheduled, and rescheduled cases occurred at a median of 25 days (range, one to 425) after cancellation. There were no significant differences in rescheduling rates and time to reschedule cases between the reasons for cancellation. CONCLUSION/CONCLUSIONS:Approximately 1% of patients experienced a same-day cancellation of their elective TJA, most of which occurred due to operative concerns. These findings may guide the development of preoperative optimization strategies aimed at reducing the occurrence of same-day cancellations for high-risk patients, thereby maximizing the utilization of operative resources and enhancing care for TJA patients.

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.

BACKGROUND:Arthrofibrosis is a debilitating complication of total knee arthroplasty (TKA) and may benefit from arthroscopic lysis of adhesions (LOA) to improve range of motion and decrease pain. However, the rates of periprosthetic joint infection (PJI) and of the need for future revision TKA (rTKA) have only been studied in a limited capacity in the literature. In this study, we aimed to compare PJI and revision outcomes in patients who had undergone TKA between those who subsequently underwent arthroscopic LOA and those who did not undergo arthroscopic LOA. METHODS:The PearlDiver database was utilized to identify patients who had undergone primary TKA between 2016 and 2021. ICD-10 (International Classification of Diseases, Tenth Revision) and CPT (Current Procedural Terminology) codes were then used to identify patients who underwent LOA for arthrofibrosis. The rates of PJI and rTKA were compared between patients who did and did not undergo LOA. Multivariable logistic and Cox regressions, controlling for age, sex, Charlson Comorbidity Index, tobacco use, and a body mass index of >30 kg/m2, were performed to compare the rates of PJI and revision between the LOA and no-LOA groups. RESULTS:A total of 383,143 patients were identified, of whom 703 had undergone arthroscopic LOA. Patients who underwent LOA had higher overall rates of PJI (2.7% versus 1.3%; p = 0.001) and all-cause revision (9.8% versus 1.8%; p < 0.001) than those who did not. Patients who underwent LOA had significantly higher odds of PJI (odds ratio [OR], 2.00; p < 0.014), aseptic loosening-related revision (OR, 3.31; p = 0.002), and all-cause revision (OR, 5.32; p < 0.001) within 1 year after the initial TKA. There was no significant difference in 1-year PJI-related revisions between the groups (OR, 1.71; p = 0.193). In a time-to-event analysis, patients undergoing LOA had significantly higher risks of PJI (p = 0.003) and all-cause revision (p = 0.001) but not PJI-related revision (p = 0.322) or aseptic loosening-related revision (p = 0.111). CONCLUSIONS:Arthroscopic LOA after primary TKA was associated with higher rates of PJI and subsequent revision surgery. Surgeons should consider the results of these studies when counseling patients on the importance of early rehabilitation and improving modifiable risk factors after TKA. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty and total knee arthroplasty are among the most successful orthopedic procedures, with increasing numbers performed annually in the United States. However, adverse perioperative complications like acute kidney injury (AKI) can adversely affect patient outcomes and increase health care costs. The incidence of AKI post-total joint arthroplasty varies widely, with large-scale studies reporting less than 2% and smaller studies indicating rates as high as 21.9%. Holding angiotensin converting enzyme inhibitors, aldosterone receptor blockers, NSAIDs, diuretics, and avoiding nephrotoxic antibiotics can help mitigate the risk.

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.

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.