Faculty Bibliography

BACKGROUND:Prior literature has demonstrated that diabetic (DM) patients undergoing total joint arthroplasty (TJA) with elevated preoperative HbA1c scores have poorer clinical outcomes. However, no literature has reported the effect of undergoing TJA on laboratory markers of glycemic control. This study sought to evaluate effect of undergoing TJA on postoperative glycemic control and outcomes. METHODS:This retrospective study reviewed all patients with DM who underwent primary, elective TJA at our high volume orthopedic institution. Included patients had at least one HbA1c value 3 months to 2 weeks pre-surgery and 3-6 months after surgery. Changes in HbA1c from before to after surgery were calculated. Change in HbA1c greater than 1.0% was considered clinically meaningful. Change in HbA1c was analyzed and stratified into subgroups. RESULTS:In total, 770 primary TJA patients were included. Patients with preoperative HbA1c > 7% vs. ≤ 7% were significantly more likely to have clinically meaningful post-TJA decrease in HbA1c (24.5 vs. 2.9%, p < 0.001). Patients with preoperative HbA1c > 8 were significantly more likely to have decrease of > 2.0 compared to those with HbA1c < 8 (p < 0.001). Multivariate regression revealed that preop HbA1c > 7.0, former and current smokers, males, and African-Americans were significantly more likely to achieve clinically meaningful decrease in HbA1c. Additionally, postoperative increase in HbA1c > 1% was associated with significantly higher 90-day ED visits. DISCUSSION/CONCLUSIONS:Patients with higher preoperative HbA1c were more likely to have clinically meaningful decreases in HbA1c postoperatively. A combination of preoperative medical optimization and improvements in mobility after TJA may play a role in these changes. Those with elevated HbA1c can have meaningful improvement in HbA1c after TJA.

BACKGROUND/UNASSIGNED:Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. METHODS/UNASSIGNED:A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS/UNASSIGNED: = .012). CONCLUSIONS/UNASSIGNED:In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

PURPOSE/OBJECTIVE:The study aimed to determine whether body mass index (BMI) classification for patients undergoing total knee arthroplasty (TKA) is associated with differences in mean patient reported outcome measure (PROM) score improvements across multiple domains-including pain, functional status, mental health, and global physical health. We hypothesized that patients with larger BMIs would have worse preoperative and postoperative PROM scores, though improvements in scores would be comparable between groups. MATERIALS AND METHODS/METHODS:. Preoperative, postoperative, and pre/post-changes (Δ) in knee injury and osteoarthritis, joint replacement (KOOS, JR) and Patient-Reported Outcome Measurement Information System (PROMIS) measures of pain intensity, pain interference, physical function, mobility, mental health, and physical health were compared. Multivariate linear regression was used to assess for confounding comorbid conditions. RESULTS:In univariate analysis, patients with larger BMIs had worse scores for KOOS, JR and all PROMIS metrics preoperatively. Postoperatively, scores for KOOS, JR and PROMIS pain interference, mobility, and physical health were statistically worse in higher BMI groups, though differences were not clinically significant. Morbidly obese patients achieved greater pre/post-Δ improvements in KOOS, JR and global physical health scores. Multivariate regression analysis showed high BMI was independently associated with greater pre/post-Δ improvements in KOOS, JR and global health scores. CONCLUSION/CONCLUSIONS:Obese patients report worse preoperative scores for function and health, but greater pre/post-Δ improvements in KOOS, JR and physical health scores following TKA. Quality of life benefits of TKA in obese patients should be a factor when assessing surgical candidacy.

BACKGROUND:Aseptic loosening persists as one of the leading causes of failure following cemented primary total knee arthroplasty (TKA). Cement technique may impact implant fixation. We hypothesized that there is variability in TKA cement technique among arthroplasty surgeons. METHODS:A 28-question survey regarding variables in surgeons' preferred TKA cementation technique was distributed to 2,791 current American Association of Hip and Knee Surgeons (AAHKS) members with a response rate of 30.8% (903 respondents). Patterns of responses were analyzed by grouping respondents by their answers to certain questions including cementing technique, tibial cement location, and femoral cement location. RESULTS:A total of 73.5% reported performing at least 7 of 8 of the highest consensus techniques, including vacuum mixing (79.9%), using two bags (76.1%), tibial implant first (95.2%), single-stage cementing (96.9%), compression of the implants in extension (91.7%), and use of a tourniquet (84.3%). Medium and high viscosity cement was most commonly used (37.9 and 37.8%, respectively). Finger pressurization was most common (76.1%) compared to a gun (29.8%). There were 26.5% of respondents performing 6 or fewer of the most common majority techniques and seemed to perform other less common techniques (eg, use of a single bag of cement, trialing or closure prior to cement curing, and heating to accelerate cement curing). Cement was most commonly applied to the entire bone and implant surface on both the tibia (46.4%) and femur (47.7%), leaving much variation in the remaining cement application location responses. DISCUSSION/CONCLUSIONS:There appears to be variability in cemented TKA technique among arthroplasty surgeons. There were 26.5% of respondents performing less of the majority techniques and also performed other additional low-response rate techniques. Further studies that look at the impacts of variation in techniques on outcomes may be warranted. Our study demonstrates the need for defining best practices for cement technique given the substantial variability identified.

BACKGROUND:Revision total knee arthroplasty (rTKA) can be performed with isolated tibial, isolated femoral, and combined tibial and femoral component exchange for different indications. Replacement of only 1 fixed component in rTKA leads to shorter operative times and decreased complexity. We sought to compare functional outcomes and rates of rerevision in patients undergoing partial and full rTKA. METHODS:This retrospective study examined all aseptic rTKA patients with a minimum follow-up of 2 years in a single center between September 2011 and December 2019. Patients were divided into two groups: full rTKA (F-rTKA) if both components (femoral and tibial) were revised and partial rTKA (P-rTKA) if only 1 component was revised. A total of 293 patients (P-rTKA = 76, F-rTKA = 217) were included. RESULTS:P-rTKA patients had significantly shorter surgical time (109 ± 37 Versus. 141 ± 44 minutes, P < .001). At mean follow-up of 4.2 (range 2.2-6.2) years, rerevision rates did not significantly differ between groups (11.8 Versus. 16.1%, P = .358). Improvements in postoperative Visual Analogue Scale (VAS) pain and Knee Injury and Osteoarthritis Scale (KOOS), Joint Replacement scores were similar as well (P = .100 and P = .140, respectively). For patients undergoing rTKA due to aseptic loosening, freedom from rerevision due to aseptic loosening was similar between groups (100 Versus. 97.8%, P = .321). For patients undergoing rTKA due to instability, freedom from rerevision due to instability did not significantly differ as well (100 Versus. 98.1%, P = .683). In the P-rTKA cohort, freedom from all-cause and aseptic revision of preserved components was 96.1% and 98.7% at the 2-year follow-up. CONCLUSION:Compared to F-rTKA, P-rTKA yielded similar functional outcomes and implant survivorship with shorter surgical time. When indications and component compatibility allow for such a procedure, surgeons can expect good outcomes when performing P-rTKA.

INTRODUCTION/BACKGROUND:Previous studies have shown lower morbidity and mortality rates after total hip arthroplasty (THA) at academic teaching hospitals. This study sought to determine the relationship between hospital teaching status and patient-reported outcome measures (PROMs) following primary THA. METHODS:Using American Joint Replacement Registry data from 2012 to 2020, 4,447 primary, elective THAs with both preoperative and one-year postoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) scores were analyzed. The main exposure variable was hospital teaching status, with three cohorts: major teaching hospitals; minor teaching hospitals; and non-teaching hospitals. Mean preoperative and one-year postoperative HOOS, JR scores were compared. RESULTS:Preoperative HOOS, JR scores (non-teaching: 49.69±14.42 vs. major teaching: 47.68±15.10 vs. minor teaching: 42.46±19.19, P<0.001) were significantly higher at non-teaching hospitals than major and minor teaching hospitals, and these differences persisted at one-year postoperatively (87.40±15.14 vs. 83.87±16.68 vs. 80.37±19.27, P<0.001). Both preoperative and postoperative differences in HOOS, JR scores were less than the Minimum Clinically Important Difference (MCID) at both time points. In multivariate regressions, non-teaching and minor teaching hospitals had similar odds of MCID achievement in HOOS, JR scores compared to major teaching hospitals. CONCLUSION/CONCLUSIONS:Using the HOOS, JR score as a validated outcome measure, undergoing primary THA at an academic teaching hospital did not correlate with higher postoperative HOOS, JR scores or greater chances of MCID achievement in HOOS, JR scores compared to non-teaching hospitals. Further work is required to determine the most important factors that may lead to improvement in patient-reported outcomes following THA.

INTRODUCTION/BACKGROUND:The optimal administration of dexamethasone for postoperative pain management and recovery following primary, elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS:A retrospective review was conducted of 2,256 primary elective THA, and 1,951 primary elective TKA between May 2020 and April 2021. Patients who received two perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received one perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores. RESULTS:The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48 hour and 48 to 72 hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60 hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48 hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION/CONCLUSIONS:The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control.

BACKGROUND:Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success. METHODS:We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months. RESULTS:After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant. CONCLUSION/CONCLUSIONS:Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.

INTRODUCTION/BACKGROUND:Selective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. METHODS:We retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 FB and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had fixed-bearing (FB) and DM implants. Cases were then stratified into three groups based on the attending surgeon's rate of DM utilization (≤1, 1 to 10, or >10%) and outcomes were compared. RESULTS:There were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0 to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1 to 10% of cases, and 7 (10%) in >10% of cases. The 90-day rates of readmission (7.3 vs 7.6 vs 7.2%, P=0.7) and reoperation (3.4 vs 3.9 vs 3.8%, P=0.3), as well as readmission for instability (0.5 vs 0.6 vs 0.8%, P=0.2) and reoperation for instability (0.5 vs 0.5 vs 0.8%, P=0.6), did not statistically differ between cohorts. CONCLUSION/CONCLUSIONS:Selective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (i.e., surgical approach, computer navigation, robotic assistance, and large diameter fixed-bearings) may have masked any benefits of selective DM use.

BACKGROUND:This multicenter randomized controlled trial evaluated if dual-mobility bearings (DM) lower the risk of dislocation compared to large femoral heads (≥36 mm) for patients undergoing revision total hip arthroplasty (THA) via a posterior approach. METHODS:A total of 146 patients were randomized to a DM (n = 76; 46 mm median effective head size, range 36 to 59 mm) or a large femoral head (n = 70; twenty-five 36 mm heads [35.7%], forty-one 40 mm heads [58.6%], and four 44 mm heads [5.7%]). There were 71 single-component revisions (48.6%), 39 both-component revisions (26.7%), 24 reimplantations of THA after 2-stage revision (16.4%), seven isolated head and liner exchanges (4.8%), four conversions of hemiarthroplasty (2.7%), and 1 revision of a hip resurfacing (0.7%). Power analysis determined that 161 patients were required in each group to lower the dislocation rate from 8.4 to 2.2% (power = 0.8, alpha = 0.05). RESULTS:At a mean of 18.2 months (range, 1.4 to 48.2), there were three dislocations in the large femoral head group compared to two in the DM cohort (4.3 versus 2.6%; P = .67). One patient in the large head group and none in the DM group were successfully treated with closed reduction without subsequent revision. CONCLUSION/CONCLUSIONS:Interim analysis of this randomized controlled trial found no difference in the risk of dislocation between DM and large femoral heads in revision THA, although the rate of dislocation was lower than anticipated and continued follow-up is needed.