Faculty Bibliography

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: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.

INTRODUCTION/BACKGROUND:Arthrofibrosis remains a common cause of patient dissatisfaction and reoperation after total knee arthroplasty (TKA). Losartan is an angiotensin receptor blocker (ARB) with inhibitory effects on transforming growth factor beta, previously implicated in tissue repair induced fibrosis, and has been studied to prevent stiffness following hip arthroscopy. This study aimed to evaluate pre- and postoperative range of motion (ROM) and the incidence of manipulation under anesthesia (MUA) following primary TKA in patients taking Losartan preoperatively for hypertension. MATERIALS AND METHODS/METHODS:A retrospective review of 170 patients from 2012 to 2020 who underwent a primary, elective TKA and were prescribed Losartan at least three months prior to surgery. All patients who were prescribed Losartan and had a preoperative and postoperative ROM in their chart were included and were matched to a control group of patients who underwent TKA and had no Losartan prescription. ROM, MUA, readmissions, reoperations, and revisions were assessed using chi-square and independent sample t tests. RESULTS:Seventy-nine patients met the inclusion criteria. Preoperative ROM was similar between patients on Losartan and the control group (103.59° ± 16.14° vs. 104.59° ± 21.59°, respectively; p = 0.745). Postoperative ROM and ΔROM were greater for patients prescribed Losartan (114.29° ± 12.32° vs. 112.76° ± 11.65°; p = 0.429 and 10.57° ± 14.95° vs. 8.17° ± 21.68°; p = 0.422), though this difference did not reach statistical significance. There was no difference in readmission, rate of manipulation for stiffness, or all-cause revision rates. CONCLUSION/CONCLUSIONS:In this study, we found that the use of Losartan did not significantly improve postoperative ROM, reduce MUA or decrease revision rates. Further prospective studies using Losartan are required to elucidate the potential effects on ROM and incidence of arthrofibrosis requiring MUA. LEVEL III EVIDENCE/METHODS:Retrospective cohort study.

BACKGROUND:Modern fluted titanium-tapered stems (FTTS) have been increasingly utilized to achieve primary stability in conversion and revision total hip arthroplasty with major femoral bone loss. This study sought to determine the radiographic and clinical outcomes of a monoblock FTTS in patients who had major femoral bone loss. METHODS:A multicenter retrospective observational study of all total hip arthroplasty patients who received a monoblock FTTS who had up to 5-year radiographic follow-up was conducted. Only patients with femoral Paprosky classifications of IIIa, IIIb, and IV were included. Eighty-one monoblock FTTS were examined. Median clinical follow-up was 29 months (range, 18 to 58). Stem subsidence and loosening were assessed on most recent radiographs. All-cause revisions and stem survivals were assessed. RESULTS:Median subsidence was 1.4 millimeters (mm) (range, 0 to 15.0). Sixteen (23.9%) and 3 (4.5%) stems had subsidence greater than 5 and 10 mm, respectively. All stems not acutely revised appeared stable, without evidence of loosening, at latest follow-up. Ten hips (12.3%) required reoperations. Of these, only 5 (6.2%) stems were removed; 4 due to periprosthetic joint infection and 1 for surgical exposure during acetabular revision. Kaplan-Meier analyses yielded an all-cause stem survivorship of 95.1% at 2-years and 87.1% at 4-years. Stem survivorships excluding septic causes was 98.8% at both 2 and 4 years. CONCLUSION/CONCLUSIONS:Monoblock FTTS in complex femoral reconstruction cases showed encouraging clinical and radiographic results in patients who had severe femoral bone loss at median 29 months follow-up.

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.

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.

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:Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. METHOD/METHODS:This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. RESULTS:Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). CONCLUSIONS:Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III. CLINICAL RELEVANCE/CONCLUSIONS:This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Larsen syndrome is a rare genetic disorder characterized by weak connective tissues and various musculoskeletal abnormalities. This is a case report of a 39-year-old patient with Larsen syndrome who presented with over a decade of bilateral hip pain and difficulty ambulating. This patient has a prior history of bilateral congenital hip dislocations that were treated with open reduction and spica casting as a child with good result. Years later, she went on to develop bilateral hip osteoarthritis with significant remodeling of the proximal femur. The goal of this case presentation is to demonstrate the utility of total hip arthroplasty for this patient and discuss surgical challenges and considerations.