Faculty Bibliography

Periprosthetic joint infections (PJIs) are a devastating complication of joint arthroplasty surgeries that are often complicated by biofilm formation. The development of biofilms makes PJI treatment challenging as they create a barrier against antibiotics and host immune responses. This review article provides an overview of the current understanding of biofilm formation, factors that contribute to their production, and the most common organisms involved in this process. This article focuses on the identification of biofilms, as well as current methodologies and emerging therapies in the management of biofilms in PJI.

PURPOSE/OBJECTIVE:Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF. METHODS:Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching. RESULTS:Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively. CONCLUSION/CONCLUSIONS:Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective study.

PURPOSEOF REVIEW/OBJECTIVE:The purpose of this review is to summarize the available literature on the epidemiology, biomechanics, clinical outcomes, and complications of return to sport after TJA, as well as provide guidelines for patients' safe return to athletic activity. RECENT FINDINGS/RESULTS:As volume and indications for total joint arthroplasty (TJA) expand, arthroplasty candidates today are demographically younger, more physically active, and have higher expectations for postoperative function. Many TJA patients wish to resume sports activity that may theoretically place their reconstruction under more biomechanical stress and risk for early wear or failure. Recommendations for postoperative patient activity following TJA have historically largely been surgeon-dependent and in the context of evolving prosthetic design and surgical techniques. We endorse a three-tiered framework for return to sporting activities: (1) low-impact sports are generally recommended, (2) intermediate-impact sports are generally recommended with experience, and (3) high-impact sports are generally not recommended though activity-specific joint decisions between patient and surgeon can be made.

INTRODUCTION/BACKGROUND:Lumbar spinal fusion (LSF) and total hip arthroplasty (THA) are commonly performed in patients who have concomitant spine and hip pathology. While patients who have three or more levels fused during LSF have increased postoperative opioid consumption after undergoing THA, it is unknown whether the number of levels fused during LSF affects THA functional outcomes. METHODS:A retrospective study was conducted at a tertiary academic center for patients who underwent LSF first and then had a primary THA performed with a minimum of one-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR). Operative notes were reviewed to determine the number of levels fused during LSF. There were 105 patients who underwent one-level LSF, 55 patients underwent two-level LSF, and 48 patients underwent three-or-more level LSF. No significant differences existed in age, race, body mass index, and comorbidities between the cohorts. RESULTS:While preoperative HOOS-JR was similar among the three cohorts, patients who had three-or-more level LSF had significantly lower HOOS-JR scores than patients who had two-level or one-level LSF (71.4 vs. 82.4 vs. 78.2; P = 0.010) and a lower delta HOOS-JR (27.2 vs. 39.4 vs. 35.9; P = 0.014). Patients who had three-or-more level LSF had a significantly lower rate of achieving minimal clinically important difference (61.7 vs. 87.2 vs. 78.7%; P = 0.011) and the patient acceptable symptom state (37.5 vs. 69.1 vs. 59.0%; P = 0.004) for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively. DISCUSSION/CONCLUSIONS/CONCLUSIONS:Surgeons should counsel patients who have had three-or-more level LSF that they may have a lower rate of hip function improvement and symptom acceptability after THA, compared to patients who have had a fewer number of levels fused during LSF.

BACKGROUND:Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically, but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA. METHODS:Patients 60 years or older undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically, but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversion; 247 comparison) were analyzed for 6-, 12-, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications. RESULTS:Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7 conversion vs 6.1% non-conversion, p=0.774), 12 months (11 conversion vs 12% non-conversion, p=0.999), and 24 months (14 conversion vs 22% non-conversion, p=0.163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14 vs 3.2%, p=0.001 and medical complications (17 vs 6.1% p=0.006). Inpatient and 90-day orthopaedic complications were similar. CONCLUSION/CONCLUSIONS:Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision making.

BACKGROUND:Quality data on physical activity participation following total joint arthroplasty (TJA) are limited. The purpose of this study was to explore patient participation, outcomes, and limitations in sports/physical activities following TJA. METHODS:Patients who underwent total hip (THA) and knee arthroplasty (TKA) at a single institution from 2015-2020 were surveyed on sports/physical activity participation before and after TJA. Data were correlated with perioperative demographic and outcome scores. In total, 2,366 patients were surveyed: 788 (33.3%) underwent THA, 1,175 (49.7%) underwent TKA, and 403 (17.0%) underwent both THA/TKA. RESULTS:Participation rates were 69.2, 61.5 and 61.3% at one year prior and 86.8, 81.5, and 81.6% at five years prior to THA, TKA, and THA/TKA, respectively. Participation rates were 73.1, 72.0, and 60.8% at mean 4.0 years postoperatively. Weekly time spent (p<0.05) and exertion levels (p<0.001) increased postoperatively for all three cohorts. For all three cohorts, the most common sports/activities were recreational walking, cycling, swimming, and golf, while intermediate and high-impact activity participation decreased postoperatively. Independent predictors of postoperative sports/physical activity participation were: younger age [THA (p<0.001); TKA (p=0.010)], lower body mass index [THA (p<0.001); TKA (p<0.001)], fewer comorbidities [THA (p<0.001)], and higher postoperative HOOS-JR [THA (p=0.012)], KOOS-JR [TKA (p=0.004)], SF-12 PCS [THA (p<0.001); TKA (p<0.001); THA/TKA (p=0.004)], and SF-12 MCS [TKA (p=0.004)] scores. Activity restrictions were reported among 17.5, 20.9, and 25.1% of THA, TKA, and THA/TKA patients, respectively, and were more commonly self-imposed than surgeon-directed for all cohorts. CONCLUSION/CONCLUSIONS:Though sports/physical activity participation may improve following TJA compared to one year preoperatively, participation is decreased compared to five years preoperatively, transitions to low-impact activities, and varies among subsets of patients.

BACKGROUND:Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx). METHODS:The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA). RESULTS:563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001). CONCLUSIONS:In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

INTRODUCTION/BACKGROUND:Most geriatric hip fractures occur in the femoral neck (FN) and intertrochanteric (IT) regions of the femur, while a minority occur in the subtrochanteric (ST) region. Relative outcomes based on the anatomical subtype of fracture are not well studied. This study characterizes postoperative complications and outcomes of hip fractures distinguished by anatomic region. MATERIALS AND METHODS/METHODS:The targeted hip fracture series of the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify geriatric (≥ 65 years) patients who sustained operative FN, IT, and ST hip fractures. Primary patient demographic and perioperative data were collected and correlated with 30-day postoperative complications and outcomes. Multivariate regression was used to calculate relative risks of adverse events (AEs) between groups. RESULTS:In total, 8220 geriatric hip fracture patients were identified. Risk-adjusted 30-day mortality was not significantly different between patients with ST (5.8%, p = 0.735) and IT (7.3%, p = 0.169) femur fractures relative to those with FN fractures (6.6%). The overall risk-adjusted rate of minor and major medical AEs within 30 days and risk-adjusted rate of wound complications was not significantly different between FN, IT, and ST fractures. Patients with IT [34.4%, OR 2.35 (2.35-3.08), p < 0.001] and ST fractures [49.8%, OR 5.94 (4.58-7.70), p < 0.00] had higher risk-adjusted incidence of postoperative blood transfusion relative to FN fractures (18.5%). Furthermore, patients with IT fractures had a slightly lower risk-adjusted incidence of unplanned reoperation [2.1 vs. 2.7%, OR 0.69 (0.47-0.99), p = 0.046] and hospital readmission (7.8 vs. 9.2%, OR 0.76 [0.63-0.91], p = 0.003) than patients with FN fractures. CONCLUSIONS:With respect to anatomic region, geriatric hip fractures have similar short-term mortality and medical AE profiles with differences in transfusion, reoperation, and readmission rates. Knowledge of these short-term outcomes may guide surgeons in counseling hip fracture patients peri-operatively.

BACKGROUND:Hip resection arthroplasty (HRA) is a salvage surgical technique for the management of complex hip conditions wherein arthroplasty may be contraindicated. The purpose of this study was to review modern-day indications for HRA and compare outcomes between patients undergoing HRA and revision total hip arthroplasty (RTHA). METHODS:The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients undergoing HRA or RTHA between 2012 and 2017. Patient demographics, risk factors, and perioperative complications were analyzed. Multivariate regression was used to determine predictors of early postoperative complications. Propensity score matching (PSM) was performed to compare relative risks (RR) of complications in HRA compared to RTHA. RESULTS:290 patients underwent HRA between 2012 and 2017. Infection was the most common indication for HRA (39.8%), followed by femoral neck fracture or malunion/nonunion (26%) and prosthetic instability (12.2%). Increased body mass index (BMI) (p = 0.012) and chronic obstructive pulmonary disease (COPD) (p = 0.007) were associated with increased risk of complication in HRA. There were no significant differences in short-term complication risks between RTHA and HRA. CONCLUSIONS:HRA was associated with short-term complication rates comparable to RTHA. These findings may help in surgical decision-making and appropriate indications in the present day. LEVEL OF EVIDENCE/METHODS:III.