Faculty Bibliography

INTRODUCTION/BACKGROUND:An extended trochanteric osteotomy (ETO) is used in complex cases to enhance access to the femoral canal and aid implant and cement removal during revision total hip arthroplasty (RTHA). However, there is no consensus regarding postoperative rehabilitation protocols. The aim of this study was to assess the efficacy and safety of immediate weight-bearing (WB) protocols in patients undergoing ETO during RTHA. METHODS:A multicenter retrospective review was conducted at two academic medical centers between 2014 and 2021 to identify patients undergoing an ETO during RTHA with a minimum 1-year follow-up. Thirty-nine patients underwent an immediate WB protocol postoperatively. Union rates, ambulatory status, 90-day orthopaedic-related complications, revision surgeries, revisions, and Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) scores were collected. RESULTS:Fifty-three patients were included in the final analysis. The average follow-up time was 15.8 ± 20.4 months, with a mean age of 63.7 ± 11.5 years. Bony union was achieved in 46 patients (86.8%). The mean earliest time to union was 4.2 ± 5.4 months. Average HOOS JR scores significantly improved from preoperative to 1-year follow-up (mean 16.4 ± 4.1 vs 3.5 ± 4.2), P ≤ 0.000001). At the final follow-up, ambulatory status improved, with fewer patients kept as non-weight bearing (11 (21.6%) versus 7 (15.2%)). Two complications (3.8%) due to deep infection, 5 revision surgeries (9.4%), and 6 revisions (11.0%) were observed within 90 days. CONCLUSION/CONCLUSIONS:Most patients who underwent ETO during RTHA and were placed on an immediate WB protocol achieved union at 4.2 months on average. HOOS JR scores improved as early as 2 weeks. More importantly, a greater proportion of patients experienced an improved ambulatory status at the final follow-up. These findings suggest that an immediate WB protocol-particularly WBAT-may be effective and safely implemented in patients undergoing an ETO during RTHA. LEVEL OF EVIDENCE/METHODS:Level III retrospective cohort comparison study.

BACKGROUND:Complications of hip resurfacing arthroplasty (HRA) may require conversion to total hip arthroplasty (THA). While well-fixed acetabular components are often retained during conversion, data on implant survival and associated risks are limited. This study evaluated implant-related outcomes, survivorships, and complications in patients who undergo HRA to THA conversion with acetabular component retention. METHODS:A retrospective review of 40 patients having undergone conversion from HRA to THA was conducted. Patients were included if the original HRA acetabular component was retained, provided they had at least one year of clinical follow-up. Demographics, perioperative variables, implant characteristics, and clinical outcomes were collected via chart review. The mean time to conversion was 8.2 years (range, 0.1 to 14.2) with an average of 4.1-years of follow-up (range, 1.0 to 10.9). Common indications for conversion included metallosis (40.0%), mechanical loosening (32.5%), and periprosthetic fracture (22.5%). Most cases (97.5%) were converted to dual-mobility constructs. RESULTS:There were six patients (15.0%) who underwent subsequent reoperation following conversion, including three for infection, one for dislocation, and two for aseptic stem loosening. Kaplan-Meier analysis demonstrated an all-cause revision-free survivorship of 90.0% at one year and 81.2% at 10 years, with aseptic survivorship of 88.5% and acetabular component survivorship of 100% through final follow-up. CONCLUSION/CONCLUSIONS:Conversion of HRA to THA with retention of a well-fixed acetabular component and conversion to a dual-mobility construct provides durable survivorship up to 10 years (mean follow-up: 4.1 years). However, the rates of periprosthetic joint infection (PJI) and reoperation are more aligned with those seen in revision THA than primary THA, emphasizing the need for careful patient selection and transparent preoperative counseling. These findings highlight that while this approach can be an effective option for failed hip resurfacing, appropriate caution is warranted to mitigate the elevated risks of infection and reoperation in this cohort.

BACKGROUND:Nonmodular dual mobility (DM) articulations in total hip arthroplasty (THA) aim to reduce dislocations through a large outer bearing diameter while minimizing wear via a smaller inner bearing where most motion occurs. Although routine use remains uncommon in the United States, this construct may protect against dislocation. This study aimed to evaluate clinical outcomes of a cementless, nonmodular DM acetabular cup at a mean follow-up of two years. METHODS:We conducted a single-arm retrospective review of 604 primary, elective THAs using a cementless nonmodular DM acetabular cup between April 2017 and August 2024 at a single health system with at least 90 days of follow-up. All surgeries were performed by a single hip surgeon via posterior approach. Cases were planned using digital templating and performed with manual instruments without enabling technology. Clinical outcomes were collected, including 90-days readmission and revision rates, reasons for readmission and revision, and dislocation rates. RESULTS:At a mean follow-up of 2.0 years (range, 0.25 to 8.0), all-cause and aseptic acetabular cup implant survivorship was 99.8%. There were six revisions during the study period. There was one acetabular component (0.2%) that was revised due to cup dissociation from the pelvis. The remaining revisions included two for periprosthetic femoral fracture (0.3%), one for femoral loosening (0.2%), and two for acute periprosthetic joint infection (0.3%), none of which involved revision of the acetabular cup. There were no dislocations observed, and no patients required revision for instability. CONCLUSIONS:Cementless nonmodular DM acetabular cups offered excellent clinical outcomes in primary THA at a mean follow-up of 2.0 years, with no observed dislocations in 604 cases and high implant survivorship. These findings support the use of nonmodular DM implants as a viable option to achieve THA implant stability and durable fixation even when using a posterior approach without enabling technology.

BACKGROUND:Postoperative improvement in patient-reported outcomes is a key measure of total hip arthroplasty success. The Minimum Clinically Important Difference (MCID) represents the smallest improvement perceived as beneficial. Distribution-based MCIDs have been criticized for producing thresholds smaller than anchor-based values, questioning their clinical relevance. We hypothesized they may capture early biological recovery signals associated with subsequent patient-reported outcomes and aimed to determine whether failure to achieve an early distribution-based MCID (seven to 31 days) was associated with failure to achieve a late anchor-based MCID (90 to 365 days). METHODS:This retrospective cohort study included patients undergoing primary unilateral total hip arthroplasty for osteoarthritis from January 1, 2021, to January 1, 2025, comprising 844 patients. Patients were included if they completed 'Hip disability and Osteoarthritis Outcome Score, Joint Replacement' questionnaires preoperatively, at seven to 31 days, and at 90 to 365 days. Distribution-based MCID was defined as a ≥ 7.8-point improvement, and anchor-based MCID as ≥ 23 points. Multivariable regression assessed associations between early distribution-based and late anchor-based MCID failure, adjusting for demographics and clinical factors. RESULTS:In the early period (seven to 31 days), 565 patients (67.0%) achieved the distribution-based MCID, whereas 573 (67.9%) achieved the late anchor-based MCID (90 to 365 days). Among patients who failed to attain an early distribution-based MCID, 54.1% (151 of 279) also failed the late anchor-based MCID, compared with 21.2% (120 of 565) among early achievers (P < 0.001). Early distribution-based MCID failure was a strong independent predictor of late anchor-based MCID failure (odds ratio: 2.61; 95% confidence interval: 1.85 to 3.68; P < 0.001). Higher baseline Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores and facility-based discharge were also independently associated with late failure (P < 0.05). CONCLUSIONS:Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year. Early distribution-based MCID attainment may represent an important prognostic marker, enabling timely clinical intervention.

BACKGROUND/UNASSIGNED:Periprosthetic joint infections (PJIs) following primary and revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) have been studied, but a contemporary large-scale analysis of incidence has not been performed. This study assessed PJI incidence and trends for TKA, THA, rTKA, and rTHA using a contemporary database. METHODS/UNASSIGNED:Epic Cosmos database was retrospectively queried (2015-2023). Current procedureal terminology codes identified patients: 27447 (TKA), 27130 (THA), 27486 (rTKA one component), 27487 (rTKA both components), 27134 (rTHA both components), 27137 (rTHA acetabular component), and 27138 (rTHA femoral component). PJI rates were identified using International Classification of Diseases 9/10 codes and analyzed using linear regression. RESULTS/UNASSIGNED:= .08). CONCLUSIONS/UNASSIGNED:Significant PJI reduction after primary TKA and THA was observed over the last decade, but infection rates remained stable in revision cohorts. Further investigations are required to assess underlying reasons for observed PJI rate reductions following primary arthroplasty.

BACKGROUND:The impact of body mass index (BMI) on outcomes after total knee arthroplasty (TKA) is a highly debated topic. Our study aims to investigate the implications of BMI changes from the day of surgical booking to the surgery date on perioperative and postoperative outcomes. METHODS:We retrospectively reviewed patients who underwent elective, primary, unilateral TKA at an urban academic institution from 2015-2024 with a minimum 90-day follow-up. The cohort was classified into three groups by percent BMI change from surgical booking date to TKA date: Group 1, decrease in BMI; Group 2, 0-5% increase in BMI; and Group 3, > 5% increase in BMI. Propensity-score matching (1:1:1) based on age, gender, BMI at surgical booking, and smoking status was performed; perioperative and postoperative outcomes were compared. Multivariate regression analysis evaluated risk factors for interval change in BMI. RESULTS:Before matching, 12,990 patients were included, with 39.6% in Group 1, 41.2% in Group 2, and the remaining 19.2% in Group 3. Notably, Group 3 had the longest length of stay (50.3 h vs. 48.6 [1] & 47.1 [2]; P = 0.002) and the lowest discharge-to-home rates (88.7% vs. 89.8% [1] & 91.7% [2]; P = 0.014). No significant difference was seen in 90-day ED visits, 90-day readmissions, or revision rates. Logistic regression of the pre-match cohort found that prolonged surgical booking delays were associated with decreased all-cause revisions (OR = 0.98; P = 0.038), while percent BMI change in this period did not impact revision incidence. Duration of surgical booking delay had no impact on BMI changes in obese patients. CONCLUSION/CONCLUSIONS:Our study evaluated preoperative BMI change between surgical booking and TKA, finding that most patients (60.4%) gain weight during this time. While patients with significant BMI increases (> 5%) had longer hospital stays and lower discharge-to-home rates, Percent BMI change during this period did not impact all-cause or septic revision incidence.

The use of technology in adult reconstruction (AR) reflects a balance of perceived utility, workflow considerations, and training exposure. This study evaluated whether exposure to technology during residency and fellowship training influences early-career AR surgeons’ utilization of and attitudes towards technology in total joint arthroplasty (TJA). An online survey was distributed to a nationwide cohort of 51 AR surgeons who completed fellowship between 2011 and 2022 at 13 U.S. programs. Survey items assessed exposure to technology during training, utilization, and perceived impact of technology on clinical practice. 36 surgeons (71%) reported using technology in fewer than half their training cases (< 50% group), while 15 (29%) reported use in the majority of cases (> 50% group). Most surgeons (88%) reported access to technology in their current practice, with no statistically significant difference between training exposure groups (p = 0.999). Similarly, among those with access, most surgeons (78%) reported using technology in their current practice, with no statistically significant difference between training groups (p = 0.238). However, surgeons with greater exposure rated the importance of technology in TJA and its impact on patient outcomes significantly higher (p = 0.003 for both). Greater exposure to technology during training was thus associated with higher perceived value, though no significant differences in access or utilization in early practice were observed.

BACKGROUND:The impact of postoperative antithrombotic therapy (ATT) on complications such as periprosthetic joint infection (PJI) after total knee and hip arthroplasty (TKA and THA, respectively) remains understudied. We aimed to evaluate temporal trends in ATT use and the association between ATT type and PJI following primary TKA and THA. METHODS:We retrospectively reviewed 20,376 TKA and 16,076 THA patients receiving postoperative ATT between 2013 and 2025. Trends in ATT use were analyzed for all patients, but PJI incidence (2018 International Consensus Meeting definition) was assessed only in patients who had a minimum 90-day follow-up (14,663 TKA; 11,445 THA). Of these, 0.8% and 1.3% developed a PJI, respectively. Multivariate logistic regressions adjusted for age, sex, body mass index, smoking, and the Charlson Comorbidity Index were applied to assess the association between ATT and PJI. RESULTS:From 2013 to 2025, aspirin monotherapy increased to account for the majority of prophylaxis (TKA: 2.0 to 59.4%; THA: 3.1 to 82.2%). In contrast, the use of low-molecular-weight heparin (LMWH) declined (TKA: 87.6 to 0.8%; THA: 86.7 to 2.3%), as did warfarin (TKA: 4.1 to 0.3%; THA: 3.4 to 0.9%) and rivaroxaban (TKA: 6.8 to 4.2%; THA: 8.9 to 2.8%). During the same period, apixaban use increased (TKA: 0 to 10.0%; THA: 0 to 12.7%). Aspirin monotherapy was associated with lower odds of PJI compared to non-aspirin regimens (adjusted odds ratio [OR] 0.60, 95% confidence interval [CI] 0.45 to 0.81, P = 0.001). Conversely, warfarin (OR 8.01, 95% CI 3.41 to 18.88, P < 0.001) and LMWH (OR 1.89, 95% CI 1.35 to 2.64, P < 0.001) were independently associated with increased PJI risk in THA. CONCLUSION/CONCLUSIONS:Aspirin has become the dominant postoperative ATT agent. In THA, aspirin is associated with a significantly decreased risk of PJI compared to potent anticoagulants like warfarin and LMWH, while no such association was found in the TKA cohort. Surgeons should prioritize aspirin to minimize postoperative infection risk.

INTRODUCTION/BACKGROUND:Press-fit acetabular components achieve long-term fixation through osseointegration, yet the extent of bone ingrowth necessary for durable stability in well-functioning implants remains unclear. Postmortem retrievals provide a unique opportunity to directly assess the bone-cup interface in clinically successful total hip arthroplasties (THAs). This study evaluated osseointegration and biomechanical fixation strength in deceased-donor acetabular components to better define the characteristics of stable long-term fixation. METHODS:Cadaver pelvis specimens containing uncemented THAs from a single institution were evaluated. There were 29 acetabular components that underwent axial pull-out testing using a universal testing machine. A total of seven of these were additionally processed for histologic evaluation, including dehydration, acrylic embedding, thin-sectioning, staining, and digital imaging. Osseointegration was quantified by bone-area fraction occupancy (%BAFO), representing the proportion of bone occupying the porous thread spaces of the cup. RESULTS:All 29 specimens failed through fracture of the ilium rather than at the bone-cup interface, indicating that the mechanical integrity of the osseointegrated construct exceeded that of the surrounding bone under axial tension. Among the seven histologically analyzed components, %BAFO ranged from 4.2 to 27.0% (mean 15.1%), despite all implants being clinically stable at the time of death. There were no significant linear correlations observed between %BAFO and time implanted, fracture load, or body mass index. A significant quadratic relationship between %BAFO and age was identified, peaking near 81 years. CONCLUSIONS:Cementless acetabular components exhibited strong fixation despite modest osseointegration, with failure occurring through host bone on axial testing. Durable biological fixation appears achievable with limited, but mechanically favorable bone ingrowth.

INTRODUCTION/BACKGROUND:Given the severe morbidity, mortality, and substantial cost of periprosthetic joint infection (PJI), substantial research has been conducted to compare peri- and postoperative infection-prevention strategies. To our knowledge, there are no studies to date that have evaluated the one-year efficacy of intraoperative vancomycin powder and/or dilute povidone-iodine (DPI) lavage versus saline lavage in total joint arthroplasty. We previously reported no significant group differences at three months in a large multicenter randomized controlled trial. The present study reports 1-year outcomes of the same cohort. METHODS:In this prospective, multicenter trial, 2,053 high-risk patients undergoing primary, unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomized to one of four intraoperative protocols: vancomycin powder, DPI, VPIP (combination), or saline lavage control. The primary outcome was 1-year PJI resulting in septic revision surgery. Analyses were conducted on a per-protocol basis using Chi-square tests stratified by procedure. At one year, complete follow-up was available for 798 THA and 1,032 TKA patients after accounting for withdrawals, loss to follow-up, and nine unrelated deaths. RESULTS:In the THA cohort, PJI occurred in 0.5% of vancomycin patients, 1.7% of iodine patients, 1.9% of VPIP patients, and 1.1% of saline patients (P = 0.62). In the TKA cohort, PJI occurred in 1.6% of vancomycin patients, none of the iodine patients, 2.0% of VPIP patients, and 0.4% of saline patients (P = 0.05). There were no significant differences between study groups at zero to three months (P = 0.14 for THA, P = 0.13 for TKA), three to 12 months (P = 0.67 for THA, P = 0.80 for TKA), or combined zero to 12 months (P = 0.62 for THA, P = 0.05 for TKA). CONCLUSIONS:There were no significant differences in 1-year PJI rates observed across prophylactic strategies in high-risk primary THA or TKA. These findings suggest that intraoperative antiseptic and antibiotic protocols may have limited influence on longer-term outcomes.