Faculty Bibliography

BACKGROUND:Periprosthetic joint infection (PJI) remains one of the most challenging complications after total joint arthroplasty (TJA). While conventional culture remains the standard for identification of causative pathogens in PJI, rapid identification techniques such as polymerase chain reaction (PCR) are becoming increasingly popular, with little comparative data. METHODS:A retrospective review was performed on a database of consecutive patients who underwent workup for PJI at a tertiary referral center from January 1, 2023, to May 31, 2025. Patients who underwent both standard synovial fluid culture and a PCR panel on the same day were included. Synovial fluid culture was used as the reference standard, and test result concordance and turnaround time were assessed. RESULTS:Results from the PCR panel showed strong agreement with synovial fluid culture in the 225 cases analyzed, with 88% culture-positive agreement. The PCR false negatives were due to organisms not included in the PCR panel (n = six), a false-positive culture from contamination (n = one), and a patient who had a PJI due to Candida parapsilosis (n = two). When only considering true positives with organisms included in the panel, the PCR displayed a 97.1% culture-positive agreement. The panel also detected organisms in eight culture-negative cases (94.7% culture-negative agreement). Those cases each met the 2018 International Consensus Meeting definition of PJI, were treated as PJIs, and their negative culture results were hypothesized to be due to antibiotic use before culture. The panel's turnaround time (TAT) (median 8.4 hours) is significantly faster than both culture-positive (P < 0.001) (69.2 hours) and culture-negative (P < 0.001) (139.5 hours) results from synovial fluid culture. CONCLUSIONS:The high concordance between the panel and conventional culture techniques suggests that PCR may be added as an adjunctive diagnostic tool for PJI workup after TJA. Our results also suggest that PCR may be more accurate than fluid culture in patients who have current antibiotic usage. The PCR's advantage of rapid TAT is particularly helpful in the timely optimization of antibiotic therapy.

BACKGROUND:The increasing prevalence of chronic antithrombotic medication use among aging and medically complex total joint arthroplasty (TJA) patients poses major challenges, requiring a careful balance of thrombotic and bleeding risks. METHODS:This review aimed to summarize existing guidelines and supporting literature surrounding the perioperative management of chronic antithrombotics in patients undergoing TJA and identify remaining gaps and challenges to guide future research efforts. RESULTS:Current guidelines strongly recommend continuing aspirin throughout the perioperative period for TJA patients while advising the cessation of P2Y12 inhibitors and anticoagulants preoperatively, with specific timing dependent on patient- and procedure-related risks. There remains a critical gap in high-quality evidence and standardized guidelines regarding optimal postoperative resumption of chronic antithrombotics, leading to wide variability in practices and reliance on surgeon judgment. CONCLUSIONS:Future research efforts should prioritize developing evidence-based perioperative protocols tailored specifically for TJA patients on chronic antithrombotic therapy, similar to existing multidisciplinary guidelines for immunosuppressive management.

BACKGROUND:Obesity is a known risk factor for complications after total hip arthroplasty (THA), with societal guidelines recommending surgical delay for patients above body mass index (BMI) targets. Consequently, patients are motivated to reach BMI targets before the office visit, discussing surgical booking. Our study investigates BMI fluctuations between surgical booking and the surgery date and whether these fluctuations have implications for peri- and postoperative outcomes. METHODS:We retrospectively reviewed our institutional database for elective, primary, unilateral THA from 2015 to 2024 with a minimum 90-day follow-up. The cohort was stratified into three groups by percent BMI change from booking date to THA date: Group 1, decrease in BMI; Group 2, 0 to 5% increase in BMI; and Group 3, > 5% increase in BMI. Baseline demographic factors, as well as peri- and postoperative outcomes, were compared. A multivariate regression analysis evaluated risk factors for interval change in BMI. We reviewed 10,400 THA patients who had an average 62-day delay between booking and surgery dates, where 44.2, 42.2, and 13.6% were allocated to Groups 1, 2, and 3, respectively. RESULTS:Operative time, length of stay, and discharge to a rehab facility were significantly higher in Group 3 compared to the others. There were no significant differences seen in 90-day outcomes, including emergency department (ED) visits, readmissions, or revision rates. Multivariate regression analyses identified that elevated BMI at the time of surgery predicted increased septic revision incidence (OR [odds ratio]: 1.1, P < 0.001). Surgical delay and BMI change between booking and surgery did not influence all-cause and septic revision rates. CONCLUSION/CONCLUSIONS:Our study is the first to evaluate preoperative BMI fluctuations between the booking date and surgery date. We found that most patients (55.8%) gained weight, with 13.6% increasing > 5% BMI. Importantly, these weight changes do not impact short-term complications or revision rates, comforting THA surgeons who see interval weight gain on the day of surgery.

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

BACKGROUND:Historically, total knee arthroplasty (TKA) used resection and balancing techniques to target symmetric medial and lateral gaps throughout range of motion (ROM). With modern awareness on alternate alignment concepts, one area of ongoing debate is whether asymmetric medial and lateral compartment gaps improve outcomes. Proponents of an asymmetric looser lateral compartment gap philosophy postulate that this phenotype recreates native knee kinematics with lateral femoral condylar rollback pivoting through a tighter medial compartment during knee flexion. The purpose of this study was to compare patient-reported outcomes (PROs) and ROM with respect to symmetric or asymmetric gaps. METHODS:We performed a systematic review and random-effects meta-analysis of prospective and retrospective studies. We compiled all comparative studies reporting symmetric and asymmetric gaps, irrespective of directional or nondirectional gap asymmetry. However, we performed a meta-analysis only between a cohort of directional asymmetric gaps (looser lateral than medial gap) and symmetric gaps (equal medial and lateral gaps). Gaps were compared in flexion and extension. ROM and PROs were evaluated through standardized mean difference (SMD), with statistical significance defined by 95% confidence interval (CI). RESULTS:A total of 17 studies with 3,319 knees were included. Four studies reported nondirectional gap asymmetry, whereas 13 studies reported directional gap asymmetry, of which 8 shared common outcome variables and were therefore included in the meta-analysis. Analysis of gaps in flexion revealed significantly increased ROM favoring asymmetric looser lateral gaps over symmetric gaps (SMD -0.19, 95% CI -0.29 to -0.09). Analysis of gaps in extension also revealed increased ROM favoring asymmetric looser lateral gaps (SMD -0.10, 95% CI -0.36 to 0.16). Finally, the Forgotten Joint Score (FJS) favored looser lateral gaps in flexion over symmetric gaps (SMD -0.13, 95% CI -0.41 to 0.15). However, differences in the latter 2 were nonsignificant. CONCLUSION/CONCLUSIONS:This is the first meta-analysis evaluating the postoperative outcomes as a function of symmetric vs. asymmetric mediolateral gaps. We report improved FJS and ROM favoring asymmetric looser lateral gaps in flexion. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II, systematic review of Level II and III and IV studies. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Large-diameter head total hip arthroplasty (LDH-THA) emerged in the late 1990s as a stemmed alternative to hip resurfacing arthroplasty (HRA). Both procedures use metal-on-metal (MoM) bearings to permit larger heads, lower dislocation risk, and optimize function in younger, active patients. While concerns over metal ion release and adverse local tissue reactions curtailed MoM use, long-term follow-up remains critical for the substantial population with these devices in situ. This review compares LDH-THA and HRA in clinical outcomes, metal ion levels, and revision rates to guide long-term management and future implant design. METHODS:PubMed, Embase, and Scopus were searched for studies reporting patient-reported outcomes, metal ion levels, or revision rates for both LDH-THA and HRA. The risk of bias was assessed using the Methodological Index for Non-Randomized Studies score. Random-effects meta-analysis evaluated revision risk; cobalt and chromium levels; University of California, Los Angeles (UCLA) activity; Harris-Hip Scores (HHS); Oxford Hip Scores (OHS); and Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS:Of 221 studies, 21 met inclusion criteria, including 5,545 LDH-THAs and 3,197 HRAs. The unweighted pooled revision rate was 16% for THA and 7.8% for HRA. Meta-analysis showed higher cobalt (standardized mean difference [SMD] 1.07) and chromium (SMD 0.53) levels in THA. Revision risk (odds ratio 1.75), UCLA (-0.44), and HHS (-0.32) favored HRA, though not significantly. CONCLUSION/CONCLUSIONS:Although the usage of large-head MoM THA is largely historic, our findings suggest that MoM hip resurfacing arthroplasty has a more favorable outcomes profile with reduced systemic metal ion exposure, reinforcing its role in younger, active patients, where conventional or large-head THA may fall short. LEVEL OF EVIDENCE/METHODS:Level III, systematic review of Level I, II, and III studies. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:10 years after changing our institution's total hip arthroplasty (THA) preoperative antibiotic prophylactic protocol by adding gram-negative (GN) coverage, this study aimed to assess the impact of adding GN specific coverage (GNSC) prior to THA on periprosthetic joint infection (PJI) rates. METHODS:This was a retrospective case-control study of 14,598 patients who underwent primary, elective THA between July 2012 and January 2022, with minimum 1-year follow-up. All patients were under perioperative antibiotic protocol that included GNSC with either weight-based gentamicin or aztreonam (+GNSC) and were compared to a historical control group of patients for which the antibiotic prophylactic protocol did not include GNSC (-GNSC). PJI and nephrotoxicity rates, as well as the severity of nephrotoxicity according to the RIFLE criteria, were compared between the study populations and 4122 controls. RESULTS: = 0.567), which are the two more severe forms of nephrotoxicity, were comparable between the groups. CONCLUSIONS:The addition of gentamicin or aztreonam prior to THA reduces the incidence of GN-related PJIs. Increased nephrotoxicity rates were limited to the mildest form, usually associated with reversibility and favourable outcomes.