Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this study was to identify common complications and the rates of readmission and revision in total knee arthroplasty (TKA) patients younger than 65 years. METHODS:Using the American Joint Replacement Registry, we conducted a retrospective review of all TKAs done in patients aged 18 to 65 years from 2012 to 2020. Demographic factors such as age, sex, Charlson Comorbidity Index (CCI), and preoperative Veterans RAND 12-Item Health Survey Physical Component Summary (VR-12 PCS) scores were collected. We excluded patients older than 65 years and revision, oncologic, and nonelective cases. Primary outcomes included cumulative revision rate, 90-day readmission rate, and reason for revision. Univariate analysis and the Kaplan-Meier method were used. RESULTS:Six thousand one hundred seventy-nine patients were included. The average age was 58.8 years (SD 5.5 years), 61% were female, 82% were White, and 88% had a CCI of 0 (1 = 8% and ≥2 = 4%). The mean follow-up was 42.51 months. Seventy-four patients (1.2%) underwent revision. Sixty-nine patients (1.1%) were readmitted within 90 days. No factors assessed increased revision rates. Revision-free survivorship was 98.7% (95% CI 98.4 to 99.0) and 98.6% (95% CI 98.2 to 99.0) at 5 and 8 years, respectively. Infection (15%), aseptic loosening (14%), and instability (12%) were the most common indications for revision. CONCLUSION/CONCLUSIONS:TKA done in young and presumed active patients has excellent survivorship. Long-term follow-up is needed to assess survival trends in this growing population.

INTRODUCTION/BACKGROUND:Surgeons can improve their practice by understanding potentially avoidable reasons for early revision total knee arthroplasty (rTKA). The purpose of this study is to describe potentially avoidable indications for rTKA within 5 years of the index procedure. METHODS:This retrospective observational analysis utilized the rTKA database at a large, academic orthopedic specialty hospital to identify 167 consecutive rTKA from 2014 to 2019 performed within 5 years after primary TKA (pTKA). Two fellowship-trained arthroplasty surgeons reviewed the cases to classify them as potentially avoidable or unavoidable. Unavoidable indications for rTKA included infection/wound complication, arthrofibrosis, instability due to underlying collagen disease or significant weight loss, and any traumatic event leading to pTKA failure. Potentially avoidable indications included atraumatic instability, intraoperative fracture, metal allergy, and atraumatic patellar instability or maltracking. Aseptic loosening was considered avoidable if it occurred in the presence of component malpositioning or poor cementation technique. RESULTS:There were 112 (67.1%) unavoidable cases and 55 avoidable cases (32.9%). Of the unavoidable cases, there were 68 rTKA for infection or wound complications (60.7%), 23 for arthrofibrosis (20.5%), 6 for instability (5.4%), 6 for postoperative fracture (5.4%), 6 for aseptic loosening (5.4%), and 3 for extensor mechanism pathology following trauma (2.6%). Of the potentially avoidable rTKA, 24 were for aseptic loosening (43.7%), 23 for atraumatic instability (41.8%), 6 for atraumatic extensor mechanism pathology (10.9%), 1 for nickel allergy (1.8%), and 1 for intraoperative fracture (1.8%). CONCLUSION/CONCLUSIONS:These findings indicate that over 30% of early rTKA are potentially avoidable. Interventions should focus on addressing potentially avoidable causes such as short-term aseptic loosening and instability to reduce the need for costly and resource-intensive rTKA. Level of evidence III, retrospective observational analysis.

BACKGROUND:Although several techniques and implants have been developed to address bone loss in revision total knee arthroplasty (rTKA), management of these defects remains challenging. This review article discusses the indications and management options of bone loss following total knee arthroplasty based on preoperative workup and intraoperative findings. MAIN TEXT/METHODS:Various imaging modalities are available that can be augmented with intraoperative examination to provide a clear classification of a bony defect. For this reason, the Anderson Orthopaedic Research Institute (AORI) classification is frequently used to guide treatment. The AORI provides a reliable system by which surgeons can classify lesions based on their size and involvement of surrounding structures. AORI type I defects are managed with cement with or without screws as well as impaction bone grafting. For AORI type IIA lesions, wedge or block augmentation is available. For large defects encompassing AORI type IIB and type III defects, bulk allografts, cones, sleeves, and megaprostheses can be used in conjunction with intramedullary stems. CONCLUSIONS:Treatment of bone loss in rTKA continues to evolve as different techniques and approaches have been validated through short- and mid-term follow-up. Extensive preoperative planning with imaging, accurate intraoperative evaluation of the bone loss, and comprehensive understanding of all the implant options available for the bone loss are paramount to success.

Patients undergoing total joint arthroplasty (TJA) with multiple comorbidities require medical clearance recommendations from their primary care provider, which if not adhered to can lead to adverse postoperative complications. In this quality improvement initiative, we explore the impact of a standardized handoff process incorporating medical clearance postoperative recommendations and orthopaedic-specific context on information transfer in TJA. A systematic review of quantitative and qualitative studies from 2014 to 2019 was completed to draw a conclusion about the best practice methods for the development of a standardized handoff process. Prior to implementation, evidence was reviewed to inform activities such as baseline chart audits, attainment of stakeholder input regarding handoff, exploration of wound closure equipment utilization, and standardization of a structured "smart phase" that incorporates medical clearance recommendations and orthopaedic-specific context information. After provider education was completed and the new handoff approach initiated, data were collected to compare postintervention outcomes such as transfer of information and wound kit distribution cost analysis. At baseline, 42% of patients had medical clearance postoperative recommendations handed off when they were provided. At completion, the new handoff smart phrase was used 97% for the first handoff and 100% for the second handoff. Medical clearance postoperative recommendations were captured in the electronic health record 83% of the time when they were provided. When the new smart phrases were utilized, wound closure, precautions, and postoperative void status were always handed off. Once wound closure technique was specified, bedside nurses were able to provide the appropriate wound closure removal equipment at discharge, projecting cost savings of $0.69 per case (∼234 cases per month). The use of a standardized handoff smart phrase that includes specialty specific context and postoperative medical management requirements successfully improved the information transfer between providers in a large academic orthopaedic medical center.

AIMS/OBJECTIVE:Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. METHODS:We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. RESULTS:Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). CONCLUSION/CONCLUSIONS: 2022;3(7):543-548.

Purpose/UNASSIGNED:Use of dual mobility (DM) articulations can reduce the risk of instability in both primary and revision total hip arthroplasty (THA). Knowledge regarding the impact of this design on patient-reported outcome measures (PROMs) is limited. This study aims to compare clinical outcomes between DM and fixed bearing (FB) prostheses following primary THA. Materials and Methods/UNASSIGNED:All patients who underwent primary THA between 2011-2021 were reviewed retrospectively. Patients were separated into three cohorts: FB vs monoblock-D vs modular-DM. An evaluation of PROMs including HOOS, JR, and FJS-12, as well as discharge-disposition, 90-day readmissions, and revisions rates was performed. Propensity-score matching was performed to limit significant demographic differences, while ANOVA and chi-squared test were used for comparison of outcomes. Results/UNASSIGNED:=0.608) between the groups. Conclusion/UNASSIGNED:DM bearings yield PROMs similar to those of FB implants in patients undergoing primary THA. Although DM implants are utilized more often in patients at higher-risk for instability, we suggest that similar patient satisfaction may be attained while achieving similar dislocation rates.

BACKGROUND:Demographic variables play an important role in outcomes following revision total hip arthroplasty (rTHA). Surgical and in-patient variables as well as outcomes vary between indications for rTHA. The purpose of this study was to investigate the impact of the indication for the rTHA on costs and postoperative outcomes. METHODS:This retrospective cohort analysis investigated all patients who underwent unilateral, aseptic rTHA at an academic orthopaedic specialty hospital who had at least 1-year postoperative follow-up. In total, 654 patients were evaluated and categorized based on their indication for aseptic rTHA. Demographics, direct and total procedure costs, surgical factors, postoperative outcomes, and re-revision rates were collected and compared between indications. RESULTS:Younger patients had the greatest leg length discrepancy (LLD) and older patients had the highest incidence of periprosthetic fracture (PPF) (P = .001). The greatest proportion of full revisions were found for LLD (16.7%) and head/polyethylene liner-only revisions for metallosis/adverse tissue reaction (100%). Operative time was significantly longest for LLD revisions and shortest for metallosis/adverse tissue reaction revisions (P < .001). Length of stay was longest for periprosthetic fracture and shortest for LLD and stiffness/heterotopic ossification (P < .001). Re-revision rate was greatest for implant failure and lowest for LLD. Total cost was highest for PPF (148.9%) and lowest for polyethylene liner wear (87.7%). CONCLUSIONS:Patients undergoing rTHA for indications such as PPF and aseptic loosening were associated with longer operative times, length of stay and higher total and direct costs. Therefore, they may need increased perioperative attention with respect to resource utilization, risk stratification, surgical planning, and cost-reducing measures. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.

Background/UNASSIGNED:There is considerable disparity in institutional practices surrounding routine pathologic examination of femoral heads removed during total hip arthroplasty (THA). Multiple groups have studied the merits of routine femoral head pathology in THA, without clear consensus. We sought to further investigate the existing evidence on routine pathologic examination of femoral heads retrieved during THA to determine if this practice provides additional clinical value and is cost-effective. Material and methods/UNASSIGNED:To conduct a systematic review of the literature, a medical librarian was consulted to develop and perform comprehensive searches in PubMed (1809-present), Embase (embase.com 1974-present), CINAHL (EBSCO, 1937-present), and the Cochrane Central Register of Controlled Trials (Wiley). Final searches resulted in 727 references. Through multiple reviewer screenings and assessments of eligible full-text articles, we included 14 articles for review. Results/UNASSIGNED:Our systematic review yielded pathologic examination results from 17,388 femoral head specimens collected during THA. In 0.85% of cases, the pathologic diagnosis differed in a meaningful way from the preoperative clinical diagnosis. Routine pathology changed patient management in approximately 0.0058% of cases. The average cost for pathologic examination of each specimen was $126.38. Conclusion/UNASSIGNED:Routine pathologic examination of femoral heads retrieved during THA has limited impact on patient management. With an estimated 500,000 THAs performed in 2019, the economic feasibility of routine femoral head pathology is limited at an annual cost of up to $63,000,000 and cost per quality-adjusted life-year approaching infinity. However, surgeon discretion on a patient-specific or practice-specific basis should be used to make the final determination on the need for femoral head pathology.