Faculty Bibliography

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.

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:Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants. Methods:We retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions. Results:Of the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups. Conclusion:.

BACKGROUND:Surgical site infection (SSI) after total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare expenditures. Our institution intensified hygiene standards during the COVID-19 pandemic; hospital staff exercised greater hand hygiene, glove use, and mask compliance. We examined the effect of these factors on SSI rates for primary THA (pTHA) and revision THA (rTHA). METHODS:A retrospective review was performed identifying THA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic and during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods of the pandemic. Cohorts were compared using the Chi-squared test and independent samples t-test. RESULTS:A total of 2,682 pTHA (prepandemic: 1,549 [57.8%]; pandemic: 1,133 [42.2%]) and 402 rTHA (prepandemic: 216 [53.7%]; Pandemic: 186 [46.2%]) were included. For primary and revision cases, superficial and deep SSI rates were similar before and during COVID-19. During COVID-19, the incidence of all (-0.43%, P = .029) and deep (-0.36%, P = .049) SSIs decreased between the first and second periods for rTHA. pTHA patients had longer operative times (P < .001) and shorter length of stay (P = .006) during COVID-19. Revision cases had longer operative times (P = .004) and length of stay (P = .046). Both pTHA and rTHA were discharged to skilled nursing facilities less frequently during COVID-19. CONCLUSION/CONCLUSIONS:During COVID-19, operative times were longer in both pTHA and rTHA and patients were less likely to be discharged to a skilled nursing facility. Although intensified hygienic standards may lower SSI rates, infection rates did not significantly differ after our hospital implemented personal protective guidelines and a mask mandate.

Purpose/UNASSIGNED:Computer navigation in total hip arthroplasty (THA) offers potential for more accurate placement of acetabular components, avoiding impingement, edge loading, and dislocation, all of which can necessitate revision THA (rTHA). Therefore, the use of computer navigation may be particularly beneficial in patients undergoing rTHA. The purpose of this study was to determine if the use of computer-assisted hip navigation reduces the rate of dislocation in patients undergoing rTHA. Methods/UNASSIGNED:A retrospective review of 72 patients undergoing computer-navigated rTHA between February 2016 and May 2017 was performed. Demographics, indications for revision, type of procedure performed, and incidence of postoperative dislocation were collected for all patients. Clinical follow-up was recorded at 3 months, 1 year and 2 years. Results/UNASSIGNED: < 0.05). Conclusion/UNASSIGNED:Our study demonstrates a significant reduction in dislocation rate following rTHA with computer navigation. Although the cause of postoperative dislocation is often multifactorial, the use of computer navigation may help to curtail femoral and acetabular malalignment in rTHA. Level of Evidence/UNASSIGNED:Level III: retrospective.

INTRODUCTION/UNASSIGNED:Isolated head and liner exchange in aseptic revision total hip arthroplasty (rTHA) is an appealing option rather than full acetabular component revision; however, early outcome reports suggest high rates of complications requiring re-revision. This study seeks to compare the outcomes of these procedures. METHODS/UNASSIGNED:This retrospective study assessed 124 head and liner exchanges and 59 full acetabular cup revisions conducted at a single center between 2011 and 2019 with at least 2 years of follow-up. Baseline demographics did not vary by group. Mean follow-up was 3.7 (range 2.0-8.6) years. RESULTS/UNASSIGNED:0.22) were associated with failure within 2 years. CONCLUSIONS/UNASSIGNED:In this analysis, 2-year outcomes for isolated head and liner exchange were non-inferior to full acetabular component revision. A future randomised prospective study should be conducted to better assess the optimal approach to revision in an aseptic failed hip arthroplasty.

PURPOSE/OBJECTIVE:A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS). MATERIAL AND METHODS/METHODS:This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated. RESULTS:In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge. CONCLUSION/CONCLUSIONS:Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.

BACKGROUND:Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA. METHODS:We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models. RESULTS:Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (p=0.013) in total costs. Direct costs of TKA across all insurance providers (p=0.001 and p<0.001) and total hip arthroplasty (THA) for Medicare (p=0.009) and GMM (p=0.001) plans demonstrated significant upward trends. Despite this, 2011 to 2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018 to 2021 financial data demonstrate a significant downward trend in contribution margin across Medicare (p<0.001) and GMM (p<0.001) insurers for both TKA and THA. CONCLUSION/CONCLUSIONS:Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time if further efficiency and cost-saving measures are not developed.

INTRODUCTION/BACKGROUND:Patient-reported outcome measures (PROMs) can be used to evaluate post-operative health care quality and patient satisfaction. The Patient's Joint Perception (PJP) question gathers a single PRO to measure how patients appraise their joint. This study compares PJP to the Forgotten Joint Score (FJS) at 21-months post-operation to assess its value. METHODS:A retrospective review was performed at an orthopedic specialty hospital for patients who completed both PJP and FJS questionnaires in 2020-2021 and underwent either a unilateral elective primary Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA). Spearman's correlation coefficients and p-values were calculated to determine external validity of PJP. Floor and ceiling effects were analyzed and considered significant if ≥15% of patients achieved the worst or best score (0-4 for PJP and 0-100 for FJS). RESULTS:In total, 534 patients (327 THA and 207 TKA) were surveyed at 21 months post-operation. External validity against FJS was assessed for both TKA (r=0.66, p<0.01) and THA (r=0.69, p<0.01). For TKA, the floor and ceiling effects were 0.97% and 25.12% for PJP and 3.86% and 4.83% for FJS, respectively. For THA, the floor and ceiling effects were 0.92% and 50.46% for PJP and 2.47% and 20.50% for FJS, respectively. CONCLUSION/CONCLUSIONS:PJP was correlated with FJS moderately for both TKA and THA and can be collected with less burden. However, ceiling effects were significantly higher in both TKA and THA for PJP compared with FJS. Further studies are needed to investigate the questionnaires at additional timepoints and to evaluate the implications of high ceiling effects.