Faculty Bibliography

Arthrofibrosis can be a major source of dissatisfaction for patients undergoing total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) may be offered to improve motion in selected cases. Advancements in computer-navigated and robotic-assisted technology have been championed to improve component positioning with fewer soft tissue releases. We sought to investigate whether these technologies impact MUA rates. An institutional retrospective review was conducted on 18,815 patients who underwent a primary, elective, unilateral TKA between January 2010 and December 2022. Patients were stratified into conventional (n = 12,659), computer-navigated (n = 4,071), or robotic-assisted TKA (n = 2,085) cohorts. Patient demographics and implant data, including mode of fixation and level of constraint (cruciate-retaining [CR] vs. posterior-stabilized) were collected. MUA rates were the primary outcome. Data were analyzed using analysis of variance with Tukey post hoc testing and multivariate logistic regression analysis. We report a 1.7% overall MUA rate, with a rate of 1.6% for conventional and 1.5% for navigated TKA, which were significantly lower than robotic-assisted TKA at 3.2% (p < 0.001). However, on multivariate analysis, there was no difference in MUA rates for navigated and robotic-assisted when compared with conventional techniques. Cementless and hybrid fixation and CR implant designs were higher with robotic-assisted compared with conventional and navigated TKA. Multivariate regression revealed that TKA with fully cementless (odds ratio [OR]: 1.80 [95% confidence interval [CI]: 1.16-2.78]; p = 0.008) or hybrid fixation (OR: 2.92 [95% CI: 1.77-4.81]; p < 0.001) increased the risk for future MUA. Constraint also significantly influenced MUA rates, with CR designs yielding higher MUA rates (OR: 1.51 [95% CI: 1.16-1.96]; p = 0.002). When controlling for confounding factors, navigated and robotic-assisted TKA generated comparable odds for MUA when compared with conventional techniques. However, robotic-assisted TKA were more likely to utilize cementless or hybrid fixation and CR implant constraint, each of which were independently associated with increased odds of MUA. These operative factors should be considered when risk-stratifying and counseling patients on the likelihood of MUA. LEVEL OF EVIDENCE:  III.

AIMS/UNASSIGNED:Total hip arthroplasty (THA) in the setting of proximal femoral defects and poor bone stock often necessitates distal fixation using specialized implants, such as monolithic tapered, fluted titanium stems (TFTSs), to ensure adequate stability. This study evaluates the mid-term outcomes of TFTS in both primary and revision THA. METHODS/UNASSIGNED:This was a multi-institutional retrospective review of patients who received monolithic TFTS between July 2016 and June 2020 during either complex primary THA or revision THA. Outcomes included pre-, intra- and postoperative characteristics, as well as five-year all-cause, septic and aseptic revisions, and Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) at different postoperative timepoints. RESULTS/UNASSIGNED:A total of 115 patients with a mean follow-up of 6.3 years (SD 1.2) were included. Femoral component survivorship free from aseptic revisions was 99.1% (95% CI 97.3 to 100) at 5.1 years after TFTS. Aseptic revision occurred in a single patient (0.9%) due to periprosthetic acetabular fracture that necessitated femoral component removal for exposure 60.6 months following TFTS. Survivorship from septic revisions was 93.2% (95% CI 91.5 to 99.9) at 5.3 years. Septic revisions included debridement, irrigation and exchange of modular components (n = 3, 2.6%), and two-stage revision arthroplasties (n = 4, 3.5%) at a mean of 27.7 months after surgery (1.5 to 63.9). All-cause survivorship from any revision was 92.4% (95% CI 90.5 to 100) at 5.3 years after TFTS. HOOS, JR scores improved from preoperative to five-year follow-up (46.1 (SD 20.8) to 83.8 (SD 19.0), respectively). CONCLUSION/UNASSIGNED:The TFTS demonstrates excellent mid-term survivorship (99.1% at five years) and significant clinical improvement in complex primary and revision THA. These outcomes suggest that the TFTS can be considered a valuable option in this challenging patient population.

BACKGROUND:This study examined whether the timing of total hip or knee arthroplasty (TJA) relative to elective hand surgery (HS) is associated with perioperative TJA outcomes, as both are among the most common orthopaedic procedures in the United States. METHODS:A retrospective cohort study was conducted of patients who underwent elective HS and TJA between 2011 and 2024. Patients were grouped by surgical order: HS first (HSF, n = 645) and TJA first (TJAF, n = 785). Differences between HSF and TJAF were assessed. Multivariable logistic regressions, Cox proportional hazards regressions, and linear regressions were used to adjust for patient demographics and comorbidities. The HSF patients were older (67.1 versus 64.3 years, P < 0.001), more prone to be discharged home (90.7 versus 83.8%, P < 0.001), and had a shorter length of stay (45.6 versus 60.4 hours, P < 0.001) compared to TJAF patients. RESULTS:Surgical order showed no association with 90-day emergency department visits and readmissions. Multivariable Cox regressions revealed that HSF was associated with a significantly higher hazard of aseptic revision (hazard risk (HR) = 2.65, P = 0.012). Functional TJA outcomes did not differ (P > 0.05) between groups. Although both groups improved in Patient-Reported Outcomes Measurements Information System (PROMIS) Pain Intensity and Pain Interference scores after TJA, HSF patients showed significantly less improvement in Pain Intensity at all timepoints (P < 0.05). Surgical order was not associated with improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Hip Injury and Osteoarthritis Outcome Score for Joint Replacement, or PROMIS Pain Interference scores. CONCLUSIONS:The timing of these elective surgeries is associated with TJA outcomes. While HSF is linked to a higher adjusted risk of aseptic revision, it is also independently associated with less adjusted improvement in PROMIS Pain Intensity. These findings suggest that although surgical order impacts specific recovery metrics, a patient's comorbidities may be the primary driver of complications.

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.

PURPOSE/OBJECTIVE:To investigate the incidence and risk factors for dressing-induced allergic contact dermatitis (DIACD) following total hip and knee arthroplasty (THA and TKA, respectively) across different dressings and sealants. METHODS:A retrospective review was conducted of patients who underwent primary, elective THA or TKA between 2019 and 2024 with ≥ 90 days of follow-up. Incidences of DIACD were identified by reviewing medical records for "allergy" diagnoses and use of antihistamines or corticosteroids within 30 days postoperatively. Patient characteristics, prior exposure, treatment, dressing type, and allergy history were analyzed. RESULTS:A total of 61 (0.3%) of the 23,396 investigated patients developed a DIACD on average 12.2 ± 7.3 days postoperatively. Overall, 41% had a preoperative allergy (excluding seasonal), and 55.7% were treated with topical or low-dose oral antihistamines and corticosteroids. The majority (41%) of the DIACD involved mesh-adhesive dressings, and a liquid skin adhesive (2-octyl cyanoacrylate) was also used in 41% of cases, often in combination with the primary dressing. Of the 61 DIACD patients, 24 (39.3%) had previously undergone THA or TKA, and nearly half of these (n = 11, 45.8%) had been exposed to the same dressing without prior occurrence of DIACD. DIACD patients were significantly more likely to have undergone TKA (73.8 vs. 58.3%, p = 0.015) and to have never smoked (75.4 vs. 58.4%, p = 0.014). The effect sizes of these findings were negligible (Cramer's V = 0.016 and 0.019, respectively). CONCLUSIONS:The incidence of DIACD following joint arthroplasty is low (0.3%) but remains a frustrating complication, primarily occurring two weeks postoperatively, with mesh-adhesive dressings most frequently implicated. Patients with prior exposure to dressings, those undergoing TKA, and non-smokers are at higher risk. Identifying at-risk patients can guide dressing selection and application.

The rise in solid organ transplantations (SOTs) has led to increased long-term survival and also a higher incidence of joint degenerative diseases, necessitating more total joint arthroplasties (TJAs). SOT recipients face unique challenges, including immunosuppression, infection risks, and altered bone metabolism, requiring meticulous perioperative management. Despite higher complication rates, TJAs in SOT patients provide significant pain relief and functional improvement. Preoperative evaluation, tailored antibiotic prophylaxis, and careful implant selection are crucial. Multidisciplinary collaboration is essential to optimize outcomes, reduce complications, and improve quality of life for this high-risk population.

BACKGROUND:Despite theoretical risks of fatigue wear, there is little empirical evidence correlating postoperative impact level from physical activity with failure rates following total hip and knee arthroplasty (THA and TKA). This study aimed to assess the relationship between the impact level from self-reported sports and physical activity participation and revision rates following primary arthroplasty. METHODS:A survey was conducted on recreational sports participation among primary elective THA and TKA patients from an urban, academic health system between June 1, 2011, and January 31, 2022. A total of 1,622 THA and 1,388 TKA respondents were included in the study. The survey was administered cross-sectionally at various time points, with a minimum follow-up of at least one year required for inclusion (THA, 5.3 years; TKA, 4.8 years postoperation on average). Patients were divided into four cohorts based on participation and intensity of the sport: no sports, low-impact sports, intermediate-impact sports, and high-impact sports. Descriptive comparisons were made to evaluate revision rates and mean time to follow-up among these groups in THA and TKA patients. The Kaplan-Meier method was utilized to assess 10-year implant survivability. RESULTS:Healthier and younger patients who underwent THA or TKA were significantly more likely to participate in intermediate- to high-impact sports and were found to have noninferior revision rates than those who engaged in no sports or low-impact sports: THA (2.9 [no sports] versus 1.9 [low impact] versus 1.6% [intermediate/high impact]), TKA (3.0 versus 1.6 versus 0.0%). When analyzing aseptic versus septic revisions separately, no notable patterns or differences were observed. CONCLUSIONS:At a mean 5-year follow-up, healthier and younger patients who participated in intermediate- and high-impact physical activities had noninferior revision rates as than patients who were less active. These findings offer guidance for clinicians when advising patients on the safe resumption of sports activities following total joint arthroplasty.

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.