Faculty Bibliography

The Food and Drug Administration has only approved mobile-bearing unicompartmental knee arthroplasty (MB-UKA) to be performed with a hanging leg holder. The purpose of this study is to evaluate the impact of a supine knee position on MB-UKA performance.In total, 16 cadavers were randomized so that either the right or left knee was placed in the flexed or supine positions. One board-certified orthopaedic surgeon and three adult reconstruction fellows that attended the required Oxford partial knee instructional course performed four operations in each position. The primary outcome was final knee balance. Secondary outcomes included procedure duration, timing of individual surgical steps, implant sizes, range of motion, implant alignment, and fracture. A Students t-test was used to examine differences between positions with significance set at p < 0.05. Secondary analyses using two one-sided tests were conducted to explore equivalence between the two positions.There was no significant difference in mean final balance between supine (1.7 mm ± standard deviation [SD] = 1.5 mm) and flexed (1.3 ± 1.3 mm) positions (p = 0.390). There were also no significant differences between positions for procedure time (p = 0.497), tibia coronal alignment (p = 0.614), tibial slope (p = 0.194), femoral component sagittal alignment (p = 0.091), and fractures (n = 0). Exploratory equivalence analyses indicated that the positions were equivalent for final balance (p = 0.002).MB-UKA performed in the supine position is not significantly different from the flexed position in terms of ligament balance, overall procedure time, and radiographic appearance. These initial safety data warrant further clinical investigations and support the expansion of the surgical technique to include performing MB-UKAs in the supine position.

OBJECTIVE:To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS:We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS:The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION:This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

OBJECTIVE:To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS:We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS:The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION:This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

BACKGROUND:Concerns have been voiced regarding how surgical approach impacts risk of dislocation after total hip arthroplasty (THA). This study investigated how surgical approach impacts rate, direction, and timing of dislocations following THA. METHODS:We conducted a retrospective review of 13,335 primary THAs from 2011 to 2020 and identified 118 patients with prosthetic hip dislocation. Patients were stratified into cohorts by surgical approach used during primary THA. Patient demographics, index THA acetabular cup positioning, number, direction, timing of dislocations, and subsequent revisions were collected. RESULTS:Dislocation rate differed significantly between posterior approach (PA), direct anterior approach (DAA), and laterally-based approach (LA) (1.1 versus 0.7% versus 0.5%, P = .026). Rate of hips dislocating anteriorly was lowest in the PA group (19.2%) compared to LA (50.0%) and DAA groups (38.2%, P = .044). There was no difference in rate of hips dislocating posteriorly (P = .159) or multidirectional (P = .508) instability; notably 58.8% of dislocations in the DAA cohort occurred posteriorly. There were no differences in dislocation timing or revision rate. Acetabular anteversion was highest in the PA cohort compared to DAA and LA (21.5 versus 19.2 versus 11.7 degrees, P = .049). CONCLUSION:After THA, patients in the PA group had a slightly higher dislocation rate compared to the DAA and LA groups. The PA group had a lower rate of anterior dislocation and nearly 60% of DAA dislocations occurred posteriorly. However, with no differences in other parameters including revision rates or timing, our data suggests surgical approach may impact dislocation characteristics to a lesser degree than previous studies have suggested.

OBJECTIVE:To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS:We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS:The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION/CONCLUSIONS:This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

BACKGROUND:Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up. METHODS:Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria. RESULTS:Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA. CONCLUSIONS:A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets. LEVEL OF EVIDENCE/METHODS:Case series (IV).

BACKGROUND:Revision total knee arthroplasty (rTKA) can be performed with isolated tibial, isolated femoral, and combined tibial and femoral component exchange for different indications. Replacement of only 1 fixed component in rTKA leads to shorter operative times and decreased complexity. We sought to compare functional outcomes and rates of rerevision in patients undergoing partial and full rTKA. METHODS:This retrospective study examined all aseptic rTKA patients with a minimum follow-up of 2 years in a single center between September 2011 and December 2019. Patients were divided into two groups: full rTKA (F-rTKA) if both components (femoral and tibial) were revised and partial rTKA (P-rTKA) if only 1 component was revised. A total of 293 patients (P-rTKA = 76, F-rTKA = 217) were included. RESULTS:P-rTKA patients had significantly shorter surgical time (109 ± 37 Versus. 141 ± 44 minutes, P < .001). At mean follow-up of 4.2 (range 2.2-6.2) years, rerevision rates did not significantly differ between groups (11.8 Versus. 16.1%, P = .358). Improvements in postoperative Visual Analogue Scale (VAS) pain and Knee Injury and Osteoarthritis Scale (KOOS), Joint Replacement scores were similar as well (P = .100 and P = .140, respectively). For patients undergoing rTKA due to aseptic loosening, freedom from rerevision due to aseptic loosening was similar between groups (100 Versus. 97.8%, P = .321). For patients undergoing rTKA due to instability, freedom from rerevision due to instability did not significantly differ as well (100 Versus. 98.1%, P = .683). In the P-rTKA cohort, freedom from all-cause and aseptic revision of preserved components was 96.1% and 98.7% at the 2-year follow-up. CONCLUSION:Compared to F-rTKA, P-rTKA yielded similar functional outcomes and implant survivorship with shorter surgical time. When indications and component compatibility allow for such a procedure, surgeons can expect good outcomes when performing P-rTKA.

INTRODUCTION/BACKGROUND:Prior studies have demonstrated an association between time to revision total knee arthroplasty (rTKA) and indication; however, the impact of early versus late revision on post-operative outcomes has not been reported. MATERIALS AND METHODS/METHODS:A retrospective, observational study examined patients who underwent unilateral, aseptic rTKA at an academic orthopedic hospital between 6/2011 and 4/2020 with > 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary TKA (pTKA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared. RESULTS:470 rTKA were included (199 early, 271 late). Early rTKA patients were younger by 2.5 years (p = 0.002). The predominant indications for early rTKA were instability (28.6%) and arthrofibrosis/stiffness (26.6%), and the predominant indications for late rTKA were aseptic loosening (45.8%) and instability (26.2%; p < 0.001). Late rTKA had longer operative times (119.20 ± 51.94 vs. 103.93 ± 44.66 min; p < 0.001). There were no differences in rTKA type, disposition, hospital length of stay, all-cause 90-day emergency department visits and readmissions, reoperations, and number of re-revisions. CONCLUSIONS:Aseptic rTKA performed before 2 years had different indications but demonstrated similar outcomes to those performed later. Early revisions had shorter surgical times, which could be attributed to differences in rTKA indication. LEVEL OF EVIDENCE/METHODS:III, retrospective observational analysis.