Faculty Bibliography

Objective/UNASSIGNED:The purpose of this study was to investigate whether immediate or delayed tailored DAIR treatment based on microbial species is the optimal treatment for acute post-operative periprosthetic joint infection (PJI). Methods/UNASSIGNED:A multicenter retrospective study was conducted to identify patients who underwent debridement, antibiotics, and implant retention (DAIR) for PJI. Decision analysis modeling was employed to determine the treatment strategy that yielded the greatest patient outcome. Results/UNASSIGNED:316 patients who underwent DAIR for PJI were identified. Conclusion/UNASSIGNED:The decision analysis model determined that the optimal treatment strategy is to perform an immediate DAIR to achieve the greatest QALY outcomes in TKA and THA patients with acute PJI.

Background/UNASSIGNED:There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA. Methods/UNASSIGNED:A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used. Results/UNASSIGNED:< .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group. Conclusion/UNASSIGNED:The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.

Dual mobility constructs have become an increasingly popular option for primary and revision total hip arthroplasty. Two monoblock implants and three modular implants are available for use in the United States. Although short- and mid-term outcome data have been positive overall for these systems, each construct has unique features that the orthopaedic surgeon might consider when selecting the appropriate implant for his or her patient. In this review article, we discuss the design specifications and published literature for each dual mobility system and organize this information into a concise resource that can be easily referenced during preoperative planning.

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff's assignments to help both with the institution's efforts and our patients' needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution's and our patient demands, our leadership starts planning for the return to a new "normal".

BACKGROUND:In response to the COVID-19 pandemic, hospitals in the United States were recommended to stop performing elective procedures. This stoppage has led to the cancellation of a large number of hip and knee arthroplasties. The effect of this on patients' physical mental and economic health is unknown. METHODS:A survey was developed by the AAHKS Research Committee to assess pain, anxiety, physical function, and economic ability of patients to undergo a delayed operation. Six institutions conducted the survey to 360 patients who had to have elective hip and knee arthroplasty cancelled between March and July of 2020. RESULTS:Patients were most anxious about the uncertainty of when their operation could be rescheduled. Although 85% of patients understood and agreed with the public health measures to curb infections, almost 90% of patients plan to reschedule as soon as possible. Age and geographic region of the patients affected their anxiety. Younger patients were more likely to have financial concerns and concerns about job security. Patients in the Northeast were more concerned about catching COVID-19 during a future hospitalization. CONCLUSIONS:Patients suffering from the pain of hip and knee arthritis continue to struggle with pain from their end-stage disease. They have anxiety about the COVID-19 pandemic. Few patients feel they will be limited financially and 90% want to have surgery as soon as possible. Age and physical location of the patients affect their causes for anxiety around their future surgery.

BACKGROUND:Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS:In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS:From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION/CONCLUSIONS:Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.

Much attention has recently been focused on the relationship between the hip and spine and its contribution to postoperative instability following total hip arthroplasty. However, the terminology can be confusing. Through an understanding of spinopelvic parameters, spinopelvic motion, and the interplay between the spine and pelvis, the surgeon can plan for and decrease the risk of instability after total hip arthroplasty. This review details spinopelvic parameters that predispose to instability and guides readers in understanding spinopelvic motion as it relates to THA instability.

Limb alignment is a critically important factor to consider in the management of the patient with knee arthritis. Abnormal alignment is associated with the accelerated progression of osteoarthritis and, if not addressed at the time of surgery, may contribute to early failure of knee replacement implants. The contribution of the hindfoot to overall limb alignment has received limited attention in the context of deformity correction in total knee arthroplasty (TKA). In this review, we present evidence supporting the inclusion of the hindfoot in the consideration of overall limb alignment for TKA and propose a management algorithm.

BACKGROUND:The ideal femoral component in revision total hip arthroplasty (rTHA) remains undetermined; however, tapered, fluted, titanium (TFT) stems are now widely used with favorable results in all types of revision scenarios. With both modular and monoblock TFT stem options, neither has been proven to be superior. Femoral stem subsidence has been linked to aseptic loosening, instability, and leg length discrepancy. This study aims to assess stem subsidence of modular and monoblock TFT stems at a single urban orthopedic specialty hospital within a tertiary academic medical center. METHODS:Electronic medical records of rTHAs performed between January 2013 and March 2018 utilizing modular and monoblock TFT stems were examined. Data collected included baseline demographics, surgical indication, femoral Paprosky classification, and stem subsidence at most recent follow up (3 months to 3 years). Two-sample t-tests and chi-squared tests were used for statistical analysis. RESULTS:A total of 186 patients (106 modular, 80 monoblock) were included in the analysis. Modular stems underwent significantly greater subsidence than monoblock stems at latest radiographic follow-up (3.9 ± 2.6 vs 2.3 ± 2.5 mm, P < .001). A significantly greater proportion of modular stems underwent >5 mm of subsidence at latest follow-up (29.2% vs 11.3%, P < .001). CONCLUSION/CONCLUSIONS:Monoblock TFT stems have displayed promising clinical results in prior studies, and now have been shown to decrease the incidence of postoperative subsidence. With the potential for stem subsidence to lead to aseptic loosening, limb length discrepancy, and instability, the orthopedic surgeon should weigh the risks and benefits of utilizing modular vs monoblock TFT stems in rTHA.

BACKGROUND:Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI. METHODS:High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively. RESULTS:The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin. CONCLUSIONS:PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI. LEVEL OF EVIDENCE/METHODS:Retrospective Observational Cohort.