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/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.

INTRODUCTION/BACKGROUND:Computer-assisted navigation systems (CAS) are increasingly being integrated into total knee arthroplasty (TKA) procedures, but perceptions of associated learning curve and increased operative time continue to curtail uptake. Newer-generation navigational systems aim to streamline integration into surgical workflow to mitigate increases in operative time. Here, we assess the impact of a novel imageless CAS on operative time for TKA. METHODS:A retrospective analysis of prospectively collected data of a cohort of patients undergoing primary unilateral TKA with one of three surgeons between October 2019 and March 2020 was conducted. Consecutive cases using a novel imageless CAS were included in analysis. For each surgeon, average operative time was recorded and compared in sequential five-case cohorts to average operative time for the same procedure performed conventionally using a two-tailed t test. RESULTS:Average conventional operative times were 95.9 ± 15.0, 86.6 ± 13.7, and 116.9 ± 25.1 min for the three surgeons. Initial CAS-assisted operative times increased to 107.0 ± 9.8 (p = 0.07) and 102.4 ± 13.2 (p = 0.06) min for Surgeons 1 and 2 and decreased to 113.2 ± 9.8 min (p = 0.52) for Surgeon 3. Most recent CAS-assisted operative times were 94.8 ± 13.9 (p = 0.88), 88.7 ± 15.3 (p = 0.84), and 104.8 ± 13.2 (p = 0.12) min as compared to pre-CAS. Absolute differences for the most recent navigated procedures ranged from 12.1 min faster to 2.0 min slower. CONCLUSION/CONCLUSIONS:The learning curve for TKA navigation may be as few as 10 cases, and any associated increases in operative time may be transient and non-significant. Moreover, navigation may ultimately speed operative time, perhaps as the result of enhanced intraoperative assessment of alignment.

INTRODUCTION/BACKGROUND:The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty. MATERIALS AND METHODS/METHODS:We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences. RESULTS:This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort. CONCLUSION/CONCLUSIONS:Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes. LEVEL OF EVIDENCE/METHODS:III, Retrospective Cohort Study.

Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.

PURPOSE/OBJECTIVE:Navigated total knee arthroplasty (TKA) improves implant alignment by providing feedback on resection parameters based on femoral and tibial cutting guide positions. However, saw blade thickness, deflection, and cutting guide motion may lead to final bone cuts differing from planned resections, potentially contributing to suboptimal component alignment. We used an imageless navigation device to intraoperatively quantify the magnitude of error between planned and actual resections, hypothesizing final bone cuts will differ from planned alignment. MATERIALS AND METHODS/METHODS:A retrospective study including 60 consecutive patients undergoing primary TKA using a novel imageless navigation device was conducted. Device measurements of resection parameters were obtained via attachment of optical trackers to femoral and tibial cutting guides prior to resection. Following resection, optical trackers were placed directly on the bone cut surface and measurements were recorded. Cutting guide and bone resection measurements of both femoral and tibial varus/valgus, femoral flexion, tibial slope angles, and both femoral and tibial medial and lateral resection depths were compared using a Student's t-test. RESULTS:Femoral cutting guide position differed from the actual cut by an average 0.6 ± 0.5° (p = 0.85) in the varus/valgus angle and 1.0 ± 1.0° (p = 0.003) in the flexion/extension angle. The difference between planned and actual cut measurements for medial and lateral femoral resection depth was 1.1 ± 1.1 mm (p = 0.32) and 1.2 ± 1.0 mm (p = 0.067), respectively. Planned cut measurements based on tibial guide position differed from the actual cut by an average of 0.9 ± 0.8° (p = 0.63) in the varus/valgus angle and 1.1 ± 1.0° (p = 0.95) in slope angle. Measurement of medial and lateral tibial resection depth differed by an average of 0.1 ± 1.8 mm (p = 0.78) and 0.2 ± 2.1 mm (p = 0.85), respectively. CONCLUSIONS:Significant discrepancies between planned and actual femoral bone resection were demonstrated for flexion/extension angle, likely the result of cutting error. Our data highlights the importance of cut verification postresection to confirm planned resections are achieved, and suggests imageless navigation may be a source of feedback that would allow surgeons to intraoperatively adjust resections to achieve optimal implant alignment.

AIMS/OBJECTIVE:As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. METHODS:A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. RESULTS:= 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. CONCLUSION/CONCLUSIONS: 2021;2(7):535-539.

The purpose of this study was to investigate whether preoperative opioid use had any effect on clinical outcomes and patient-reported outcome measures (PROMs) before and after primary, elective total hip arthroplasty (THA). The authors retrospectively reviewed 793 patients who underwent primary THA from November 2018 to March 2020 with available PROMs. Patients were stratified into two groups based on whether or not they were taking opioids preoperatively. Demographics, clinical data, and PROMs (Forgotten Joint Score-12 [FJS-12], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Veterans RAND 12 [VR-12] Physical Component Score [PCS] and Mental Component Score [MCS]) were collected at various time periods. Demographic differences were assessed with chi-square and independent sample t tests. Clinical data and PROMs were compared using multilinear regressions. Seventy-five (10%) patients were preoperative opioid users and 718 (90%) were not. Preoperative opioid users had a longer stay (1.37 vs 1.07 days; P=.030), a longer surgical time (102.44 vs 90.20 minutes; P=.001), and higher all-cause postoperative emergency department visits (6.7% vs 2.1%; P=.033) compared with patients not taking opioids preoperatively. Preoperative HOOS, JR (46.63 vs 51.26; P=.009), VR-12 PCS (27.79 vs 31.53; P<.001), and VR-12 MCS (46.24 vs 49.33; P=.044) were significantly lower for preoperative opioid users, but 3-month and 1-year postoperative scores were not statistically different. At 3 months and 1 year, FJS-12 scores did not differ significantly. Mean improvement preoperatively to 1 year in HOOS, JR values exceeded the minimal clinically important difference, with preoperative opioid users experiencing a greater improvement (36.50 vs 33.11; P=.008). Preoperative opioid users had a longer stay, a longer surgical time, and higher all-cause emergency department visits compared with preoperatively opioid naïve patients. Although preoperative opioid users reported significantly lower preoperative PROMs, they did not statistically differ postoperatively, which indicates a larger delta improvement and similar benefits following THA. [Orthopedics. 2021;44(2):77-84.].

INTRODUCTION/BACKGROUND:Longevity and success of total hip arthroplasty (THA) is largely dependent on component positioning. While use of robotic platforms can improve this positioning, published evidence on its clinical benefits is limited. Therefore, the aim of this study was to assess the clinical outcomes of THA with robotic surgical assistance. MATERIALS AND METHODS/METHODS:We conducted an analysis of robotic arm-assisted primary THAs performed by a single surgeon utilizing a posterior approach. A total of 99 patients (107 cases) who had a minimum two-year follow up were identified. Their mean age was 61 years (range, 33 to 84 years), and their mean body mass index was 30.5 kg/m2 (range, 18.5 to 49.1 kg/m2). There were 56% female patients and primary osteoarthritis was the principal hip diagnosis in 88.8%. Operative times, lengths of hospital stay, and discharge dispositions were recorded, along with any complications. Modified Harris Hip Scores (HHS) were calculated to quantify clinical outcomes. RESULTS:Mean postoperative increases in HHS at 2- to 5.7-year follow up was 33 points (range, 6 to 77 points). There were no complications attributable to the use of robotic assistance. Surgical-site complications were rare; one case underwent a revision for prosthetic joint infection (0.93%) but there were no dislocations, periprosthetic fractures, or cases of mechanical implant loosening. There was no evidence of progressive radiolucencies or radiographic failure. DISCUSSION/CONCLUSIONS:Robotic arm-assisted THA resulted in low complication rates at minimum two-year follow up, with clinical outcomes comparable to those reported with manual surgery.1-4 The haptically-guided acetabular bone preparation enabled reliable cementless acetabular fixation and there were no adverse events related to the use of the robot. Dislocations were avoided in this case series. Randomized controlled clinical trials are needed to compare manual to robotic surgery and to investigate whether the precision found with this functional planning will reliably reduce the incidence of dislocations.