Faculty Bibliography

BACKGROUND:Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing. METHODS:We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received TXA, and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline Hgb levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regression and receiver operating characteristic curve analysis. RESULTS:The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index, and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The receiver operating characteristic analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively. CONCLUSIONS:In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is >12 g/dL, challenging the need for universal type and screening. Conversely, patients who have Hgb < 11.0 g/dL, remain at substantial risk for transfusion. Between Hgb 11 and 12 g/dL, patient age, sex, body mass index, American Society of Anesthesiologists classification, anticipated estimated blood loss, and surgical time may help predict transfusion risk and the need for a perioperative type and screen. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/UNASSIGNED:Older adults undergoing surgery are at risk of postoperative neurocognitive disorders, prompting the need for preoperative cognitive screening in this population. Traditionally, cognitive screening has been conducted in-person using brief assessment tools such as the Montreal Cognitive Assessment (MoCA) or the Mini-Mental State Examination (MMSE). More comprehensive test batteries, such as the Uniform Data Set (UDS) Neuropsychological Battery, and its remote testing version, the Uniform Data Set version 3 tele-adapted test battery (UDS v3.0 T-cog), have been developed to assess cognitive decline in normal aging and disease conditions, but have not been applied in the perioperative setting. METHODS/UNASSIGNED:We assessed the feasibility of using this remote UDS v3.0 T-cog battery for preoperative cognitive assessment in 81 older adults 65+ scheduled for lower extremity joint replacement surgery. RESULTS/UNASSIGNED:Our results indicate that the UDS v3.0 T-cog achieves 99% completion rates and demonstrates high patient satisfaction. Further, we found 28% of subjects were cognitively impaired in this patient cohort. DISCUSSION/UNASSIGNED:These findings suggest that the UDS v3.0 T-cog is a feasible tool for assessing cognitive function in the older adult perioperative population. To our knowledge, this is the first study to apply this comprehensive remote test battery in the preoperative setting.

BACKGROUND/UNASSIGNED:Quadriceps weakness following total knee arthroplasty (TKA) delays rehabilitation and increases fall risk. The combined impact of tourniquets and adductor canal blocks (ACBs) on postoperative quadriceps strength has not been defined. This study evaluated the early effects of tourniquet and/or ACB usage on quadriceps strength following TKA. METHODS/UNASSIGNED:Primary, elective TKA patients were assigned to one of four groups based on whether they received an ACB and/or tourniquet. We prospectively measured bilateral, isometric knee extension strength preoperatively and within 36 hours postoperatively. Pre/post-change (Δ) and percent strength change were calculated and standardized to the contralateral leg. Strength, postoperative pain, mobility, knee buckling incidence, and falls were compared across groups. Measurements were collected for 203 patients: 68, 45, 45, and 45 in the tourniquet/ACB, tourniquet/ no ACB, ACB/no tourniquet, and no tourniquet/ no ACB groups, respectively. RESULTS/UNASSIGNED:Tourniquet use was associated with shorter operative time (p=0.004), while ACB use was associated with longer lengths of stay (p=0.005). Average preoperative (p=0.53), postoperative (p=0.12), pre/post-Δ (p=0.60), percent change (p=0.14), and standardized percent change (p=0.85) in strength measures were comparable across groups. Postoperative pain (p=0.67) and knee buckling events (p=0.18) were also comparable across groups. The no tourniquet/no ACB group had decreased postoperative mobility (p=0.004), though it was not clinically significant. No patients sustained inpatient falls. CONCLUSION/UNASSIGNED:.

INTRODUCTION/BACKGROUND:The role of advanced imaging in diagnosing aseptic implant loosening following total hip arthroplasty (THA) remains unclear. This study aimed to assess the diagnostic value of magnetic resonance imaging (MRI) in detecting aseptic loosening. METHODS:This was a retrospective review of 342 consecutive patients who underwent revision THA between July 2011 and April 2023 and had a pelvis MRI as part of the preoperative diagnostic evaluation. Among them, 62 patients had an intraoperative diagnosis of aseptic loosening of either the femoral or acetabular component. Patients were stratified based on the concordance between their MRI and radiographs findings. RESULTS:Preoperative MRI showed signs of aseptic loosening in 25/62 patients (sensitivity = 40.3%). Similarly, preoperative radiographs demonstrated signs of aseptic loosening in 27 patients (43.5%). Twelve patients (19.4%) had both MRI and radiographs predictive of aseptic loosening, 22 patients (35.5%) did not show signs of aseptic loosening in either MRI or radiographs, and for 28 patients (45.2%), the results were discordant. Among the patients with a negative radiograph for aseptic loosening (n = 35), 13 patients (37.1%) showed signs of aseptic loosening on MRI. CONCLUSION/CONCLUSIONS:Aseptic loosening remains an elusive diagnosis, and the findings of this study suggest that the utility of MRI and radiographs as part of the diagnostic process is limited. However, in cases of presumed aseptic loosening with inconclusive radiographs findings, MRI may play a role in improving the diagnostic process. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/UNASSIGNED:Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after primary total hip arthroplasty (THA) in this patient population remain poorly characterised. The primary purpose of this study is to compare postoperative outcomes and survivorship after primary THA in patients with and without EDS. METHODS/UNASSIGNED:The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for all patients undergoing primary elective THA between September 2009 and December 2020. Patients with EDS were identified using ICD9 and ICD10 diagnosis codes. Given the relatively low incidence of EDS in this patient population, the cohort was propensity-matched 1:10 to patients without diagnosis of EDS based on demographics characteristics and medical comorbidities as measured by the Elixhauser Comorbidity Index. RESULTS/UNASSIGNED: 0.063). CONCLUSIONS/UNASSIGNED:EDS patients undergoing primary THA have increased rate of all cause revision and demonstrate decreased revision free survival compared to non-EDS THA patients.

INTRODUCTION/BACKGROUND:Discharge disposition after total joint arthroplasty may be predictable. Previous literature has attempted to improve upon models such as the Risk Assessment and Prediction Tool (RAPT) in an effort to optimize postoperative planning. The purpose of this study was to determine whether preoperative laboratory values and other previously unstudied demographic factors could improve the predictive accuracy of the RAPT. METHODS:All patients included had RAPT scores in addition to the following preoperative laboratory values: red blood cell count, albumin, and vitamin D. All values were recorded within 90 days of surgery. Demographic variables including marital status, American Society of Anesthesiologists (ASA) scores, body mass index, Charlson Comorbidity Index, and depression were also evaluated. Binary logistic regression was used to determine the significance of each factor in association with discharge disposition. RESULTS:Univariate logistic regression found significant associations between discharge disposition and all original RAPT factors as well as nonmarried patients (P < 0.001), ASA class 3 to 4 (P < 0.001), body mass index >30 kg/m2 (P = 0.065), red blood cell count <4 million/mm3 (P < 0.001), albumin <3.5 g/dL (P < 0.001), Charlson Comorbidity Index (P < 0.001), and a history of depression (P < 0.001). All notable univariate models were used to create a multivariate model with an overall predictive accuracy of 90.1%. CONCLUSIONS:The addition of preoperative laboratory values and additional demographic data to the RAPT may improve its PA. Orthopaedic surgeons could benefit from incorporating these values as part of their discharge planning in THA. Machine learning may be able to identify other factors to make the model even more predictive.

INTRODUCTION/UNASSIGNED:Total hip arthroplasty (THA) using computer-assisted navigation (N-THA) and robot-assisted surgery (RA-THA) has been increasingly adopted to improve implant positioning and offset/leg-length restoration. Whether clinically meaningful differences in patient-reported outcomes (PROMs) compared to conventional THA (C-THA) are achieved with intraoperative technology has not been established. This systematic review aimed to assess whether published relative PROM improvements with technology use in THA achieved minimal clinically important differences (MCIDs). METHODS/UNASSIGNED: 2786) studies, respectively, for analyses. RESULTS/UNASSIGNED:Statistically significant improvements in postoperative PROM scores were reported in 2/6 (33.3%) studies comparing N-THA with C-THA, though only 1 (16.7%) reported clinically significant relative improvements. Statistically significant improvements in postoperative PROMs were reported in 6/10 (60.0%) studies comparing RA-THA and C-THA, though none reported clinically significant relative improvements. Improved radiographic outcomes for N-THA and RA-THA were reported in 83.3% and 70.0% of studies, respectively. Only 1 study reported a significant improvement in revision rates with RA-THA as compared to C-THA. CONCLUSIONS/UNASSIGNED:Reported PROM scores in studies comparing N-THA or RA-THA to C-THA often do not achieve clinically significant relative improvements. Future studies reporting PROMs should be interpreted in the context of validated MCID values to accurately establish the clinical impact of intraoperative technology.

INTRODUCTION/BACKGROUND:Mechanical falls represent a potential adverse event after total knee arthroplasty (TKA) and may introduce further injury and delay postoperative recovery. This study aimed to identify patient characteristics associated with inpatient falls, to determine the impact of inpatient falls on surgical outcomes following TKA, and to describe the relationship between tourniquet and/or adductor canal block (ACB) use and fall rates. METHODS:Patients undergoing primary, elective TKA at a single institution between 2018 and 2022 were retrospectively analyzed. Patients were stratified into groups based on whether they sustained a postoperative inpatient fall or not. Perioperative characteristics, lengths of stay (LOS), rates of 90-day readmissions, and revisions were compared, and fall characteristics were described. Subanalysis was conducted comparing fall incidence based on tourniquet and/or ACB use. RESULTS:In total 6472 patients were included with 39 (0.6%) sustaining falls. Falls most commonly occurred on postoperative days one (43.6%) and two (30.8%), and were most commonly due to loss of balance (41.9%) or buckling (35.5%). Six (15.4%) fall patients sustained minor injuries, and one (2.6%) sustained major injury (malleolar fracture requiring non-operative orthopaedic management). The LOS (3.0 ± 1.5 vs 2.3 ± 1.5 days, p = 0.002) and all-cause revision rates at latest follow-up (10.3% vs. 2.0%, p = 0.008) were significantly higher in the fall group. Falls were comparable across subgroups based on tourniquet and/or ACB use (p = 0.429). CONCLUSION/CONCLUSIONS:Patients who fell had a longer LOS and higher revision rate postoperatively. Rates of inpatient falls were comparable regardless of tourniquet and/or ACB use. Concern for inpatient falls should not influence surgeons when considering the use of tourniquets and/or ACBs, though well-designed, large-volume, prospective randomized studies are warranted to better understand this relationship.

PURPOSE/OBJECTIVE:Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF. METHODS:Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching. RESULTS:Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively. CONCLUSION/CONCLUSIONS:Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective study.