Faculty Bibliography

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.

BACKGROUND:There is a growing number of patients who undergo multiple primary hip and knee joint arthroplasties during their lifetime. Whether patients who have multiple replaced joints are at an increased long-term risk of periprosthetic joint infection (PJI) is not known. The purpose of this study was to compare rates of PJI in patients who have more than one primary arthroplasty. METHODS:We reviewed 36,129 patients who underwent primary total joint arthroplasty at a single institution from 2011 to 2024. Patients were categorized as having one to four primary hip or knee arthroplasties. The PJI incidence was compared using Chi-square testing and binary logistic regressions, and multivariate models adjusted for sex, body mass index, diabetes, renal disease, smoking status, and Charlson Comorbidity Index (CCI). Sub-analyses compared patients who had one versus two, three, and four arthroplasties. RESULTS:When comparing patients who had one, two, three, or four primary joint arthroplasties, there was no significant difference in the rates of PJI between groups (P = 0.112). Multivariate analyses showed no statistically significant association between the number of arthroplasties and PJI (adjusted odds ratio (OR) for two, three, and four arthroplasties versus one: 1.34, 95% confidence interval (CI) 1.02 to 1.74, P = 0.083; 1.98, 95% CI 0.77 to 4.12, P = 0.105; 1.57, 95% CI 0.09 to 7.24, P = 0.657, respectively). Sub-analyses comparing one versus three and one versus four arthroplasties showed no significant differences. CONCLUSION/CONCLUSIONS:In this single-institution cohort, additional primary hip or knee arthroplasties did not appear to substantially increase PJI risk. These findings suggest a potential trend that requires confirmation with larger, prospective, multicenter, or registry-based studies. Nevertheless, these results provide preliminary evidence to inform patient counseling and guide future research on the risks of multiple arthroplasties.

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.

BACKGROUND:Return to sports is a concern for many patients undergoing total hip arthroplasty (THA). As younger, active patients increasingly undergo THA, identifying factors that influence athletic recovery is critical. Although prior work has reported favorable outcomes, large-scale studies comparing return rates across both surgical approaches and sport types remain limited. METHODS:We retrospectively analyzed 1,115 athletically participant THA patients and compared rates of returning to sports up to one year postoperatively. Survey data captured sport type, participation at four time points, frequency, exertion, and perceived recovery. Patients were stratified by surgical approach: posterior (PA) (n = 519), anterior (AA) (n = 556), and lateral (LA) (n = 50). RESULTS:Preoperatively, 45.2% of patients were active in at least one sport versus 43.7% at one year postoperatively; 73.2% of preoperative athletes returned, and 23.3% of those previously inactive took up sports. Return-to-sport rates were 68.1, 77.0, and 81.8% for PA, AA, and LA, respectively (Chi-square = 3.42, P = 0.181). There were no significant differences between AA and PA, and the lateral approach was not statistically comparable due to a smaller sample size. Low-impact sports had significantly higher return rates than high-impact sports (72.4 versus 50.0%; P < 0.001). At survey completion (> one year postoperatively), satisfaction rates were high across all sports, and activity restrictions were reported by about one in five patients, regardless of approach. Sport-specific outcomes showed that most patients maintained or improved performance. CONCLUSION/CONCLUSIONS:Patients undergoing THA can expect high return rates and satisfaction with athletic endeavors. Surgical approach generally does not affect return-to-sport outcomes after THA. Most patients, regardless of approach, resumed or exceeded preoperative activity. In addition to high return rates among previously active patients, many previously inactive patients participated in sports after THA, highlighting the role of THA in enabling sport resumption and participation.

BACKGROUND:Obesity is a known risk factor for complications after total hip arthroplasty (THA), with societal guidelines recommending surgical delay for patients above body mass index (BMI) targets. Consequently, patients are motivated to reach BMI targets before the office visit, discussing surgical booking. Our study investigates BMI fluctuations between surgical booking and the surgery date and whether these fluctuations have implications for peri- and postoperative outcomes. METHODS:We retrospectively reviewed our institutional database for elective, primary, unilateral THA from 2015 to 2024 with a minimum 90-day follow-up. The cohort was stratified into three groups by percent BMI change from booking date to THA date: Group 1, decrease in BMI; Group 2, 0 to 5% increase in BMI; and Group 3, > 5% increase in BMI. Baseline demographic factors, as well as peri- and postoperative outcomes, were compared. A multivariate regression analysis evaluated risk factors for interval change in BMI. We reviewed 10,400 THA patients who had an average 62-day delay between booking and surgery dates, where 44.2, 42.2, and 13.6% were allocated to Groups 1, 2, and 3, respectively. RESULTS:Operative time, length of stay, and discharge to a rehab facility were significantly higher in Group 3 compared to the others. There were no significant differences seen in 90-day outcomes, including emergency department (ED) visits, readmissions, or revision rates. Multivariate regression analyses identified that elevated BMI at the time of surgery predicted increased septic revision incidence (OR [odds ratio]: 1.1, P < 0.001). Surgical delay and BMI change between booking and surgery did not influence all-cause and septic revision rates. CONCLUSION/CONCLUSIONS:Our study is the first to evaluate preoperative BMI fluctuations between the booking date and surgery date. We found that most patients (55.8%) gained weight, with 13.6% increasing > 5% BMI. Importantly, these weight changes do not impact short-term complications or revision rates, comforting THA surgeons who see interval weight gain on the day of surgery.

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.

INTRODUCTION/BACKGROUND:Social support improves outcomes after total hip and knee arthroplasty (THA/TKA), but the demands on informal caregivers, especially as surgeries transition to outpatient care, are understudied. This study strived to assess caregiver burden, predictors, and implications following joint arthroplasty. METHODS:This prospective cohort study enrolled 185 patient-caregiver dyads undergoing primary THA or TKA for osteoarthritis at a tertiary academic center. Caregivers completed assessments at four weeks postoperatively, including the Caregiver Strain Index (CSI) and Appraisal of Caregiving Scale (ACS), which measures perceived benefit, threat, and stress. Demographic, socioeconomic, and caregiving-related variables were collected. Multivariate linear regression identified factors associated with caregiver strain and experiences. Caregivers had a mean age of 64 years (range, 52.3 to 76.3), and 60% were women. Most (72.4%) were spouses, and 46.5% were retired. RESULTS:The CSI scores showed considerable strain, especially among women caregivers (β = 1.29, P = 0.001), those who had higher daily time commitment postoperatively, and those who had lower preoperative preparedness. Regarding employment status, 7% worked part-time, and 3.2% were homemakers. Among ACS subscales, non-White race (β = 0.31, P = 0.035) and homemaker status (β = 0.65, P = 0.049) were positively associated with perceived benefit, while lower preparedness predicted higher perceived threat. Caregiver age (β = 0.0217, P = 0.004), higher initial social support (β = 0.013, P = 0.001), and preparedness (β = 0.19, P = 0.016) predicted higher stress appraisals. Part-time employment was associated with lower stress (β = -0.47, P = 0.042). CONCLUSION/CONCLUSIONS:Caregiver burden after joint arthroplasty is substantial and influenced by sex, age, race, employment, social support, and preparedness. Targeted interventions addressing these factors are needed to mitigate strain in at-risk caregivers and improve surgical recovery for patients.

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.