Faculty Bibliography

BACKGROUND:Historically, total knee arthroplasty (TKA) used resection and balancing techniques to target symmetric medial and lateral gaps throughout range of motion (ROM). With modern awareness on alternate alignment concepts, one area of ongoing debate is whether asymmetric medial and lateral compartment gaps improve outcomes. Proponents of an asymmetric looser lateral compartment gap philosophy postulate that this phenotype recreates native knee kinematics with lateral femoral condylar rollback pivoting through a tighter medial compartment during knee flexion. The purpose of this study was to compare patient-reported outcomes (PROs) and ROM with respect to symmetric or asymmetric gaps. METHODS:We performed a systematic review and random-effects meta-analysis of prospective and retrospective studies. We compiled all comparative studies reporting symmetric and asymmetric gaps, irrespective of directional or nondirectional gap asymmetry. However, we performed a meta-analysis only between a cohort of directional asymmetric gaps (looser lateral than medial gap) and symmetric gaps (equal medial and lateral gaps). Gaps were compared in flexion and extension. ROM and PROs were evaluated through standardized mean difference (SMD), with statistical significance defined by 95% confidence interval (CI). RESULTS:A total of 17 studies with 3,319 knees were included. Four studies reported nondirectional gap asymmetry, whereas 13 studies reported directional gap asymmetry, of which 8 shared common outcome variables and were therefore included in the meta-analysis. Analysis of gaps in flexion revealed significantly increased ROM favoring asymmetric looser lateral gaps over symmetric gaps (SMD -0.19, 95% CI -0.29 to -0.09). Analysis of gaps in extension also revealed increased ROM favoring asymmetric looser lateral gaps (SMD -0.10, 95% CI -0.36 to 0.16). Finally, the Forgotten Joint Score (FJS) favored looser lateral gaps in flexion over symmetric gaps (SMD -0.13, 95% CI -0.41 to 0.15). However, differences in the latter 2 were nonsignificant. CONCLUSION/CONCLUSIONS:This is the first meta-analysis evaluating the postoperative outcomes as a function of symmetric vs. asymmetric mediolateral gaps. We report improved FJS and ROM favoring asymmetric looser lateral gaps in flexion. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II, systematic review of Level II and III and IV studies. See Instructions for Authors for a complete description of levels of evidence.

Genetics is a burgeoning field within adult reconstructive surgery. Genome-wide sequencing has identified genetic variants found to be associated with not only the development of osteoarthritis but also arthroplasty-related complications, such as aseptic loosening, prosthetic joint infection, arthrofibrosis, and postoperative pain. Examples include newer technology, such as next-generation sequencing, in diagnosing culture-negative prosthetic joint infection. Genetics drives new therapeutic technologies, such as gene therapy, gene-editing, and bacteriophage treatment. Although still rare, a handful of phase 3 clinical trials of gene therapy for osteoarthritis have begun to demonstrate efficacy with low-risk profiles. As the field continues to grow, public and professional buy-in as well as cost present challenges.

INTRODUCTION/BACKGROUND:The integration of computer-assisted navigation systems (CASs) in total knee arthroplasty (TKA) procedures has gained popularity in recent years. However, additional validation of the accuracy of CAS feedback is necessary. We used short-length and full-length postoperative radiographs to quantify the differences between alignment parameters measured by a novel imageless CAS and alignment outcomes as evidenced on postoperative radiographs. MATERIALS AND METHODS/METHODS:A retrospective analysis was conducted on prospectively collected data from a cohort of patients undergoing navigated primary TKA. Fifty-eight patients had met inclusion criteria, and intraoperative CAS measurements were obtained from device recordings. Alignment parameters were measured digitally and included femorotibial angle on short-length films and hip-knee-ankle axis, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) on full-length films. These were compared between CAS and radiograph measurements using a 2-tailed t test. RESULTS:The mean mLDFA measured by the CAS was 0.7° ± 1.1°, compared with 1.3° ± 1.4° as measured on full-body radiographs (P = .1). The mean mMPTA measured by the CAS was 0.2° ± 1.0°, compared with 0.9° ± 1.4° as measured on full-body radiographs (P = .06). On average, radiograph and CAS measurements differed by 0.5° ± 1.5° for mLDFA and 0.7° ± 1.5° for mMPTA. The average postoperative hip-knee-ankle axis was 177.6° ± 2.1°, and the average femorotibial angle was 176.0° ± 9.6° as measured on radiographs. CONCLUSION/CONCLUSIONS:No significant differences in either average or individual measured values for mLDFA or mMPTA were observed between the intraoperative CAS measurements and alignment outcomes postoperatively. Our data highlight the clinical utility of CASs to accurately achieve intended TKA alignment objectives.

BACKGROUND/UNASSIGNED:Electronic medical record portals enable real-time communication between patients and surgeons after total knee arthroplasty (TKA). This study evaluated the impact of message timing and frequency on postoperative outcomes and patient-reported outcome measures (PROMs). MATERIALS AND METHODS/UNASSIGNED:We retrospectively reviewed 9,353 primary TKAs performed at a single academic institution. Of these, 1,219 patients sent messages within 2 weeks of surgery (early), 507 sent messages between 2 and 8 weeks (late), and 7,627 did not message. RESULTS/UNASSIGNED:< .001). There was no difference in PROMs regardless of message timing, and there was no association between the number of messages sent and perioperative outcomes or PROMs. CONCLUSION/UNASSIGNED:Older age and longer LOS were associated with less patient-initiated contact after TKA. Older patients may be less familiar with digital platforms and less likely to send messages. Early messaging may reflect heightened recognition of postoperative issues, enabling counseling or intervention and reducing readmissions. These findings underscore the importance of preoperative education and equitable access, though long-term effects of messaging warrant further study.

BACKGROUND/UNASSIGNED:Technological advancements in total hip arthroplasty (THA), including robotic-assisted (RA-THA) and navigation-assisted (NA-THA) techniques, aim to improve outcomes. However, impact on recovery timing remains unclear. This study examined whether these technologies reduce the time to reach the minimal clinically important difference (MCID) on the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement compared with conventional THA. METHODS/UNASSIGNED:This retrospective study analyzed osteoarthritic THA patients (01/2020-04/2023) who completed preoperative and postoperative Hip Disability and Osteoarthritis Outcome Score for Joint Replacement questionnaires. The exclusion criteria included bilateral procedures or revision within 1 year. MCID was defined using anchor-based (23 points) and distribution-based thresholds (7.6 points). Multivariable interval-censored accelerated failure time models assessed time to MCID. RESULTS/UNASSIGNED:= .140). CONCLUSIONS/UNASSIGNED:Anchor-based MCID demonstrated comparable recovery times across RA, NA, and conventional THA, suggesting no patient-perceived advantage with technology. Distribution-based thresholds indicated RA-THA achieved faster statistically significant improvement, though the relevance remains uncertain.

BACKGROUND:Patients who undergo primary total knee arthroplasty (TKA) may return to work at variable times following surgery, the timeline for which is partly affected by the physical intensity of their occupation. The purpose of this study was to evaluate patient satisfaction and limitations when returning to work following TKA. METHODS:This retrospective review surveyed patients undergoing primary TKA between June 2011 and January 2022, with at least 1 year of follow up, regarding return to work. Of the 914 respondents, 507 (55.5 %) worked preoperatively and were stratified into high intensity (HI) (i.e., laborer, construction), standard intensity (SI) (i.e., walking, climbing stairs), or low intensity (LI) (i.e., sedentary desk jobs) groups. Baseline characteristics and survey responses were compared across groups. Among those who worked preoperatively, 35 (6.9 %), 213 (42 %), and 259 (51.1 %) were in the HI, SI, and LI groups, respectively. RESULTS:Of the 507 patients who worked prior to TKA, 447 (88.2 %) returned to work after surgery and 60 (11.8 %) did not. The HI group was comprised of more young males and more smokers than the SI and LI groups. In the LI group, 30 % returned within 1 month following surgery and an additional 44 % within 2 months. Similarly in the SI group, 11 % returned to work in less than 1 month with an additional 39 % returning within 2 months. In the HI group, 4 % returned within the first month and additional 42 % returned within 2 months. HI workers were more commonly hindered in their return (HI: 30.8 %, SI: 23.1 %, LI: 7.7 %), 'moderately declined' in their work ability (HI: 23.1 %, SI: 9.7 %, 3.0 %), and 'very unsatisfied' with their return (HI: 11.5 %, SI: 10.8 %, LI: 8.1 %). CONCLUSION/CONCLUSIONS:TKA leads to improvements in work function and satisfaction across all intensity levels, but HI work is associated with longer recovery times and comparatively lower return-to-work satisfaction compared to SI and LI groups.

INTRODUCTION/BACKGROUND:There is increased awareness of socioeconomic disparities among total hip arthroplasty (THA) patients. Most studies contain small sample sizes and few control for confounding variables. This study aims to evaluate postoperative outcomes and survivorship after THA in patients of different races/ethnicities. METHODS:Patients who underwent a primary THA were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were stratified into 4 groups: White, Black, Hispanic, or Asian. Categorical variables and continuous variables were compared, and revision free survival was calculated using Kaplan Meier survival analysis. Multivariate Cox proportional hazard regression was used to calculate revision hazard ratios. RESULTS: = 0.021). There were no significant differences in the cumulative revision event rate up to 10 years postoperatively. CONCLUSIONS:Non-White patients are significantly more likely to have worse short-term outcomes and complications. However, overall rates of revision at 1 year are similar across these groups, with a slightly lower rate of revision in Black patients after controlling for confounding factors.

INTRODUCTION/BACKGROUND:While the number of absolute and relative contraindications to total joint arthroplasty (TJA) has gradually decreased, active cancer patients have traditionally been challenging surgical candidates. We sought to compare perioperative and two-year postoperative clinical outcomes of patients with and without active cancer. METHODS:Patients over 18 years with active cancer undergoing primary, unilateral TJA from 2017 to 2023 at a single urban academic center were reviewed for a minimum two-year follow-up. Cancer status, type, and stage were confirmed manually. 68 cancer patients were propensity-matched 3:1 to 204 non-cancer patients from a pool of 9,382 based on age, sex, BMI, smoking status, race, and ASA class. Demographic, perioperative, and clinical data were analyzed using t-tests, Chi-square, and ANOVA. Subgroup analyses compared cancer patients receiving active therapy versus those not on treatment. RESULTS:There were no significant demographic differences between groups, except Charlson Comorbidity Index (P < 0.001). The most common cancers were breast (22%) and prostate (20%). There were no differences in discharge disposition (P = 0.20), operative time (P = 0.87), or length of stay (P = 0.29). The all-cause revision rate (including infection) was higher in patients with active cancer (7.4% vs. 2.5%), though not statistically significant (P = 0.15; Power = 46.5%). Of the various causes for revision, infection was significantly more likely in cancer patients than other causes compared (4.4% vs. 0%, P = 0.003). When analyzing only the active cancer group, those receiving cancer therapy had higher revision rates, though this was not statistically significant (11.1% vs. 6.0%, P = 0.487). DISCUSSION/CONCLUSION/CONCLUSIONS:Despite often being excluded from arthroplasty studies, active cancer patients demonstrated comparable overall outcomes after primary TJA. Although infection-related revisions were more common, they were effectively treated. With proper preoperative optimization and multidisciplinary care, TJA can be safely performed in selected active cancer patients.