Faculty Bibliography

INTRODUCTION/BACKGROUND:The subset of patients admitted to the intensive care unit (ICU) following total joint arthroplasty (TJA) has yet to be studied in detail. Specifically, there is little data on the effects of vasopressor administration in patients who require critical care after TJA. We sought to characterize patient outcomes and mortality by vasopressor administration in the ICU following primary TJA. METHODS:We retrospectively reviewed 187 patients who required admission to the ICU within 14 days following primary, unilateral TJA from 2012 to 2024, out of 47,083 patients who underwent TJA during this time (0.40%). Exclusion criteria included TJA for trauma, acute fracture, and revision or conversion TJA. Patients were classified by whether they received any vasopressor (i.e., norepinephrine, phenylephrine, or vasopressin) medication at any point during their ICU stay. Limited intraoperative use of vasopressor did not qualify. Demographic and surgical data were collected and compared. Primary outcomes included complications, revisions/reoperations. RESULTS:Of the 187 patients requiring ICU admission following primary TJA, 20 received vasopressors during their stay. No significant demographic differences were found between cohorts. Hypotension (26%) was the most common indication for ICU admission. Vasopressor use was not associated with a significant increase in 30-day or one-year mortality (5.0 vs. 0.6%, P=0.07; 5.0 vs. 1.2%, P=0.20, respectively), but was associated with a significant increase in revisions/reoperations 25.0 vs 6.0%, P=0.005). No significant differences were observed for 90-day VTE events (P=0.62). Dislocations were significantly more common in patients who received vasopressors (14.3 vs. 1.0%, P=0.047). CONCLUSION/CONCLUSIONS:Patients who received vasopressors in the ICU following TJA had significantly higher rates of revisions, reoperations, and dislocation. There were no differences in mortality rates or VTE rates between groups. Further investigation is required to better characterize outcomes following vasopressor requirement in the total joint arthroplasty population.

BACKGROUND:10 years after changing our institution's total hip arthroplasty (THA) preoperative antibiotic prophylactic protocol by adding gram-negative (GN) coverage, this study aimed to assess the impact of adding GN specific coverage (GNSC) prior to THA on periprosthetic joint infection (PJI) rates. METHODS:This was a retrospective case-control study of 14,598 patients who underwent primary, elective THA between July 2012 and January 2022, with minimum 1-year follow-up. All patients were under perioperative antibiotic protocol that included GNSC with either weight-based gentamicin or aztreonam (+GNSC) and were compared to a historical control group of patients for which the antibiotic prophylactic protocol did not include GNSC (-GNSC). PJI and nephrotoxicity rates, as well as the severity of nephrotoxicity according to the RIFLE criteria, were compared between the study populations and 4122 controls. RESULTS: = 0.567), which are the two more severe forms of nephrotoxicity, were comparable between the groups. CONCLUSIONS:The addition of gentamicin or aztreonam prior to THA reduces the incidence of GN-related PJIs. Increased nephrotoxicity rates were limited to the mildest form, usually associated with reversibility and favourable outcomes.

BACKGROUND:The relationship between total hip arthroplasty (THA) surgeon volume and outcomes is informative in this era of health care value optimisation. The purpose of this study was to evaluate outcomes based on modern-day surgeon practice volumes. METHODS:The SPARCS database was queried for patients undergoing primary THA from 2010 to 2020. Annual case volume thresholds were 30 and 150, differentiating high-volume (HV), intermediate-volume (IV), and low-volume (LV) groups. Perioperative outcomes and all-cause cumulative revision rates were evaluated. RESULTS: 0.001). While controlling for confounders, multivariate regression revealed increased odds of PJI for IV (1.5) and LV (1.87) and increased all-cause revision hazard ratio for IV (1.1) and LV (1.3). Cumulative revision rates were lower for HV at 1 and 2 years, but rates converged with IV group at 9 years. CONCLUSIONS:HV surgeons have the most favourable short-term outcomes. However, in the long-term the difference in all-cause revision event rates becomes less apparent.

BACKGROUND:With the increased rates of revision total hip (rTHA) and total knee arthroplasty (rTKA), the financial burden of these procedures is at risk of straining the healthcare system. Our study sought to create a model to evaluate the cost-effectiveness of rTKA and rTHA performed by high-volume (HV) and low-volume (LV) surgeons. METHODS:percentile in annual volume were classified as HV surgeons and the remainder were classified as LV surgeons. Previously published cost estimates were utilised for operative time, hospital length of stay (LOS), discharge disposition, 90-day readmission, and 1-year re-revision. RESULTS: < 0.001). Both groups had equivalent discharge disposition, 90-day readmission, and 1-year re-revision. HV surgeons had lower estimated mean costs for rTHA ($22,027.81 vs. $24,617.39) and rTKA ($20,343.23 vs. $18,554.67). CONCLUSIONS:HV surgeons have a lower estimated mean cost for both rTHA and rTKA. Healthcare systems may benefit from having rTHA and rTKA procedures performed by HV surgeons who are able to perform these revision procedures for a lower cost without negatively impacting patient outcomes.

INTRODUCTION/BACKGROUND:Technology is increasingly incorporated into unicompartmental knee arthroplasty (UKA) through computer-assisted navigation (N-UKA) and robot-assisted surgery (R-UKA) to improve alignment, implant positioning, and gap balancing. Whether intraoperative technology helps achieve the minimal clinically important difference (MCID) in patient-reported outcomes (PROMs) compared to conventional UKA (C-UKA) remains unclear. This systematic review aimed to assess whether differences in PROMs between C-UKA and technology-assisted UKA reached MCID values. MATERIALS AND METHODS/METHODS:PubMed/MEDLINE/Cochrane Library were reviewed for studies comparing PROMs between primary C-UKA (control group) and N-UKA or R-UKA. Delta improvements were compared to established MCID values. Additional radiographic and clinical differences were assessed. The review yielded four (N=328) N-UKA and seven (N=526) R-UKA studies with C-UKA cohorts as controls. RESULTS:Differences in preoperative and postoperative PROMs were reported as statistically significant in three of four studies (75%) comparing N-UKA and C-UKA; however, none of the studies reported values that reached the MCID. Differences in preoperative and postoperative PROMs were reported as statistically significant in four of seven studies (57.1%) comparing R-UKA and C-UKA; however, only three of the studies (42.9%) reported values that reached the MCID. Improved radiographic outcomes for N-UKA and R-UKA were reported in 75% and 57.1% of studies, respectively. Only one study reported improved revision rates with R-UKA compared to C-UKA. CONCLUSION/CONCLUSIONS:Though studies may report better improvements in PROMs in N-UKA and R-UKA compared to C-UKA, these often may not achieve clinical significance. Future studies should present outcome differences in the context of validated MCID as well as other metrics such as revision rates and radiographic outliers as the impetus for technology-assisted UKA.

BACKGROUND:Cementless total knee arthroplasty (TKA) has recently regained popularity, yet data has raised concerns about rates of arthrofibrosis following these procedures. The purpose of this study was to utilize the American Joint Replacement Registry to compare rates of early manipulation under anesthesia (MUA) in cementless and cemented primary TKAs that use technology or manual instrumentation. METHODS:We queried the American Joint Replacement Registry for all patients ages 18 to 95 years who underwent cemented or cementless primary TKA over a 7-year period. Patients were stratified based on whether technology (robotics or computer-assisted navigation) was used during the primary surgery. Groups were then compared for rates of MUA within 90-day of the index surgery using multivariable logistic regression models. A total of 340,841 cases were included in the study, 78,397 (23%) of which used technology and 262,444 (77%) which did not. Within the technology cohort, there were 51,500 (65%) robotic and 26,897 (35%) navigated cases. There were 65% of technology-assisted TKAs and 92% of manual TKAs cemented. RESULTS:In the technology group, multivariable analysis demonstrated significantly higher odds of MUA in cemented TKAs compared to cementless (odds ratio [OR] 1.95, 95% confidence interval [CI] [1.06 to 3.59]; P = 0.031). Robotic cases had significantly higher odds of MUA with cemented compared to cementless implants (OR 2.38, 95% CI [1.27 to 4.46]; P = 0.007), while there was no difference in MUA related to cementation in the navigated cases (OR 3.53, 95% CI [0.48 to 25.95]; P = 0.22). In the manual group, there were no significant differences in MUA rates related to cementation use (OR 1.14, 95% CI [0.8 to 1.64]; P = 0.46). CONCLUSIONS:Cementless TKA did not increase odds of MUA. In further analyzing cement use into technology and manual cohorts, robotic-assisted cemented TKAs had higher rates of early MUA than cementless. Identification of risk factors leading to early arthrofibrosis may be patient dependent and further study is required to elucidate any surgical considerations.

BACKGROUND:Recovery after total knee arthroplasty (TKA) shows considerable variability in both pain relief and functional improvement. The Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) is a widely used measure for evaluating these outcomes. This study aimed to identify distinct latent recovery trajectories, which represent underlying, unobserved patterns of postoperative recovery inferred from KOOS-JR scores, and to explore patient characteristics associated with these trajectories. METHODS:This retrospective cohort study analyzed patients who underwent primary TKA for osteoarthritis at a tertiary academic center from January 2020 to March 2023. Inclusion criteria required patients to have completed a preoperative KOOS-JR questionnaire and at least two postoperative follow-ups at 1, 3, 6, or 12 months. Exclusion criteria included bilateral or revision procedures. Collected characteristics included age, sex, Body Mass Index, American Society of Anesthesiologists physical status classification, race, smoking status, procedure type, anesthesia type, length of hospital stay, and discharge disposition. Growth mixture modeling was used to model recovery trajectories, with associations evaluated using the "three-step approach." Model fit was assessed using the Akaike and Bayesian Information Criteria, Vuong-Lo-Mendell-Rubin likelihood ratio, posterior probabilities, and entropy values. RESULTS:Of 700 eligible patients, growth mixture modeling identified two recovery trajectories: 95.4% of patients (trajectory 1 [T1]) demonstrated steady improvement, while 4.6% (trajectory 2 [T2]) began with lower KOOS-JR scores (mean 9.7 vs. 47.9 for T1) but recovered to near T1 levels by 1 month. Trajectory 2 patients were markedly younger (mean 64 vs. 67 years), had higher Body Mass Index (36 vs. 31), included more Black or African American individuals (38% vs. 20%), and were more frequently discharged to rehabilitation facilities (16% vs. 3.3%; all P < 0.05). Each additional year of age reduced the likelihood of following T2 by 4% (odds ratio = 0.96, 95% confidence interval, 0.92 to 0.99; P = 0.016), while discharge to rehabilitation increased the likelihood 6-fold (odds ratio = 6.22, 95% confidence interval, 1.89 to 17.8; P = 0.001). CONCLUSION/CONCLUSIONS:This study identified two distinct recovery trajectories after TKA, with notably no trajectory emerging showing decline or stagnation from preoperative levels. Despite lower baseline scores, patients in T2 achieved substantial recovery, suggesting TKA provides meaningful improvement even for those with substantially compromised function. The findings also highlight the need to explore whether rehabilitation discharge directly influences the observed postoperative gains.

BACKGROUND:Patients' satisfaction and job limitations after primary total hip arthroplasty (THA) based on occupation intensity have not been evaluated. This study aimed to assess patients' ability and satisfaction with their return to work following primary THA depending on intensity of their occupation. METHODS:This retrospective review surveyed patients undergoing primary THA between June 2011 and January 2022, with at least one year of follow-up, on return to work rates. Of 1,713 participants, 1,176 (68.7%) reported working prior to THA and were stratified into high intensity (HI) (i.e. laborer, construction), standard intensity (SI) (i.e. walking, climbing stairs), and low intensity (LI) (i.e. desk jobs) groups. Baseline demographics and survey responses were compared. Among patients who worked preoperatively, 66 (5.6%), 450 (38.3%), and 660 (56.1%) were in the HI, SI, and LI groups, respectively. RESULTS:High rates of workers across all groups reported improvements in their ability to work following THA, with 74.8% of SI, 68.8% of LI workers and 63.6% of HI workers reporting "remarkable" or "modest improvement." The HI group was more likely male, younger, and a current smoker compared to the SI and LI groups. Among LI workers, 47.2% returned within the first month and83.6% returned within two months. SI workers showed a similar pattern, with 36.2% returning in less than a month and 79.7% returning within two months. HI workers had a comparatively lower return rate, with 12.3% returning within the first month and 52.6% returning within two months. CONCLUSION/CONCLUSIONS:Across all intensity levels, THA enables improvements in perceived work function and satisfaction. However, higher-intensity work requires more time, is more difficult, and yields lower return-to-work satisfaction compared to low-intensity work.