Faculty Bibliography

BACKGROUND:Tranexamic acid (TXA) has reduced, but not eliminated, blood transfusions surrounding total knee arthroplasty (TKA). Identifying risk factors for transfusion remains important for risk reduction and type and screen (T and S) optimization. METHODS:We retrospectively reviewed 7,254 patients who underwent primary, unilateral TKA and 307 patients who underwent primary bilateral TKA between January 2014 and January 2023, who received perioperative 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 regressions and receiver operating characteristic (ROC) analyses. A total of 172 unilateral TKA patients (2.4%) received perioperative transfusions, with 170 (2.3%) receiving postoperative transfusions and two (0.03%) receiving intraoperative transfusions. There were 26 bilateral TKA patients (8.5%) who received postoperative transfusions with no documented intraoperative transfusions. RESULTS:For unilateral TKA, the risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index (BMI), and a direct correlation with American Society of Anesthesiologists (ASA) class and estimated blood loss (EBL) on multivariate testing. The ROC analyses demonstrated an optimal Hgb cutoff of 12.1 g/dL for predicting transfusion. The transfusion rate below Hgb of 12.1 g/dL was 6.6%, compared to a rate of 1.4% above this Hgb threshold. Below Hgb of 11 g/dL, the transfusion rate was 11.1%, while for Hgb between 11 and 12 g/dL, the transfusion rate was 4.6%. CONCLUSION/CONCLUSIONS:Transfusion is rare in unilateral TKA when TXA is used and preoperative Hgb is ≥ 12.1 g/dL, challenging universal T and S. Patients who have Hgb less than 11.0 g/dL and bilateral TKA patients remain at higher risk. Risk factors such as Hgb between 11 and 12 g/dL, BMI, ASA and EBL may predict transfusion risk and need for T and S.

PURPOSE/OBJECTIVE:To evaluate the safety and efficacy of genicular artery embolization and its longitudinal effects on biomarkers implicated in knee osteoarthritis (KOA) pathogenesis.. MATERIALS AND METHODS/METHODS:This is a prospective, single-arm clinical trial of patients with symptomatic KOA resistant to conservative therapy for greater than 3 months. Twenty-five patients who underwent GAE using 250-μm microspheres were included. Patient reported outcome measures were evaluated at baseline and 1-, 3-, and 12-months following GAE. Blood samples were collected for biomarker analysis. Magnetic resonance imaging was obtained at baseline and 3 months post GAE. The primary endpoint was the clinical success rate at 12 months. Baseline and follow-up outcomes were analyzed using the Wilcoxon matched-pairs signed-rank test. RESULTS:The technical success was 100%, with no significant adverse events. The clinical success rate was 62%. The mean VAS pain score for the target knee decreased by 48.5% at 1 month, 50.8% at 3 months, and 55.4% at 12 months (p < .001). WOMAC pain scores improved by 39.6% at 1 month, 50.1% at 3 months, and 43.7% at 12 months (p < .001). There was a statistically significant decrease in the serum levels of vascular endothelial growth factor (VEGF) and Interleukin-1 receptor antagonist (IL-1Ra) at 12 months. The remaining biomarkers showed no significant change. CONCLUSIONS:GAE is a safe treatment for symptomatic KOA, providing clinically significant pain relief for a subset of patients. The observed reductions in serum VEGF and IL-1Ra levels following GAE may contribute to local pain relief and decreased inflammation in the knee joints.

BACKGROUND:Sleep impairment following total hip arthroplasty (THA) is common and may decrease patient satisfaction and early recovery. Standardized postoperative recommendations for sleep disturbance have not been established. We aimed to assess whether melatonin use improves sleep quality and quantity in the acute period following THA. METHODS:Patients undergoing primary, elective THA between July 2021 and March 2024 were prospectively enrolled and randomized to receive either five mg of melatonin or a placebo nightly for 14 days postoperatively. Participants recorded nightly pain scores on the visual analog scale (VAS), the number of hours slept, and the number of nighttime awakenings in a sleep diary. Sleep disturbance was assessed preoperatively and on postoperative day (POD) 14 using the patient-reported outcome measurement information system sleep disturbance (PROMIS-SD) form. Epworth Sleepiness Scores (ESS) were collected to assess sleep quality and were the primary outcome of this study. Of the 139 patients who completed the study protocol, there were 64 patients in the placebo group and 75 patients in the melatonin group. RESULTS:Both groups demonstrated comparable postoperative ESS (melatonin: 6.0 ± 4.0; placebo: 6.8 ± 4.5, P = 0.35). Melatonin patients experienced significantly more hours slept on POD2 (6.5 ± 1.7; 5.7 ± 2.4, P = 0.017) and averaged over POD one to three (6.1 ± 1.6; 5.7 ± 2.0, P = 0.14), although this was not statistically significant. Fewer nighttime awakenings in the melatonin group were observed on POD two (2.7 ± 1.5; 3.1 ± 2.0, P = 0.28), although this was not statistically significant. The melatonin group demonstrated significantly lower postoperative PROMIS-SD scores (52.5 ± 9.3; 56.3 ± 9.2, P = 0.040). CONCLUSION/CONCLUSIONS:Melatonin may not improve overall postoperative sleep quality following THA as measured by the ESS. Melatonin may promote sleep duration in the POD one to three period, although potential benefits wane after POD three. Melatonin is safe and can be considered for THA patients experiencing early postoperative sleep disturbance.

BACKGROUND:Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase fluid retention and the risk of heart failure (HF). Type 2 diabetes mellitus (T2DM) is known to increase the risk of cardiac disease, including HF. As part of a modern multimodal pain protocol, NSAIDs are commonly used in total knee arthroplasty (TKA), but the risk of NSAID use in TKA for T2DM patients is not well understood. The purpose of this study was to compare rates of new-onset HF following TKA in Type 2 diabetics with varying NSAID use. METHODS:We reviewed 3,906 patients who underwent primary TKA from 2015 to 2023 at a single academic institution. Data collected included demographics, preoperative diagnosis of T2DM, postoperative development of new-onset HF, NSAIDs taken perioperatively, and aspirin use for deep vein thrombosis (DVT) prophylaxis. Propensity matching was conducted to control for age, American Society of Anesthesiologists (ASA) Score, and aspirin use. Rates of postoperative HF within T2DM patients who took meloxicam versus celecoxib were compared using Chi-square analyses. RESULTS:Among patients who took meloxicam or celecoxib perioperatively, a preoperative diagnosis of T2DM was disproportionately associated with postoperative HF (P = 0.006). When comparing peri-TKA use of meloxicam versus celecoxib in T2DM patients, the use of celecoxib was disproportionately associated with the development of postoperative HF (2.2% [meloxicam], 4.8% [celecoxib], P = 0.002). CONCLUSIONS:We found patients who had T2DM developed postoperative HF at higher rates compared to non-diabetics following peri-TKA NSAID use and that T2DM patients developed new-onset HF at higher rates when utilizing celecoxib than meloxicam in the peri-TKA period. Along with the many other factors that contribute to an orthopaedic surgeon's decision on which NSAID to use postoperatively, we advocate for consideration of the risk of new-onset HF in T2DM patients when prescribing meloxicam and celecoxib in the post-TKA period.

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.

BACKGROUND:Cement fixation for total hip arthroplasty (THA) remains a controversial topic. While cemented stems are associated with lower risk of periprosthetic fractures (PPF), cementless stems may offer superior biological fixation. This study analyzed peri-operative and short-term outcomes of cemented vs. cementless stem fixation in THA. METHODS:A retrospective review was conducted on 15,012 patients who underwent primary elective THA at an academic medical center from 2011 to 2021. Of these patients, 429 were cemented. Patients were stratified into 3 age cohorts (25-69, 70-79 and ≥ 80 years). Cemented stem patients were 1:1 propensity-score matched to cementless stem patients for baseline characteristics. Perioperative and short-term outcomes were compared. RESULTS:The mean operative time for cemented cases was significantly longer across all age cohorts (25-69, P = 0.005; 70-79, P < 0.001; ≥80, P < 0.001). In the 70-79 and ≥ 80 cohorts, cemented patients demonstrated a significantly shorter length of stay (LOS) compared to cementless patients (2.2 vs. 2.6 days, P = 0.017; 3.0 vs. 3.4, P = 0.041, respectively). In the 70-79 and ≥ 80 cohorts, cemented patients were significantly more likely to be discharged home when compared to cementless patients (88.2 vs. 80.5%, P = 0.031; 64.0 vs. 54.2%, P = 0.046, respectively). Across age cohorts, there were no differences in all-cause revision rates (Cohort 1: 5.4% vs. 1.1%, P = 0.108; Cohort 2: 3.0% vs. 1.8%, P = 0.362; Cohort 3: 1.8% vs. 1.2%, P = 0.714). The ≥ 80 cohort demonstrated increased rates of PPF in the cementless cohort compared to cemented (1.2 vs. 0%, P = 0.082, respectively), but it did not reach significance. CONCLUSION/CONCLUSIONS:Patient age has a substantial impact on perioperative outcomes following cemented versus cementless stem THA. Patients > 70 with a cemented femoral stem had improved perioperative outcomes such as shorter LOS, increased discharge to home and reduced rates of PPF compared to their cementless stem counterparts. Patient age should be considered prior to selecting a stem fixation strategy. LEVEL OF EVIDENCE/METHODS:III, Therapeutic Study.

INTRODUCTION/BACKGROUND:Prosthetic dislocation after total hip arthroplasty (THA) is one of the most common causes of revision THA. Dual-mobility (DM) bearings were introduced to mitigate complications; however, there is minimal data on their performance in younger patients. This study compared results of patients who were under 55 years of age undergoing primary THA with DM or fixed-bearing (FB) implants. METHODS:A retrospective review of patients younger than 55 years who underwent primary THA with at least 2 years of follow-up between June 2011 and August 2019 was performed. Patients were stratified into two cohorts based on the implant they received (DM vs. FB). Primary outcomes were 90-day all-cause readmission, dislocation, all-cause revision, 90-day readmission and revision due to dislocation, and implant component survivorship. Demographic differences were assessed using chi-squared and independent samples t-tests. Outcomes were compared using multivariate linear and logistic regressions to control for confounding variables. RESULTS:A total of 803 patients were included (DM = 73, FB = 730). The DM and FB cohorts had similar rates of 90- day all-cause readmission (6.8% vs. 3.2%; p = 0.243) and 90-day readmission due to dislocation (4.1% vs. 0.8%; p = 0.653). At a mean follow-up of 4.42 ± 1.91 years, dislocation (4.1% vs. 1.1%; p = 0.723) and all-cause revision (5.5% vs. 4.9%; p = 0.497) rates between the DM and FB cohorts were similar. Kaplan Meier analysis yielded no significant differences in survivorship between groups for all-cause revision (95.1% vs. 94.5%; p = 0.923), revision due to dislocation (100% vs. 98.9%; p = 0.370), and acetabular component revision (97.3% vs. 98.6%; p = 0.418). CONCLUSION/CONCLUSIONS:Dual mobility implants demonstrate similar dislocation rates and implant survivorship compared to FB in patients less than 55 years of age. Larger trials with long-term follow-up may be required to further elucidate the effects of DM bearings compared to FB inserts in younger patients undergoing primary THA.

BACKGROUND:Sleep impairment following total knee arthroplasty (TKA) is common and may decrease patient satisfaction and recovery. Standardized postoperative recommendations for sleep disturbances have not been established. We aimed to assess whether melatonin use could promote healthy sleep and reduce sleep disturbance in the acute period following TKA. METHODS:Patients undergoing primary, elective TKA between July 19, 2021 and January 4, 2024 were prospectively enrolled and randomized to receive either 5 mg of melatonin nightly or placebo for 14 days postoperatively. Participants recorded their nightly pain on the visual analog scale, the number of hours slept, and the number of nighttime awakenings in a sleep diary starting the night of surgery (postoperative day [POD] 0). Sleep disturbance was assessed preoperatively and on POD 14 using the patient-reported outcome measurement information system sleep disturbance form. Epworth Sleepiness Scores were collected on POD 14 to assess sleep quality. RESULTS:Of the 138 patients enrolled, 128 patients successfully completed the study protocol, with 64 patients in each group. Melatonin patients trended towards more hours of sleep on POD 2 (placebo: 5.0 ± 2.4, melatonin: 5.8 ± 2.0, P = 0.084), POD 3 (placebo: 5.6 ± 2.2, melatonin: 6.3 ± 2.0, P = 0.075), and averaged over POD 1 to 3 (placebo: 4.9 ± 2.0, melatonin: 5.6 ± 1.8, P = 0.073), though no differences were observed on POD 4 or after. Fewer nighttime awakenings in the melatonin group were observed on POD 1 (placebo: 4.4 ± 3.9, melatonin: 3.6 ± 2.4, P = 0.197), although this was not statistically significant. Preoperative and postoperative Patient-Reported Outcomes Measurement Information System Sleep Disturbance (PROMIS-SD) score increases were comparable for both groups (placebo: 4.0 ± 8.4, melatonin: 4.6 ± 8.2, P = 0.894). The melatonin (65.4%) and placebo (65%) groups demonstrated similar rates of increased sleep disturbance. CONCLUSION/CONCLUSIONS:Melatonin may promote longer sleep in the immediate postoperative period after TKA, though these benefits wane after POD 3. Disturbances in sleep should be expected for most patients, though melatonin may have an attenuating effect. Melatonin is safe and can be considered for TKA patients experiencing early sleep disturbances postoperatively.