Faculty Bibliography

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.

BACKGROUND:Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS:Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS:There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS:In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

INTRODUCTION/BACKGROUND:Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS:We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS:In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION/CONCLUSIONS:More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE/METHODS:III, Retrospective Review.

Genicular artery embolization is increasingly recognized as a safe and effective treatment option for symptomatic knee osteoarthritis and recurrent hemarthrosis following total knee arthroplasty. Genicular arteries are an essential vascular supply for the knee joint and demonstrate considerable variability. Familiarity with the anatomy and common variations is critical for pre-procedural planning, accurate target selection, and minimizing adverse events in trans-arterial embolization procedures. This review aims to provide a detailed discussion of the genicular artery anatomy that is relevant to interventional radiologists performing genicular artery embolization.

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.