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Does femoral morphology and stem alignment influence outcomes of cementless total hip arthroplasty with proximally coated double-tapered titanium stems?

Narayanan, Rajkishen; Elbuluk, Ameer M; Chen, Kevin K; Eftekhary, Nima; Zuckerman, Joseph D; Deshmukh, Ajit J
INTRODUCTION/UNASSIGNED:Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component. METHODS/UNASSIGNED:We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries. RESULTS/UNASSIGNED: 0.03) and FNS was inversely associated with postoperative HOOS scores. CONCLUSIONS/UNASSIGNED:Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.
PMID: 31912748
ISSN: 1724-6067
CID: 4257332

Total Knee Arthroplasty Is Safe in Jehovah's Witness Patients-A 12-Year Perspective

Wolfson, Theodore S; Novikov, David; Chen, Kevin K; Kim, Kelvin Y; Anoushiravani, Afshin A; Deshmukh, Ajit J; Lajam, Claudette M
Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.
PMID: 30620987
ISSN: 1938-2480
CID: 3579892

Re-revision total hip arthroplasty: Epidemiology and factors associated with outcomes

Yu, S; Saleh, H; Bolz, N; Buza, J; Iorio, R; Rathod, P A; Schwarzkopf, R; Deshmukh, A J
Introduction/UNASSIGNED:The epidemiology of re-revision total hip arthroplasty (THA) is not yet well-understood. We aim to investigate the epidemiology and risk-factors that are associated with re-revision THA. Methods/UNASSIGNED:288 revision THA were analyzed between 1/2012 and 12/2013. Patients who underwent two or greater revision THA were included. Hips with first-revision due to periprosthetic joint infection (PJI) were excluded. Failure was defined as reoperation. Results/UNASSIGNED:51 re-revision patients were available. Mean age was 59.6 (±14.2 years), 32 (67%) females, average BMI of 28.8 (±5.4), and median ASA 2 (23; 55%). The most common re-revision indications were acetabular component loosening (15; 29%), PJI (13; 25%) and instability (9; 18%). The most common indications for first revision in the re-revision population were acetabular component loosening (11; 27%), polyethylene wear (8; 19%) and instability (8; 19%). There was an increased risk of re-revision failure if the re-revision involved exchanging only the head and polyethylene liner (RR = 1.792; p = 0.017), instability was the first-revision indication (RR = 3.000; p < 0.001), and instability was the re-revision indication (RR = 1.867; p = 0.038). If isolated femoral component revision was indicated during the re-revision, there was a decreased risk of failure (RR = 0.268, p = 0.046). 1-year re-revision survival was 54% (23/43). Discussion/UNASSIGNED:Acetabular component loosening, instability, and PJI were the most common indications for re-revision. Revision due to instability is a recurrent problem that leads to re-revision failure. There was a higher infection rate in the re-revision population compared to published revision PJI. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population.
PMID: 32001983
ISSN: 0976-5662
CID: 4294362

Nonmodular Stems Are a Viable Alternative to Modular Stems in Revision Total Hip Arthroplasty

Clair, Andrew J; Cizmic, Zlatan; Vigdorchik, Jonathan M; Poultsides, Lazaros A; Schwarzkopf, Ran; Rathod, Parthiv A; Deshmukh, Ajit J
BACKGROUND:Nonmodular and modular femoral stems have been associated with complications after revision total hip arthroplasty (rTHA). As such, the ideal femoral component for rTHA remains undecided. This study aims to report outcomes of titanium, tapered-fluted, modular and nonmodular femoral components in rTHA. METHODS:From January 1, 2013 to September 30, 2017, all rTHAs using modular or nonmodular femoral stems were identified. Demographic data including age, gender, and American Society of Anesthesiologists scores were collected. Surgical details including operative time and implant cost were also collected. Clinical outcomes including length of stay, dislocation, infection, fracture, reoperation, and re-revision were collected. Statistical analysis was performed using chi-square test and Student's t-test for all categorical and continuous variables, respectively. RESULTS:One hundred forty-six rTHA cases (103 modular and 43 nonmodular) were identified with an average follow-up of 29 months (range 3-59 months). Nonmodular stems had a significantly lower cost when compared to modular implants (modular stems 120.8% higher cost; P < .001). The surgical time of nonmodular components was significantly greater (193 minutes vs 163 minutes; P = .029). There were no differences observed in any other surgical details or clinical outcomes assessed, including length of stay (P = .323), rate of re-revision of the femoral implant (P = .389), rate of re-operation (P = .383), and postop complications (P = .241), including infection (P = .095), dislocation (P = .778), and fracture (P = .959). CONCLUSIONS:Nonmodular components provide encouraging clinical results with significantly lower costs compared to modular implants in rTHA. The use of titanium, tapered-fluted, nonmodular components may offer a more cost-effective approach to rTHA compared to their modular counterparts.
PMID: 31010773
ISSN: 1532-8406
CID: 3821422

Optimum anatomic socket position and sizing for the direct anterior approach: impingement and instability

Mercer, Nathaniel; Hawkins, Evan; Menken, Luke; Deshmukh, Ajit; Rathod, Parthiv; Rodriguez, Jose A
A comprehensive strategy is important for ensuring reproducible and safe acetabular component sizing and positioning. Presented here is our approach for anatomic acetabular component positioning in direct anterior total hip arthroplasty. This strategy has evolved with our understanding of the ramifications of socket sizing and positioning on instability and impingement. Data collected by a single surgeon (J.A.R.) between 2009 and 2011 influenced our current paradigm. We compare the sizing and positioning parameters of the anterior and posterior approach, thus demonstrating how the 2 are different. By highlighting these differences, we hope to provide a clear, defined approach to acetabular placement and sizing for direct anterior-approach total hip arthroplasty.
PMID: 31286036
ISSN: 2352-3441
CID: 4069492

Total Knee Arthroplasty is Safe in Jehovah's Witness Patients-A 12-year Perspective [Meeting Abstract]

Wolfson, Theodore; Novikov, David; Chen, Kevin; Kim, Kelvin; Anoushiravani, Afshin; Deshmukh, Ajit; Lajam, Claudette
ISSN: 0003-2999
CID: 3727532

Salvage of failed internal fixation of intertrochanteric hip fractures: clinical and functional outcomes of total hip arthroplasty versus hemiarthroplasty

Luthringer, Tyler A; Elbuluk, Ameer M; Behery, Omar A; Cizmic, Zlatan; Deshmukh, Ajit J
Background/UNASSIGNED:Failed internal fixation of intertrochanteric (IT) hip fractures presents a significant challenge in the elderly, osteoporotic population. Conversion total hip arthroplasty (cTHA) and hemiarthroplasty (cHA) are both accepted salvage operations for failed IT fracture fixation, though limited clinical data exist regarding the optimal treatment between these procedures. Methods/UNASSIGNED:A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were English-language studies that compared clinical or functional outcomes after failed fixation of IT fractures with total hip arthroplasty and hemiarthroplasty in adult subjects (>18 years of age). Data regarding research design, surgical technique, and clinical or functional outcomes were obtained and analyzed from eligible studies using a Mantel-Haenszel random-effects analysis model. Results/UNASSIGNED:< .001) in the cTHA group (47.5 ± 4.9) than that in the cHA (38.9 ± 7.2) group at minimum 14-month follow-up. Conclusions/UNASSIGNED:Despite potential advantages of cTHA or cHA for failed IT fractures, there were no differences in complications between either of the salvage procedures. Our analysis found a slight advantage in functional outcomes (Harris Hip Score) for cTHA at a minimum 14-month follow-up. Our study suggests that cTHA and cHA are both effective salvage procedures. Additional prospective studies are warranted to further delineate outcomes after salvage arthroplasty performed for failed IT fracture fixation.
PMID: 30186926
ISSN: 2352-3441
CID: 3274752

Nonmodular stems are a viable alternative to modular stems in revision total hip arthroplasty [Meeting Abstract]

Clair, A; Cizmic, Z; Vigdorchik, J; Poultsides, L; Schwarzkopf, R; Rathod, P; Deshmukh, A
Introduction/objectives: Nonmodular and modular femoral stems have been associated with complications following revision total hip arthroplasty (rTHA). This study aims to report outcomes of modular and nonmodular femoral components in rTHA. Methods: From January 1st, 2013 to September 30th, 2017, all rTHAs using modular or nonmodular femoral stems were identified. Demographic data including age, gender, American Anesthesiology Society (ASA) score. Surgical details including operative time, length of implant, and implant cost were collected. Clinical outcomes including length of stay (LOS), dislocation, infection, fracture, femoral implant re-revision, reoperation, and mortality were also collected. Simple linear regression analysis and sub-analysis using multivariable logistic regression were performed. Results: Of 247 rTHA cases identified, 136 (55.1%) cases utilized modular stems while 111 (44.9%) cases utilized nonmodular components. The average follow-up was 15.5 months (range 0.5-59 months). Nonmodular stems had a significantly lower cost when compared to modular implants (54.3% of modular cost; p<0.001). There were no differences appreciated in cohort demographics including age (p=0.831), gender (p=0.459), and ASA (p=0.053). In addition, there were no differences observed in the surgical details or clinical outcomes assessed, including operative time (p=0.386), LOS (p=0.638), and rates of re-revision of the femoral implant (p=0.327), re-operation (p=0.410), and post-op complications including, infection (p=0.322), dislocation (p=0.687), fracture (p=0.528), and mortality (p=0.446). Conclusion: The use of distal fixation, tapered-fluted, titanium nonmodular components may offer a more costeffective approach to rTHA compared to their modular counterparts
ISSN: 1120-7000
CID: 3370752

Obesity: The Modifiable Risk Factor in Total Joint Arthroplasty

Bookman, Jared S; Schwarzkopf, Ran; Rathod, Parthiv; Iorio, Richard; Deshmukh, Ajit J
Obesity is an epidemic in the health care system. Obesity poses several challenges and raises unique issues for the arthroplasty surgeon. Obese patients are at higher risk for infection and dislocation. Additionally, obese patients have poorer implant survivorship and functional scores postoperatively. Obesity is a modifiable risk factor and weight loss preoperatively should be strongly considered. Obese patients must be counseled so that they have realistic expectations after total joint arthroplasty.
PMID: 29929710
ISSN: 1558-1373
CID: 3157702

The Role of Bariatric Surgery in the Obese Total Joint Arthroplasty Patient

Hooper, Jessica M; Deshmukh, Ajit J; Schwarzkopf, Ran
Although bariatric surgery is a proven means of weight loss and treatment of obesity-related comorbidities in morbidly obese patients, it is not yet clear how it affects outcomes after total joint arthroplasty in this high-risk patient population. This article explores the effects of obesity and bariatric surgery on osteoarthritis and total joint arthroplasty, and also discusses the financial and ethical implications of use of bariatric surgery for risk reduction before total joint arthroplasty.
PMID: 29929711
ISSN: 1558-1373
CID: 3157712