Faculty Bibliography

BACKGROUND:A tourniquet is commonly used during total knee arthroplasty (TKA) to improve surgical field visibility and minimize blood loss. While the short-term effects of tourniquet use on postoperative outcomes have been studied extensively and found to be minimal, its influence on longer-term outcomes remains underexplored. This study examined tourniquet use in TKA with up to five-year follow-up. METHODS:In this post hoc analysis of a randomized controlled trial, 227 patients who underwent primary TKA in the tourniquet (T) group (n = 112) or no tourniquet (NT) group (n = 115) were evaluated. Clinical outcomes and patient-reported outcome measures (PROMs) were compared between the two groups. RESULTS:The T group had non-significant trends toward reduced blood loss (131.8 versus 116.7 ml, P = 0.098) and shorter operative time (97.8 versus 95.7 minutes, P = 0.264), with slightly higher postoperative day-one Visual Analog Scale (VAS) pain scores (3.1 versus 3.6, P = 0.197). Length of stay (2.0 versus 2.1 days, P = 0.837) and home discharge rate (88.7 versus 92.0%, P = 0.340) were comparable. The NT group had three 90-day readmissions, while none occurred in the T group (2.7 versus 0%, P = 0.081). The active range of motion at the final follow-up was similar between groups (108.3 versus 106.5 degrees, P = 0.457). All-cause revision rates at five years were comparable between the NT and T groups (5.2 versus 3.6%, P = 0.546). Kaplan-Meier survivorship analysis revealed comparable aseptic implant survival at five years (P = 0.769). There were no significant differences in Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, PROMIS pain interference, or PROMIS physical health scores at three months, one year, and five years postoperatively. CONCLUSION/CONCLUSIONS:Using a tourniquet during primary TKA was not associated with differences in clinical or patient-reported outcomes at up to five-year follow-up. These findings suggest that tourniquet use in TKA can be left to the surgeon's discretion.

BACKGROUND:Tranexamic acid (TXA) is a renally-excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty. METHODS:Through a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or hemiarthroplasty (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; nonelective/hemiarthroplasty: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (ROA; intravenous, topical), were extracted. Pre- and postoperative (≤ 7 days) creatinine, perioperative transfusions, revisions, and 90-day emergency department (ED) visits, readmissions, and mortalities were recorded and compared between TXA groups. RESULTS:In the total sample and all cohorts, change in pre- to postoperative creatinine and incidence of postoperative acute kidney injury (AKI), per Kidney Disease Improving Global Outcomes (KDIGO) guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or ROA (P values ≥ 0.256). There were no statistically significant differences in 90-day ED visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA, three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA, one no TXA, P = 0.882) in the nonelective/hemiarthroplasty cohort, with none in the elective cohorts. CONCLUSIONS:The administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or hemiarthroplasty for fracture, suggesting TXA should not be contraindicated in this population.

INTRODUCTION/UNASSIGNED:Previous studies have demonstrated the use of technology in total hip arthroplasty (THA) provided favorable outcomes. This study sought to describe the effect preoperative two-dimensional low-dose (2DLD) full-body radiographs had on the prevention of adverse outcomes following THA. METHODS/UNASSIGNED:We reviewed 11,814 cases of patients who underwent primary, elective THA from 2016 to 2021. Patient demographics and clinical data were compared between patients who did or did not have preoperative standing and sitting 2DLD images (29.5% vs. 70.5%, respectively) using Chi-squared test and multivariate logistic regressions. RESULTS/UNASSIGNED: < 0.001). Multivariate analysis demonstrated preoperative 2DLD images to be significantly associated with lower odds of dislocation, independent from surgical approach, coexisting spinal fusion, and utilization of dual-mobility implants. CONCLUSION/UNASSIGNED:Preoperative 2DLD images were independently associated with decreased risk for dislocations. Even in a higher risk cohort with spinal fusion, the rate of dislocation in the 2DLD cohort was significantly lower.

INTRODUCTION/UNASSIGNED:Previous studies have demonstrated the use of technology in total hip arthroplasty (THA) provided favorable outcomes. This study sought to describe the effect preoperative two-dimensional low-dose (2DLD) full-body radiographs had on the prevention of adverse outcomes following THA. METHODS/UNASSIGNED:We reviewed 11,814 cases of patients who underwent primary, elective THA from 2016 to 2021. Patient demographics and clinical data were compared between patients who did or did not have preoperative standing and sitting 2DLD images (29.5% vs. 70.5%, respectively) using Chi-squared test and multivariate logistic regressions. RESULTS/UNASSIGNED: < 0.001). Multivariate analysis demonstrated preoperative 2DLD images to be significantly associated with lower odds of dislocation, independent from surgical approach, coexisting spinal fusion, and utilization of dual-mobility implants. CONCLUSION/UNASSIGNED:Preoperative 2DLD images were independently associated with decreased risk for dislocations. Even in a higher risk cohort with spinal fusion, the rate of dislocation in the 2DLD cohort was significantly lower.

INTRODUCTION/UNASSIGNED:Total hip arthroplasty (THA) using computer-assisted navigation (N-THA) and robot-assisted surgery (RA-THA) has been increasingly adopted to improve implant positioning and offset/leg-length restoration. Whether clinically meaningful differences in patient-reported outcomes (PROMs) compared to conventional THA (C-THA) are achieved with intraoperative technology has not been established. This systematic review aimed to assess whether published relative PROM improvements with technology use in THA achieved minimal clinically important differences (MCIDs). METHODS/UNASSIGNED: 2786) studies, respectively, for analyses. RESULTS/UNASSIGNED:Statistically significant improvements in postoperative PROM scores were reported in 2/6 (33.3%) studies comparing N-THA with C-THA, though only 1 (16.7%) reported clinically significant relative improvements. Statistically significant improvements in postoperative PROMs were reported in 6/10 (60.0%) studies comparing RA-THA and C-THA, though none reported clinically significant relative improvements. Improved radiographic outcomes for N-THA and RA-THA were reported in 83.3% and 70.0% of studies, respectively. Only 1 study reported a significant improvement in revision rates with RA-THA as compared to C-THA. CONCLUSIONS/UNASSIGNED:Reported PROM scores in studies comparing N-THA or RA-THA to C-THA often do not achieve clinically significant relative improvements. Future studies reporting PROMs should be interpreted in the context of validated MCID values to accurately establish the clinical impact of intraoperative technology.

BACKGROUND:The impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB). METHODS:We retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group). RESULTS:Total (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049). CONCLUSIONS:Increased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Computer navigation and robotic assistance may reduce total hip arthroplasty (THA) dislocations by improving the accuracy and precision of component positioning. We investigated dislocation rates for THAs using conventional techniques, robotic assistance, and computer navigation, while controlling for surgical approach, dual mobility (DM) use, and fluoroscopic guidance. METHODS:We reviewed 11,740 primary THAs performed between June 2016 and December 2022, including 5,873 conventional, 1,293 with robotic-arm assistance, and 4,574 with navigation. The approach was posterior in 6,580 (56.0%), anterior in 4,342 (37.0%), and lateral in 818 (7.0%). A DM was used in 10.4%. Fluoroscopy was used in 3,653 cases and only with the anterior approach. Multivariate analyses yielded odds ratios (OR) for dislocation and revision. Additional regression analyses for dislocation were performed for approach and DM. RESULTS:Raw dislocation rates were as follows: conventional 1.2%, robotic 0.4%, navigation 0.9%, anterior with fluoroscopy 0.4%, anterior without fluoroscopy 2.3%, posterior 1.3%, and lateral 0.5%. Upon multivariate analysis, use of robotics was found to be associated with significantly reduced dislocation risk compared to conventional (OR: 0.3), as did anterior (OR: 0.6) compared to posterior approach; navigation and lateral approach were not found to be associated with a significant reduction in risk. For the anterior approach, multivariate analysis demonstrated that fluoroscopy significantly reduced dislocation risk (OR: 0.1), while DM, robotics, and navigation were not significant. For the posterior approach, the dislocation risk was lower with robotics than with conventional (OR: 0.2); the use of navigation or DM did not demonstrate a significant reduction in risk. CONCLUSIONS:The use of robotics was associated with a reduction in dislocations for this cohort overall. Further, fluoroscopy in the anterior approach and robotic assistance in the posterior approach were both associated with decreased dislocation risk. The role of imageless computer navigation and DM implants requires further study.

BACKGROUND:With the increasing utilization of total hip arthroplasty (THA) in patients who have a high comorbidity burden (HCB), coinciding with modifications to reimbursement models over the past decade, an evaluation of the financial impact of HCB on THA over time is warranted. This study aimed to investigate trends in revenue and cost associated with THA in HCB patients. METHODS:Of 13,439 patients who had primary, elective THA between 2013 and 2021 at our institution, we retrospectively reviewed 978 patients considered to have HCB (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores 3 or 4). We collected patient demographics, perioperative data, revenue, cost, and contribution margin (CM) of the inpatient episode. We analyzed changes as a percentage of 2013 values over time for these financial markers. Linear regression determined trend significance. The final analysis included 978 HCB patients who had complete financial data. RESULTS:Between 2013 and 2021, direct costs increased significantly (P = .002), along with a nonsignificant increase in total costs (P = .056). While revenue remained steady during the study period (P = .486), the CM decreased markedly to 38.0% of 2013 values, although not statistically significant (P = .222). Rates of 90-day complications and home discharge remained steady throughout the study period. CONCLUSIONS:Increasing costs for HCB patients undergoing THA were not matched by an equivalent increase in revenue, leading to dwindling CMs throughout the past decade. Re-evaluation of reimbursement models for THA that account for patients' HCB may be necessary to preserve broad access to care. LEVEL OF EVIDENCE/METHODS:III.

Image-based robotic-assisted total knee arthroplasty (RA-TKA) allows three-dimensional surgical planning informed by osseous anatomy, with intraoperative adjustment based on a dynamic assessment of ligament laxity and gap balance. The aim of this study was to identify ranges of implant alignment and bone resections with RA-TKA. We retrospectively reviewed 484 primary RA-TKA cases, stratified by preoperative coronal alignment. Demographics and intraoperative data were collected and compared using Chi-square and ANOVA tests. Planned limb, femoral, and tibial alignment became increasingly varus in a progressive order from valgus to neutral to the highest in varus knees (p < 0.001). Planned external transverse rotation relative to the TEA was lowest in the valgus cohort; relative to the PCA, whereas the varus cohort was highest (p < 0.001, both). Planned resections of the lateral distal femur and of the medial posterior femur were greater in the varus group compared to neutral and valgus (p < 0.001). There were significant differences between cohorts in planned tibia resections, laterally and medially. Varus knees demonstrated higher variability, while valgus and neutral had more metrics with low variability. This study demonstrated trends in intraoperative planned alignment and resection metrics across various preoperative coronal knee alignments. These findings contribute to the understanding of RA-TKA and may inform surgical decision-making.

INTRODUCTION/UNASSIGNED:Spinopelvic mobility drives functional acetabular position, influencing dislocation risk after total hip arthroplasty (THA). Patients have been described as "stuck sitting" or "stuck standing" based on pelvic tilt (PT). We hypothesised that some patients are "stuck in the middle," meaning their PT changes minimally from sitting to standing - increasing their risk of dislocation. METHODS/UNASSIGNED:We reviewed 195 patients with standing and sitting whole body radiographs prior to THA. Standing anterior pelvic plane tilt (APPT) and standing and sitting sacral slope (SS) were measured and used to calculate sitting APPT. Normal standing and sitting were defined as APPT >-10° and <-20°, respectively. Spinal stiffness was classified as <10° change in sacral slope between sitting and standing. Patients were categorised as: (A) able to fully sit and stand; (B) "stuck sitting" - able to fully sit; unable to fully stand; (C) "stuck standing" - able to fully stand; unable to fully sit; or (D) "stuck in the middle" - unable to sit or stand fully. RESULTS/UNASSIGNED:84 patients could sit and stand normally (A), 22 patients were stuck sitting (B), 76 patients were stuck standing (C), and 13 patients were stuck in the middle (D). While 111 patients (56.9%) were considered stuck, only 58 patients (29.7%) met criteria for spinal stiffness. DISCUSSION/UNASSIGNED:We identified a subset of patients with stiff spines and abnormal PT in both sitting and standing, including 37.1% of patients who would be classified as "stuck sitting" based only on standing radiographs. Placing acetabular components in less than anatomic anteversion in these patients may increase posterior dislocation risk.