Faculty Bibliography

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.

INTRODUCTION/BACKGROUND:Obtaining an accurate preoperative diagnosis of periprosthetic joint infections (PJI) is challenging, making differentiating between septic and aseptic failures difficult. We sought to identify the value of common serum biomarkers and evaluate the accuracy of three ratios in the diagnosis of PJI after primary total knee arthroplasty (TKA): albumin-globulin ratio (AGR), C-reactive protein-albumin ratio (CAR), and C-reactive protein-AGR ratio (CAGR). METHODS:Patients undergoing PJI and aseptic revisions after TKA between 2011 and 2021 were retrospectively reviewed at a single institution. Only patients who had reported serum white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin (Alb), and total protein (TP) were included. Areas under the curve (AUCs), which optimize diagnostic performance by balancing sensitivity and specificity at a specific cutoff, were calculated for each individual biomarker and the three ratio groups: AGR = Alb / [TP - Alb], CAR = CRP / Alb, and CAGR = CRP / AGR). Higher AUCs indicate improved identification of PJI while reducing misclassification. RESULTS:Out of the 126 included cases, 89 were confirmed PJIs and 37 were aseptic revisions. Among the single and combination serum biomarkers, the AUCs were as follows: CRP (0.85), ESR (0.76), Alb (0.81), AGR (0.78), CAR (0.87), and CAGR (0.87). The CAR demonstrated excellent accuracy at a cutoff of 2.46, with a sensitivity of 0.74 and specificity of 0.84. CAGR also demonstrated excellent accuracy at a cutoff of 7.09, with a sensitivity of 0.80 and specificity of 0.78. CONCLUSION/CONCLUSIONS:The CRP, CAR, and CAGR showed an excellent diagnostic accuracy as markers for PJI. In patients undergoing revision TKA, common serum biomarkers such as Alb, TP, CRP, and ESR can be obtained, and CAR or CAGR ratios can be calculated to aid in the diagnosis of PJI, especially in cases where synovial analysis is inconclusive, allowing for better clinical decision-making.

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.

INTRODUCTION/BACKGROUND:Total knee arthroplasty can substantially affect global lower limb alignment. However, its specific impacts on ankle and subtalar joint alignment remain poorly understood. This study investigates changes in ankle and subtalar alignment following varying degrees of varus/valgus knee correction in order to further our understanding of this association. MATERIALS AND METHODS/METHODS:This retrospective study included 100 patients who underwent surgery for primary osteoarthritis. Patients diagnosed with conditions other than primary knee OA and those with incomplete or poor-quality imaging were excluded. Patients were categorized into four groups by the degree of intraoperative coronal knee alignment correction: Group 1 (< 10° varus, n = 37), Group 2 (≥ 10° varus, n = 30), Group 3 (< 10° valgus, n = 18), and Group 4 (≥ 10° valgus, n = 15). Hip-knee-ankle angle, tibial plafond inclination, talar inclination, tibiotalar tilt, and subtalar varus-valgus angle, were measured preoperatively and postoperatively on full-length, standing, anteroposterior X-ray images. RESULTS:TKA resulted in postoperative changes in all measured angles regardless of the degree of varus/valgus correction. Notably, ≥ 10° valgus correction led to statistically significant postoperative alterations in ankle and subtalar alignment: tibial plafond inclination from 84.9 to 89.5° (Δ 4.6, range,1.5-7.8, P <.01), tibiotalar tilt from 83.1 to 89.3° (Δ 6.2, range,1.1-9.6, P =.02), and subtalar varus-valgus angle from 66.4 to 72.6° (Δ 6.2, range,1.9-12.1, P <.01). CONCLUSION/CONCLUSIONS:While knee deformity correction during TKA generally realigns the ankle and subtalar joint, our study has shown that large valgus knee correction (≥ 10°) during TKA significantly alters ankle and subtalar joint alignment. Thus, potentially leading to unfavorable postoperative outcomes in patients with abnormal or stiff joints. We recommend that future studies investigate the long-term effects of large valgus knee corrections during TKA on ankle and subtalar joint alignment and their impact on postoperative outcomes.

Total hip arthroplasty (THA) is one of the most common and successful procedures for the treatment of end-stage hip arthritis. However, in certain complex scenarios, THA can present important and unique challenges, specifically following acetabular fractures in adolescent patients, following failed fixation of proximal femoral fractures, and in developmental dysplasia of the hip (DDH). As these cases involve distorted anatomy, poor bone quality, retained hardware, and previous surgeries, detailed planning, specialized instrumentation and implants, and novel surgical techniques are required. This narrative review examines the challenges, surgical considerations, outcomes, and complications in complex THA management.

BACKGROUND:Robotic assistance (RA) is increasingly used in total knee arthroplasty (TKA) for more accurate bony resection and balancing. However, the impact of robotic TKA (RATKA) on clinical outcomes and patient-reported measures (PROMs) remains unclear. This study aims to compare RATKA and conventional TKA (CTKA) using a novel robotic system. METHODS:A retrospective review was conducted on 10,031 patients who underwent TKA from February 2021 to October 2024. 289 RATKAs were performed with a hand-held robotic system. These RATKA cases were 1:1 propensity-score matched to CTKA for patient demographics, surgeon, implant system, and articulation design. Postoperative and clinical outcomes including surgical time, length of stay (LOS), discharge disposition, 90-day emergency department (ED) visits, manipulation under anesthesia (MUA), debridement, reoperations and revisions were collected and analyzed. Patient-reported outcomes measures (PROMs) included Knee Injury and Osteoarthritis Outcome Scores (KOOS, JR) and Patient Reported Outcome Measurement Information System (PROMIS) scores. RESULTS:RATKA demonstrated significantly shorter LOS (30.04 vs. 51.91 hours, p < 0.001, respectively) compared to CTKA. There was no difference in surgical time (107.18 vs. 106.22 minutes, p = 0.349). Although there was no statistical difference in 90-day ED visits, the majority of the CTKA revisits were due to surgery-related causes when compared to the RATKAs (1.38% vs. 0.34%, p = 0.239). While RATKAs had higher incidence of MUAs (2.07% vs. 0.34%, p = 0.201), CTKAs had more reoperations (1 vs. 0, p = 0.369) and more revisions than the RATKAs (6 vs. 0, p = 0.117). In terms of PROMs, both RATKAs and CTKAs showed similar improvements in KOOS, JR and PROMIS pain scores following TKA, with no significant differences in the magnitude of improvement at early postoperative timepoints. However, at the one-year follow-up, RATKA demonstrated significantly greater reduction in PROMIS pain intensity (Δ-9.12, p = 0.032) compared to CTKAs. CONCLUSIONS:This retrospective analysis showed that the novel RATKA resulted in reduced length of stay, fewer reoperations, and greater reduction in one-year PROMIS pain intensity compared to CTKAs, despite having a higher incidence of MUA rates. Further research is needed to clarify these differences clinically and enhance patient outcomes.

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.

INTRODUCTION/BACKGROUND:A two-stage revision has long been the gold standard for chronic periprosthetic joint infections (PJI), with real-component articulating spacers becoming overwhelmingly popular. While several studies have evaluated the success of these spacers in revision total knee arthroplasty (rTKA), to our knowledge, this is the first to specifically compare outcomes of spacers stratified by the level of liner constraint. METHODS:This retrospective analysis reviewed 135 patients who were indicated for two-stage rTKA due to PJI between 2011 and 2023 at a single specialty urban academic institution. Patients were categorized into three groups based on the polyethylene liner constraint used during the first stage: cruciate retaining (CR), posterior stabilized (PS), and varus-valgus constrained (VVC). Of these 135 patients, 60 (44%) were categorized in the CR group, 47 (35%) were in the PS group, and 28 (21%) were in the VVC group. These groups were compared after each stage for peri- and postoperative outcomes such as operative time, length of stay (LOS), discharge disposition, knee range of motion (ROM), as well as incidence of re-revision and reinfection. RESULTS:The mean postoperative LOS was not different among cohorts for both stages. Operative time was significantly longer in the VVC group after the second stage (P = 0.007), while there was no difference after the first stage (P = 0.085). There were no differences in ROM after both stages. The mean ROM after the first stage was 92° in the CR group, 90° in the PS group, and 85° in the VVC group (P = 0.46). After the second stage, ROM was 101° in both the CR and VVC groups and 107° in the PS group (P = 0.28). There were no differences in the risk of re-revision due to re-infection across the groups after the first or second stage procedures. The re-infection incidence after the first stage was 14% in the VVC group, compared to 5% in the CR group and 4% in the PS group (P = 0.14). After the second stage, the reinfection risk was 21% in the VVC group, 8% in the CR group, and 13% in the PS group (P = 0.21). CONCLUSION/CONCLUSIONS:No significant differences were observed in the risk of complications such as re-infection, re-revisions, and postoperative ROM, suggesting that the choice of liner constraint in two-stage revision can be left up to surgeon's discretion.

INTRODUCTION/BACKGROUND:Modular dual mobility (DM) liners are commonly used in total hip arthroplasty (THA) to decrease the risk of instability. However, there are concerns about accelerated wear, corrosion, and metal ion release in modular DM constructs. This study aimed to investigate serum metal ion levels over time after THA and evaluate any differences between implant manufacturers. METHODS:This retrospective study enrolled 165 patients who underwent THA with a modular DM liner. Serum cobalt (Co), chromium (Cr), and zirconium (Zr) levels were assessed via a one-time blood draw. Patients were grouped into time cohorts of one to two, two to five, five to eight, and eight plus years based on years since DM placement. The primary outcome was serum Co, Cr, and Zr levels. Reference values of < 1.5 mcg/L for Co and < 1.2 mcg/L for Cr were considered within normal limits. RESULTS:Median Co and Cr levels were 0.3 (range, 0.2 to seven) and 0.3 (range, zero to 3.1) mcg/L, respectively. There were 13 patients (7.9%) who had abnormally elevated metal ion levels; 10 received Implant A (13%), two received Implant B (4%), and one received Implant C (3%). The Zr levels were undetectable in all patients. Median Co levels (0.4 mcg/L) were higher within two years of DM implantation and had a greater range of values than other time periods (P < 0.001). Successive time periods displayed a decreased range of Co values over time. CONCLUSION/CONCLUSIONS:There was a greater range of Co levels within two years of implantation, which reduced in variability over successive time periods. Although this could suggest an initial "settling-in" period of DM constructs, sequential blood draws from individual patients over time are needed to confirm such trends. Longitudinal tracking of metal ion levels over time in modular DM implants is recommended.

BACKGROUND:Periprosthetic joint infection (PJI) is a high-cost and extremely morbid complication following total joint arthroplasty (TJA); thus, developing a better understanding of perioperative infection prevention strategies is prudent. Literature is mixed regarding the efficacy of vancomycin powder and dilute povidone-iodine lavage, and limited on the combination thereof. To our knowledge, no prospective orthopaedic clinical trials to date have evaluated the efficacy of local vancomycin powder, dilute povidone-iodine lavage, or a combination vancomycin-povidone-iodine-protocol (VPIP) against normal saline irrigation. METHODS:In a large, prospective, multi-center, randomized-controlled study, four distinct infection prevention strategies were implemented in high-risk TJA patients. Local vancomycin powder, dilute povidone-iodine solution, combined VPIP, and saline control were used. Primary outcomes included PJI, wound complications, revisions, emergency department (ED) visits, readmissions, and serious adverse events within three months of index surgery. Chi-square tests were used to compare incidence rates. The criteria used for the diagnosis of PJI were the International Consensus Meeting (ICM) guidelines. RESULTS:There were 821 total hip arthroplasty (THA) and 1,080 total knee arthroplasty (TKA) patients randomized into well-balanced study groups. In the THA and TKA cohorts, respectively, there were no statistically significant differences in rates of persistent wound drainage or dehiscence (P = 0.98, P = 0.95), cellulitis or abscess (P = 0.81, P = 0.51), 3-month infection rates (P = 0.14, P = 0.13), type of septic revisions performed (P = 0.51, P = 0.80), aseptic revision rates (P = 0.07, P = 0.90), ED visits (P = 0.61, P = 0.46), or readmissions (P = 0.78, P = 0.87) between the four treatment groups. CONCLUSIONS:There were no statistically significant differences in PJI or other surgical outcomes following THA or TKA among the study groups. Therefore, the use of such prophylactic measures, including povidone-iodine and vancomycin powder in high-risk patients, can be left up to the surgeon or hospital discretion.