Faculty Bibliography

BACKGROUND:Total hip arthroplasty (THA) is commonly performed using either an anterior- or posterior-based approach (AA or PA), with similar long-term outcomes. However, operative timings, including time for patient positioning, device implantation, wound closure, and total operating room (OR) time, may differ between these approaches. This study assessed differences in various OR timings between AA and PA for primary THA. METHODS:A retrospective review was performed of all patients who underwent primary, unilateral, elective THA at our large urban academic medical center between January 1, 2019, and January 31, 2025. Patient demographics and operative parameters were determined from clinical and operative records. Surgeons who began practicing during the study period had their first 50 cases excluded. Perioperative timings were compared between approaches. Multivariable regression analyses controlled for age, American Society of Anesthesiologists status, body mass index, cementation, robotic use, navigation assistance use, discharge disposition, sex, smoking status, and year of surgery. There were 8,120 procedures included (4,670 PA and 3,450 AA). RESULTS:The AA had shorter total OR time (156.7 versus 167.4 minutes, P < 0.001). Regression analysis found AA was associated with longer implantation time (+3.3 minutes, P < 0.001), but shorter set-up time (-2.0 minutes, P < 0.001), closure time (-7.5 minutes, P < 0.001), overall operative time (-4.2 minutes, P < 0.001), and take-down time (-3.6 minutes, P < 0.001). Cement fixation had an increased effect on AA operative times compared to PA (+28.9 versus +14.4 minutes; P < 0.001). CONCLUSIONS:Anterior approach THA procedures displayed faster set-up, closure, take-down, and OR times compared to PA. Controlling for covariates, AA reduces total OR time by nearly 10 minutes, although operative time with AA is more significantly impacted by cementation. Further studies investigating the cost analysis of AA versus PA are needed to contextualize these findings regarding timing.

BACKGROUND:Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are widely used as screening tools for periprosthetic joint infection (PJI) following total knee and hip arthroplasty (TKA and THA, respectively). However, the significance of an isolated elevated ESR with a normal CRP, especially in cases with low clinical suspicion, remains unclear. METHODS:We retrospectively reviewed 19,872 primary TKAs and 12,143 primary THAs performed between March 2012 and March 2023 at a high-volume academic orthopaedic hospital. Of these, 656 TKA and 253 THA patients ≥ 18 years old who underwent elective TJA for osteoarthritis had an elevated ESR (higher than 30 millimeters/hour) and a normal CRP (less than or equal to 10 milligrams/liter) at least 90 days postoperatively. These cutoffs were chosen in concordance with the International Consensus Meeting (ICM) 2018 diagnostic criteria for PJI. Patients who were already undergoing PJI treatment were excluded, as it was inferred the serum biomarkers were not drawn for screening purposes. The final cohorts consisted of 641 TKA and 252 THA patients. Data collected through manual chart review of clinical progress notes included presenting symptoms, inflammatory markers, and PJI diagnoses. We calculated the incidence of PJI within the cohort of patients who had an isolated, elevated ESR. RESULTS:Of the 641 TKA patients who had an isolated, elevated ESR, seven (1.1%) were subsequently diagnosed with PJI. Of the 252 THA patients who had an isolated, elevated ESR, three (1.2%) were subsequently diagnosed with PJI. Of the seven TKA and three THA patients subsequently diagnosed with PJI, three (0.5%) TKA and two (0.8%) THA patients had clinical findings highly suspicious for PJI, such as a large effusion and severe, sudden-onset swelling. These patients did not represent cases where a surgeon would encounter true uncertainty regarding whether to pursue further workup and testing. This left four TKA (0.5%) and one THA (0.4%) patient who had an isolated, elevated ESR who were eventually diagnosed with PJI despite limited clinical concern beyond nonspecific pain. The positive predictive value (PPV) of an isolated, elevated ESR for the diagnosis of PJI was 1.1% in the TKA cohort and 1.2% in the THA cohort. CONCLUSION/CONCLUSIONS:Isolated, elevated ESR with a normal CRP should not automatically trigger a full PJI workup. The risk of PJI is low in this specific patient population, especially when only accompanied by nonspecific symptoms. Most PJI cases in this cohort were found in patients who also had relevant clinical symptoms like sudden-onset swelling or large effusions, suggesting that important weight should be given to the presence or absence of additional PJI symptoms when deciding whether to pursue further testing after an isolated, elevated ESR.

INTRODUCTION/BACKGROUND:As the number of total hip arthroscopies performed rises, further research is needed on the impact hip arthroscopy (HA) may have on total hip arthroplasty (THA). This study aimed to compare clinical and patient-reported outcomes of THA in patients with and without a history of HA. METHODS:= 448) based on age, sex, race, smoking status, American Society of Anesthesiologists score, body mass index, and Charlson Comorbidity Index. Perioperative data, rates of complications and reoperation/revisions, Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected. Logistic regression was used to assess if the likelihood of reoperation was related to prior HA and surgical approach. RESULTS:= 0.009). Surgical approach for THA was not associated with postoperative dislocation rate. Patient-reported outcomes were not different among the 2 cohorts. CONCLUSIONS:In our study, THA patients with history of HA experienced increased rates of dislocation and return to operation room. These findings highlight a need for increased clinical awareness. These findings may inform intraoperative and postoperative modifications to increase prosthetic hip stability. Additionally, this knowledge can have implications for insurance billing and payments, as these cases are coded as primary THA but may present with more complexity or worse outcomes.

BACKGROUND:Vancouver B2 and B3 periprosthetic femur fractures (PPFF) have posed significant treatment challenges due to stem instability and lack of adequate femoral bone stock. This study investigated subsidence, survivorship, and outcomes of Vancouver B2 and B3 fractures, based on the order in which revision stem placement and fracture reduction occurred during revision total hip arthroplasty (rTHA). METHODS:This retrospective, cohort study included 46 rTHAs between June 2011 and April 2023. Included patients underwent rTHA for Vancouver B2 or B3 PPFF with minimum one-year radiographic and two-year clinical follow-up. All patients were treated with diaphyseal-engaging tapered fluted titanium stems and stem modularity decisions were based on surgeon preference. Cohorts were separated based on if stem placement (SF, n = 19), or fracture reduction (RF, n = 27) occurred first. Patient demographics, intraoperative information, and clinical and radiographic outcomes were collected. RESULTS:The SF and RF cohort showed no statistically significant differences in rate of subsidence ≥5 mm [26.3%[SF], 22.2%[RF], P = 0.749), rate of subsidence ≥ 10 mm (15.8%[SF], 14.8%[RF], P = 0.928), nor average subsidence (4.1 mm[SF], 4.4 mm[RF], P = 0.861). We found no statistically significant differences in surgery-related clinical outcomes or all-cause revision rates within a two-year follow-up period. The groups demonstrated comparable rates of procedure-related 90-day emergency department visits(P = 0.370) and readmissions(P = 0.712). The SF group underwent four revisions for three PJIs and one acetabular component aseptic loosening. The RF cohort underwent four revisions for one acetabular component aseptic loosening, one dislocation, one PPFF, and one PJI. Rates of all-cause revision were comparable(P = 0.583). There was one case within the RF cohort to explant the trochanteric plate with no revision of arthroplasty components. CONCLUSIONS:The present analysis suggests the order in which intraoperative femoral stem implantation and fracture reduction occurs does not affect short-term clinical and radiographic outcomes. This intraoperative decision should be based upon patient anatomy, fracture patterns, and surgeon discretion.

BACKGROUND:Solid organ transplant (SOT) patients undergoing total joint arthroplasty (TJA) may be at higher risk for complications due to complex medical and surgical histories, chronic immunosuppressive medications, and significant ongoing comorbidities. This study aimed to evaluate postoperative outcomes following primary, elective TJA in patients with a history of SOT. METHODS:We retrospectively reviewed 53,043 primary, elective TJA patients from 2011 to 2025. Patients were screened for SOT history prior to TJA. All SOT patients were taking some form of immunosuppressive medication following their transplantation. Demographics, SOT details, and surgical data were obtained. SOT patients (n = 70) underwent a nearest-neighbor 1:3 propensity-score matching to non-SOT (NSOT) controls (n = 210) based on age, sex, smoking, Charlson Comorbidity Index, body-mass index, and TJA indication. Kidney transplants were most common (61.4%), followed by liver (24.3%), and heart (8.6%). Differences in surgical outcomes and postoperative complications between the patients were investigated using Chi-squared tests, independent t-tests and effect size (ES) estimates. Baseline characteristics did not differ between the groups (P > 0.05). RESULTS:SOT patients had significantly longer hospital stays (92 vs. 51 h, P < 0.001, ES = 0.82), higher rates of discharge to skilled nursing facilities (SNF) (15.7% vs. 5.7%, P = 0.014, ES = 0.17) and all-cause 90 day readmissions (15.7% vs. 6.7%, P = 0.040, ES = 0.12), primarily driven by non-surgical reasons (14.3% vs. 4.3%, P = 0.010, ES = 0.16) compared to NSOT patients. All-cause revision rates were comparable between SOT and NSOT patients (4.3% vs. 3.8%, P = 0.999), including aseptic (2.9% vs. 1.9%, P = 0.642) and septic causes (1.4% vs. 1.9%, P = 0.999). CONCLUSIONS:Despite higher rates of SNF discharge and non-surgical 90 day readmissions, SOT patients achieved similar all-cause, septic, and aseptic revision rates, compared to NSOT patients. These findings suggest that compared to well-matched comorbid controls, SOT patients can safely undergo elective TJA with comparable revision risk. Enhanced perioperative care may help reduce readmission risks in this complex population.

PURPOSE/UNASSIGNED:The impact of altering a patient's hip offset during total hip arthroplasty (THA) on periprosthetic fracture risk is unknown. The purpose of this study was to compare periprosthetic fracture risk in patients where THA offset was "matched" to their contralateral native hip versus those where offset was mismatched. MATERIALS AND METHODS/UNASSIGNED:-tests and chi square analyses were used for data comparison. Relative risk (RR) with a 95% confidence interval (CI) was then calculated. RESULTS/UNASSIGNED:=0.015). CONCLUSION/UNASSIGNED:Failure to restore a patient's offset during THA is associated with increased rates of periprosthetic fracture. Although restoration of native hip anatomy is an important technical consideration of this procedure, alterations in the hip lever arm may predispose patients to periprosthetic fracture.

BACKGROUND/UNASSIGNED:Periprosthetic joint infections (PJIs) following primary and revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) have been studied, but a contemporary large-scale analysis of incidence has not been performed. This study assessed PJI incidence and trends for TKA, THA, rTKA, and rTHA using a contemporary database. METHODS/UNASSIGNED:Epic Cosmos database was retrospectively queried (2015-2023). Current procedureal terminology codes identified patients: 27447 (TKA), 27130 (THA), 27486 (rTKA one component), 27487 (rTKA both components), 27134 (rTHA both components), 27137 (rTHA acetabular component), and 27138 (rTHA femoral component). PJI rates were identified using International Classification of Diseases 9/10 codes and analyzed using linear regression. RESULTS/UNASSIGNED:= .08). CONCLUSIONS/UNASSIGNED:Significant PJI reduction after primary TKA and THA was observed over the last decade, but infection rates remained stable in revision cohorts. Further investigations are required to assess underlying reasons for observed PJI rate reductions following primary arthroplasty.

BACKGROUND/UNASSIGNED:Osteoporosis (OP) is a common comorbidity in patients undergoing total hip arthroplasty (THA) and is a known risk factor for poor postoperative outcomes such as periprosthetic fracture (PPF). The impact of preoperative OP medications in patients with OP undergoing THA remains unclear. This study aimed to compare THA outcomes by OP diagnosis and preoperative bone strengthening medication usage. METHODS/UNASSIGNED:This was a retrospective review of primary elective THAs from June 2011-January 2024. Patients were stratified by OP diagnosis and OP medication usage, then propensity matched in a 1:2:3 ratio by age, sex, body mass index, and comorbidities. The resulting cohorts: (1) OP and medication usage for at least 1 year preoperatively and within 7 years of the procedure (n = 296), (2) OP and no medication usage (n = 592), and (3) no diagnosis of OP and no medication usage (n = 888) were then compared for postoperative outcomes. RESULTS/UNASSIGNED:= .009). Of the 12 revisions due to periprosthetic femoral fracture in cohorts 1 and 2 combined, 11 (91.7%) occurred around an uncemented implant. CONCLUSIONS/UNASSIGNED:Osteoporotic patients on OP medications did not have improved outcomes after THA compared with nonmedicated osteoporotic patients or those without a diagnosis of OP. PPF in osteoporotic patients overwhelmingly occurred around uncemented femoral implants. Surgeons should use caution when operating on osteoporotic patients, regardless of utilization of preoperative medications, and strongly consider using cemented femoral implants to decrease the risk of PPF.

BACKGROUND:Severe obesity and its association with advanced knee osteoarthritis are established risk factors for surgical complications and associated costs of total knee arthroplasty (TKA). This clinical trial examines the functional knee outcomes of severely obese patients who have severe knee osteoarthritis undergoing bariatric surgery versus immediate TKA and examines the impact of surgical weight loss on the pursuit of TKA. METHODS:The SWIFT Trial (Surgical Weight-loss to improve Functional status Trajectories) following total knee arthroplasty was a multicenter, prospective trial examining outcomes of weight loss surgery and TKA in patients who have severe obesity (body mass index ≥ 40 or greater than 35 who have comorbidities) and symptomatic Kellgren-Lawrence grades 3 or 4 radiographic knee osteoarthritis. Study patients were recruited prospectively from November 2015, to October 2024 and divided into two groups: the bariatric arm (patients undergoing bariatric surgery) and the TKA arm (patients undergoing TKA). Each study arm underwent a comprehensive battery of knee functional assessments at baseline, six, 12, and 24 months, as well as re-evaluations in the bariatric surgery arm to assess the need for delaying or proceeding with TKA at 12 and 24 months. There were 232 study subjects who completed surgery and knee evaluation (n = 159: immediate TKA versus n = 73: bariatric surgery). The study groups had comparable degrees of knee disability at study initiation. RESULTS:Longitudinal functional analysis demonstrated major improvement extending to two years in patient-reported outcomes and performance-based functional assessments in both study arms, with a slight superiority in the TKA arm. Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.0001). Bariatric surgery resulted in 45 and 36% delays in TKA at 12 and 24 months, respectively, due to improved knee status. CONCLUSION/CONCLUSIONS:Knee function and mobility improved significantly in both study arms, with superiority in the Knee Injury and Osteoarthritis Outcome and Western Ontario and McMaster Universities Osteoarthritis Index scores in the TKA group. Improved knee function with surgical weight loss can be associated with up to a two-year delay in the need for TKA.

BACKGROUND:Management of severe acetabular bone loss during revision total hip arthroplasty (rTHA) remains challenging. Cup-cage constructs and custom triflange acetabular components are commonly used, but comparative outcomes remain poorly defined. METHODS:This meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were four electronic databases searched for studies published from 2015 to 2025 that reported outcomes of cup-cage or custom triflange reconstruction in patients who had Paprosky 2 to 3B acetabular defects. Indications for cup-cage and triflange constructs were recorded. Re-revision, periprosthetic joint infection (PJI), instability, and aseptic loosening were pooled using fixed- and random-effects models. Meta-regression was performed to adjust for acetabular defect severity. RESULTS:There were 18 studies comprising 808 revision THAs (293 cup-cage and 515 custom triflange) included. Across both reconstruction strategies, the most common indications were aseptic loosening and conversion after periprosthetic joint infection. The weighted mean follow-up was 5.8 years for cup-cage and 6.2 years for triflange reconstructions (P = 0.071). The cup-cage cohort had a higher proportion of Paprosky 3B defects than the triflange cohort (79.2 versus 71.8%, P < 0.001). After adjustment for acetabular defect severity, no differences in re-revision rates were observed between cup-cage and triflange constructs. Likewise, there were no differences in PJI, instability, or aseptic loosening between groups. CONCLUSIONS:Among patients undergoing rTHA with cup-cage or custom triflange reconstruction for Paprosky 2 to 3B defects, outcomes were equivalent across major failure modes after adjustment for bone loss severity. Neither construct demonstrated superior survivorship; therefore, implant selection should be individualized according to defect pattern, available resources, surgical goals, and surgeon preference rather than an expectation of differential clinical performance.