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Aseptic Acetabular Revisions ≤90 Days, 91 Days to 2 Years, and >2 Years After Total Hip Arthroplasty: Comparing Etiologies, Complications, and Postoperative Outcomes

Sobba, Walter; Habibi, Akram A; Shichman, Ittai; Aggarwal, Vinay K; Rozell, Joshua C; Schwarzkopf, Ran
BACKGROUND:Isolated acetabular component revision is an effective treatment for revision total hip arthroplasty patients who have well-fixed femoral implants. We aimed to evaluate the modes of acetabular failure following primary total hip arthroplasty and to identify factors associated with increased morbidities and postoperative outcomes. METHODS:We conducted a retrospective analysis and identified 318 isolated aseptic acetabular revisions. We separated patients by ≤90 days, 91 days to 2 years, and >2 years for acetabular revisions and compared demographics, reasons for revision, 90-day readmissions, rerevisions, and postrevision infections. Revisions ≤90 days, 91 days to 2 years, and >2 years accounted for 10.7, 19.2, and 70.1% of revisions, respectively. Revisions ≤90 days, 91 days to 2 years, and >2 years had their primary total hip arthroplasty at a mean age of 66, 63, and 55 years (P < .001), respectively. RESULTS:Revisions within 90 days were mainly indicated for dislocation/instability (58.8%) or periprosthetic fracture (23.5%) while revisions over 2 years were indicated for polyethylene wear/osteolysis (37.2%). Patients with revisions past 90 days were more likely to require rerevision compared to patients with revisions within 90 days (P < .001). There were no differences in readmissions (P = .28) or infection rates (P = .37). CONCLUSIONS:Acetabular revisions within 90 days were more commonly indicated for instability and periprosthetic fracture, while those over 2 years were indicated for polyethylene wear. Revisions past 90 days were more likely to require subsequent rerevisions without increased 90-day readmissions or infections. LEVEL III EVIDENCE/METHODS:Retrospective cohort study.
PMID: 37717835
ISSN: 1532-8406
CID: 5635382

Erratum to "2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective" [The Journal of Arthroplasty 38 (2023) 2193-2201]

Hannon, Charles P; Goodman, Susan M; Austin, Matthew S; Yates, Adolph; Guyatt, Gordon; Aggarwal, Vinay K; Baker, Joshua F; Bass, Phyllis; Bekele, Delamo Isaac; Dass, Danielle; Ghomrawi, Hassan M K; Jevsevar, David S; Kwoh, C Kent; Lajam, Claudette M; Meng, Charis F; Moreland, Larry W; Suleiman, Linda I; Wolfstadt, Jesse; Bartosiak, Kimberly; Bedard, Nicholas A; Blevins, Jason L; Cohen-Rosenblum, Anna; Courtney, P Maxwell; Fernandez-Ruiz, Ruth; Gausden, Elizabeth B; Ghosh, Nilasha; King, Lauren K; Meara, Alexa Simon; Mehta, Bella; Mirza, Reza; Rana, Adam J; Sullivan, Nancy; Turgunbaev, Marat; Wysham, Katherine D; Yip, Kevin; Yue, Linda; Zywiel, Michael G; Russell, Linda; Turner, Amy S; Singh, Jasvinder A
PMID: 38049357
ISSN: 1532-8406
CID: 5595422

Response to Letter to the Editor Regarding "Does the Primary Surgical Approach Matter When Choosing the Approach for Revision Total Hip Arthroplasty?" [Letter]

Christensen, Thomas H; Humphrey, Tyler J; Salimy, Mehdi S; Roundy, Robert S; Goel, Rahul K; Guild, George N; Schwarzkopf, Ran; Bedair, Hany S; Aggarwal, Vinay K
PMID: 38182330
ISSN: 1532-8406
CID: 5628482

Does the Primary Surgical Approach Matter when Choosing the Approach for Revision Total Hip Arthroplasty?

Christensen, Thomas H; Humphrey, Tyler J; Salimy, Mehdi S; Roundy, Robert; Goel, Rahul K; Guild, George N; Schwarzkopf, Ran; Bedair, Hany S; Aggarwal, Vinay K
INTRODUCTION/BACKGROUND:Multiple surgical approaches are used for primary total hip arthroplasty (pTHA) and revision total hip arthroplasty (rTHA). This study sought to investigate prevalence of discordance of pTHA and rTHA surgical approaches and to evaluate the impact of approach concordance on postoperative outcomes. METHODS:A multi-center retrospective review of patients who underwent rTHA from 2000 to 2021 was conducted at three large, urban academic centers. Patients who had a minimum one-year follow-up post-rTHA were included and grouped based on whether they received pTHA via a posterior (PA), direct anterior (DA), or laterally-based (DL) approach, and by concordance of index rTHA approach with their pTHA approach. Of the 917 patients studied, 839 (91.5%) were included in the concordant cohort and 78 (8.5%) in the discordant cohort. Patient demographics, operative characteristics, and postoperative outcomes were compared. RESULTS:Discordance was most prevalent in the DA-pTHA subset (29.5%), compared to the DL-pTHA subset (14.7%) or PA-pTHA subset (3.7%). Discordance varied significantly between primary approaches among all revisions, with DA-pTHA patients having the highest discordance rate for patients revised for aseptic loosening (46.3%, P<0.001), fracture (22.2%, P<0.001), and dislocation (33.3%, P<0.001). There were no differences between groups in dislocation rate, re-revision for infection, or re-revision for fracture. CONCLUSION/CONCLUSIONS:The results of this multicenter study showed patients who received pTHA via the DA were more likely to receive rTHA via a discordant approach compared to other primary approaches. Since approach concordance did not impact dislocation, infection, or fracture rates after rTHA, surgeons can feel reassured using a separate approach for rTHA.
PMID: 37393962
ISSN: 1532-8406
CID: 5538902

Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty?

Cieremans, David; Muthusamy, Nishanth; Singh, Vivek; Rozell, Joshua C; Aggarwal, Vinay; Schwarzkopf, Ran
INTRODUCTION/BACKGROUND:Infection after total knee arthroplasty (TKA) impacts the patient, surgeon, and healthcare system significantly. Surgeons routinely use antibiotic-loaded bone cement (ALBC) in attempts to mitigate infection; however, little evidence supports the efficacy of ALBC in reducing infection rates compared to non-antibiotic-loaded bone cement (non-ALBC) in primary TKA. Our study compares infection rates of patients undergoing TKA with ALBC to those with non-ALBC to assess its efficacy in primary TKA. METHODS:A retrospective review of all primary, elective, cemented TKA patients over the age of 18 between 2011 and 2020 was conducted at an orthopedic specialty hospital. Patients were stratified into two cohorts based on cement type: ALBC (loaded with gentamicin or tobramycin) or non-ALBC. Baseline characteristics and infection rates determined by MSIS criteria were collected. Multilinear and multivariate logistic regressions were performed to limit significant differences in demographics. Independent samples t test and chi-squared test were used to compare means and proportions, respectively, between the two cohorts. RESULTS:) and Charlson Comorbidity Index values (4.51 ± 2.15 vs. 4.04 ± 1.92) were more likely to receive ALBC. The infection rate in the non-ALBC was 0.8% (63/7,980), while the rate in the ALBC was 0.5% (7/1,386). After adjusting for confounders, the difference in rates was not significant between the two groups (OR [95% CI]: 1.53 [0.69-3.38], p = 0.298). Furthermore, a sub-analysis comparing the infection rates within various demographic categories also showed no significant differences between the two groups. CONCLUSION/CONCLUSIONS:Compared to non-ALBC, the overall infection rate in primary TKA was slightly lower when using ALBC; however, the difference was not statistically significant. When stratifying by comorbidity, use of ALBC still showed no statistical significance in reducing the risk of periprosthetic joint infection. Therefore, the advantage of antibiotics in bone cement to prevent infection in primary TKA is not yet elucidated. Further prospective, multicenter studies regarding the clinical benefits of antibiotic use in bone cement for primary TKA are warranted.
PMID: 37133753
ISSN: 1432-1068
CID: 5503052

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study

Shichman, Ittai; Sobba, Walter; Beaton, Geidily; Polisetty, Teja; Nguyen, Hillary Brenda; Dipane, Matthew V; Hayes, Emmitt; Aggarwal, Vinay K; Sassoon, Adam A; Chen, Antonia F; Garceau, Simon P; Schwarzkopf, Ran
BACKGROUND:Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up. METHODS:Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria. RESULTS:Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA. CONCLUSIONS:A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets. LEVEL OF EVIDENCE/METHODS:Case series (IV).
PMID: 37353111
ISSN: 1532-8406
CID: 5543022

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

Hannon, Charles P; Goodman, Susan M; Austin, Matthew S; Yates, Adolph; Guyatt, Gordon; Aggarwal, Vinay K; Baker, Joshua F; Bass, Phyllis; Bekele, Delamo Isaac; Dass, Danielle; Ghomrawi, Hassan M K; Jevsevar, David S; Kwoh, C Kent; Lajam, Claudette M; Meng, Charis F; Moreland, Larry W; Suleiman, Linda I; Wolfstadt, Jesse; Bartosiak, Kimberly; Bedard, Nicholas A; Blevins, Jason L; Cohen-Rosenblum, Anna; Courtney, P Maxwell; Fernandez-Ruiz, Ruth; Gausden, Elizabeth B; Ghosh, Nilasha; King, Lauren K; Meara, Alexa Simon; Mehta, Bella; Mirza, Reza; Rana, Adam J; Sullivan, Nancy; Turgunbaev, Marat; Wysham, Katherine D; Yip, Kevin; Yue, Linda; Zywiel, Michael G; Russell, Linda; Turner, Amy S; Singh, Jasvinder A
OBJECTIVE:To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS:We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS:The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION/CONCLUSIONS:This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
PMID: 37778918
ISSN: 1532-8406
CID: 5590162

What a Junior-Senior Partnership Should Look Like Today: A Young Arthroplasty Group Committee Editorial [Editorial]

Aggarwal, Vinay K; Gold, Peter A; Sonn, Kevin A; Frisch, Nicholas B; Cohen-Rosenblum, Anna R
PMID: 37236283
ISSN: 1532-8406
CID: 5508682

Selective Use of Dual-Mobility Did Not Significantly Reduce 90-Day Readmissions or Reoperations after Total Hip Arthroplasty

Simcox, Trevor; Singh, Vivek; Ayres, Ethan; Macaulay, William; Schwarzkopf, Ran; Aggarwal, Vinay K; Hepinstall, Matthew S
INTRODUCTION/BACKGROUND:Selective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. METHODS:We retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 FB and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had fixed-bearing (FB) and DM implants. Cases were then stratified into three groups based on the attending surgeon's rate of DM utilization (≤1, 1 to 10, or >10%) and outcomes were compared. RESULTS:There were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0 to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1 to 10% of cases, and 7 (10%) in >10% of cases. The 90-day rates of readmission (7.3 vs 7.6 vs 7.2%, P=0.7) and reoperation (3.4 vs 3.9 vs 3.8%, P=0.3), as well as readmission for instability (0.5 vs 0.6 vs 0.8%, P=0.2) and reoperation for instability (0.5 vs 0.5 vs 0.8%, P=0.6), did not statistically differ between cohorts. CONCLUSION/CONCLUSIONS:Selective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (i.e., surgical approach, computer navigation, robotic assistance, and large diameter fixed-bearings) may have masked any benefits of selective DM use.
PMID: 37068565
ISSN: 1532-8406
CID: 5466022

Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study

Arraut, Jerry; Thomas, Jeremiah; Oakley, Christian T; Schmicker, Thomas; Aggarwal, Vinay K; Schwarzkopf, Ran; Rozell, Joshua C
BACKGROUND:Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients. METHODS:A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications. RESULTS:The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION/CONCLUSIONS:Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.
PMID: 37040822
ISSN: 1532-8406
CID: 5502782