Does needle penetration of the shoulder joint prior to arthroscopy increase infection risk? The effect of preoperative magnetic resonance arthrogram or corticosteroid injection

BACKGROUND

Prior literature has associated preoperative corticosteroid shoulder injection (CSI) with infection following shoulder surgery. A recent study found an equally elevated risk of total knee arthroplasty infection with preoperative injection of either CSI or hyaluronic acid. The implication is that violation of a joint prior to surgery, even in the absence of corticosteroid, may pose an elevated risk of infection following orthopedic surgery. The aim of the present study was to determine whether violation of the shoulder joint for magnetic resonance arthrogram (MRA) poses an elevated risk of infection following shoulder arthroscopy, and to compare this risk to that introduced by preoperative CSI.

METHODS

A national, all-payer database was queried to identify patients undergoing shoulder arthroscopy between January 2015 and October 2020. Patients were stratified into the following groups: (1) no CSI or MRA within 6 months of surgery (n = 5000), (2) CSI within 2 weeks of surgery (n = 1055), (3) CSI between 2 and 4 weeks prior to surgery (n = 2575), (4) MRA within 2 weeks of surgery (n = 414), and (5) MRA between 2 and 4 weeks prior to surgery (n = 1138). Postoperative infection (septic shoulder or surgical site infection) was analyzed at 90 days, 1 year, and 2 years, postoperatively. Multivariable logistic regression analysis controlled for differences among groups.

RESULTS

MRA within 2 weeks prior to shoulder surgery was associated with an increased risk of infection at 1 year (odds ratio [OR], 2.17; P = .007), while MRA 2-4 weeks preceding surgery was not associated with an increased risk of postoperative infection at any time point. By comparison, CSI within 2 weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.72; P = .022), 1 year (OR, 1.65; P = .005), and 2 years (OR, 1.63; P = .002) following surgery. Similarly, CSI 2-4 weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.83; P < .001), 1 year (OR, 1.62; P < .001), and 2 years (OR, 1.79; P < .001).

CONCLUSION

Preoperative CSI within 4 weeks of shoulder arthroscopy elevates the risk of postoperative infection. Needle arthrotomy for shoulder MRA elevates the risk of infection in a more limited fashion. Avoidance of MRA within 2 weeks of shoulder arthroscopy may mitigate postoperative infection risk. Additionally, the association between preoperative CSI and postoperative infection may be more attributed to medication profile than to needle arthrotomy.

Biologic Therapies for the Treatment of Knee Osteoarthritis: An Updated Systematic Review

BACKGROUND

Use of "orthobiologics" continues to expand for patients who have knee osteoarthritis (OA). We sought to perform a systemic review of biologic therapies relative to comparative groups, including the following: (1) platelet-rich plasma (PRP); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amniotic-derived mesenchymal stem cells (AMSCs). We assessed the following: (1) study methodologies; (2) cell preparations and formulations; (3) patient-reported outcome scores (PROMs); and (4) structural changes.

METHODS

PubMed, Cochrane Library, and Embase databases were queried (2013-2021) to conduct a systematic review of biologic therapies for knee OA, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighty-two studies were included: PRP (51); BMSC (15); ADSC (11); and AMSC (5). Study evaluations were made using the Modified Coleman Methodology Score. PROMs included the Western Ontario and McMaster Universities Arthritis Index and the Visual Analog Scale. Structural change evaluations included ultrasounds, radiographs, or magnetic resonance imaging.

RESULTS

PRP comprised a majority of the studies (n = 51), most with "fair" to "good" Modified Coleman Methodology Score. Studies had variable cell preparations and formulations, with comparison study results leading to inconsistent PROMs, and structural changes. A limited number of studies were included for BMSC, ADSC, and AMSC, all with similar findings to PRP.

CONCLUSION

Available literature evaluating "orthobiologics" for knee OA remain nonsuperior to comparison cohorts. Higher level studies with larger sample sizes and improved methodologies are warranted to suggest differences. Despite a growth of "orthobiologics" in clinics, this updated systematic review highlights the uncertain efficacy for use in knee OA.

The association between lumbar paraspinal muscle functional cross-sectional area on MRI and regional volumetric bone mineral density measured by quantitative computed tomography

Osteosarcopenia is a common condition among elderly and postmenopausal female patients. Site-specific bone mineral density is more predictive of bone-related complications. Few studies have investigated muscle-bone associations. Our results demonstrated that in women, significant positive associations between paraspinal muscles FCSA and vBMD exist at different lumbosacral levels. These regional differences should be considered when interpreting bone-muscle associations in the lumbar spine.

INTRODUCTION

There is increasing evidence between bone and muscle volume associations. Previous studies have demonstrated comorbidity between osteoporosis and sarcopenia. Recent studies showed that sarcopenic subjects had a fourfold higher risk of concomitant osteoporosis compared to non-sarcopenic individuals. Although site-specific bone mineral density (BMD) assessments were reported to be more predictive of bone-related complications after spinal fusions than BMD assessments in general, there are few studies that have investigated level-specific bone-muscle interactions. The aim of this study is to investigate the associations between muscle functional cross-sectional area (FCSA) on magnetic resonance imaging (MRI) and site-specific quantitative computed tomography (QCT) volumetric bone mineral density (vBMD) in the lumbosacral region among spine surgery patients.

METHODS

We retrospectively reviewed a prospective institutional database of posterior lumbar fusion patients. Patients with available MRI undergoing posterior lumbar fusion were included. Muscle measurements and FCSA were conducted and calculated utilizing a manual segmentation and custom-written program at the superior endplate of the L3-L5 vertebrae level. vBMD measurements were performed and calculated utilizing a QCT pro software at L1-L2 levels and bilateral sacral ala. We stratified by sex for all analyses.

RESULTS

A total of 105 patients (mean age 61.5 years and 52.4% females) were included. We found that female patients had statistically significant lower muscle FCSA than male patients. After adjusting for age and body mass index (BMI), there were statistically significant positive associations between L1-L2 and S1 vBMD with L3 psoas FCSA as well as sacral ala vBMD with L3 posterior paraspinal and L5 psoas FCSA. These associations were not found in males.

CONCLUSIONS

Our results demonstrated that in women, significant positive associations between the psoas and posterior paraspinal muscle FCSA and vBMD exist in different lumbosacral levels, which are independent of age and BMI. These regional differences should be considered when interpreting bone and muscle associations in the lumbar spine.

Delaying Total Knee Arthroplasty More than 4 Weeks after Intra-Articular Knee Injection Does Not Further Decrease Risk of Septic Revision

Hyaluronic acid (HA) and corticosteroid (CS) injections are utilized in symptom management for patients with osteoarthritis. However, contamination of the joint may increase the risk of infection following total knee arthroplasty (TKA). Therefore, the purpose of this study was to examine 90-day surgical site infection (SSI) and manipulation under anesthesia (MUA) as well as up to 2-year prosthetic joint infection (PJI) in intra-articular knee injection recipients prior to TKA compared with patients who did not have knee injections. We specifically assessed (1) timing of HA and CS prior to TKA; (2) type of intra-articular knee injection; as well as (3) associated risk factors. We queried a national database to identify patients who underwent primary TKA from September 2015 to October 2020 (n = 1.5 million). Patients with prior knee injections were stratified to five cohorts: HA within 4 weeks (n = 140), HA 4 to 6 weeks prior (n = 337), CS within 4 weeks (n = 2,344), CS 4 to 6 weeks (n = 2,422), and a no injection, control, cohort prior to TKA (n = 5,000). Bivariate chi-square analyses of outcomes were conducted, and multivariate regressions were used to adjust for comorbidities and assess associated risk factors. The adjusted analysis showed a significant risk in infection for patients receiving an injection within 4 weeks of TKA (p < 0.023) and showed no difference in type of injection (p > 0.050). Additionally, SSIs were increased 1.58 times in the CS within 4 weeks of TKA cohort (p = 0.023). However, no difference in MUA risk was shown at 90-day postoperative (p > 0.212). Furthermore, tobacco use was identified as a risk factor that further increased likelihood of PJI. Intra-articular knee injection less than 4 weeks before TKA increased the risk for PJI; however, past 4 weeks did not confer infection risk. Tobacco use was identified as an associated risk factor that further increased likelihood for PJI. These results highlight the need for surgeons to wait 4 weeks between knee injection and TKA to decrease risk of septic revision.

Knee Arthroscopy Prior to Total Knee Arthroplasty: Temporal Relationship to Surgical Complications

Mechanical knee symptoms secondary to knee osteoarthritis (OA) may warrant knee arthroscopy (KA). Degenerative changes may progress and require a subsequent total knee arthroplasty (TKA). Recent studies have evaluated the timing of KA prior to TKA, associated a narrow interval with increased post-TKA complications. However, an updated analysis is required. We compared surgical outcomes in recipients of KA prior to TKA as stratified by four, time-dependent cohorts (< 12, 12 to 16, 16 to 20, and 20 to 24 weeks prior to TKA). We specifically compared: 90-day (1) manipulations under anesthesia (MUAs); (2) septic revisions at 90 days, 1 year, and 2 years; as well as (3) how various independent risk factors influenced the manipulations or revisions. We queried a national database for patients undergoing TKA. Patients who underwent KA with the following intervals: < 12 (n = 1,023), 12 to 16 (n = 816), 16 to 20 (n = 1,957), and 20 to 24 weeks (1,727) prior to TKA were compared with those patients who did not have a history of KA (n = 5,000). Bivariate analyses were utilized to assess 90 days through 2 years surgical outcomes. Afterwards, multivariate regression models were utilized to assess for independent risk factors. The unadjusted analyses showed an increase in MUA through 2 years among all the KA recipients (p < 0.001). Septic revisions and surgical site infections at all time points were not associated with any of the four arthroscopy time intervals (p > 0.476). The adjusted analyses showed an increased risk for 90-day MUA among all TKA cohorts (p < 0.001). Risk for septic revisions did not reach significance. Delaying TKA by 24 weeks in KA recipients was not associated with a decreased risk in septic revisions. However, there was an apparent risk of MUA at 90 days for all KA cohorts suggesting that waiting after KA before TKA makes no difference in MUA rates. These results update existing literature, may serve as an adjunct to current practice guidelines, and can contribute to shared decision making in the preoperative setting.

Dressing Management during Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Dressings for total knee arthroplasty (TKA) typically focus on promoting optimal healing, while preventing infection, allowing for functionality and immediate ambulation, while providing for excellent cosmesis. We have previously described four aspects of closure after TKA involving the: (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) a specific aseptic dressing. In this meta-analysis and systematic review of the literature, we will focus on the dressing. Specifically, we assessed: (1) infection risk of different techniques; (2) re-operation or readmission risk; and (3) length of time until dressing change needed. There were 16 reports on infection risk, re-operation risk, and length of time until change needed. A meta-analysis focused on the qualifying wound complication risk reports was also performed. The meta-analysis including four studies (732 patients) demonstrated overall lower wound complication risk with the use of adhesives and mesh dressings (odds ratio 0.67) versus traditional closures. Additionally, studies demonstrated fewer re-operations and readmissions with the use of adhesives and mesh dressings. Furthermore, one report demonstrated mesh dressings persist longer than silver dressings. Therefore, multiple recent reports suggest superior outcomes when using adhesive and mesh dressings for TKAs.

Unicompartmental Knee Arthroplasty Has Lower Infection, Conversion, and Complication Rates Compared to High Tibial Osteotomy

INTRODUCTION

 Isolated medial knee osteoarthritis can be surgically treated with either unicompartmental knee arthroplasty (UKA) or high tibial osteotomy (HTO). Proponents of UKA suggest superior survivorship, while HTO offers theoretically improved alignment and joint preservation delaying total knee arthroplasty (TKA). Therefore, we compared complications in a large population of patients undergoing UKAs or HTOs. We specifically assessed 90 days, 1 year, and 2 years: (1) periprosthetic joint infection (PJI) rates, (2) conversion to TKA rates, as well as (3) complication rates.

METHODS

 A review of an administrative claims database was used to identify patients undergoing primary UKA (n = 13,674) or HTO (n = 1,096) from January 1, 2010 to December 31, 2019. Complication rates at 90 days, 1 year, and 2 years were compared between groups using unadjusted odds ratios (ORs) with 95% confidence intervals. Subsequently, multivariate logistic regressions were performed for PJI and conversion to TKA rates.

RESULTS

 At all time points, patients who underwent UKA were associated with lower rates of infection compared with those who underwent HTOs (all OR ≤ 0.51, all p ≤ 0.010). After 1 year, patients who received UKAs were found to have lower risk of requiring a conversion to a TKA versus those who received HTOs (all OR ≤ 0.55, all p < 0.001). Complications such as dislocations, periprosthetic fractures, and surgical site infections were found at lower odds in UKA compared with HTO patients.

CONCLUSION

 This study provides large-scale analyses demonstrating that UKA is associated with lower infection rates and fewer conversions to TKA compared with patients who have undergone HTO. Dislocations, periprosthetic fractures, and surgical site infections were also found to be lower among UKA patients. However, with careful patient selection, good results and preservation of the native knee are achieved with HTOs. Therefore, UKA versus HTO may be an important discussion to have with patients in an effort to lower the incidence of postoperative infections and complications.

Two-Year Survivorship and Outcomes of a Three-Dimensional Printed Metaphyseal Cone in the Setting of Revision Total Knee Arthroplasty

Poor metaphyseal fixation secondary to bone loss in revision total knee arthroplasty (TKA) continues to be challenging. One technique to increase implant stability is the use of novel three-dimensional (3D) printed titanium metaphyseal cones with adjunctive stems for added fixation. However, the survival of these novel constructs is poorly understood. Therefore, we sought to examine 3D-printed titanium metaphyseal cone components in revision TKA for aseptic as well as septic reasons and aimed to evaluate: (1) revision-free survivorships; (2) patient-reported outcomes measures (PROMs); (3) postoperative medical complications; and (4) radiographic outcomes. A consecutive series of 62 patients who underwent revision TKA with use of a titanium metaphyseal cone at a single institution between September 1, 2015 and May 31, 2021 were examined. The patients had a minimum follow-up period of 2 years (mean, 40 months, range, 24-72 months). PROMS included Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR) scores at baseline and last clinical follow-up. Overall, when excluding infections, the combined implant survivorship was 96% (52 out of 54), while it was 95% (35 out of 57) for aseptic revisions and 100% (17 out of 17) for septic revisions. Reasons for revisions within the aseptic revision cohort included loosening (5%) as well as periprosthetic joint infections (PJIs) (7.5%). All failures following an index septic revision were due to PJI. Mean KOOS scores at baseline as well as at final follow-up was 43 points (range, 16-80) and 70 points (range, 34-100), respectively. None of the patients had medical complications. Other than the loosening reported (only femoral component), of the surviving patients no patients had evidence of progressive radiolucencies. The use of titanium cones in revision TKA provides good revision-free survivorship at 2 years. Further research is warranted on the longer-term survivorship of 3D-printed titanium cones. The current study has found that 3D-printed titanium cones can be incorporated as part of the revision knee surgeon's armamentarium.

Phenotypic Frailty Score Predicts Perioperative Outcomes for Geriatric Total Joint Arthroplasty

Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32-3.70]), postoperative delirium (6.40 [1.78-23.03]), and length of stay greater than 2 days (3.90 [1.00-15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66-4.72]) or discharge to a specialized facility (1.48 [0.80-2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [Orthopedics. 2022;45(6):e315-e320.].

The Efficacy of Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis Symptoms and Structural Changes: A Systematic Review and Meta-Analysis

BACKGROUND

Platelet-rich plasma (PRP) usage in orthopedics continues to rise, despite guidelines suggesting non-superiority to comparative cohorts. Therefore, we performed a systematic review and meta-analysis on PRP efficacy using two clinical assessments: (1) Visual Analog Scale and (2) Western Ontario and McMaster Universities Osteoarthritis Index. We assessed consistency and clinical relevancy by determining study heterogeneity (eg, sample sizes, ages, body mass index, arthritic severities, etc.). Comparative cohorts were: (A) hyaluronic acid (HA); (B) corticosteroid (CS); (C) normal saline (NS); and (D) exercise therapy. We performed sub-analyses of structural changes assessed on ultrasound, radiograph, or magnetic resonance imaging .

METHODS

We utilized PubMed, Cochrane Library, and Embase databases up to December 1, 2021, according to Preferred Reporting Items for Systematic-Reviews and Meta-Analyses guidelines. Twenty-four studies met criteria, with comparisons to: HA (n = 11); CS (n = 6); NS (n = 5); and exercise therapy (n = 3). Seven studies assessed structural changes. Evaluations utilized a methodological scoring system. I² statistics and forest plots pooled analyses and delineated study results.

RESULTS

PRP led to Visual Analog Scale and Western Ontario and McMaster Universities Osteoarthritis Index improvements in most studies when compared to HA, CS, and NS (P ≤ .05). Comparison to exercise therapy resulted in inconclusive findings (P ≥ .05). However, substantial heterogeneity (I² ≥ 76%) was reported due to study variability. No differences were found when assessing structural changes or cartilage thickness by magnetic resonance imaging (standardized mean difference -0.01 [-0.19, 0.18], P = .91).

CONCLUSIONS

PRP may be associated with pain and functional improvements but was not clinically relevant (inconsistent study- and patient-metrics). In addition, PRP did not confer superiority when assessing knee-related structural changes.

Tapered Modular Femoral Stems for Revision Total Hip Arthroplasty Show Excellent Mid-Term Survivorship

INTRODUCTION

Revision total hip arthroplasty (THA) can be challenging in the face of proximal femoral bone loss, catastrophic implant failure, or recurrent hip instability. Tapered modular femoral stems have shown substantial success at short follow up for aseptic revisions. The purpose of this study was to report mid-term revision THA outcomes of a tapered modular femoral stem at a tertiary referral center used to treat both aseptic as well as periprosthetic joint infections (PJIs). We specifically sought to assess: (1) revision-free implant survivorship; (2) patient-reported outcome measurements (i.e., Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]); (3) postoperative surgical complications and 30-day readmissions; as well as (4) radiographic outcomes.

MATERIALS AND METHODS

We reviewed a consecutive series of 92 patients who underwent revision THA between 2009 and 2013 with a tapered modular femoral stem. After accounting for mortality (n=7) and loss to follow up (n=13), a total of 72 implants in 66 patients who had eight years of mean follow up (range, 2 to 11) were included. PJI (46%) was the predominant preoperative indication for revision THA, followed by aseptic loosening (25%), periprosthetic fracture (18%), and symptomatic hardware (10%). Outcomes of interest included all-cause revision-free survivorship, postoperative complications, and HOOS JR, as well as SF-12 scores. Radiographically, they were evaluated for subsidence, radiolucencies, and loosening.

RESULTS

Aseptic revision-free survivorship of the femoral component was 95.8% (69 out of 72). Including septic cases, revision-free survivorship was 87.5% (63 cases), and 60 implants (83.3%) had an all-cause revision-free survivorship. For those patients who underwent septic revisions, eight out of nine remained infection free, while one underwent a resection arthroplasty. Furthermore, the cause for femoral aseptic revisions were subsidence (1.4%) and aseptic loosening (2.8%). Functional score improvements for HOOS JR, SF-12 PCS, as well as MCS were 29, 13, and 2, respectively (all p<0.001). There were eight emergency department visits (11.1%,) and six inpatient readmissions (8.3%). Additionally, two patients had dislocations (2.8%, two out of 72) not requiring revision. There were two cases of femoral subsidence and one aseptic loosening requiring revision; whereas, the rest did not demonstrate any progressive radiographic lucencies.

DISCUSSION

The eight-year mean survivorship results of the tapered modular femoral stems in revision THA demonstrated excellent results. Our series found improved outcome scores and relatively low postoperative complications, which indicate a favorable implant survivorship profile for revision THA.

CONCLUSION

These results serve to inform arthroplasty surgeons of expected outcomes of the modular stems when used for patients who need complex revision THA.

Is Conversion Total Knee Arthroplasty a Distinct Surgical Procedure? A Comparison to Primary and Revision Total Knee Arthroplasty

Conversion total knee arthroplasty (TKA) is suggested to incur similar complication rates to revision arthroplasties. However, current billing codes do not allow for the differentiation between this operation and primary TKAs. Therefore, the purpose of this study was to compare outcomes of these two surgeries, as well as revision TKAs. Specifically, we analyzed (1) medical complications, (2) surgical complications, and (3) revision rates at 90 days and 1 year. We queried a national, all-payer database to identify patients who underwent TKA without prior implants (n = 1,358,767), required conversion TKA (n = 15,378), and who underwent revision TKA (n = 33,966) between January 1, 2010, and April 30, 2020. Conversion TKA patients (prior implant removal) were identified using the Current Procedural Terminology (CPT) codes. Outcomes studied included 30-day readmission rates and 90-day, as well as 1-year, medical and surgical complications. Conversion TKAs had greater 30-day readmission rates and incidences of most of the complications studied when compared with primary TKAs. The majority of outcomes when comparing between primary, conversion, and revision TKAs were significantly different (p < 0.01). In contrast, conversion TKA complications were similar to revision TKA. Conversion TKAs have higher postoperative complications than primary TKAs and share more similarities with revision TKAs. Thus, the lack of billing codes differentiating conversion and primary TKAs creates a challenge for orthopaedic surgeons.

Liner Dissociation and Acetabular Erosion Treated by Implant Retention and Dual-Mobility Liner Cementation: A Case Report

CASE

A 56-year-old woman underwent a left total hip arthroplasty (THA) after developing avascular necrosis after chemotherapeutic treatment of breast cancer. She presented approximately 2 years after index THA with left groin pain and complaints of instability. Imaging revealed pseudodislocation of the ceramic femoral head with erosion through the acetabular component. Intraoperative evaluation revealed a dissociated polyethylene liner, damaged acetabular locking mechanism, metallosis, and well-fixed and aligned components. Treatment consisted of component retention, bone grafting, and dual-mobility liner cementation into the acetabular component.

CONCLUSIONS

The two-year follow-up demonstrated a pain-free, well-functioning hip, bone graft incorporation, and no evidence of loosening.

Low Wear at 10-Year Follow-Up of a Second-Generation Highly Cross-Linked Polyethylene in Total Hip Arthroplasty

BACKGROUND

Characterizations and factors influencing longer term performance of second-generation sequentially irradiated and annealed highly cross-linked polyethylene (HXLPE) are lacking. We evaluated patients who underwent total hip arthroplasty with HXLPE at mean 10-year follow-up for (1) linear and volumetric wear rates, (2) patient and implant characteristics, (3) implant survivorships, and (4) functional scores.

METHODS

We evaluated 130 hips (110 patients) that received HXLPE acetabular liners at a single center. The mean age was 56 years (range, 20-79 years), with a mean follow-up of 10 years (range, 8-15). Radiographic linear (millimeters/year) and volumetric (cubic millimeters/year) wear rates were quantified using radiographic analysis. Survivorship was assessed by all-cause and wear-related revision rates. Functional outcomes were assessed by Short Form 12 and modified Harris Hip Scores.

RESULTS

The mean linear wear rate was 0.02 ± 0.03 mm/y, and the mean volumetric wear rate was 12.6 ± 5.3 mm³/y. Younger age had higher volumetric wear (total and yearly, P = .01). Increasing body mass index trended toward higher total and yearly linear (both, P ≤ .09) and volumetric wear (both, P ≤ .07). Ten patients required revisions, with an all-cause survivorship of 92% and a wear survivorship of 100%. The mean modified Harris Hip Scores was 84, and the mean Short Form 12 scores were 46 (physical) and 55 (mental).

CONCLUSION

We observed low linear and volumetric wear rates for HXLPE at 10-year mean follow-up. Younger age and higher body mass index at the time of surgery may be important patient characteristics influencing long-term wear. These results illustrate the potential for this second-generation HXLPE to be an appropriate long-term total hip arthroplasty interface.

Social Determinants of Health in Total Hip Arthroplasty: Are They Associated With Costs, Lengths of Stay, and Patient Reported Outcomes?

BACKGROUND

Social determinants of health (SDOH) may play a larger role in predicting patient outcomes as outpatient total hip arthroplasty (THA) expands. We specifically examined the association between SDOH and patient metrics (demographics and comorbidities) for: (1) 30-day post-discharge costs of care; (2) lengths of stay (LOS); and (3) patient-reported outcomes (Hip Disability and Osteoarthritis Outcomes Score for Joints Replacement (HOOS JR)).

METHODS

Medicare patients who underwent primary THA between 2018 and 2019 were identified. Those who had complete social determinant data were included (n = 136). Data elements were drawn from institutional, regional, and government databases, as well as the Social Vulnerability Index (SVI). Multiple regression analyses were performed to determine SDOH and baseline comorbidities associations with costs, LOS, and HOOS JR scores.

RESULTS

Various SDOH factors were associated with higher 30-day costs, including residing in a food desert ($53,695 ± 15,485; P < .001) and the following SVI themes: 'Minority Status and Language' ($24,075 ± 9845; P = .01) and 'Housing and Transportation' ($16,190 ± 8501; P = .06), although the latter did not meet statistical significance. Baseline depression was associated with longer LOS (P = .02), while none of the other SDOH or patient metrics affected LOS. No relationships were observed between SDOH and HOOS JR changes from baseline.

CONCLUSION

Patients who live in food deserts and have minority status had higher costs of care after primary THA. Poor housing and transportation may also increase costs, albeit insignificantly. These results highlight the utility of assessing SDOH-related risk factors to optimize post-operative outcomes, with potential implications for bundled care.

Neighborhood Socioeconomic Disadvantages Associated With Prolonged Lengths of Stay, Nonhome Discharges, and 90-Day Readmissions After Total Knee Arthroplasty

BACKGROUND

Low socioeconomic status and neighborhood context has been linked to poor health care outcomes after total knee arthroplasty (TKA). The area deprivation index (ADI) addresses this relationship by ranking neighborhoods by socioeconomic disadvantage. We examined the following relationships of the ADI among TKA recipients: (1) patient demographics, (2) lengths of stay (LOS), (3) nonhome discharges, and (4) 90-day readmissions, emergency department visits, and reoperations.

METHODS

We reviewed a consecutive series of primary TKAs from 2018 through 2020 at a tertiary health care system. A total of 3928 patients who had complete ADI data were included. A plurality of patients (14.9%) were categorized within ADI 31-40, below the national median ADI of 47. Associations between the national ADI decile and 90-day postoperative health care utilization metrics were evaluated using multivariate regressions (adjusted for patient demographics and comorbidities).

RESULTS

The 91-100 ADI cohort was disproportionately African American, female, younger, and smokers. Compared with ADI 31-40 (reference), the ADI 61-70 cohort was associated with higher odds of LOS ≥3 days (odds ratio [OR] = 1.6 [1.08-2.36], P = .019) and nonhome discharges (OR = 1.73 [1.08-2.75], P = .021). The ADI 91-100 cohort was associated with the highest odds of prolonged LOS (OR = 2.27; [1.47-3.49], P < .001), nonhome discharges (OR = 3.49 [2.11-5.78], P < .001), and all-cause readmissions (OR: 1.79, [1.02-3.14], P = .044). No significant associations were found between the ADI and 90-day emergency department visits or reoperations (P > .05).

CONCLUSION

A higher ADI was associated with prolonged LOS, nonhome discharge status, and 90-day readmissions after TKA. This index highlights potential areas of intervention for assessing health care outcomes.

Revision Distal Femoral Replacement for Patello-Femoral Maltracking: A Surgical Technique

The use of the distal femoral replacement (DFR) has grown in recent years. Historically, this procedure was reserved for malignancy and complex revision cases with relative success. In recent years, complex reconstruction cases have had relative success. DFR has been associated with a range of complications including anterior knee pain, patellar instability, limitations in knee motion, and rotational instability that are sequelae of altered patello-femoral mechanics. Thus, subsequent dysfunction may require revision. To our knowledge, no surgical technique to correct DFR patello-femoral maltracking has been demonstrated in current literature. We present a surgical technique for DFR patello-femoral maltracking corrected surgically with femoral component revision and femoral stem retention.

A Novel Mobile App-Based Neuromuscular Electrical Stimulation Therapy for Improvement of Knee Pain, Stiffness, and Function in Knee Osteoarthritis: A Randomized Trial

Background

Knee osteoarthritis (OA) is a widespread and debilitating disease that continues to plague patients. Over the past decade, neuromuscular electrical stimulation (NMES) therapy has shown promise in alleviating knee OA-related symptoms. This study sought to evaluate the efficacy and safety of a home-based NMES therapy for reduction of pain, stiffness, and function associated with knee OA.

Material and methods

A randomized, sham-controlled, double-blind, multicenter trial was conducted with 12-week follow-up in 156 knee OA patients receiving either home-based NMES therapy or a modified low-voltage NMES therapy. Outcome measures including knee pain, stiffness, and functionality were collected at baseline through week 12 after the therapy. The primary endpoint was the percentage change from baseline (PCFB) in the Visual Analog Scale (VAS) pain for a patient-nominated physical activity. Secondary endpoints included VAS for general knee pain, Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score Joint Replacement, and isometric quadriceps strength test.

Results

A clinically meaningful reduction for VAS Nominated Activity was higher in the per-protocol treatment-compliant NMES group than that in the sham low-voltage NMES group at week 12 (PCFB of 42.8% vs 38.6%, P = .562). This was similarly true for the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale (PCFBs of 36.8% vs 26.6%, P = .038). Similar trends and reductions of pain were observed for VAS General, Knee Injury and Osteoarthritis Outcome Score Joint Replacement Pain subscale, and isometric quadriceps strength.

Conclusion

Home-based NMES treatment resulted in a clinically meaningful reduction of knee pain, stiffness, and knee functional improvements at week 12 compared with sham NMES treatment.

Survival and Outcomes of 1.5-Stage vs 2-Stage Exchange Total Knee Arthroplasty Following Prosthetic Joint Infection

BACKGROUND

Traditional management of prosthetic joint infection following total knee arthroplasty (TKA) consists of a 2-stage approach. However, 1.5-stage exchange has seen preliminary success, whereby metal femoral and all-polyethylene tibia components are placed without intention for subsequent second stage. We sought to examine all patients who underwent a 1.5-stage exchange TKA at a single institution compared to historical 2-stage controls. We assessed the following: (1) infection-free survivorship and risk factors for reinfection; (2) 1-year surgical/medical outcomes; (3) patient-reported outcomes (ie, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS JR]); and (4) radiographic outcomes.

METHODS

We reviewed all patients undergoing a 1.5-stage (between 2015 and 2019) and 2-stage exchange TKA (between 2011 and 2016) at a single institution. A total of 162 knees were included (1.5-stage: 114; 2-stage: 48) with mean clinical follow-up of 2.6 years. KOOS JR scores and radiographic outcomes were evaluated at last clinical follow-up.

RESULTS

The 1.5-stage exchange TKA resulted in a 10.1% difference in infection-free survival (85.1% vs 75.0%, P = .158), compared to 2-stage exchange. Prior prosthetic joint infection was found to be an independent risk factor for reinfection (P = .030). Overall, postoperative complications were lower among 1.5-stage exchanges (8.8% vs 31.3%, P < .001). KOOS JR scores improved more from baseline among 1.5-staged (Δ24.7 vs Δ16.6, P < .001). Radiographic review did not demonstrate any progressive radiolucent lines, subsidences, or failures in either group.

CONCLUSION

A 1.5-stage exchange TKA is an effective alternative to the traditional 2-stage protocols with noninferior infection eradication and absence of radiographic complications at over 2 years of mean follow-up.

Intra-articular Versus Extra-articular Coracoid Grafts: A Systematic Review of Capsular Repair Techniques During the Latarjet Procedure

Background:

Various methods exist for managing the joint capsule during the Latarjet procedure. Repairing the capsule to the native glenoid rim results in an extra-articular bone block, while repairing it to the remnant coracoacromial ligament stump of the coracoid graft renders it intra-articular. The technique that optimizes patient outcomes is not well defined.

Purpose:

To compare the outcomes of intra-articular and extra-articular bone block techniques for the Latarjet procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Using PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines, we queried the PubMed, EMBASE, and the Cochrane Library for all studies reporting outcomes of the Latarjet procedure with a clearly defined method of capsular repair that rendered the coracoid graft intra-articular or extra-articular. The included levels of evidence and degree of heterogeneity in this study precluded meta-analysis. Outcomes of interest included preoperative variables, surgical technique, rehabilitation protocols, functional outcome assessments, recurrent instability, range of motion, and radiographic findings.

Results:

A total of 16 studies including 816 patients were included. A total of 8 studies employed an intra-articular bone block in 338 patients, while the other 8 employed an extra-articular technique in 478 patients. There was variation among studies in reference to baseline patient characteristics, surgical techniques, rehabilitation, methods for assessing patient outcomes, and follow-up times. Rates of postoperative instability were reported in 8 intra-articular (0%, 0%, 2.1%, 2.7%, 3.2%, 5%, 5.4%, 5.9%) and 7 extra-articular (0%, 0%, 1.2%, 2%, 3.9%, 6.3%, 14%) bone block studies. Postoperative osteoarthritis or progression of preoperative osteoarthritis was reported in 5 intra-articular bone block studies (0%, 5.6%, 23.5%, 23.5%, 25%) and 4 extra-articular bone block studies (0%, 1.9%, 5.2%, 8.6%).

Conclusion:

Varying capsular repair methods appeared to provide similar outcomes regarding stability. There was an apparent trend toward higher rates of post-traumatic arthritis among studies in which an intra-articular bone block technique was employed; however, it is possible that this was influenced by substantially different follow-up times between groups and other various sources of heterogeneity among the included studies. There were no studies in the literature directly comparing intra-articular and extra-articular bone block techniques. Large-scale randomized controlled trials or comparative studies are needed to draw stronger conclusions comparing the 2 techniques.

THAs Performed Within 6 Months of Clostridioides difficile Infection Are Associated with Increased Risk of 90-Day Complications

BACKGROUND

Clostridioides difficile infection (CDI) may be a surrogate for poor patient health. As such, a history of CDI before THA may be used to identify patients at higher risk for postoperative CDI and complications after THA. Investigations into the associations between CDI before THA and postoperative CDI and complications are lacking.

QUESTIONS/PURPOSES

We compared the (1) frequency and potential risk factors for CDI after THA, (2) the frequency of 90-day complications after THA in patients with and without a history of CDI, and (3) the length of stay and frequency of readmissions in patients experiencing CDIs more than 6 months before THA, patients experiencing CDIs in the 6 months before THA, and patients without a history of CDI.

METHODS

Patients undergoing primary THA from 2010 to 2019 were identified in the PearlDiver database using ICD and Current Procedural Terminology codes (n = 714,185). This analysis included Medicare, Medicaid, and private insurance claims across the United States with the ability to perform longitudinal and costs analysis using large patient samples to improve generalizability and reduce error rates. Patients with a history of CDI before THA (n = 5196) were stratified into two groups: those with CDIs that occurred more than 6 months before THA (n = 4003, median 2.2 years [interquartile range 1.2 to 3.6]) and those experiencing CDIs within the 6 months before THA (n = 1193). These patients were compared with the remaining 708,989 patients without a history of CDI before THA. Multivariable logistic regression was used to evaluate the association of risk factors and incidence of 90-day postoperative CDI in patients with a history of CDI. Variables such as antibiotic use, proton pump inhibitor use, chemotherapy, and inflammatory bowel disease were included in the models. Chi-square and unadjusted odds ratios with 95% confidence intervals were used to compare complication frequencies. A Bonferroni correction adjusted the p value significance threshold to < 0.003.

RESULTS

Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before THA: OR 8.44 [95% CI 6.95 to 10.14]; p < 0.001; CDI ≤ 6 months before THA: OR 49.92 [95% CI 42.26 to 58.54]; p < 0.001). None of the risk factors included in the regression were associated with increased odds for postoperative CDI in patients with preoperative history of CDI. Patients with a history of CDI before THA were associated with higher unadjusted odds for every 90-day complication compared with patients without a history of CDI before THA. CDI during either timespan was associated with longer lengths of stay (no CDI before THA: 3.8 days; CDI > 6 months before THA: 4.5 days; CDI ≤ 6 months before THA: 5.3 days; p < 0.001) and 90-day readmissions (CDI > 6 months before THA: OR 2.21 [95% CI 1.98 to 2.47]; p < 0.001; CDI ≤ 6 months before THA: OR 3.39 [95% CI 2.85 to 4.02]; p < 0.001).

CONCLUSION

Having CDI before THA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. A history of CDI within the 6 months before THA was associated with the greatest odds for postoperative complications and readmissions. Providers should strongly consider delaying THA until 6 months after CDI, if possible, to provide adequate time for patient recovery and eradication of infection.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparing Primary Total Hip Arthroplasty in Renal Transplant Recipients to Patients on Dialysis for End-Stage Renal Disease: A Nationally Matched Analysis

BACKGROUND

Renal transplants are the most commonly performed solid-organ transplants worldwide. It is unclear whether a kidney transplant is associated with reduced postoperative complications in comparison with patients on dialysis for end-stage renal disease (ESRD). The purpose of this study was to utilize a national database to compare readmissions, complications, and costs associated with primary total hip arthroplasty (THA) between matched renal transplant recipients (RTRs) and patients on dialysis for ESRD.

METHODS

Patients with a renal transplant (N = 1,401) and those on dialysis for ESRD (without a transplant) (N = 1,463) prior to being treated with a THA from 2010 to 2019 were identified within the PearlDiver database. RTRs and patients on renal dialysis were frequency-matched 1:1 on the basis of 9 patient characteristics, resulting in 582 patients in each group. Length of hospital stay, readmissions, complication rates up to 2 years, and total costs up to 1 year were compared between the groups using chi-square and multivariable logistic regression analyses to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Patients on renal dialysis had an increased mean length of stay (6.3 days) compared with RTRs (4.6 days, p < 0.01). After adjusting for age, tobacco use, and diabetes, patients on renal dialysis were more likely to be readmitted by 90 days (OR = 1.59; CI = 1.11 to 2.29, p < 0.01) and have mechanical complications (OR = 2.13; CI = 1.08 to 4.45, p = 0.03) and revisions (OR = 2.14; CI = 1.14 to 4.01, p = 0.01) by 2 years. Patients on renal dialysis were also more likely to have periprosthetic joint infections at 1 year (OR = 1.91; CI = 1.02 to 3.71, p = 0.04). Patients on dialysis incurred 14% higher costs at 1 year (p = 0.11).

CONCLUSIONS

Patients on renal dialysis had more readmissions, complications, and costs after THA when compared with RTRs. Specifically, patients on renal dialysis were more likely to have longer index lengths of stay, more readmissions by 90 days, and more mechanical complications and revision surgery by 2 years. Patients on dialysis also incurred higher costs and had greater odds of PJI. These results suggest that joint surgeons may consider delaying THA in suitable patients until after renal transplantation to reduce postoperative complications and costs.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.