Cementless TKA use as an alternative to cemented TKA in high BMI patients: A systematic review and meta-analysis

Purpose

Obesity is prevalent, with nearly one-third of the world's population being classified as obese. In patients with high body mass index (BMI)/body mass undergoing total knee arthroplasty (TKA), there is an increase in strain placed on the implant fixation interfaces. As such, component fixation is a potential concern when performing TKA in the obese patient. To address the growing concerns around the longevity of implant fixation, some have advocated cementless over cemented fixation. However, there is no clear consensus on whether a cementless fixation has more favourable outcomes. The aim of this paper was to present a systematic review and meta-analysis of the existing evidence to establish if cementless TKA has a lower rate of aseptic loosening in high BMI patients when compared to cemented TKA procedures.

Methods

A systematic review was performed, and the following databases Medical Literature Analysis and Retrieval System Online (1946 to date), PubMed (1966 to date) and Excerpta Medica Database (1974 to date) were searched. All studies comparing cementless to cemented TKA in patients with BMI > 30 were considered. Meta-analysis compared aseptic loosening and all-cause revision between cemented and uncemented implant use in BMI > 30 patients.

Results

The search returned 91 articles in total; after duplicates were removed, the yield was 44 studies. Of the remaining studies that were assessed, three studies met the inclusion criteria for meta-analysis. The pooled odds ratio for all-cause revisions was 0.17 (95%, 0.08-0.36) in favour of uncemented implants (p < 0.01). The pooled odds ratio for aseptic loosening was 0.15 (95% confidence interval, 0.02-0.90) in favour of uncemented implants (p = 0.04).

Conclusions

Meta-analysis demonstrated a significant decrease in all-cause revisions and revisions for aseptic loosening when using uncemented fixation in high BMI patients when compared to the use of cemented implants.

Level of Evidence

The level of evidence is 1 for our systematic review.

Fluoroscopy-Assisted Computer Navigation Accurately Determines Cup Position and Leg Length for Anterior Hip Arthroplasty

BACKGROUND

Recently, fluoroscopy-assisted computer navigation has been developed to assess intraoperative cup inclination/anteversion and leg-length discrepancy (LLD) in the operating room. However, there is a relative dearth of studies investigating the accuracy of this software compared with postoperative radiographs.

MATERIALS AND METHODS

We prospectively enrolled 211 navigated anterior total hip arthroplasties using fluoroscopy-assisted computer navigation software. Intraoperative navigated measurements were compared with postoperative anteroposterior radiographs to assess accuracy of cup inclination/anteversion and LLD. Continuous variables were analyzed using the Student's t test, and categorical variables were analyzed using Fisher's exact test.

RESULTS

On postoperative radiographs, 94.3% of cups (199 of 211) were positioned within the Lewinnek "safe zone," compared with 99.1% navigated intraoperatively (P=.01). Eighty-two percent of hips (174 of 211) were navigated intraoperatively to LLDs within ±2 mm; on postoperative radiographs, 65% of hips (138 of 211) had LLDs within ±2 mm (P=.0001). Intraoperatively, 100% of hips (211 of 211) were navigated to LLDs within ±5 mm; similarly, on postoperative radiographs, 98% of hips (207 of 211) had LLDs within ±5 mm (P=.12).

CONCLUSION

A novel fluoroscopy-assisted computer navigation platform accurately assessed intraoperative cup position and LLD during anterior total hip arthroplasty. Careful attention to fluoroscopic technique, positioning of radiographic landmarks, and knowledge of the limitations of fluoroscopy, including parallax effect, are important concepts that surgeons should incorporate into their decision algorithm. [Orthopedics. 2024;47(4):e174-e180.].

Direct Hospital Costs per Case of Periprosthetic Hip and Knee Joint Infections in Europe - A Systematic Review

BACKGROUND

The rise of periprosthetic joint infections (PJIs) due to aging populations is steadily increasing the number of arthroplasties and treatment costs. This study analyzed the direct health care costs of PJI for total hip arthroplasty and total knee arthroplasty (TKA) in Europe.

METHODS

The databases PubMed, Scopus, Embase, Cochrane, and Google Scholar were systematically screened for direct costs of PJI in Europe. Publications that defined the joint site and the procedure performed were further analyzed. Mean direct health care costs were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and 2-stage revisions for hip and knee PJI, respectively. Costs were adjusted for inflation rates and reported in US-Dollar (USD).

RESULTS

Of 1,374 eligible publications, 12 manuscripts were included in the final analysis after an abstract and full-text review. Mean direct costs of $32,933 were identified for all types of revision procedures for knee PJI. The mean direct treatment cost including DAIR for TKA after PJI was $19,476. For 2-stage revisions of TKA, the mean total cost was $37,980. For all types of hip PJI procedures, mean direct hospital costs were $28,904. For hip DAIR, one-stage and 2-stage treatment average costs of $7,120, $44,594, and $42,166 were identified, respectively.

CONCLUSIONS

Periprosthetic joint infections are associated with substantial direct health care costs. As detailed reports on the cost of PJI are scarce and of limited quality, more detailed financial data on the cost of PJI treatment are urgently required.

Reverse Fragility Index: Comparing Revision Rates Between Direct Anterior and Other Approaches in Total Hip Arthroplasty. A Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite increasing adoption of the direct anterior (DA) approach in total hip arthroplasty (THA), uncertainty persists regarding its outcomes beyond the 1-year mark in comparison to other approaches. We used the reverse fragility index (RFI) to evaluate the robustness of reported findings in the literature.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) comparing implant revision rates between DA and other approaches in THA, defined as all those different from DA. Our primary outcome was the RFI, which gauges the number of events needed for a nonsignificant result to become significant, in the revision rate between DA and other approaches. We also calculated the reverse fragility quotient by dividing the RFI by each study's sample size. Median values and interquartile ranges (IQRs) were displayed.

RESULTS

A total of 10 RCTs with a total of 971 patients were included. The median RFI was 5 (IQR, 4 to 5), indicating the study's results would be statistically significant if the outcomes of 5 patients in 1 treatment arm were reversed. The median reverse fragility quotient was 0.049 (IQR, 0.04 to 0.057), indicating that a change of outcome in 4.9% of patients would render the revision rate significant. The median number of patients lost to follow-up was 4 (IQR, 0 to 7). Of the 10 RCTs, 6 had more patients lost to follow-up than their respective RFI values.

CONCLUSIONS

Notable fragility was evidenced in most studies comparing DA to other approaches for THA. Surgeons should not solely rely on the P value to determine clinical significance and instead use multiple metrics.

LEVEL OF EVIDENCE

II.

Robot-Assisted Total Hip Arthroplasty is Associated with an Increased Risk of Periprosthetic Fracture

INTRODUCTION

Total Hip Arthroplasty (THA) aims to restore joint function and relieve pain. New technology, such as robot assistance, offers the potential to reduce human error, improve precision, and improve postoperative outcomes. The aim of this study was to compare outcomes between conventional and robot-assisted THA.

METHODS

This is a retrospective cohort study utilizing a national database from 2016 to 2019. Patients undergoing THA, conventional or robot-assisted, were identified via the International Classification of Diseases, Tenth Revision (ICD-10) code. Multivariate regressions were performed to assess outcomes between groups. Negative binomial regressions were performed to assess discharge disposition, readmission, and reoperation. Gamma regressions with log-link were used to assess total charges and lengths of hospital stays. Patient demographics and comorbidities, measured via the Elixhauser comorbidity index, were controlled for in our analyses. A total of 1,216,395 patients undergoing THA, 18,417 (1.51%) with robotic assistance, were identified.

RESULTS

Patients undergoing robot-assisted procedures had increased surgical complications (odds ratio (OR) 1.31 [95% CI (confidence interval) 1.14 to 1.53]; P < 0.001), including periprosthetic fracture (OR 1.63 [95% CI 1.35 to 1.98]; P < 0.001). Notably, these patients also had significantly greater total charges (OR 1.20 [95% CI 1.11 to 1.30]; P < 0.001).

CONCLUSION

Robotic assistance in THA is associated with an increased risk of surgical complications, including periprosthetic fracture, while incurring greater charges.

The involvement of signaling pathways in the pathogenesis of osteoarthritis: An update

Osteoarthritis (OA) is one of the most common disabling pathologies, characterized by joint pain and reduced function, significantly worsening the quality of life. Even if important progresses have been made in OA research, little is yet known about the precise cellular and molecular mechanisms underlying OA. Understanding dysregulated signaling networks and their crosstalk in OA may offer a strong opportunity for the development of combined targeted therapies. Hence, this review highlights the recent findings on the main pathways involved in OA development, including Wnt, Notch, Hedgehog, MAPK, AMPK, and JAK/STAT, providing insights on current targeted therapies in OA patients' management.

The translational potential of this article

The identification of key signaling pathways involved in OA development and the investigation of their signaling crosstalk could pave the way for more effective treatments and improved management of OA patients in the future.

A qualitative analysis of pediatric otolaryngology fellowship websites

OBJECTIVE

To evaluate the availability and breadth of information provided by program-created pediatric otolaryngology fellowship websites as well as the American Society of Pediatric Otolaryngology (ASPO) program directory.

METHODS

Program-created pediatric otolaryngology fellowship websites and the ASPO directory were evaluated for 16 key criteria deemed to be relevant to fellowship applicants.

RESULTS

All 36 ACGME-accredited pediatric otolaryngology fellowship programs had websites that were readily available by Google search, and the ASPO program directory contained direct links to 17 (47.2 %) program-created websites. On average, program-created websites fulfilled 6.9 (43.1 %, range 1-11) and the ASPO directory fulfilled 6.9 (43.1 %, range 3-11) of the 16 key criteria. When utilizing both resources, the average increased to 8.3 (51.2 %) - criteria included program description (94.4 %), location description (30.4 %), fellowship director contact information (94.4 %), program coordinator contact information (72.2 %), teaching responsibilities (68.6 %), call responsibilities/schedule (41.7 %), operative volume (80 %), breadth of surgical exposure (94.4 %), research opportunities (72.2 %), research expectations (63.9 %), current fellow(s) (42.9 %), post-fellowship placement (28.6 %), fellow clinic (28.6 %), medical missions/outreach (20 %), and resident coverage (36.1 %).

CONCLUSION

Pediatric otolaryngology fellowship websites as well as program-specific data sheets from ASPO lack many key criteria that would otherwise be valuable to applicants. Inclusion of these criteria could help applicants make a more well-informed decision when applying into pediatric otolaryngology fellowship.

The Effect of Postoperative Sleeping Position on Knee Extension and Range of Motion Following Primary Total Knee Arthroplasty

Total knee arthroplasty (TKA) is an orthopaedic operation that improves quality of life and reduces pain in patients with disabling arthritis of the knee. One commonly recognized complication is flexion contracture of the knee. Early physical therapy helps prevent flexion contracture and improve range of motion (ROM) postoperatively. This study evaluated postoperative sleeping position and its effect on terminal knee extension and ROM following primary TKA. We hypothesized that patients who slept in the supine position would achieve earlier knee extension and greater ROM when compared to those in the lateral recumbent position. A total of 150 consecutive primary TKAs were performed by a single surgeon (J.M.C.) from April 2014 to December 2014. The data were collected prospectively to determine preoperative ROM, postoperative ROM, and sleeping position. Mean postoperative terminal extension ROM at 1 month was 2.9 degrees in the supine group versus 6.0 degrees (p< .001) in the lateral group. No significant demographic differences between the two groups at baseline were found. Our results demonstrate that sleeping position affects initial postoperative terminal extension, however, not overall ROM. We found a statistically significant difference in extension when comparing patients in the supine versus lateral group. Patients who slept in the lateral position lacked 6 degrees of extension which is greater than the 5 degrees needed for normal gait mechanics. Those in the supine group lacked 2.9 degrees of extension, allowing for normal gait mechanics. This study identifies an easy, effective means of increasing patients initial ability to achieve knee extension and satisfaction following TKA.

Total hip arthroplasty outcomes in Ehlers-Danlos patients: data from the Statewide Planning and Research Cooperative System

INTRODUCTION

Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after primary total hip arthroplasty (THA) in this patient population remain poorly characterised. The primary purpose of this study is to compare postoperative outcomes and survivorship after primary THA in patients with and without EDS.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for all patients undergoing primary elective THA between September 2009 and December 2020. Patients with EDS were identified using ICD9 and ICD10 diagnosis codes. Given the relatively low incidence of EDS in this patient population, the cohort was propensity-matched 1:10 to patients without diagnosis of EDS based on demographics characteristics and medical comorbidities as measured by the Elixhauser Comorbidity Index.

RESULTS

A total of 66 THA patients with and 660 without EDS were included in each group after 1:10 propensity-matching. There were no significant differences in baseline characteristics or THA indications. Early postoperative outcomes such as length of hospital stay and discharge disposition were similar. Emergency Room visits and inpatient readmission rates at 3 months postoperatively did not significantly differ between groups. Patients with EDS had a higher overall revision rate compared to those without (15.0% vs. 3.2%, p < 0.001). Revision free survival after primary THA in patients with EDS was significantly lower than those without EDS at 9-year follow-up. Cox proportional hazard regression demonstrated EDS patients had 7-times higher risk of revision (hazard ratio [HR] 7.43; 95% CI, 3.46-16.00; p < 0.001). Lastly, revision due to instability insignificantly trended higher in the EDS cohort (HR 2.29; 95% CI, 0.95-5.49; p = 0.063).

CONCLUSIONS

EDS patients undergoing primary THA have increased rate of all cause revision and demonstrate decreased revision free survival compared to non-EDS THA patients.

A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties

BACKGROUND

Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA.

METHODS

Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size.

RESULTS

The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975).

CONCLUSIONS

There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older

BACKGROUND

Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older.

METHODS

We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance.

RESULTS

The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries.

CONCLUSIONS

This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

5-Factor Modified Frailty Index as a Predictor of Outcomes After Hemiarthroplasty or Total Hip Arthroplasty for Femoral Neck Fracture

INTRODUCTION

Although the 5-factor modified frailty index (mFI-5) has been shown to be an independent predictor of complications after primary total hip arthroplasty (THA), its predictive value has not been evaluated in the setting of hip fracture. We therefore assessed the utility of mFI-5 score as an independent predictor of morbidity and mortality in patients who underwent THA or hemiarthroplasty for femoral neck fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients with femoral neck fractures treated with THA or hemiarthroplasty between 2006 and 2020. A multivariate logistic regression analysis was done using mFI-5 as a predictor while controlling for baseline demographic and clinical variables.

RESULTS

In total, 45,185 patients (hemiarthroplasty: 37,645; THA: 7,540) were identified. For hemiarthroplasty patients, the mFI-5 strongly predicted risk of any complication (OR, 1.1; 95% CI, 1.1 to 1.2; P < 0.001), bleeding (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001), and readmission (OR, 1.2; 95% CI, 1.1 to 1.3; P < 0.001). For THA patients, the mFI-5 was a strong predictor of any complication (OR, 1.2; 95% CI, 1.0 to 1.3; P = 0.023), pneumonia (OR, 1.4; 95% CI, 1.0 to 2.0; P = 0.047), and readmission (OR, 1.3; 95% CI, 1.1 to 1.6; P = 0.004).

DISCUSSION

The mFI-5 is an independent predictor of morbidity and complications after hemiarthroplasty and THA for femoral neck fracture. Importantly, readmission risk was predicted by the mFI-5. The mFI-5 may present a valuable clinical tool for assessment of high-risk patients who might require additional resources and specialized care after femoral neck fracture.

Conventionally instrumented inverse kinematic alignment for total knee arthroplasty: How is it done?

Purpose

For primary total knee arthroplasty (TKA), there is an increasing trend towards patient-specific alignment strategies such as kinematic alignment (KA) and inverse kinematic alignment (iKA), which by restoring native joint mechanics may yield higher patient satisfaction rates. Second, the most recent Australian joint registry report describes favourable revision rates for conventionally instrumented TKA compared to technology-assisted techniques such as those using navigation, robotics or custom-cutting blocks. The aim of this technique article is to describe in detail a surgical technique for TKA that: (1) utilises the principles of iKA and (2) uses conventionally instrumented guided resections thereby avoiding the use of navigation, robotics or custom blocks.

Methods

A TKA technique is described, whereby inverse kinematic principles are utilised and patient-specific alignment is achieved. Additionally, the patellofemoral compartment of the knee is restored to the native patellofemoral joint line. The sequenced technical note provided may be utilised for cemented or cementless components; cruciate retaining or sacrificing designs and for fixed or rotating platforms.

Results

An uncomplicated, robust and reproducible technique for TKA is described.

Discussion

Knee arthroplasty surgeons may wish to harness the emerging benefits of both a conventionally instrumented technique and a patient-specific alignment strategy.

Level of Evidence

Level V.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications?: A Japanese DPC study

BACKGROUND

The global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients.

METHODS

Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture.

RESULTS

One-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418-0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379-1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675-1.929).

CONCLUSION

The findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

Comparison of Novel 3D-printed Stepped Porous Metal Cones and Metaphyseal Sleeves for Reconstruction of Severe Knee Bone Defects: Short-term Clinical Outcomes

OBJECTIVE

Both porous metal cones and metaphyseal sleeves are excellent implants for reconstructing severe bone defects in the knee joint, but they both exhibit design limitations. The porous metal cone, especially, has significant room for improvement in its shape design. The existing porous metal cones often feature a conical external surface with a relatively small taper, potentially compromising both rotational and axial stability. To improve both axial and rotational stability in porous metal cones, we developed a 3D-printed stepped porous metal cone. This study aimed to assess the short-term clinical outcome of the 3D-printed stepped porous metal cone and to compare it with the clinical outcome of patients who underwent revision total knee arthroplasty (rTKA) with the metaphyseal sleeves during the same period.

METHOD

Patients who underwent total knee arthroplasty revision with metaphyseal bone defect reconstruction from 2019 to 2021 were retrospectively analyzed. A total of 61 patients were enrolled in the study, including 15 patients using 3D-printed stepped porous metal cones and 46 patients using metaphyseal metal sleeves. Thirty patients using metaphyseal sleeves were screened by propensity score matching method and compared with those using stepped cones. Analysis included the American Knee Society Score, the Hospital for Special Surgery knee score, the Western Ontario and McMaster Universities Arthritis index, the Short Form 12 (SF-12) health survey, and radiographic assessment with a mean follow-up of 28.5 ± 8.3 months. To conduct comparative analyses, unpaired Student's t-tests were employed for continuous variables, while categorical variables were analyzed using the appropriate Fisher exact or chi-squared test.

RESULTS

In this study, the survival rates of both the stepped cone and metaphyseal sleeve were 100%. There was no statistically significant difference in postoperative knee function scores between the two groups (p > 0.05). However, patients in the cone group had significantly higher mental component summary scores on the SF-12 scale (p < 0.05) and higher increases in mean postoperative physical component summary scores than patients in the sleeve group (p < 0.05). In addition, patients in the cone group experienced fewer intraoperative and postoperative complications compared to the sleeve group.

CONCLUSION

The 3D-printed stepped porous metal cone can effectively reconstruct bone defects in complex rTKA and provide satisfactory early clinical and radiographic results. The 3D-printed stepped cone provides a more stable structure similar to the sleeve while maintaining the original benefits of the cone making it a promising choice for rTKA.

Accuracy and clinical role of digital templating for total knee arthroplasty performed on haemophilic knees

INTRODUCTION

In total knee arthroplasty (TKA), choosing the correct implant size is important. There is lack of data on accuracy of templating on haemophilic knees. Our aim was to test the accuracy of 2D digital templating for TKA on haemophilic arthropathy (HA) of knee.

MATERIALS AND METHODS

TKAs performed on HA between January 2011 and January 2022 were screened. Osteoarthritis (OA) group was created as control group by a one-to-one matching regarding type of implant used. Intra- and interobserver correlations were measured in HA, then correlation between templated and implanted sizes was investigated in four assessments (femur AP, femur lateral, tibia AP, tibia lateral), then compared with OA group. Fifty-eight knees in each group included.

RESULTS

Regarding intraobserver correlation in HA, there was excellent correlation for femur AP [.93 (.73-.98)], femur lateral [.98 (.91-.99)], and tibia AP (1.0) templating. Regarding interobserver correlation in HA, excellent correlation was observed for femur lateral [.93 (.74-.98)] and tibia AP templating [.90 (.65-.97)]. Regarding correlation of templated and applied sizes in HA; tibia AP, tibia lateral and femur lateral templating showed good correlation [.81 (.70-.89), .86 (.77-.91), .79 (.67-.87) while femur AP templating showed moderate correlation [.67 (.50-.79)]. Comparing HA and OA, there was no difference in correlation levels regarding femur AP, femur lateral, tibia AP and tibia lateral templating (p = .056, p = .781, p = .761, p = .083, respectively).

CONCLUSION

Although 2D digital templating shows comparable correlation in HA and OA, clinical applicability of templating on HA appears to be limited in its current state.

A Perspective of Growth of Unicompartmental Knee Replacement in India - Registry Data and Global Trends

Introduction

The purpose of this study is to analyze the trend of unicompartmental knee replacement (UKR) in India, based on the data obtained from the Indian joint registry, in comparison with the global trends.

Materials and Methods

This study is a retrospective analysis of data from an Indian joint registry for cases performed between 2016 and 2021. A total of 1086 UKRs were identified and the following information was analyzed: demographic data, diagnosis leading to primary UKR, yearwise surgeon inclination toward UKR, implant preference, regions where UKR was preferred, and the effect of robotics in UKR. UKR registry data were compared with the registry data from the UK (NJR), Sweden (SKAR), Australia (AOJR), and the USA (AJRR).

Results

One thousand eighty-six UKRs were included in the study: The vast majority of them (97%) were implanted due to primary osteoarthritis followed by deformity (2%), as in accordance with other registries. Since 2016, though very minimal, there has been a gradual increase in the numbers and the percentage of cases contributed by UKR, of all knee replacements with the maximum of 2.85% reported in 2019. The same has been observed in the global trends as well. Oxford knees (60%) are the most preferred implants followed by journey uni knee (20%) in India. The cities where more unicompartmental knee are performed are in the order of Mumbai (32.78%), Faridabad (9.39%), Pune (7.92%), and Hyderabad (6.35%). Surgeon preference for robotic assisted UKR is increasing, accounting for 34% of UKR in 2020, which is in coherence with AOJR.

Conclusion

The percentage of knee replacements contributed by UKR is increasing globally and the same trend can be observed in India. Oxford phase III prosthesis are the most preferred UKR prosthesis. UKRs are mostly performed in selected pockets of India, with Mumbai almost contributing to one-third of all the cases. The use of robotics in UKR is increasing and is expected to give better results in the future.

Exploring consistent ratios in morphometry of the proximal tibia: insights for knee arthroplasty

INTRODUCTION

The current study, which delves into proximal tibia morphometric parameters in a Greek sample, not only analyzes whether specific linear distance ratios are consistent but also paves the way for a potential novel metric system for knee arthroplasty imaging studies using constant ratios. These findings could have significant implications for future enlarged research and clinical practice.

METHODS

A total of 38 dried tibiae were evaluated by two independent investigators. The following distances were measured with a digital Vernier sliding caliper: (1) the mediolateral distance of the proximal surface (A), (2) the anteroposterior distance of the proximal surface (B), (3) The longitudinal length of the bone (C), (4) the line connecting the anterior margin of the proximal surface with the highest peak of the tibia tuberosity (D), (5) the depth of the proximal margin of the medial articular facet (AF) (medial plateau) (E) and (6) the depth of the proximal margin of the lateral AF (lateral plateau) (F).

RESULTS

The A, B, C, D, E, and F mean distances were 71.3 mm, 47.4 mm, 340.2 mm, 37.1 mm, 42 mm, and 35.9 mm. Reliability analysis for each observer on all measurements revealed an interclass correlation (ICC) score of 0.975 (observer 1) and 0.971 (observer 2). The ratio A/B was 1.5, A/C was a constant 0.2, and D/C was 0.1. The ratio E/F was 1.2. The six measurements (A-F) showed excellent inter-observer reliability (all ICC values > 0.990).

CONCLUSIONS

The study established constant ratios of the studied linear distances around the proximal tibia. Considering these ratios, asymmetrical tibial components in knee arthroplasty seem to replicate the native anatomy more closely. Furthermore, the distance from the anterior margin of the proximal surface to the tibial tuberosity peak, constituting one-tenth of the longitudinal length of the tibia, shows promise as a metric system for imaging studies, especially in assessing lesions around tibial components.

Should a low starting point be abandoned for cannulated screw fixation of femoral neck fractures?

A validated femoral neck fracture model stabilized with three inverted cannulated screws was used to consider different intraoperative scenarios when the inferior screw hole is inadvertently started too inferiorly. These scenarios were to: (1) abandon the misplaced inferior screw hole and restart this hole more proximally, or (2) accept the mispositioned placement of the inferior screw and insert the remaining superior screws parallel or convergent to the inferior screw. Utilizing the second option and accepting the errant hole was associated with the greatest interfragmentary motion and stresses in the bone and hardware. In contrast, the first option created an improved mechanical environment for healing.

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system produced similar cup accuracy and precision relative to a computerized tomography-based robotic platform

Robotic assistance for total hip arthroplasty (THA) has been demonstrated to improve accuracy of acetabular cup placement relative to manual, unassisted technique. The purpose of this investigation was to compare the accuracy and precision between a fluoroscopy-based robotic total hip arthroplasty platform (FL-RTHA) and a computerized tomography-based (CT-RTHA) platform. The study included 98 consecutive FL-RTHA and 159 CT-RTHA procedures performed via direct anterior approach (DAA). All cases were performed for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included cup implantation accuracy and precision (variance). Implantation accuracy was calculated as the absolute value of the difference between pre-operative target cup angles (inclination and anteversion) and the same post-operative angles. Percentage placement in the Lewinnek safe zone was also measured for both cohorts. The FL-RTHA and CT-RTHA cohorts demonstrated a 1.2° difference in absolute values for cup inclination accuracy (4.6° ± 3.6 vs. 3.4 ± 2.7; p = 0.005), and no difference in absolute values for cup anteversion accuracy (4.7° ± 4.1 vs. 4.6 ± 3.4; p = 0.991). Cohorts demonstrated similar precision for cup inclination and anteversion placement parameters, as well as equivalent Lewinnek safe zone placement. The use of a fluoroscopy-based robotic assistance platform for primary DAA THA resulted in similar accuracy and precision of acetabular cup placement when compared to a CT-based robotic assistance system.

The Principles of Hip Joint Preservation

The three primary factors involved in preservation of the hip joint include femoroacetabular impingement (FAI), hip dysplasia/instability, and femoral torsion abnormalities. Each of these factors affects the health of the acetabular labrum and femoroacetabular cartilage. The appropriate surgical treatments for each of these factors include arthroscopic or open femoroplasty/acetabuloplasty for FAI, periacetabular osteotomy for hip dysplasia/instability, and derotational femoral osteotomy for femoral torsion abnormalities. When evaluating patients with prearthritic hip conditions, orthopaedic surgeons should be aware of the various factors involved in hip joint preservation and, if surgery is indicated, the surgeon should be sure to address all factors that need surgical treatment rather than focusing on the commonly diagnosed issue or visible injury, for example, a labral tear. If any of these factors is ignored, the hip joint may not thrive. The purpose of this review was to explain the importance of the most common factors involved in hip joint preservation and the appropriate surgical treatments for pathology in these factors.

Target Organs of Metals Released from Metal-on-Polyethylene Knee and Hip Arthroplasty Implants: Implications for Tissue Metal Profiles

Metals are used in orthopedic implants. The wear of arthroplasty implant can lead to the release of arthroprosthetic metals, both locally and systemically, after migration into the organs. While the toxicity of metal-on-metal arthroplasty implants is well-known and monitored, the toxicity associated with metal-on-polyethylene (MoP) ones is not as comprehensively understood. This study aimed to investigate the release of metals from MoP arthroplasty implants and their impact on the tissue metal profile in autopsied individuals, comparing them to deceased controls without prostheses. High-resolution ICP-MS was employed to analyze 39 metals in the blood, urine, hair, organs, and periprosthetic tissue of 25 deceased individuals with arthroplasty implants and 20 control subjects (Prometox study, protocol ID: APHP180539, NCT03812627). Eight metals (beryllium, chromium, cobalt, lanthanum, molybdenum, nickel, tellurium, titanium) exhibited significant impacts in arthroplasty implant wearers across various organs. Increased concentrations of La and Be were observed, the origin of which could not be precisely defined within the scope of this study. Notably, the lungs emerged as the primary target organ for metallic ions contained in implants. This study suggests that MoP arthroplasty implants, even when functional and not visibly worn, release arthroprosthetic metals into the body, potentially causing disturbances. Furthermore, considering the presence of an arthroplasty implant in autopsy reports may be relevant, as the released metals could influence the tissue metal profile.

Comparison of postoperative outcomes between endoscopy assisted minimal invasive direct anterior approach and bikini direct anterior approach in total hip arthroplasty

BACKGROUND

We have innovatively developed a modified bikini direct anterior approach total hip arthroplasty (THA), endoscopy assisted minimal invasive direct anterior approach (Endo-DAA). The study compared aesthetic appearance of the scar, postoperative radiographic and functional outcomes, and complications of Endo-DAA with Bikini-DAA.

METHODS

Patients who underwent primary THA using Endo-DAA or Bikini-DAA were included. The main innovation of Endo-DAA is the use of minimally invasive 5-7 cm proximal transverse incision and distal puncture with an endoscopy assisted split-type tool to complete the acetabular preparation and prosthesis implantation. Outcomes evaluated included evaluation of scar satisfaction, hip reconstruction including inclination, anteversion and leg-length discrepancy (LLD) and patient-reported outcomes including Harris Hip Scores (HHS) and Forgotten Joint Score (FJS). Follow-up time points included preoperative, 6 weeks, 6 months and 12 months.

RESULTS

Finally, 195 hips in Endo-DAA and 207 hips in Bikini DAA completed the follow-up. The Endo-DAA group was superior to the Bikini-DAA group in the cosmetic aspects of scars. the cup anteversion angle of Endo-DAA group was significantly better than that in the Bikini-DAA group. The early HHS and FJS of the Endo-DAA group were superior to those of the Bikini-group. Operation time, blood loss, incision length, length of stay and duration to start no-assistive-device walking were also significantly better in the Endo-DAA group. Furthermore, the Bikini-DAA group had a higher incidence of complication.

CONCLUSION

Compared with Bikini-incision, Endo-DAA improves patients' subjective satisfaction with scar aesthetics, accelerates rapid recovery of postoperative function, and reduces postoperative complications.

Device and surgical procedure-related infections in Canadian acute care hospitals, 2018-2022

Background

Healthcare-associated infections (HAIs) are a significant healthcare burden in Canada. National surveillance of HAIs at sentinel acute care hospitals is conducted by the Canadian Nosocomial Infection Surveillance Program.

Objective

This article describes device and surgical procedure-related HAI epidemiology in Canada from 2018 to 2022.

Methods

Data were collected from over 60 Canadian sentinel acute care hospitals between January 1, 2018, and December 31, 2022, for central line-associated bloodstream infections (CLABSIs), hip and knee surgical site infections (SSIs), cerebrospinal fluid shunt (CSF) SSIs and paediatric cardiac SSIs. Case counts, rates, patient and hospital characteristics, pathogen distributions and antimicrobial resistance data are presented.

Results

Between 2018 and 2022, 2,258 device-related infections and 987 surgical procedure-related infections were reported. A significant rate increase was observed in adult mixed intensive care unit CLABSIs (1.07-1.93 infections per 1,000 line days, p=0.05) and a non-significant rate increase was observed in SSIs following knee arthroplasty (0.31-0.42 infections per 100 surgeries, p=0.45). A fluctuating rate trend was observed in CSF shunt SSIs over the time period and a significant rate decrease in paediatric cardiac SSIs was observed (68%, from 7.5-2.4 infections per 100 surgeries, p=0.01). The most commonly identified pathogens were coagulase-negative staphylococci (22.8%) among CLABSIs and Staphylococcus aureus (42%) among SSIs.

Conclusion

Epidemiological and microbiological trends among selected device and surgical procedure-related HAIs are essential for benchmarking infection rates nationally and internationally, identifying any changes in infection rates or antimicrobial resistance patterns and helping inform hospital infection prevention and control and antimicrobial stewardship policies and programs.

Characteristics and Epidemiology of Megaprostheses Infections: A Systematic Review

BACKGROUND

Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants' infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors.

METHODS

We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons.

RESULTS

The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively.

CONCLUSIONS

The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management.

Medial opening wedge high tibial osteotomy performs similarly irrespective of body mass index

PURPOSE

This study investigates the effect of the body mass index (BMI) on the early (2 years) to midterm (5 years) results of medial opening wedge high tibial osteotomy (MOWHTO).

METHODS

A prospectively maintained single-centre database of 1138 knee osteotomies, between 2002 and 2022, was retrospectively reviewed. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee osteoarthritis (OA), with varus knee malalignment, having failed conservative management, were included. Patients were categorized into three groups according to their BMI as per the classification from the National Institute for Health and Care Excellence (NICE): the healthy weight (HW) group (BMI of 18.5-24.9 kg/m2), the overweight (OW) (BMI of 25-29.9 kg/m2), and the obesity (OB) group (BMI ≥ 30 kg/m2). Multiple patient-reported outcome measures (n = 6) were recorded preoperatively and at 2 and 5 years postoperatively. Deformity analysis was undertaken preoperatively and postoperatively. The relative risk (RR) of the complications between the HW, OW and OB groups was calculated. The rate of conversion to arthroplasty, and 5 and 10 years survivorship were recorded, as well as the hazard ratio (HR) of BMI on survivorship.

RESULTS

A total of 574 cases were included in the study: the HW group (n = 96), the OW group (n = 233) and the OB group (n = 245), with a mean BMI of 23 ± 1.5 kg/m2, 27.4 ± 1.4 kg/m2 and 34.4 ± 3.8 kg/m2, respectively. The mean follow-up was 13.3 years (4.8-20.3). The mean mechanical tibiofemoral angle corrections were in the HW group: 7.1 ± 3°, OW group: 6.6 ± 3.5° and OB group: 7.1 ± 3.8°, with no intergroup significant difference (p = n.s.). Clinically, despite lower preoperative scores in the OW and OB groups, no difference was observed postoperatively amongst the three groups. The overall complication rate was 12.5% in the HW group, 6.8% in the OW group, and 9.8% in the OB group. There was no significant difference in the RR of complications between the HW and OW groups (RR = 0.6, 95% confidence interval [CI] = 0.3-1.3) (p = 0.2), and the HW and OB groups (RR = 0.8; 95% CI = 0.3-2.2) (p = 0.7). There was no overall significant difference in survival outcomes based on the BMI between the three groups (p = 0.4). The HR of conversion to arthroplasty between the HW and OW groups was 1.4 [95% CI = 0.6-3.5](p = 0.5) and between the HW and OB groups was 1.8 [95% CI = 0.8-4.4] (p = 0.2).

CONCLUSION

BMI has no significant effect on either the radiological corrections, clinical outcomes, complications or survivorship of MOWHTO at short- to medium-term follow-up. No specific cutoff point for BMI can be recommended as a contraindication to MOWHTO.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Computed Tomography Evaluation of Alumina Ceramic-on-Ceramic Total Hip Arthroplasty With More Than 20 years of Follow-Up: Is a Follow-Up Computed Tomography Scan Necessary?

BACKGROUND

Ceramic-on-ceramic (CoC) bearings have been increasingly used in total hip arthroplasty (THA) because of their superior wear resistance and biocompatibility. However, there is a scarcity of reports on the computed tomography (CT) evaluation of CoC bearings with more than 10 years. The aim of this study was to evaluate the long-term CT results of THA using CoC bearings for more than 20 years of follow-up. We hypothesized that there would be no wear, osteolysis, or ceramic fracture.

METHODS

Between November 1997 and June 2003, 956 hips underwent THA using alumina-on-alumina bearings at a tertiary referral hospital. Among them, 107 hips were assessed, all of which underwent a CT examination more than 20 years after the index surgery. The mean age at the time of surgery was 41 years, and a CT scan was performed at an average of 22.0 years postoperatively (range, 20.0 to 25.1). The CT scans were thoroughly assessed for osteolysis, stem notching, and ceramic component fracture.

RESULTS

No loosening was observed in the acetabular cup or femoral stem. Stem notching was observed in 3 hips (2.8%). In the CT scan taken after a minimum of 20 years of follow-up, 1 case (0.9%) of osteolysis around the cup and 2 cases (1.9%) of osteolysis around the femoral stem were noted. Suspected chip fractures of the ceramic insert were discovered in 4 cases (3.7%). Despite these findings, the patients remained asymptomatic, and no subsequent surgical intervention was needed after close follow-up.

CONCLUSIONS

Routine CT examinations for patients who underwent THA using CoC bearings over 20 years ago revealed unexpected findings, such as osteolysis and suspected chip fractures of the ceramic liner. However, routine CT scans may not be universally necessary. The CT evaluation in this cohort should be selectively performed for patients who have relevant clinical symptoms.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

What Is the Carbon Footprint of Adult Spinal Deformity Surgery?

Background/Objectives: While the economic cost of adult spinal deformity (ASD) surgery has been studied extensively, its environmental impact is unknown. The aim of this study is to determine the carbon footprint (CF) associated with ASD surgery. Methods: ASD patients who underwent > four levels of corrective surgery between 2017 and 2021 were included. The open group included a posterior-only, single-stage technique, while the minimally invasive surgery (MIS) group was defined as the use of lateral interbody fusion and percutaneous posterior screw fixation. The two groups were propensity-score matched to adjust for baseline demographic, surgical, and radiographic characteristics. Data on all disposables and reusable instruments, anesthetic gas, and non-gas medications used during surgery were collected from medical records. The CF of transporting, using, and disposing of each product and the footprint of energy use in operating rooms were calculated. The CF produced was evaluated using the carbon dioxide equivalent (CO2e), which is relative to the amount of CO2 with an equivalent global warming potential. Results: Of the 175 eligible patients, 15 pairs (65 ± 9 years, 47% female) were properly matched and analyzed for all variables. The average CF generated per case was 147.7 ± 37.3 kg-CO2e, of which 54% was attributable to energy used to sterilize reusable instruments, followed by anesthetic gas released into the environment (17%) and operating room air conditioning (15%). Conclusions: The CF generated during ASD surgery should be reduced using a multidisciplinary approach, taking into account that different surgical procedures have different impacts on carbon emission sources.

Advantages and limitations of mobile-bearing unicompartmental knee arthroplasty: an overview of the literature

INTRODUCTION

Interest in unicompartmental knee arthroplasty (UKA) has recently grown. Mobile bearing UKA, in which the bearing is not fixed but rather perfectly conforms with femoral and tibial components and moves completely passively between the femoral and tibial implant, has now been used for approximately half a century.

AREAS COVERED

Alongside the recognized advantages of UKA, the mobile-bearing variant benefits from an extremely low rate of polyethylene wear and tolerable minor malalignment. Revision rates for UKA have been reported to exceed those of total knee arthroplasty, but long-term survival rates and outcomes from mobile-bearing UKA have been found to be satisfactory. In addition to the lateral osteoarthritis and loosening, which are main complications of UKA, bearing dislocation is a specific complication of mobile bearing UKA. Fractures and valgus subsidence are more prevalent than in the cementless UKA. While these continue to be features to be addressed, they have been partially solved.

EXPERT OPINION

Given the manifold benefits of UKA, its application could be extended to a larger patient population. Successful outcomes rely on careful patient selection and the surgeon's extensive familiarity with the procedure. Looking ahead, the incorporation of robotic surgery, already a feature of some fixed-bearing UKAs, might shape the future trajectory of mobile-bearing UKA.

Disparities in Total Knee and Total Hip Arthroplasty Rates in the Population of Alaska, 2015 to 2018

OBJECTIVE

Racial and ethnic disparities in total joint replacements have been documented. Our objective was to determine the rates of total joint replacements for Alaska Native/American Indian (AN/AI) individuals compared with non-AN/AI individuals in Alaska and investigate the differences in characteristics and outcomes by race.

METHODS

We used hospital discharge data from the Alaska Health Facilities Data Reporting Program from 2015 to 2018. We identified people with an inpatient primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA). We determined the population proportion of each procedure, age-adjusted rates by race, age-specific rates, and multivariable adjusted rate ratios for TKA or THA. We compared the characteristics of people undergoing primary TKA and THA by race.

RESULTS

In 2,195,806 person-years, there were 8,131 arthroplasty procedures (4,594 primary TKAs, 2,791 primary THAs, 378 revision TKAs, and 368 revision THAs). Primary TKAs and THAs were less likely in people of AN/AI or "Other" race compared with people of White race, with some heterogeneity in the "Other" race category. In multivariable models, the adjusted rate ratio for AN/AI compared with White race for TKA was 0.70 (95% confidence interval [CI] 0.60-0.82) and for THA was 0.69 (95% CI 0.55-0.85). AN/AI individuals undergoing TKA and THA were more likely to reside in rural locations, be younger than 65 years, have longer hospital stay, and discharge to home.

CONCLUSION

This study confirmed the existence of racial disparities in TKA and THA in Alaska. There may be many underlying causes, and future research should focus on improving access to care.

10-Year Cumulative Incidence and Indications for Revision Total Joint Arthroplasty for Patients Who Have Ehlers-Danlos Syndrome

BACKGROUND

Long-term complications following total joint arthroplasty are not well established for patients who have Ehlers-Danlos syndrome (EDS), a group of connective tissue disorders. This study compared 10-year incidence of revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients who have and do not have EDS.

METHODS

A retrospective cohort analysis was conducted using a national all-payer claims database from 2010 to 2021 to identify patients who underwent primary TKA or THA. Patients who had and did not have EDS were propensity score-matched by age, sex, and a comorbidity index. Kaplan-Meier analyses and Cox proportional hazard models were used to determine the cumulative incidence and risks of revision experienced by patients who have and do not have EDS.

RESULTS

The EDS patients who underwent TKA had a higher risk of all-cause revision (hazard ratio [HR]: 1.50, 95% confidence interval [95% CI]: 1.09 to 2.07, P < .014) and risk of revision due to instability (HR = 2.49, 95% CI: 1.37 to 4.52, P < .003). The EDS patients who underwent THA had a higher risk of all-cause revision (HR = 2.32, 95% CI: 1.47 to 3.65, P < .001), revision due to instability (HR = 4.26, 95% CI: 2.17 to 8.36, P < .001), and mechanical loosening (HR = 3.63, 95% CI: 2.05 to 6.44, P < .001).

CONCLUSIONS

Patients who had EDS were found to have a higher incidence of revision within 10 years of undergoing TKA and THA compared to matched controls, especially for instability. Patients who have EDS should be counseled accordingly. Surgical technique and implant selection should include consideration for increased constraint in TKA and larger femoral heads or dual mobility articulations for THA.

Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND

Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA.

METHODS

We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected.

RESULTS

The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31).

CONCLUSIONS

This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches.

LEVEL OF EVIDENCE

Level III.

Improved Pain and Function With Triamcinolone Acetonide Extended-Release and Cryoneurolysis for Knee Osteoarthritis: Use of a New Real-World Registry

BACKGROUND

Knee osteoarthritis (OA) affects 19% of American adults aged more than 45 years and costs $27+ billion annually. A wide range of nonoperative treatment options are available. This study compared 6 treatments: cryoneurolysis with deep genicular nerve block (Cryo-Deep/Both), cryoneurolysis with superficial nerve block (Cryo-Superficial), intra-articular hyaluronic acid (IA-HA) injections, nonsteroidal anti-inflammatory drug injections (IA-NSAIDs), IA-corticosteroids (IA-CS) injections, or IA-triamcinolone extended release (IA-TA-ER) injections over 4 months for: (1) pain severity and analgesic use; and (2) physical function (from Knee Injury and Osteoarthritis Outcome Score for Joint Replacement).

METHODS

Patients who had unilateral knee OA and received nonoperative intervention were enrolled in the Innovations in Genicular Outcomes Research registry, a novel, multicenter real-world registry, between September 2021 and February 2024. A total of 480 patients were enrolled. Both pain and functional outcomes were assessed at baseline, weekly, and monthly, which were analyzed by overall trend, magnitude changes pretreatment to post-treatment, and distribution-based minimally clinically important difference (MCID) score. Multivariate linear regressions with adjustments for 7 confounding factors were used to compare follow-up outcomes among 6 treatment groups.

RESULTS

Use of IA-TA-ER injections was associated with the lowest pain, greatest pain reduction, and highest prevalence of patients achieving MCID relative to other treatments (P < .001). Deep/Both-Cryo and IA-CS were associated with a higher prevalence of achieving MCID than IA-HA, IA-NSAIDs, and Cryo-Superficial (P ≤ .001). Use of IA-TA-ER was also associated with the greatest functional score, improvement from baseline, and highest prevalence of patients achieving MCID than other treatments (P ≤ .003).

CONCLUSIONS

The IA-TA-ER appears to outperform other treatments in terms of pain relief and functional improvement for up to 4 months following treatment. In addition, outcomes in the novel cryoneurolysis and conventional IA-CS were similar to one another and better than those in IA-HA and IA-NSAIDs.

Impact of emergency department boarding on patients outcomes in hip fractures

BACKGROUND

Boarding time in the Emergency Department (ED) is an area of concern for all patients and potentially more problematic for the hip fracture population. Identifying patient outcomes impacted by ED boarding and improving emergent care to reduce surgical delay for this patient population is a recognized opportunity. The objective of this study is to examine the impact of ED boarding in relation to patient outcomes in the surgical hip fracture population.

METHODS

This is a retrospective study of hip fracture patients who presented at the ED of a Level 1 trauma center between January 2020 and December 2021. Patients were categorized into four quartiles based on boarding time. Study outcomes-hospital length of stay, time to surgery, visit to ICU post-operative, total blood products, in-hospital complications, discharge disposition, in-hospital mortality, and 30-day readmission-were compared among these four quartiles.

RESULTS

The outcome endpoints were comparable among the four quartiles except for time to surgery. Time to surgery significantly differed among the quartiles, increasing from 20.39 to 29.03 h (p < 0.001) from the first to fourth quartile.

CONCLUSION

In contrast to the existing literature, ED boarding in our study was not associated with adverse outcomes except for time to surgery. By expediting the time to surgery in accordance with established guidelines, adverse outcomes were mitigated even when our patients boarded for a longer duration. System processes including a 24/7 trauma nurse practitioner model, availability of in-house orthopedic surgeons, and timely cardiac evaluation need to be considered in relation to time to surgery, in turn impacting ED boarding and patient outcomes.

Trends in Hospital Stay, Complication Rate, and Mortality in Hip Fracture Patients: A Two-Decade Comparison at a National Tertiary Referral Center

Background: Since the turn of the century, the age-adjusted incidence of proximal femoral fractures has caused a plateau or fall. However, it was anticipated that the number of patients with proximal femoral fractures would rise as life expectancy rose and the population over 80 years old expanded. The aim of this study was to compare the length of hospital stay, complication rate, and mortality in patients with proximal femoral fractures between two different time periods: 20 years ago and the present. Methods: We conducted a retrospective review of medical records of patients aged 65 years and above who underwent surgery for proximal femoral fractures between January 2000 and December 2001 and between January 2020 and December 2021. We collected information on age, gender, fracture type, length of hospital stay, and complication rate. Dates of death were obtained from the Ministry of the Interior and Safety. Results: We included 136 patients who were operated on between 2000 and 2001 and 134 patients between 2020 and 2021. The average age increased significantly from 71.6 years to 79.0 years (p < 0.001). The length of hospital stay decreased dramatically from 15.1 days to 6.0 days (p < 0.001). There was no statistically significant difference in delirium, urinary tract infection, or pneumonia. No difference was found in 30-day or 1-year mortality between the two groups. Conclusions: The complication rate and mortality between the two time periods appeared comparable, although the length of hospital stay decreased substantially. Therefore, we recommend considering expedited discharge from the acute care hospital for elderly hip fracture patients while implementing an individualized approach for better outcomes.

A comparison of the top 500 papers in Clinical Nutrition ranked by citation and Altmetric Attention Scores

BACKGROUND AND AIMS

Citation scores (CS) have been traditionally used to measure the impact of scientific publications. Sourced from the Internet, Altmetric Attention Scores (AAS) are complementary metrics that assess how often publications are discussed and used globally. We compared by rank the top 500 papers by CS and AAS published in Clinical Nutrition with corresponding AAS and CS.

METHODS

A search for all publications in Clinical Nutrition was performed on Dimensions (https://app.dimensions.ai/discover/publication) on 3rd April 2024. Outputs were ranked according to CS and then by AAS with the top 500 in each category selected. Scores, year and type of publication were recorded. Correlation was expressed as the Spearman's rank coefficient (ϱ).

RESULTS

We identified 18,790 outputs. Within the top 500 publications ranked by CS, there was a significant weak positive correlation (ϱ = 0.235, P < 0.0001) between CS [median (IQR) 149 (116-223)] and AAS [7 (3-22)]. Ranked by AAS, there was a non-significant very weak positive correlation (ϱ = 0.072, P = 0.106) between AAS [55.5 (36-115)] and CS [42 (16.5-94.5)]. Trends remained similar when grouped by publication type. Guidelines, ranked by CS, had the highest CS and ranked by AAS, the highest CS and AAS. Publications per year, by year, ranked by CS, had a negatively skewed distribution peaking in 2012 and declined thereafter, but when ranked by AAS, had a moderately positive linear trend from 2001 to 2024 (ϱ = 0.513, P < 0.0001).

CONCLUSION

Correlation between CS and AAS was weak. Guidelines had the highest CS and AAS. CS are iterative taking years to mature while AAS are immediate.

Blood Transfusion in the Age of Tranexamic Acid: Who Needs a Type and Screen Before Total Hip Arthroplasty?

BACKGROUND

Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing.

METHODS

We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received TXA, and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline Hgb levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regression and receiver operating characteristic curve analysis.

RESULTS

The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index, and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The receiver operating characteristic analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively.

CONCLUSIONS

In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is >12 g/dL, challenging the need for universal type and screening. Conversely, patients who have Hgb < 11.0 g/dL, remain at substantial risk for transfusion. Between Hgb 11 and 12 g/dL, patient age, sex, body mass index, American Society of Anesthesiologists classification, anticipated estimated blood loss, and surgical time may help predict transfusion risk and the need for a perioperative type and screen.

LEVEL OF EVIDENCE

III.

High-dose vancomycin spacers provided early recovery without nephrotoxicity compared with standard-dose in MRSA-induced periprosthetic joint infection model of rats

BACKGROUND

Periprosthetic joint infections (PJIs) are commonly treated with two-stage revision surgery utilising antibiotic-loaded spacers; however, antibiotic release from spacers is limited and usually drops below effective levels a few days after placement. This study compared high-dose and standard-dose vancomycin-loaded spacers in terms of efficacy, safety, and overall treatment duration in a rat periprosthetic joint infection model.

METHODS

Thirty male Wistar albino rats (8-10 weeks old, 300-320 g) were housed individually at standard conditions. A periprosthetic infection model was established in the right knee of the rats using methicillin-resistant Staphylococcus aureus (MRSA) -contaminated Kirschner wires. Two weeks later, the infection was verified, and the Kirschner wires were removed. Rats were randomly divided into three groups (n = 10): standard-dose (SVanc) and high-dose (HVanc) vancomycin groups had 2.5 and 7.5% vancomycin in their spacers, respectively, while the control group had no spacers. All groups received intramuscular (IM) vancomycin and gentamicin for 4 weeks after spacer implantation. Microbiological counts and vancomycin levels in the blood and joint flush samples were measured, and histopathological assessments were conducted on the femur and kidneys.

RESULTS

After spacer implantation, MRSA was eliminated in the HVanc group with 4 weeks of treatment, while the SVanc group required 6 weeks of treatment (P < 0.001). Histopathological findings of the femoral medulla and cortical samples were better in the HVanc group compared with other groups (P = 0.007). Vancomycin levels in serum remained within safe limits in all groups, and kidney damage was not observed.

CONCLUSION

The use of high-dose vancomycin spacers might accelerate the transition period, which in turn reduces the duration of systemic antibiotic use and mitigates the risk of nephrotoxicity. Thus, this method may decrease the medical costs associated with PJI treatment.

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications

BACKGROUND

Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems.

METHODS

An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator.

RESULTS

Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B.

CONCLUSIONS

We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal.

LEVEL OF EVIDENCE

Level III.

Epidemiological Trends and Outcomes of Unicompartmental Knee Arthroplasty Among 104 Million Patients in the United States

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty (TKA) for localized osteoarthritis. Recent advancements in UKA implant design and expanding patient criteria may have increased its utilization. However, few studies have examined the use of UKA in the United States. Thus, this study assessed the current and projected future trends of UKA and robotic UKA in the United States through 2035, along with postoperative outcomes.

METHODS

A collaborative healthcare research network was queried to identify patients who had undergone UKA. Primary outcomes measured included prevalence (P), incidence proportion (IP), and incidence rate (IR) from 2012 to 2022. Chi-squared analyses were done to compare outcomes across categorical data. Regression modeling was performed to project UKA to the year 2035. Statistical significance was held at P < .05 for all analyses.

RESULTS

In 2022, 1,662 UKAs were performed within the network, a 590% increase from 2012 (241 performed). The IP increased on an average annual basis by 41.8%, the IR by 50%, and the P by 51.3%. A year following UKA, conversion to TKA was the most common orthopaedic complication (39.9%). As of 2022, there were 68 robotic UKAs performed, a 518% increase from the 11 performed in 2012. Regression analysis for UKA through 2035 showed that IP will be 0.04%, IR will be 1.75 × 10-6 cases/person-day, and P will be 0.3%.

CONCLUSIONS

These findings are consistent with prior studies indicating a higher utilization of UKA over the past decade. Reported complications were not uncommon, as nearly 40% of patients required a conversion to a TKA. Further research is needed to optimally identify criteria for appropriate patients and determine the benefits robotic UKA may provide, specifically reducing the risk of conversion to a TKA.

Excellent Results of Large-Diameter Ceramic-On-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-Up

BACKGROUND

This study reports the minimum 10 years results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head ceramic-on-ceramic bearing.

METHODS

Of the 276 THAs included in this study, there were eleven deaths and 27 patients lost to follow up (11%) during the follow-up, leaving 237 (85%) hips available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up.

RESULTS

After a minimum of 10 years, implant survivorship was 98.7%. There were 3 revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. All patients (100%) were satisfied or very satisfied. Since implantation, 43% of patients reported hearing a squeaking noise from the prosthesis. But all patients who reported squeaking were satisfied with the surgery. The mean titanium level was 2.2 μg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation.

CONCLUSIONS

A large-diameter head ceramic-on-ceramic THA provides outstanding long-term (minimum 10 years) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Examining the influence of body fat distribution on standing balance and functional performance in overweight female patients with degenerative lumbar disease

Introduction: Degenerative lumbar disease (DLD) is a prevalent disorder that predominantly affects the elderly population, especially female. Extensive research has demonstrated that overweight individuals (categorized by body fat distribution) have a higher susceptibility to developing DLD and an increased risk of falling. However, there is limited research available on the standing balance and functional performance of overweight females with DLD. Aims: To determine the impact of body fat distribution on standing balance and functional performance in overweight females with DLD. Methods: This cross-sectional study evaluated thirty females with DLD were categorized into three types of body fat distribution based on body mass index (BMI) and waist-hip ratio, specifically as android-type, gynoid-type, and normal weight groups. In addition, a control group of ten age-matched females with normal weight was recruited. The Visual Analogue Scale, Roland Morris Disability Questionnaire, Cobb angle (Determined using x-ray), and body composition (Determined using the InBody S10), were conducted only on the DLD groups. All participants were assessed standing balance in the anteroposterior and mediolateral directions. The functional assessments included timed-up-and-go and 5-times-sit-to-stand tests. Results: There were 10 people in each group. Android-type (Age = 65.00 ± 6.34 years; BMI = 26.87 ± 2.05 kg/m2), Gynoid-type (Age = 65.60 ± 4.99 years; BMI = 26.60 ± 1.75 kg/m2), Normal weight (Age = 65.70 ± 5.92 years; BMI = 22.35 ± 1.26 kg/m2), and Control (Age = 65.00 ± 5.23 years; BMI = 22.60 ± 1.12 kg/m2). The android-type group had higher body fat, visceral fat, and lower muscle mass (p < 0.05), along with an increased Cobb angle (p < 0.05). They showed greater ellipse area, total excursion, and mean distance in the anteroposterior direction (p < 0.05). During the functional performance assessments, the android-type group had longer durations in both the 5-times-sit-to-stand and timed-up-and-go tasks (p < 0.05). Conclusion: Our study found that android-type overweight individuals showed postural instability, reduced functional performance, and insufficient lower limb muscle strength and mass. These findings might help physical therapists in planning interventions, as they imply that patients with DLD may require specific types of standing balance training and lower extremities muscle-strengthening based on their body fat distribution. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT05375201.

PyFaceWipe: a new defacing tool for almost any MRI contrast

RATIONALE AND OBJECTIVES

Defacing research MRI brain scans is often a mandatory step. With current defacing software, there are issues with Windows compatibility and researcher doubt regarding the adequacy of preservation of brain voxels in non-T1w scans. To address this, we developed PyFaceWipe, a multiplatform software for multiple MRI contrasts, which was evaluated based on its anonymisation ability and effect on downstream processing.

MATERIALS AND METHODS

Multiple MRI brain scan contrasts from the OASIS-3 dataset were defaced with PyFaceWipe and PyDeface and manually assessed for brain voxel preservation, remnant facial features and effect on automated face detection. Original and PyFaceWipe-defaced data from locally acquired T1w structural scans underwent volumetry with FastSurfer and brain atlas generation with ANTS.

RESULTS

214 MRI scans of several contrasts from OASIS-3 were successfully processed with both PyFaceWipe and PyDeface. PyFaceWipe maintained complete brain voxel preservation in all tested contrasts except ASL (45%) and DWI (90%), and PyDeface in all tested contrasts except ASL (95%), BOLD (25%), DWI (40%) and T2* (25%). Manual review of PyFaceWipe showed no failures of facial feature removal. Pinna removal was less successful (6% of T1 scans showed residual complete pinna). PyDeface achieved 5.1% failure rate. Automated detection found no faces in PyFaceWipe-defaced scans, 19 faces in PyDeface scans compared with 78 from the 224 original scans. Brain atlas generation showed no significant difference between atlases created from original and defaced data in both young adulthood and late elderly cohorts. Structural volumetry dice scores were ≥ 0.98 for all structures except for grey matter which had 0.93. PyFaceWipe output was identical across the tested operating systems.

CONCLUSION

PyFaceWipe is a promising multiplatform defacing tool, demonstrating excellent brain voxel preservation and competitive defacing in multiple MRI contrasts, performing favourably against PyDeface. ASL, BOLD, DWI and T2* scans did not produce recognisable 3D renders and hence should not require defacing. Structural volumetry dice scores (≥ 0.98) were higher than previously published FreeSurfer results, except for grey matter which were comparable. The effect is measurable and care should be exercised during studies. ANTS atlas creation showed no significant effect from PyFaceWipe defacing.

Decreased "Polar Axis Angle" is Associated with Instability after Total Hip Arthroplasty: A New Method to Assess Functional Component Position on Lateral Seated Radiographs

BACKGROUND

Research on hip instability has focused on establishing "safe" ranges of combined component position in supine posture or functional placement of the acetabular component based on the hip-spine relationship. A new angle, the polar axis angle (PAA), of the total hip arthroplasty (THA) components describes the concentricity of both components and can be evaluated in functional positions that confer a greater risk of instability (i.e., sitting). The goal of this study was to compare the polar axis angle in functional positions between patients who experienced a postoperative dislocation, and a matched control group who did not have a dislocation.

METHODS

An institutional database was searched for patients experiencing a dislocation after primary THA. Patients who had postoperative full-length standing and seated lateral radiographs were included in the dislocator group. A control group of non-dislocator patients was matched 2:1 by age, body mass index (BMI), sex, and hip-spine classification. Radiographic measurements of the neck angle, acetabular ante-inclination, and polar axis angle (PAA) were performed by two separate blinded, trained reviewers.

RESULTS

The lateral seated neck angle and lateral seated polar axis angle measurements were significantly lower in the dislocator groups (n = 37) when compared with the control group (n = 74) (23 versus 33 degrees, P < 0.001; 74 versus 83 degrees, P = 0.012, respectively). Significant differences were also observed in changes in the polar axes and neck angles between standing and seated positions (P < 0.001 and P < 0.001, respectively). When comparing patients who have mobile spines versus stiff spines within the dislocator group, there were no differences in the acetabular, neck, or polar axis angles. The effect of neck angle on the polar axis angle showed a linear trend across cohorts.

CONCLUSIONS

Patients who experience postoperative instability have a significantly lower polar axis angle on lateral seated radiographs when matched for age, sex, BMI, and hip-spine classification. In addition, the lower seated polar axis angle is driven more strongly by decreased functional femoral anteversion, which emphasizes the role of functional femoral version on stability in THA.

Catastrophic case of the total knee arthroplasty dislocation: A case report

INTRODUCTION AND IMPORTANCE

Arterial injury is extremely rare after total knee arthroplasty.

CASE PRESENTATION

We describe a 68-year-old woman with dislocation of total knee arthroplasty after falling from a height. She had a popliteal artery injury and a vascular bypass was performed in delay. The patient died of a second myocardial infarction 3.5 months after her first introduction to our center.

CLINICAL DISCUSSION

Due to the prominent risk of vascular injuries after dislocation in TKA patients, we recommend performing vascular evaluations using CT angiography for all patients.

CONCLUSION

Any untreated vascular compromise in the setting of TKA dislocation may lead to devastating outcomes such as amputation and death.

Valgus stress knee radiographs accurately anticipate the bone resection in medial unicompartmental knee arthroplasty: Protocol validation using an image-based robotic system

PURPOSE

The objective of this study was to describe a planning method for medial unicompartmental knee arthroplasty (UKA) implantation using preoperative stress radiographs to measure the thickness of tibial and femoral bone resections and to validate this method with data from an image-based robotic surgery system. Having such method for preoperative planning would be of interest for surgeons performing UKA in order to anticipate optimal bone resection on both tibia and femoral sides.

METHODS

A new planning method for medial UKA based on valgus stress knee radiographs validated it with an image-based robotic surgery system (Restoris MCK, MAKO®, Stryker Corporation) was proposed. This retrospective study involved radiographic measurements of 76 patients who underwent image-based robotic medial UKA between April 2022 and February 2023. Preoperative anteroposterior stress radiographs of the knee were used to simulate UKA implantation. The UKA technique was based on Cartier's angle and aimed at restoring the joint line. The total dimension measured was 14 mm (8 mm for minimal tibial component and polyethylene insert + 4 mm for femoral component + 2 mm for safety laxity). Bone resections were measured in the preoperative valgus stress radiographs and then against the intraoperative bone resection data provided by the robotic system. Inter- and intra-observer reliability was assessed using 25 measurements.

RESULTS

The mean planned tibial resection measured in the radiographs was 4.3 ± 0.4 [2.9-5.8], while the mean robotic resection was 4.2 ± 0.5 [2.7-5.8] (mean difference = 0.15 mm, 95% confidence interval [CI] [-0.27 to 0.57]). There was a strong correlation between these two values (Pearson's rank R = 0.79, p < 0.001). Intra- and inter-observer reliability were also very strong (Pearson's rank R = 0.91, p < 0.001, and Pearson's rank R = 0.82, p < 0.001, respectively). The mean planned femoral bone resection measured in the radiographs was 2.7 ± 0.7 mm [1-4.5], while the mean robotic resection was 2.5 ± 0.9 [1-5] (mean difference = 0.21 mm, 95% CI [-0.66 to 1.08]). There was a strong correlation between these two values (Pearson's rank R = 0.82, p < 0.001). Intra- and inter-observer reliability were also strong (Pearson's rank R = 0.88, p < 0.001, and Pearson's rank R = 0.84, p < 0.001, respectively).

CONCLUSION

This study describes and validates with robotic information a simple and reproducible preoperative planning method to determine femoral and tibial bone resection for medial UKA implantation using antero-posterior valgus stress knee radiographs, leaving a medial safety laxity of 2 mm. It represents a very valuable contribution to the understanding of UKA principles, which can serve to extend its indications and increase reproducibility of the surgical technique.

LEVEL OF EVIDENCE

III. Retrospective cohort study.

Prior fragility fractures are associated with a higher risk of 8-year complications following total shoulder arthroplasty

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications.

PURPOSE

As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture.

METHODS

Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery.

RESULTS

The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001).

CONCLUSIONS

Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

LEVEL OF EVIDENCE

III.

Patellar reconstruction in primary total knee arthroplasty using bone chips from routine cuts: A case report and review of literature

BACKGROUND

Total patellectomy is currently reserved for exceptional cases, such as recalcitrant patellofemoral instability and comminuted fractures, due to its demonstrated negative impact on knee biomechanics. Therefore, managing patellectomy is crucial to mitigate its inherent deleterious effects. Various techniques have been described, including autologous or allogeneic bone grafts for reconstruction and soft tissue realignment to enhance the extensor mechanism.

CASE SUMMARY

A 73-year-old male underwent a patellectomy due to a comminuted fracture, subsequently developing osteoarthritis and experiencing a decline in functional status. Concurrent with total knee replacement, we conducted a patellar reconstruction, incorporating routine bone cuts and utilizing bone chips to fashion a new patella. This intervention resulted in the restoration of full extension and improvement of knee function.

CONCLUSION

Patellar reconstruction demonstrates benefits on knee mechanics and stabilization, contributing to enhanced outcomes and satisfaction following knee replacement. We present an affordable technique for managing patellectomized patients undergoing total knee replacement.

Evaluating the Reliability and Quality of YouTube Videos Regarding Medial Collateral Ligament Knee Injury as a Patient Education Resource

OBJECTIVES

The purpose of this study was to assess the educational reliability and quality of videos shared on YouTube regarding medial collateral ligament (MCL) injuries of the knee.

METHODS

Using the search keywords "medial collateral ligament" on YouTube, the first 50 videos were evaluated by two independent reviewers. Video characteristics were extracted, and each video was categorized by upload source and content type. Three scoring systems were used to evaluate the videos: the Journal of the American Medical Association (JAMA) Benchmark Score to assess a video's reliability; the Global Quality Score (GQS) to assess educational quality; the novel MCL Specific Score (MCL-SS) to assess MCL-specific content quality. Linear regression analyses were conducted to explore relationships between video characteristics and scores.

RESULTS

Collectively, the videos were viewed 5,759,427 times with a mean number of views per video of 115,189 ± 177,861. The mean JAMA score was 1.8, GQS was 2.1, and MCL-SS was 5.6, indicating both poor reliability and quality. Only videos uploaded by physicians showed a statistically significantly higher mean MCL-SS (P = .032) but were still of low quality with a mean MCL-SS of 9.2 ± 5.9. Multivariate linear regression revealed that videos uploaded by physicians were statistically significant predictors of greater MCL-SS (β = 4.108; P = .029). Longer video durations were statistically significant predictors of greater GQS (β = .001; P = .002) and MCL-SS (β = .007; P < .001).

CONCLUSIONS

YouTube videos regarding MCL injuries, despite their popularity, were found to be on average of poor overall reliability and quality as measured by JAMA, GQS, and MCL-SS.

LEVEL OF EVIDENCE

III - Cross-sectional Study.

Contemporary Aseptic Revision Total Hip Arthroplasty in Patients ≤50 Years of Age: Results of >500 Cases

BACKGROUND

There has been a paucity of long-term outcomes data on aseptic revision total hip arthroplasties (THAs) in the young adult population. The purpose of this study was to evaluate implant survivorship, complications, and clinical outcomes in a large cohort of contemporary aseptic revision THAs in patients ≤50 years of age at the time of the surgical procedure.

METHODS

We identified 545 aseptic revision THAs performed at a single academic institution from 2000 to 2020 in patients who were 18 to 50 years of age. Patients who underwent conversion THAs and patients with a history of any ipsilateral hip infection were excluded. The mean age was 43 years, the mean body mass index (BMI) was 29 kg/m 2 , and 63% were female. The index indication for revision THA was aseptic loosening in 46% of cases, polyethylene wear or osteolysis in 28% of cases (all revisions of conventional polyethylene), and dislocation in 11% of cases. There were 126 hips (23%) that had undergone at least 1 previous revision (median, 1 revision [range, 1 to 5 revisions]). The mean follow-up was 10 years.

RESULTS

In the entire cohort, the 20-year survivorship free of any re-revision was 76% (95% confidence interval [95% CI], 69% to 82%). There were 87 re-revisions, with 31 dislocations, 18 cases of aseptic loosening of the femoral component, and 16 periprosthetic joint infections (PJIs) being the most common reasons for re-revision. Dislocation as the indication for the index revision was associated with an increased risk of re-revision (hazard ratio, 2.9; p < 0.001). The 20-year survivorship free of any reoperation was 73% (95% CI, 66% to 78%). There were 75 nonoperative complications (14%), including 32 dislocations. The mean Harris hip score significantly improved (p < 0.001) from 65 preoperatively to 81 at 10 years postoperatively.

CONCLUSIONS

Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. Dislocation, aseptic loosening of the femoral component, and PJI were the most common reasons for re-revision. Index revision THAs for dislocation had a 3 times higher risk of re-revision.

LEVEL OF EVIDENCE

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