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Schmerler J, Harris AB, Srikumaran U, Khanuja HS, Oni JK, Hegde V. Body Mass Index and Revision Total Knee Arthroplasty: Does Cause for Revision Vary by Underweight or Obese Status? J Arthroplasty 2023; 38:2504-2509.e1. [PMID: 37331444 DOI: 10.1016/j.arth.2023.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Body mass index (BMI) impacts risk for revision total knee arthroplasty (rTKA), but the relationship between BMI and cause for revision remains unclear. We hypothesized that patients in different BMI classes would have disparate risk for causes of rTKA. METHODS There were 171,856 patients who underwent rTKA from 2006 to 2020 from a national database. Patients were classified as underweight (BMI < 19), normal-weight, overweight/obese (BMI 25 to 39.9), or morbidly obese (BMI > 40). Multivariable logistic regressions adjusted for age, sex, race/ethnicity, socioeconomic status, payer status, hospital geographic setting, and comorbidities were used to examine the effect of BMI on risk for different rTKA causes. RESULTS Compared to normal-weight controls, underweight patients were 62% less likely to undergo revision due to aseptic loosening, 40% less likely due to mechanical complications, 187% more likely due to periprosthetic fracture, 135% more likely due to periprosthetic joint infection (PJI). Overweight/obese patients were 25% more likely to undergo revision due to aseptic loosening, 9% more likely due to mechanical complications, 17% less likely due to periprosthetic fracture, and 24% less likely due to PJI. Morbidly obese patients were 20% more likely to undergo revision due to aseptic loosening, 5% more likely due to mechanical complications, and 6% less likely due to PJI. CONCLUSION Mechanical reasons were more likely to be the cause of rTKA in overweight/obese and morbidly obese patients, compared to underweight patients, for whom revision was more likely to be infection or fracture related. Increased awareness of these differences may promote patient-specific management to reduce complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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2
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Wall CJ, Vertullo CJ, Kondalsamy-Chennakesavan S, Lorimer MF, de Steiger RN. A Prospective, Longitudinal Study of the Influence of Obesity on Total Knee Arthroplasty Revision Rate: Results from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2022; 104:1386-1392. [PMID: 35703139 DOI: 10.2106/jbjs.21.01491] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to investigate the relationship of obesity with all-cause revision and revision for infection, loosening, instability, and pain after total knee arthroplasty (TKA) performed in Australia. METHODS Data for patients undergoing primary TKA for osteoarthritis from January 1, 2015, to December 31, 2020, were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The rates of all-cause revision and revision for infection, loosening, instability, and pain were compared for non-obese patients (body mass index [BMI], 18.50 to 29.99 kg/m 2 ), class-I and II obese patients (BMI, 30.00 to 39.99 kg/m 2 ), and class-III obese patients (BMI, ≥40.00 kg/m 2 ). The results were adjusted for age, sex, tibial fixation, prosthesis stability, patellar component usage, and computer navigation usage. RESULTS During the study period, 141,673 patients underwent primary TKA for osteoarthritis in Australia; of these patients, 48.0% were class-I or II obese, and 10.6% were class-III obese. The mean age was 68.2 years, and 54.7% of patients were female. The mean follow-up period was 2.8 years. Of the 2,655 revision procedures identified, the reasons for the procedures included infection in 39.7%, loosening in 14.8%, instability in 12.0%, and pain in 6.1%. Class-I and II obese patients had a higher risk of all-cause revision (hazard ratio [HR], 1.12 [95% confidence interval (CI), 1.03 to 1.22]; p = 0.007) and revision for infection (HR, 1.25 [95% CI, 1.10 to 1.43]; p = 0.001) than non-obese patients. Class-III obese patients had a higher risk of all-cause revision after 1 year (HR, 1.30 [95% CI, 1.14 to 1.52]; p < 0.001), revision for infection after 3 months (HR, 1.72 [95% CI, 1.33 to 2.17]; p < 0.001), and revision for loosening (HR, 1.39 [95% CI, 1.00 to 1.89]; p = 0.047) than non-obese patients. The risks of revision for instability and pain were similar among groups. CONCLUSIONS Obese patients with knee osteoarthritis should be counseled with regard to the increased risks associated with TKA, so they can make informed decisions about their health care. Health services and policymakers need to address the issue of obesity at a population level. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia.,School of Medicine, Rural Clinical School, University of Queensland, Queensland, Australia
| | - Christopher J Vertullo
- Knee Research Australia, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | | | - Michelle F Lorimer
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Richard N de Steiger
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia
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3
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Lin TL, Tsai CH, Fong YC, Shie MY, Chen HY, Chen YW. Posterior-Stabilized Antibiotic Cement Articulating Spacer With Endoskeleton-Reinforced Cam Reduces Rate of Post-Cam Mechanical Complications in Prosthetic Knee Infection: A Preliminary Study. J Arthroplasty 2022; 37:1180-1188.e2. [PMID: 35131390 DOI: 10.1016/j.arth.2022.01.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Posterior-stabilized antibiotic cement articulating spacers (PS spacers) reduce spacer mechanical complications in prosthetic knee infections (PKIs); however, joint dislocation after femoral cam fracture has been reported. We hypothesized that the rate of post-cam mechanical complications is lower in PS spacers with an endoskeleton-reinforced cam. METHOD A retrospective study of PKIs using PS spacers with or without a Kirschner wire-reinforced cam (K-PS or nK-PS spacers, respectively) was conducted between 2015 and 2019. The rates of post-cam mechanical complications and reoperation, as well as risk factors for post or cam failure, were analyzed. RESULTS The cohort included 118 nK-PS and 49 K-PS spacers. All patients were followed up for 2 years. The rate of joint subluxation/dislocation after femoral cam fracture was lower in K-PS (0%) than in nK-PS spacers (17.8%; P = .002). The reoperation rate for spacer mechanical complications was lower in K-PS (0%) than in nK-PS spacers (11.9%; P = .008). The identified risk factors for femoral cam fractures were body mass index ≥25 kg/m2, femoral spacer size ≤2, and surgical volume ≤12 resection arthroplasties per year. CONCLUSION This preliminary study highlights that K-PS spacers have a lower rate of post-cam mechanical complications than nK-PS spacers. We recommend the use of PS spacers with endoskeleton-reinforced cam when treating PKIs performed by surgeons with lower surgical volumes, especially in patients with higher body mass index and smaller femoral spacer sizes.
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Affiliation(s)
- Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Department of Orthopedics, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Ming-You Shie
- X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; School of Dentistry, China Medical University, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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4
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Hinterwimmer F, Lazic I, Langer S, Suren C, Charitou F, Hirschmann MT, Matziolis G, Seidl F, Pohlig F, Rueckert D, Burgkart R, von Eisenhart-Rothe R. Prediction of complications and surgery duration in primary TKA with high accuracy using machine learning with arthroplasty-specific data. Knee Surg Sports Traumatol Arthrosc 2022; 31:1323-1333. [PMID: 35394135 PMCID: PMC10050062 DOI: 10.1007/s00167-022-06957-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The number of primary total knee arthroplasties (TKA) is expected to rise constantly. For patients and healthcare providers, the early identification of risk factors therefore becomes increasingly fundamental in the context of precision medicine. Others have already investigated the detection of risk factors by conducting literature reviews and applying conventional statistical methods. Since the prediction of events has been moderately accurate, a more comprehensive approach is needed. Machine learning (ML) algorithms have had ample success in many disciplines. However, these methods have not yet had a significant impact in orthopaedic research. The selection of a data source as well as the inclusion of relevant parameters is of utmost importance in this context. In this study, a standardized approach for ML in TKA to predict complications during surgery and an irregular surgery duration using data from two German arthroplasty-specific registries was evaluated. METHODS The dataset is based on two initiatives of the German Society for Orthopaedics and Orthopaedic Surgery. A problem statement and initial parameters were defined. After screening, cleaning and preparation of these datasets, 864 cases of primary TKA (2016-2019) were gathered. The XGBoost algorithm was chosen and applied with a hyperparameter search, a cross validation and a loss weighting to cope with class imbalance. For final evaluation, several metrics (accuracy, sensitivity, specificity, AUC) were calculated. RESULTS An accuracy of 92.0%, sensitivity of 34.8%, specificity of 95.8%, and AUC of 78.0% were achieved for predicting complications in primary TKA and 93.4%, 74.0%, 96.3%, and 91.6% for predicting irregular surgery duration, respectively. While traditional statistics (correlation coefficient) could not find any relevant correlation between any two parameters, the feature importance revealed several non-linear outcomes. CONCLUSION In this study, a feasible ML model to predict outcomes of primary TKA with very promising results was built. Complex correlations between parameters were detected, which could not be recognized by conventional statistical analysis. Arthroplasty-specific data were identified as relevant by the ML model and should be included in future clinical applications. Furthermore, an interdisciplinary interpretation as well as evaluation of the results by a data scientist and an orthopaedic surgeon are of paramount importance. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany. .,Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany.
| | - Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Severin Langer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Suren
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Fiona Charitou
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology-Liestal, Kantonsspital Baselland, Bruderholz, Laufen, Switzerland.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Georg Matziolis
- Orthopaedic Department Campus Eisenberg, University Hospital Jena, Eisenberg, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Fritz Seidl
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Rueckert
- Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
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5
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Preoperative Weight Loss and Postoperative Weight Gain Independently Increase Risk for Revision After Primary Total Knee Arthroplasty. J Arthroplasty 2022; 37:674-682. [PMID: 34915131 DOI: 10.1016/j.arth.2021.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The current American Association of Hip and Knee Surgeons (AAHKS) guidelines recommend preoperative weight loss before total knee arthroplasty (TKA) in patients with body mass index (BMI) ≥40 kg/m2. However, there is a paucity of evidence on TKA outcomes after preoperative weight loss. This study therefore evaluated predictors of preoperative and postoperative BMI changes and their impact on outcomes after TKA. METHODS This is a retrospective review of 3058 primary TKAs at an academic institution from 2015 to 2019. BMI was collected on the day of surgery. Preoperative and postoperative BMI at 6 months and 1 year were also obtained. BMI change of ≥5% was considered clinically significant. Mean follow-up was 3.2 years. Patient demographics, acute postoperative outcomes, and all-cause revisions were compared between patients who gained, lost, or maintained weight using univariate and multivariable analyses. RESULTS Preoperative weight loss was predictive of postoperative weight gain (P < .001), and preoperative weight gain was predictive of postoperative weight loss (P < .001). Cox regression analysis revealed that ≥5% BMI loss preoperatively increased risk for all-cause revisions (P = .030), while ≥5% BMI gain postoperatively increased risk for prosthetic joint infections (P = .016). Patients who lost significant weight both before and after surgery had the highest risk for all-cause revisions (P = .022). CONCLUSION Weight gain postoperatively was associated with inferior outcomes. Significant weight loss before surgery led to a "rebound" in weight gain, and independently increased risk for all-cause revision. Therefore, current recommendations for weight loss before TKA in morbidly obese patients should be re-evaluated.
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6
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Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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