All-cause Revision Research Articles

POSITIONING THE LIPPED LINER IN TOTAL HIP ARTHROPLASTY: A KINEMATIC MODEL ANALYSIS OF LIP ORIENTATION, CUP POSITION, AND STEM ANTEVERSION

We have previously reported on the improved all-cause revision and improved revision for instability risk in lipped liner THAs using the NJR dataset. These findings corroborate studies from the Australian (AOANJRR) and New Zealand (NZOA) joint registries. The optimal orientation of the lip in THAs utilising a lipped liner remains unclear to many surgeons. The aim of this study was to identify impingement-free optimal liner orientations whilst considering femoral stem version, cup inclination and cup version.A cementless THA kinematic model was developed using a 20 degree XLPE liner. Physiological ROM and provocative dislocation manoeuvre analyses were performed. A total of 9 cup positions were analysed (inclination 30–40–50 degrees, anteversion 5-15-25 degrees) and combined with 3 stem positions (anteversion 0-15-30 degrees) and 5 lip orientations (right hip 11 to 7 o'clock).Some lip orientation/component position combinations lead to impingement within the physiological ROM range. Using a lipped liner increases the femoral head travel distance prior to dislocation when impingement occurs in the plane of the lip. In THAs with a cup inclination of 30 and 40 degrees, inferior lip orientations (7–8 o'clock for a right hip) performed best. Superior lip orientation performed best with a cup inclination of 50 degrees. Femoral stem version has a significant effect on the range of movement prior to impingement and hence the preferred lip orientation.The optimal orientation of the lip in lipped liner THA is dependent on the position of both the acetabular and femoral components. In the common component orientation combination of stem anteversion 15, cup inclination 40 and cup anteversion 15, the optimal lip orientation was postero-inferiorly (8 o'clock for a right hip). Preventing impingement during physiological ROM is possible with appropriate lip liner orientation.

Preoperative Depression Is Associated With Increased Short-term Complications But Equivalent Long-term Outcomes in Total Knee Arthroplasty.

Concomitant depression negatively impacts outcomes following total knee arthroplasty (TKA). Patient-Reported Outcomes Measurement Information System (PROMIS) surveys are validated measures that quantify depression, pain, and physical function. We hypothesized that higher preoperative PROMIS-depression scores would be associated with inferior outcomes following TKA. A total of 258 patients underwent primary TKA at a tertiary academic center between June 2018 and August 2020. PROMIS scores were collected preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. Patients with preoperative PROMIS depression scores of 55 or greater were considered PROMIS depressed (PD) and patients with scores less than 55 were considered not PROMIS depressed (ND). The primary outcomes were changes in PROMIS scores. Secondary outcomes included total and daily mean morphine milligram equivalents (MME) received during admission as well as 90-day hospital readmission and 2-year all-cause revision rates. There were 66 (25.58%) patients in the PD group and 192 (74.42%) in the ND group. Patients in the PD group had improved depression scores at all follow-up intervals (P<.001) and decreased pain scores at 1 year (P=.016). Both groups experienced similar changes in function scores at each follow-up interval. Patients in the PD group had higher total (P=.176) and daily (P=.433) mean MME use while admitted. Ninety-day hospital readmissions were higher in the PD group (P=.002). There were no differences in 2-year revision rates (P=.648). Preoperative PROMIS-depression scores of 55 or greater do not negatively impact postoperative function, depression, or pain, and patients with these scores have greater improvement in depression and pain at certain intervals. Patients in the PD group had higher readmission rates. [Orthopedics. 2024;47(1):40-45.].

Osteoporosis in the Setting of Shoulder Arthroplasty: A Narrative Review.

Patients who undergo shoulder surgery are frequently affected by osteoporosis and osteopenia, and the prevalence of this association is expected to increase due to the growing number of elderly individuals undergoing these procedures. It may be advisable to conduct a preoperative DXA scan for orthopedic surgical candidates at high risk, to detect those who could benefit from early intervention and avoid any related adverse events. Some of these complications include periprosthetic fractures, infection, subsequent fragility fractures, and have an all-cause revision arthroplasty at 2years post-op. Some studies analyzed the beneficence of antiresorptive medications pre-operatively but the latter did not show favorable outcomes. Surgical management may include cementing components of the prosthesis as well as modifying the diameter of the shoulder stem. Nevertheless, more studies are needed to evaluate the efficacy of any intervention, whether medical or surgical, to avoid any shoulder arthroplasty related-complication that may be precipitated by the reduced bone mineral density.

Risk of Revision and Complications After Total Hip Arthroplasty for Acute Treatment of Acetabular Fracture

BackgroundTotal hip arthroplasty (THA) for the treatment of acute acetabular fractures may be indicated where there is high risk for failure of open reduction and internal fixation. This study aimed to determine risks of revision and rates of major complications of THA for acute acetabular fractures. MethodsA retrospective review was performed (all-claims data files of a large national database) by querying International Classification of Disease, 10th revision procedure codes for THA within 14 days of acetabular fracture. We identified all-cause revision and surgical complications including dislocations, mechanical failures (loosenings or broken prostheses), infections, as well as medical complications. Demographic data collected included age, sex, obesity, and Charlson Comorbidity Index (CCI). Multivariate analyses evaluated the association of revision and major surgical complications after adjusting for demographic characteristics and comorbidities. We identified 956 THAs for the treatment of acute acetabular fracture from 2015 to 2020. Of all acute acetabular fractures treated with THA, 241 were concomitant with open reduction and internal fixation (ORIF), and 715 were THA-alone. ResultsAll-cause revision risk was 18.2%, overall major surgical complication rate 26.9%, and medical complication rate was 13.2%. Women were associated with increased risk of revision (adjusted odds ratio (aOR) 1.8; confidence interval (CI) 1.3 to 2.6, P = .001), dislocation (aOR 2.0; CI 1.5 to 3.1, P < .001), mechanical complication (aOR 2.1; CI 1.4 to 3.2, P < .001), and infection (aOR 1.6; CI 1.0 to 2.5, P = .044). ConclusionWe noted risk of all-cause revision of 18.2%, overall major surgical complication rate of 26.9%, and overall major medical complication rate of 13.2% for THA as the treatment of acute acetabular fracture. We caution against broad expansion of THA for treatment of acute acetabular fractures. Furthermore, increased risks of revision and complications in women warrant additional investigation into patient and fracture characteristics that may contribute to this finding.

The utility of cemented femoral stems in modern THA: a 10-year comparative analysis of the Charnley and Exeter stems

BackgroundTotal hip replacement (THR) is one of the most common surgical procedures performed worldwide. The controversy surrounding the relative merits of a cemented composite beam or cemented taper-slip stem in total hip replacement continues. Our aims primarily were to assess the 10-year outcomes of cemented stems using Charnley and Exeter prostheses with regional registry data and secondarily to assess the main predictors of revision.MethodsWe prospectively collected registry data for procedures performed between January 2005 and June 2008. Only cemented Charnley and Exeter stems were included. Patients were prospectively reviewed at 6 months, 2, 5 and 10 years. The primary outcome measure was a 10-year all-cause revision. Secondary outcomes included ‘re-revision’, ‘mortality’ and functional ‘Western Ontario and McMaster Universities Osteoarthritis Index’ (WOMAC) scores.ResultsWe recorded a total of 1351 cases in the cohort, 395 Exeter and 956 Charnley stems. The overall all-cause revision rate at 10 years was 1.6%. The revision rate for Charnley stem was 1.4% and 2.3% revision rate for all Exeter stems with no significant difference noted between the two cohorts (p = 0.24). The overall time to revision was 38.3 months. WOMAC scores at 10 years were found to be insignificantly higher for Charnley stems (mean 23.8, σ = 20.11) compared to Exeter stems (mean 19.78, σ = 20.72) (p = 0.1).ConclusionThere is no significant difference between cemented Charnley and Exeter stems; they both perform well above the international average. The decline in the use of cemented THA is not fully supported by this regional registry data.

Caring for patients with periprosthetic femoral fractures across England and Wales in 2021.

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement. This work used data freely available from the National Hip Fracture Database (NHFD) facilities survey in 2021, which asked 21 questions about the care of patients with PPFFs, and nine relating to clinical decision-making around a hypothetical case. Of 174 centres contributing data to the NHFD, 161 provided full responses and 139 submitted data on PPFF. Lack of resources was cited as the main reason for not submitting data. Surgeon (44.6%) and theatre (29.7%) availability were reported as the primary reasons for surgical delay beyond 36 hours. Less than half had a formal process for a specialist surgeon to operate on PPFF at least every other day. The median number of specialist surgeons at each centre was four (interquartile range (IQR) 3 to 6) for PPFF around both hips and knees. Around one-third of centres reported having one dedicated theatre list per week. The routine discussion of patients with PPFF at local and regional multidisciplinary team meetings was lower than that for all-cause revision arthroplasties. Six centres reported transferring all patients with PPFF around a hip joint to another centre for surgery, and this was an occasional practice for a further 34. The management of the hypothetical clinical scenario was varied, with 75 centres proposing ORIF, 35 suggested revision surgery and 48 proposed a combination of both revision and fixation. There is considerable variation in both the organization of PPFF services England and Wales, and in the approach taken to an individual case. The rising incidence of PPFF and complexity of these patients highlight the need for pathway development. The adoption of networks may reduce variability and improve outcomes for patients with PPFF.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. Patients at least 50years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. Recent FF before TKA is associated with increased risk for additional FF and PPF within 8years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Preoperative Patient Optimization: Outcomes from Elective Total Joint Arthroplasty in a Large US Healthcare System.

Patient factors are known to affect outcomes in arthroplasty surgery. A preoperative program to address modifiable factors may aid in more appropriate patient selection. We sought to assess patient selection and 90-day postoperative outcomes for total joint arthroplasty (TJA) candidates before and after implementation of a preoperative optimization protocol. A retrospective time-trend study using data from an integrated healthcare system's total joint replacement registry was done. The study sample consisted of patients aged 18 years or older who underwent primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis between 2009 and 2019. Patients were divided into two cohorts: procedures performed from 2009 to 2013 ("preoptimization protocol") and those from 2015 to 2019 ("postoptimization protocol"); 2014 was excluded because an evidence-based preoperative patient optimization protocol was progressively implemented throughout the year. Patient characteristics, optimization factors, and 90-day outcomes (including emergency department [ED] visits, readmission, all-cause revision, deep infection, venous thromboembolism, and mortality) were compared between the two cohorts using the Pearson chi-square test or Wilcoxon test. The study sample included 25,925 THA and 60,484 TKA. In the THA cohort, 10,364 (40.0%) and 15,561 (60.0%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization THA cohort saw lower rates of ED visits (12.1% vs. 9.4%, P < 0.001) and readmissions (5.6% vs. 3.8%, P < 0.001). In the TKA cohort, 24,054 (39.8%) and 36,430 (60.2%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization TKA cohort saw lower rates of ED visits (13.1% vs. 11.9%, P < 0.001), readmissions (5.6% vs. 3.0%, P < 0.001), all-cause revisions (0.5% vs. 0.3%, P = 0.003), venous thromboembolism (1.3% vs. 0.9%, P < 0.001), and mortality (0.3% vs. 0.2%, P = 0.011). An evidence-based protocol to improve patient selection based on modifiable patient factors was adopted by orthopaedic surgeons in the system and utilization of the protocol before TJA was associated with fewer postoperative complications over time. Level IV.

Obesity does not associate with 5-year surgical complications following anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty.

Although obesity has been shown to increase the risk of short-term medical complications following total shoulder arthroplasty (TSA), evidence is lacking on the influence of obesity on longer-term surgical complications such as revision. The purpose of this study was to assess the association of increasing obesity with 2- and 5-year all-cause revision, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia (MUA) among patients undergoing reverse total shoulder arthroplasty (RTSA) or TSA. Patients who underwent RTSA or TSA with a minimum 5-year follow-up were identified in a national claims database (PearlDiver Technologies). Patients with obesity (body mass index [BMI]≥30) were compared to patients who are normal or overweight (18.5 ≤ BMI < 30). Those with obesity were further stratified to those with class I or II obesity (30 ≤ BMI < 40) and those with class III obesity (BMI ≥ 40). Outcomes for comparison included all-cause revision, PJI, aseptic loosening, and MUA within 2 or 5 years. These cohorts were compared using univariate and multivariable analysis. Patients with obesity had no significant difference in any surgical complication within 2 or 5 years for both those who underwent TSA or RTSA. After stratifying by class I or II obesity and class III obesity, there was still no significant difference in surgical complications with 2 or 5 years for both TSA patients and RTSA patients. Obesity, when other major comorbidities are controlled for, was not associated with increased risk of long-term surgical complications after shoulder replacement surgery.

Survivorship and Etiologies of Failure in Single-stage Revision Arthroplasty for Periprosthetic Joint Infection: A Meta-analysis

Single-stage revision arthroplasty for periprosthetic joint infection (PJI) may yield comparable infection-free survivorship with two-stage revision arthroplasty. It is unclear if the most common mode of failure of single-stage revision arthroplasty is infection or aseptic loosening. In this meta-analysis, we sought to (1) determine survivorship and (2) compare rates of different etiologies of failure of single-stage revision total hip arthroplasty (THA) and total knee arthroplasty (TKA). Preferred Reporting Items for Systematic Review and Meta-analyses guidelines search was done using search terms for "single stage revision," "exchange arthroplasty," "periprosthetic infection," "PJI," and "single stage." Patient demographics such as age, body mass index, and mean follow-up time were recorded. Overall survivorship and rates of revision surgery were aggregated using a random-effects model. Comparison of septic and aseptic loosening rates was done by risk difference and associated 95% confidence interval (CI) calculation. Twenty-four studies were identified with 2,062 and 147 single-stage revision THA and TKA procedures performed between 1984 and 2019, respectively. The weighted mean follow-up and age were 69.8 months and 66.3 years, respectively, with 55% men overall. The all-cause revision surgery rate was 11.1% and 11.8% for THA and TKA, respectively. The revision surgery rate secondary to infection and aseptic loosening and associated 95% CI for the risk difference for THA and TKA was 5.5% and 3.3% (-1.7% to 5.0%), and 3% and 8.8% (-11.4% to 2.3%), respectively. Revision surgeries due to instability and fracture combined and mortality rate were both less than 3%. Single-stage revision THA and TKA for PJI demonstrated overall high rates of survivorship, low mortality, and revision surgeries secondary to infection and aseptic loosening to be equivalent. Aseptic loosening after single-stage revision TKA might be higher than in primary TKA. As implant survivorship from infection improves in PJI, surgeons should be aware of aseptic loosening as an equally common mode of failure.

How do the top 10 known offending drug classes associated with decreased bone mineral density affect total shoulder arthroplasty outcomes?

Many regularly prescribed classes of drugs are known to negatively impact bone health. However, it is unclear if perioperative use of these drugs impacts total shoulder arthroplasty (TSA) outcomes. The purpose of this study was to analyze the impact of perioperative use of 10 drug classes with known negative effects on bone health on prosthesis-related outcomes of TSA. Patients who underwent primary TSA were retrospectively identified in the PearlDiver database. Within this population, patients prescribed proton pump inhibitors (PPIs), thiazolidinediones (TZDs), loop diuretics, glucocorticoids, aromatase inhibitors, calcineurin inhibitors, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), first-generation antipsychotics (FGAs), and second-generation antipsychotics (SGAs) within 6 months before or 6 months after primary TSA were identified (n=23,748). These patients were propensity score matched 1:1 with controls (n=23,748) on age, sex, and several comorbidities. After matching, patients with perioperative drug exposure were divided into 10 subgroups (ie, 1 for each drug class). Rates of prosthesis-related complications among patients taking each medication class vs. controls were compared with multivariable logistic regression. Relative to controls, SGA exposure was associated with significantly higher rates of all-cause revision (odds ratio [OR] 1.68) and aseptic revision (OR 1.57). Loop diuretic exposure was associated with significantly higher rates of all-cause revision (OR 1.44) and aseptic revision (OR 1.43). Glucocorticoid exposure was associated with significantly higher rates of all-cause revision (OR 1.32) and aseptic revision (OR 1.30). SSRI exposure was associated with significantly higher rates of all-cause revision (OR 1.27) and aseptic revision (OR 1.24). Periprosthetic fracture, aseptic loosening, and septic revision was comparable for all drug cohorts compared to matched controls (all P>.05). Patients with perioperative exposure to PPIs, TZDs, FGAs, AEDs, aromatase inhibitors, and calcineurin inhibitors displayed comparable rates of all queried complications compared with controls (all P>.05). Compared with matched controls, patients with perioperative exposure to SGAs, loop diuretics, glucocorticoids and SSRIs exhibited significantly higher rates of all-cause and aseptic revisions following primary TSA. Several other medications that are risk factors for osteoporosis and fragility fractures did not demonstrate significant associations with any complications, including periprosthetic fracture. These results highlight the need for a thorough review of patients' medical history and current medication usage prior to preoperative risk counseling for patients seeking TSA.

Assessing the Risk of Postoperative Complications for Proximal Humeral Fractures Treated by Open Reduction and Internal Fixation in Patients With Diabetes and Chronic Kidney Disease

The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) has markedly risen over the past three decades. Patients with DM and CKD are at increased risk of infection, immune dysfunction, as well as bone and mineral disorders. Although we know that patients with DM and CKD have these risks, we do not know how these translate to proximal humeral fracture (PHF) healing. We sought to analyze whether these established comorbidities had increased rates of complications after open reduction and internal fixation (ORIF) for PHF treatment. Using a national insurance database, 72,365 patients with PHF managed with ORIF were identified using records from 2010 to 2022. Patients were initially split into those with DM and those without and were further stratified by the presence or absence of CKD. For our comparison baseline cohort, patients were not diagnosed with either DM or CKD. Post-ORIF complication rates were assessed looking specifically at nonunion, postoperative infection, and all-cause revision surgery. A logistic regression statistical analysis was also conducted. Of the 72,365 patients with PHF treated by ORIF, 41,047 were non-DM without CKD (comparison); 17,025 had DM alone (no CKD); 11,729 had DM and CKD; and 2564 had CKD alone (non-DM). Multivariate analysis indicated that patients with DM and/or CKD were at increased risk of developing nonunion (odds ratio [OR] = 1.37, 1.48, 1.23) and all-cause revision surgery (OR = 1.21, 1.11, 1.18) after ORIF for PHF compared with our comparison cohort. In addition, all patients with DM alone (non-CKD) and DM with CKD had an increased risk of postoperative infection (OR = 1.39, 1.26). The management of PHF is a controversial topic, particularly regarding the degree of intervention and optimal treatment choice. Regardless, using a pragmatic design and reviewing a national insurance database, this study provides information for patients in high-risk populations, specifically patients with DM and CKD, and may prove beneficial when selecting a patient-specific treatment plan. Additional studies are needed to assess varying stages of both DM and CKD in patients who sustain PHF treated by ORIF along with postoperative strategies to minimize complications.

Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients

Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes for patients ≥70 years who receive RTSA compared to TSA for GHOA. A retrospective cohort study was conducted using data from a US integrated health care system's Shoulder Arthroplasty Registry. Patients ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared to TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, while multivariable logistic regression was used to evaluate 90-day emergency department (ED) visit, and 90-day readmission. The final study sample comprised 685 RTSA and 3,106 TSA. Mean age was 75.8 years (standard deviation 4.6) and 43.4% were male. After accounting for confounders, no significant difference in all-cause revision risk was observed for RTSA compared to TSA (hazard ratio=0.79, 95% confidence interval [CI]=0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half (54.0%) of revisions following TSA were for rotator cuff tear. No difference between procedure type was observed in likelihood for 90-day ED visits (odds ratio [OR]=0.94, 95% CI=0.71-1.26) and 90-day readmission (OR=1.32, 95% CI=0.83-2.09). RTSA and TSA for GHOA with an intact rotator cuff in patients ≥70 years had a similar revision risk, as well as likelihood for 90-day ED visits and readmissions. While revision risk was similar, the most common causes for revision were different with rotator cuff tears for TSA and glenoid component loosening for RTSA.

Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

BackgroundRegistry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty. Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach triple-tapered uncemented stem designs may provide comparable results to cemented stems. MethodsFrom 2000 to 2018, 5,809 primary total hip arthroplasties were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75 years of age. Statistical weighting accounted for baseline cohort differences. ResultsAt 10 years, there was a trend toward higher all-cause revision (hazards ratio (HR) 1.6, P = .053) and higher all-cause reoperation (HR 1.6, P = .02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P < .001) but no difference in postoperative fractures (HR 0.99, P = .96). The same was true in patients ≥75 years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years. ConclusionCompared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75 years, was associated with more intraoperative fractures but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

The association of alcohol use disorder with revision rates and post-operative complications in total shoulder arthroplasty.

Alcohol use disorder (AUD) is the most prevalent substance use disorder in the United States. However, the current literature on AUD as a preoperative risk factor for Total Shoulder Arthroplasty (TSA) outcomes is limited. The purpose of this study was to identify the association of AUD with revision rates and 90-day postoperative complications in TSA. A retrospective study was conducted using the PearlDiver database. Patients diagnosed with AUD were identified. Patients in remission or with underlying cirrhosis were excluded. Outcomes included 2-year revision, 90-day readmission, 90-day emergency, and 90-day post-operative medical complications. Analysis was performed with univariate chi-squared tests followed by multivariable logistic regression. A total of 59,261 patients who underwent TSA for osteoarthritis were identified, with 1522 patients having a diagnosis of AUD. Multivariable logistic regression showed that patients with AUD were more likely to undergo 2-year all-cause revision (OR = 1.49, p = 0.007), 2-year aseptic revision (OR = 1.47, p = 0.014), 90-day hospital readmission (OR = 1.57, p = 0.015), and 90-day transient mental disorder (OR = 2.13, p = 0.026). AUD is associated with increased rates of 2-year revision surgery, as well as 90-day readmission and 90-day transient mental disorder following primary TSA for osteoarthritis. These findings may assist orthopedic surgeons in counseling patients with AUD during the pre-operative course.

Malseating of Modular Dual Mobility Liners: High Prevalence in Revision Total Hip Arthroplasty

BackgroundModular dual mobility (MDM) acetabular components have become increasingly more popular in total hip arthroplasty (THA). Uncertainty remains regarding liner malseating and its consequences after 5 to 10 years, especially in patients who undergo revision THA. The objective of this study was to analyze the prevalence of malseating and implant survivorship of patients who underwent revision THA using an MDM liner. MethodsWe retrospectively identified patients who had a minimum 2-year follow-up and underwent revision THA using an MDM liner. Patient demographics, implant details, mortality, and all-cause revisions were recorded. Patients who had radiographic follow-up were assessed for malseating. Kaplan–Meier survival was used to determine implant survivorship. We included 143 hips in 141 patients. Mean age was 70 years (35-93 years), and 86 patients (60.1%) were female. ResultsOverall implant survival was 89.3% (95% confidence interval (CI) 0.843-0.946) at a mean follow-up of 6 years (ranging from 2 to 10 years). There were eight patients excluded from malseating assessment. Upon radiological review, 15 liners (11.1%) were malseated. Survival for all-cause revision for patients with malseated liners was 80.0% (12/15, 95% CI 0.62 - 0.99, P = .15) versus 91.5% in patients who had nonmalseated liners (110/120, 95% CI 0.86-0.96). There were no intraprosthetic dislocations and 3.5% of the patients were revised due to instability. No liners were revised due to malseating, and no patients who had malseated liners were revised due to instability. ConclusionsUsing MDM components in our cohort comprised of revision THA was associated with a high prevalence of malseating and an overall survival of 89.3% at a mean follow-up of 6 years. Malseating does not appear to impact implant survival at a mean follow-up of 6 years.

Hormone Replacement Therapy Does Not Eliminate Risk Factors for Joint Complications following Total Joint Arthroplasty: A Matched Cohort Study

Aging causes a reduction in testosterone and estrogen, which is linked to diminished bone mineral density. Hormone replacement therapy and its effect on the outcome of joint arthroplasties is unclear. The purpose of this study was to analyze the impact of testosterone replacement therapy (TRT) and estrogen replacement therapy (ERT) on the medical and joint outcomes of total hip (THA) and total knee arthroplasties (TKA). A retrospective cohort study was conducted using the PearlDiver database. Patients who received TRT or ERT perioperatively were matched to controls. Rates of 90-day medical complications and 2-year joint complications were queried. Patients who received TRT had an increased risk of revision, periprosthetic joint infection, and pooled joint complications within 2 years following a THA and increased rates of septic and aseptic revisions, and aseptic loosening after TKA compared to the control cohort. Patients receiving ERT had increased rates of aseptic loosening and pooled joint complications within 2 years following THA and increased rates of all-cause revisions and pooled joint complications after TKA. Patients who received TRT demonstrated significantly higher rates of revision rates and PJI. Patients who received perioperative ERT were significantly more likely to have increased risks of revision rates and joint infections.

MP71-02 ASSESSING THE IMPACT OF HYPOGONADISM ON SURGICAL OUTCOMES FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT

You have accessJournal of UrologyCME1 Apr 2023MP71-02 ASSESSING THE IMPACT OF HYPOGONADISM ON SURGICAL OUTCOMES FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT Andrew Gabrielson, Logan Galansky, Una Choi, and Andrew Cohen Andrew GabrielsonAndrew Gabrielson More articles by this author , Logan GalanskyLogan Galansky More articles by this author , Una ChoiUna Choi More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003339.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrospective series suggest a link between hypogonadism and complications following artificial urinary sphincter (AUS) placement. We sought to confirm this finding and evaluate whether testosterone replacement therapy (TRT) in hypogonadal patients prior to AUS placement mitigates this risk. METHODS: A retrospective cohort study was conducted using the TriNetX research network between 2006-2022. We defined 4 groups: 1) Eugonadal patients undergoing AUS, 2) Hypogonadal patients (>1 confirmatory T level <300 ng/dL) with and without TRT, 3) Hypogonadal patients who received TRT prior to AUS, 4) Hypogonadal patients who did not receive TRT prior to AUS. Propensity-score matching was used in comparing baseline differences in comorbidities of the eugonadal and hypogonadal arms. Outcomes included 5-year all-cause revision (cuff erosion, mechanical, infectious), 5-year device complication (mechanical, infectious only), and 90-day surgical site infection (SSI) rate. RESULTS: We included 4,520 eugonadal and 514 hypogonadal patients (19% with TRT, 81% without TRT) undergoing AUS (Table 1). Compared to eugonadal patients, the hypogonadal cohort had a significantly higher 5-year device complication (17% vs 13%, p=0.03) and 90-day SSI rate (2% vs 0.8%, p<0.01), but no difference in 5-year revision rate (26% vs 24%, p=0.21). When comparing hypogonadal patients who received TRT prior to AUS versus hypogonadal patients who did not receive TRT, we found no difference in 5-year revision (32% vs 26%, p=0.19), 5-year device complication (23% vs. 16%, p=0.10), or 90-day SSI (1.1% vs. 1.9%, p=0.48) rates. Hypogonadal patients receiving TRT before AUS were more likely to have pre-existing erectile dysfunction and penile implant surgery, but had similar rates of radical prostatectomy. Post-AUS, only 22 (5.3%) patients in the non-TRT arm received new TRT, suggesting minimal crossover. There was no difference in 5-year revision between eugonadal and hypogonadal patients not receiving TRT. CONCLUSIONS: Pre-existing hypogonadism may impact early SSI rates and long-term mechanical or infectious complications but was not associated with higher rates of all-cause revision likely due to similar rates of cuff erosion. TRT does not appear to impact surgical outcomes among hypogonadal patients undergoing AUS placement. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1013 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Gabrielson More articles by this author Logan Galansky More articles by this author Una Choi More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

PD35-06 PRE-EXISTING HYPOGONADISM DOES NOT IMPACT SURGICAL OUTCOMES FOLLOWING PRIMARY URETHROPLASTY

You have accessJournal of UrologyCME1 Apr 2023PD35-06 PRE-EXISTING HYPOGONADISM DOES NOT IMPACT SURGICAL OUTCOMES FOLLOWING PRIMARY URETHROPLASTY Matthew Shneyderman, Andrew Gabrielson, Logan Galansky, and Andrew Cohen Matthew ShneydermanMatthew Shneyderman More articles by this author , Andrew GabrielsonAndrew Gabrielson More articles by this author , Logan GalanskyLogan Galansky More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Decreased urethral vascularity due to a hypogonadal state may be a risk factor for complications following urethroplasty (UP). We compare reoperation and surgical site infection (SSI) rates among patients with hypogonadism with or without testosterone replacement therapy (TRT) prior to first UP. METHODS: A retrospective cohort study was conducted using the TriNetX research network between 2006-2022. Hypogonadal patients needed a diagnosis of hypogonadism and confirmatory T level <300 ng/dL preceding UP. We defined 4 groups: 1) Eugonadal patients undergoing UP 2) Hypogonadal patients with and without TRT, 3) Hypogonadal patients receiving TRT prior to UP, 4) Hypogonadal patients without TRT prior to UP. Propensity-score matching was used to adjust for differences in comorbidities listed in Table 1. Outcomes were 5-year rates and revision-free survival (RFS) for endoscopic (dilation, DVIU), surgical (repeat UP), and all-cause revision (endoscopic or surgical revision), as well as SSI within 90 days. RESULTS: We identified 12,556 eugonadal patients and 488 hypogonadal patients (147 [30%] with TRT, 341 [70%] without TRT) undergoing UP. Median age at UP and follow-up time was 55 years and 5 years, respectively. Comparing the propensity-score matched cohort of eugonadal patients to all hypogonadal patients, there was no difference in 90-day SSI (2.7% vs. 2.5%), nor were there differences in 5-year all-cause (19.4% vs. 19.6%), endoscopic (12.4% vs. 11.5%), or surgical revision (8.9% vs. 11.8%) [all p>0.05] (Table 1). Kaplan-Meier analysis found no difference in 5-year RFS rate for all-cause, endoscopic, or surgical revision (all log-rank p>0.05). Comparing hypogonadal patients who received TRT prior to UP versus hypogonadal patients who did not receive TRT, we found no difference in 5-year rates and RFS for all-cause (22.4% vs. 17.9%), endoscopic (11.6% vs. 11.2%), and surgical revision (14.3% vs. 9.7%) [all p>0.05] (Table 1). Post-UP, 83 (56%) patients in the TRT arm received additional TRT, whereas only 23 (6.7%) patients in the non-TRT arm received new TRT. CONCLUSIONS: Pre-existing hypogonadism does not appear to be an adverse predictor of surgical outcomes following primary urethroplasty based on data from a large, retrospective cohort study. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e976 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Shneyderman More articles by this author Andrew Gabrielson More articles by this author Logan Galansky More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

MP78-02 CRITICALLY EVALUATING THE ROLE FOR POSTOPERATIVE ANTIBIOTICS IN PATIENTS UNDERGOING URETHROPLASTY WITH BUCCAL MUCOSA GRAFT: A CLAIMS DATABASE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP78-02 CRITICALLY EVALUATING THE ROLE FOR POSTOPERATIVE ANTIBIOTICS IN PATIENTS UNDERGOING URETHROPLASTY WITH BUCCAL MUCOSA GRAFT: A CLAIMS DATABASE ANALYSIS Logan Galansky, Andrew Gabrielson, and Andrew Cohen Logan GalanskyLogan Galansky More articles by this author , Andrew GabrielsonAndrew Gabrielson More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although many consider administration of antibiotics after urethroplasty dogma, there is lack of evidence regarding the benefit for postoperative antibiotics. We compare perioperative and post-surgical outcomes among patients undergoing first-time urethroplasty with use of buccal mucosa graft (BMG) who receive postoperative antibiotics versus those who do not. METHODS: A retrospective cohort study was conducted using TriNetX research network, a claims database of 110 million patient encounters between 2008-2022. Using applicable CPT, ICD10, and LOINC codes, patients>18 years old undergoing primary urethroplasty with use of BMG, who received perioperative intravenous antibiotics (IVAb), and either received an outpatient prescription for antibiotics between postoperative day 0-30 or did not were queried. Patients with positive pre-operative urine culture or urinary tract infection (UTI) within 30 days prior to urethroplasty were excluded. Surgical outcomes included 5-year revision rates and revision-free survival. Safety outcomes included new UTI within 30 days, surgical site infection (SSI) or clostridium difficile infection within 90 days of the procedure. RESULTS: We identified 645 patients (505 [78%] antibiotic cohort, 140 [22%] no-antibiotic cohort) that met inclusion criteria. There was no difference in mean age at time of urethroplasty, presence of suprapubic tube, or pre-operative rates of common medical comorbidities between cohorts (Table 1). There was no difference in type of IVAb between groups. There was no difference in 5-year rates and revision-free survival for all-cause revision (18.2% vs. 15.7%, log-rank p=0.15), endoscopic revision (10.3% vs. 12.1%, log-rank p=0.94), or surgical revision (11.1% vs. 8.6%, log-rank p=0.17) between groups. Rates of UTI within 30 days, SSI within 90 days, and clostridium difficile infection within 90 days were similar between groups. CONCLUSIONS: In this large retrospective cohort study of patients undergoing urethroplasty with use of BMG, we observed no significant benefit from the use of postoperative antibiotics on revision rates or infectious complications. Limitations of this analysis include inability to delineate between continuous versus short course prophylaxis. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1131 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Logan Galansky More articles by this author Andrew Gabrielson More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...