Aseptic Revision Research Articles

Low Risk of Periprosthetic Joint Infection After Aseptic Revision Total Knee Arthroplasty With Intraosseous Vancomycin

BackgroundAseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA. MethodsA consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature. ResultsFollow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: −0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%. ConclusionsDual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases. Level of EvidenceLevel III, therapeutic study.

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

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

Role of insulin-dependent and non-insulin-dependent diabetes in aseptic revision total shoulder arthroplasty.

This study investigates the association between insulin-dependent and non-insulin-dependent diabetes and 30-day postoperative complications following aseptic revision total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aseptic revision TSA from 2015 to 2021. The study population was divided into three groups based on diabetic status: nondiabetes, insulin-dependent diabetes, and non-insulin-dependent diabetes. Logistic regression analysis was conducted to investigate the relationship between diabetic status and postoperative complications. Compared to nondiabetes, insulin-dependent diabetes was independently associated with a significantly greater likelihood of experiencing any complication (OR 1.59, 95% CI 1.08-2.35; P = 0.020) and LOS > 2days (OR 1.73, 95% CI 1.13-2.65; P = 0.012). Compared to nondiabetes, non-insulin-dependent diabetes was not independently associated with a significantly greater likelihood of experiencing complications. Preoperative insulin-dependent diabetic status was significantly associated with a greater rate of early postoperative complications following aseptic revision TSA, while preoperative non-insulin-dependent diabetic status was not. Preoperative insulin-dependent diabetic status was significantly associated with a greater rate of early postoperative complications following aseptic revision TSA. A better understanding of the role diabetes, both insulin-dependent and non-insulin-dependent, as a risk factor may help physicians better risk stratify and select surgical candidates for revision TSA.

Diagnostic and Predictive Efficacy of Synovial Fluid Versus Serum C-Reactive Protein Levels for Periprosthetic Joint Infection and Reimplantation Success

BackgroundA 2-stage exchange revision for periprosthetic joint infection (PJI) is associated with major risks for reinfection. Although serum markers are frequently used for diagnosis, their effectiveness remains debatable. Synovial fluid markers may offer a more accurate diagnosis of PJI; however, the importance of these biomarkers, notably synovial fluid C-reactive protein (syCRP), remains controversial, particularly in the context of reimplantation. The present study aimed to clarify these diagnostic uncertainties by evaluating the diagnostic efficacy of syCRP versus serum CRP (seCRP) levels in the context of PJI and recurring or persisting infections before reimplantation. MethodsA total of 186 patients were enrolled and divided into 2 groups: aseptic revision (n = 112) and PJI revision (n = 74). Of the PJI group, 65 were categorized as success and 9 as failure, based on the presence of recurrent or persistent infection before reimplantation. The syCRP and seCRP levels and their changes were assessed preoperatively and in the first-stage and second-stage revisions. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curves (AUCs) were analyzed. ResultsBoth seCRP and syCRP levels were significantly elevated in the PJI group compared with the aseptic group (P < .001). The ROC curve analysis highlighted the enhanced diagnostic accuracy of syCRP for PJI, with an AUC of 0.93 versus 0.80 for seCRP. Furthermore, syCRP proved to be more reliable in predicting reimplantation success, exhibiting an AUC of 0.86 versus 0.63 for seCRP. In evaluating trends in CRP levels to determine reimplantation timing, changes in syCRP levels demonstrated superior diagnostic utility, exhibiting an AUC of 0.79 versus 0.63 for changes in seCRP levels. ConclusionsIn assessing PJI and infections before reimplantation, syCRP may offer enhanced accuracy compared with seCRP. Nevertheless, variations in both syCRP and seCRP levels did not consistently predict the outcome of reimplantation.

Unicondylar knee arthroplasty demonstrating a significant increased risk for aseptic revisions compared to unconstrained and constrained total knee arthroplasty: An analysis of aseptic revisions after unicondylar and primary total knee arthroplasty of the German Arthroplasty Registry.

Due to ageing population, the implantation rate of total knee arthroplasties (TKAs) is continuously growing. Aseptic revisions in primary knee arthroplasty are a major cause of revision. The aim of the following study was to determinate the incidence and reasons of aseptic revisions in constrained and unconstrained TKA, as well as in unicondylar knee arthroplasties (UKAs). Data collection was performed using the German Arthroplasty Registry. Reasons for aseptic revisions were calculated. Incidence and comparison of aseptic revisions were analysed using Kaplan-Meier estimates. A multiple χ2 test with Holm's method was used to detect group differences in ligament ruptures. Overall, 300,998 cases of knee arthroplasty with 254,144 (84.4%) unconstrained TKA, 9993 (3.3%) constrained TKA and 36,861 (12.3%) UKA were analysed. Aseptic revision rate in UKA was significantly increased compared to unconstrained and constrained TKA (p < 0.0001). In constrained TKA, a 2.0% revision rate for aseptic reasons were reported after 1 year, while in unconstrained TKA 1.1% and in UKA, 2.7% of revisions were identified. After 7 years in constrained TKA 3.3%, in unconstrained TKA 2.8%, and in UKA 7.8% sustained aseptic revision. Ligament instability was the leading cause of aseptic revision accounting for 13.7% in unconstrained TKA. In constrained TKA, 2.8% resulted in a revision due to ligament instability. In the UKA, the most frequent cause of revisions was tibial loosening, accounting for 14.6% of cases, while progression of osteoarthritis accounted for 7.9% of revisions. Ligament instability was observed in 14.1% of males compared to 15.9% of females in unconstrained TKA and in 4.6% in both genders in UKA. In patients with UKA, aseptic revision rates are significantly higher compared to unconstrained and constrained TKA. Ligament instability was the leading cause of aseptic revision in unconstrained TKA. In UKA, the most frequent cause of revisions was tibial loosening, while progression of osteoarthritis was the second most frequent cause of revisions. Comparable levels of ligament instability were observed in both sexes. Level III, cohort study.

A systematic review and meta-analysis of hybrid vs. cemented stems - which method is more optimal for revision total knee arthroplasty?

The number of primary and revision Total Knee Arthroplasty (TKA) cases are expected to increase in future. There are various advantages and disadvantage to employing either of the two main types of stem fixation methods - cemented or hybrid technique. This review aimed to study the most optimal fixation method for revision TKAs by comparing radiological outcomes and re-revision rates. A systematic review and meta-analysis was performed using PubMed and Cochrane Library from 2010 to identify studies explicitly comparing outcomes between cemented against hybrid fixation revision TKA techniques, with a minimum follow up of at least 24 months. A total of 8 studies was included in this review. Egger's test and visual inspection of the funnel plot did not reveal publication bias. There was no statistically significant difference in radiological failure and loosening (OR 0.79, CI 0.37-1.66, I2 = 29%, p = 0.22), all causes of re-revision (OR 1.03, CI 0.73-1.44, I2 = 0%, p = 0.56) and aseptic revision (OR 0.74, CI 0.27-2.02, I2 = 0%, p = 0.41) between cemented and hybrid techniques. Functional and pain outcomes compared between the two fixation techniques were largely similar across the studies included in this meta-analysis. Despite a trend favouring hybrid stems in revision TKA, current evidence revealed that radiological outcomes and re-revision rates are largely similar between cemented and hybrid fixation techniques.

Highly Porous Acetabular Cup and Augment Constructs in Complex Revision Total Hip Arthroplasty: What Predicts 10-Year Implant Survivorship?

BackgroundPorous tantalum acetabular cup and augment constructs have demonstrated favorable outcomes up to 5 years postsurgery despite severe bone loss during revision total hip arthroplasty (THA). Prior literature lacks long-term studies with substantial case numbers. This study aims to assess long-term clinical and radiographic outcomes 10 years postsurgery in patients undergoing revision THA with porous tantalum acetabular cup-augment constructs and determine factors associated with long-term survivorship. MethodsBetween 2000 and 2012, 157 revision THAs were performed in cases with major acetabular defects (mainly Paprosky type IIIA and IIIB) utilizing porous tantalum cup-augment constructs. Pelvic discontinuity was noted intraoperatively in 17 hips (11%). Postoperative radiographs were evaluated at regular intervals for implant stability and radiolucent lines. There were 49 patients who had complete radiographic follow-up at 10 years or longer postsurgery. ResultsThe 10-year survivorship free of revision of the cup-augment construct for aseptic loosening was 93%, free of any acetabular construct revision was 91%, free of any hip rerevision was 77%, and free of any reoperation was 75%. Pelvic discontinuity was associated with increased risk of reoperation (hazard ratio [HR] = 2.8), any hip rerevision (HR = 3.2), any cup-augment construct revision (HR = 11.8), and aseptic construct revision (HR = 10.0). Of unrevised cases with radiographs at 10 years, 4 hips showed radiographic loosening. Mean Harris hip scores improved from 47 preoperatively to 79 at 10 years. ConclusionsPorous tantalum acetabular cup-augment constructs used in revision THA with severe acetabular bone loss provide excellent implant survivorship at 10 years when the acetabulum is intact. Due to lower survivorship of cup-augment constructs in cases of pelvic discontinuity, additional construct fixation or stabilization methods are recommended, when a discontinuity is present. Level of EvidenceIV

Unexpected positive culture (UPC) in adults revision spine surgery: a systematic review and meta-analysis of incidence, risk factors, and management.

Without clear signs of infection, spinal implant failure is attributed to mechanical overloads and aseptic loosening. However, how low-grade infections contribute to seemingly aseptic implant failure is unclear. The systematic review examined unexpected positive cultures (UPCs) in revision spine surgery regarding prevalence, isolated pathogens, risk factors, and strategies to reduce infection among asymptomatic patients undergoing revision spine surgery. We followed the PRISMA guidelines and searched four main databases (PubMed, EMBASE, SCOPUS, Web of Science) comprehensively until January 2023 for articles reporting UPC after presumed aseptic adult revision spine surgery. The UPC rates were pooled, and risk factors were compared with the culture-negative control group and represented as odds ratio (OR) or mean difference (MD). Fifteen studies of 1057 individuals were included in two groups: culture-positive or UPCs (n = 317) and culture-negative or control (n = 740). The overall UPC prevalence was 33.2% (317/1057, range: 0 to 53%, 95% CI = 30.2%-36.4%), and Cutibacterium acnes (43.0%, 95% CI = 37.4%-48.8%), Coagulase-negative Staphylococci (CoNS), (39.5%, 95% CI = 33.2%-46.2%), and Staphylococcus species in general (49.5%, 95%CI = 43.7%-55.4%) were reported the most common isolated microbes. 16.1% of the UPCs were polymicrobial. Risk factors associated with UPC rates were female sex (OR = 2.62, 95%CI = 1.76-3.90, P < 0.001), screw loosening (OR = 4.43, 95%CI = 1.31-15.02, P = 0.02), number of operated levels (MD = 0.77, 95%CI = 0.33-1.22, P = 0.0007), and shorter time since index surgery (MD = - 8.57 months, 95%CI = - 14.76, -2.39, P = 0.02). One-third of patients undergoing spine revision surgery revealed UPC in this study. Each UPC pathogen interpretation and antibiotic use decision should be interpreted case by case. IV.

Incidence and Risk Factors for Acid-fast Bacillus/Fungal Culture Positivity in Primary, Conversion, and Revision Hip and Knee Arthroplasty.

Previous literature has reported minimal incidences of positive fungal/AFB cultures, questioning the routine use of these tests. With growing concern for excessive use, predictive factors for patients at higher risk for intraoperative AFB/fungal infections would help surgeons limit unnecessary testing. This study evaluates the positivity rate and predictive factors of positive fungal and/or acid-fast bacillus (AFB) cultures after primary, conversion, or revision hip and knee arthroplasty. Two hundred thirty-eight knee and hip procedures were done between January 2007 and 2022 where intraoperative AFB/fungal cultures were obtained. Procedures included primary total knee arthroplasty, primary total hip arthroplasty, conversion, first of two-stage, second of two-stage, irrigation and débridement polyexchange, and aseptic revision. Positivity rates of intraoperative AFB/fungal cultures were calculated as binomial exact proportions with 95% confidence intervals and are displayed as percentages. Univariable generalized linear mixed models estimated the unadjusted effects of demographics, individual comorbid conditions, and procedural characteristics on the logit of positive AFB/fungal cultures. Two hundred thirty-eight knee and hip procedures recorded an overall positivity rate of 5.8% for intraoperative AFB/fungal cultures. Aseptic revisions showed the lowest rates of positivity at 3.6%, while conversions showed the highest rates of positivity at 14.3%. The positivity rates are highest among patients who are male (9.0%), of Hispanic origin (12.0%), with body mass index <30 (6.4%), and a Charlson Comorbidity Index <5 (6.1%). History of a prior infection in the same surgical joint showed statistically significant influence of odds of culture positivity with an odds ratio of 3.47 ( P -value: 0.039). Other demographic factors that we investigated including age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index did not show any notable influence on AFB/fungal positivity rates. These results suggest utility in obtaining routine intraoperative AFB/fungal cultures, given the relatively high positivity and poor predictive factors.

Comparison of Delphi Consensus Criteria and Musculoskeletal Infection Society Outcome Reporting Tool Definitions of Successful Surgical Treatment of Periprosthetic Knee Infection

BackgroundAgreement on success following surgical treatment for periprosthetic joint infection (PJI) is important for comparing the efficacy of different surgical approaches with varying consequences and outcomes and setting patient expectations. We compared success rates following two-stage exchange arthroplasty for knee PJI using two expert-consensus definitions of success. MethodsProspectively documented data for 57 knees treated by a single surgeon at an academic tertiary care center were retrospectively reviewed. Treatment outcomes were quantified using the Delphi Consensus Criteria and the Musculoskeletal Infection Society Outcome Reporting Tool (MSIS ORT). ResultsSuccess rates were 81% using the Delphi Consensus Criteria and 56% using the MSIS ORT (P = .008). The MSIS ORT success rates increased to 76% when aseptic revisions and deaths unrelated to PJI were not penalized as failures of treatment. Predicted probabilities of successful treatment in a hypothetical case scenario were lowest based on the MSIS ORT and similarly higher using Delphi Consensus Criteria and MSIS ORT modified for both women (53.0, 90.8, and 88.7%) and men (29.1, 89.1, and 89.3%). ConclusionsStudy observations underscore the need for a uniformly accepted single definition of surgical treatment success.

Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty

BackgroundOral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use. MethodsA retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis. ResultsCorticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control. ConclusionsPatients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision

BackgroundThe utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. MethodsThis was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan–Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. ResultsWe identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. ConclusionsThis study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Cemented dual-mobility constructs in uncemented revision acetabular components.

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct. We identified 64 patients (65 hips) who had a single-design cemented DM cup cemented into an uncemented acetabular shell during revision THA between 2018 and 2020 at our institution. Cups were cemented into either uncemented cups designed for liner cementing (n = 48; 74%) or retained (n = 17; 26%) acetabular components. Median outer head diameter was 42 mm. Mean age was 69 years (SD 11), mean BMI was 32 kg/m2 (SD 8), and 52% (n = 34) were female. Survival was assessed using Kaplan-Meier methods. Mean follow-up was two years (SD 0.97). There were nine cemented DM cup revisions: three for periprosthetic joint infection, three for acetabular aseptic loosening from bone, two for dislocation, and one for a broken cup-cage construct. The two-year survivals free of aseptic DM revision and dislocation were both 92%. There were five postoperative dislocations, all in patients with prior dislocation or abductor deficiency. On radiological review, the DM cup remained well-fixed at the cemented interface in all but one case. While dislocation was not eliminated in this series of complex revision THAs, this technique allowed for maximization of femoral head diameter and optimization of effective acetabular component position during cementing. Of note, there was only one failure at the cemented interface.

Evaluation of time to reimplantation as a risk factor in two-stage revision with static spacers for periprosthetic knee joint infection

IntroductionWe investigated the time to reimplantation (TTR) during two-stage revision using static spacers with regard to treatment success and function in patients with chronic periprosthetic joint infection (PJI) of the knee.Methods163 patients (median age 72 years, 72 women) who underwent two-stage exchange for chronic knee PJI between 2012 and 2020 were retrospectively analyzed (based on the 2011 Musculoskeletal Infection Society criteria). A cutoff TTR for increased risk of reinfection was identified using the maximally selected log-rank statistic. Infection control, aseptic revisions and overall survival were analyzed using Kaplan–Meier survival estimates. Adjustment for confounding factors—the Charlson Comorbidity Index (CCI) and C-reactive protein (CRP)—was done with a Cox proportional hazards model.ResultsWhen TTR exceeded 94 days, the adjusted hazard of reinfection was increased 2.8-fold (95% CI 1.4–5.7; p = 0.0036). The reinfection-free rate was 67% (95% CI 52-79%) after 2 years and 33% (95% CI 11–57%) after 5 years for a longer TTR compared to 89% (95% CI 81–94%) and 80% (95% CI 69–87%) at 2 and 5 years, respectively, for a shorter TTR. Adjusted overall survival and number of aseptic revisions did not differ between the longer TTR and shorter TTR groups. Maximum knee flexion was 90° (IQR 84–100) for a longer TTR and 95° (IQR 90–100) for a shorter TTR (p = 0.0431), with no difference between the groups in Oxford Knee Score. Baseline characteristics were similar (body mass index, age, previous surgeries, microorganisms) for the two groups, except that there was a higher CCI (median 4 vs. 3) and higher CRP (median 3.7 vs 2.6 mg/dl) in the longer TTR group.ConclusionA long TTR is sometimes unavoidable in clinical practice, but surgeons should be aware of a potentially higher risk of reinfection.Level of evidence: III, retrospective comparative study.

Characteristics associated with rerevision of primary inlay and onlay reverse shoulder arthroplasty. Analysis from the Australian Orthopaedic Association National Joint Replacement Registry

BackgroundTwo designs of primary reverse total shoulder arthroplasty (rTSA), inlay reverse total shoulder arthroplasty (in-rTSA) and onlay reverse total shoulder arthroplasty (on-rTSA) that had undergone an aseptic revision were compared to determine differences in the rate of rerevision. MethodsIn this comparative observational national registry study between January 1, 2012, and December 31, 2021, all rTSA utilizing either a modular inlay or onlay metaphyseal humeral component that had been revised for aseptic reasons formed 2 cohort groups. The cumulative percentage rerevision (2nd CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for age and sex. A minor category revision involved exchange of parts not fixed to bone whilst major revisions did. The primary and revision diagnoses, surgeon primary volume experience, and revision category were compared. Shoulder Modular Replacement (SMR)/SMR L1 or L2 combination (Lima Corporate, San Daniele del Friuli, Italy) was excluded at subanalysis. ResultsThe 2nd CPR at 3 years was 20.4% (95% confidence interval 17.1, 24.1) for in-rTSA (n = 571) and 16.1%(11.6, 22.2) for on-rTSA (n = 249). The risk of rerevision was not different between the 2 cohort groups. Primary diagnosis fracture was associated with an increased risk of rerevision for on-rTSA (entire period on-rTSA HR = 3.16(1.50, 6.68), P = .002), and in-rTSA at subanalysis (entire period on-rTSA HR = 2.91(1.33, 6.33), P = .007). 59.9% of in-rTSA and 24.1% of on-rTSA aseptic revisions were minor. The revision diagnosis, the surgical experience of rTSA and if the revision was major or minor did not change the rate of rerevision. The most common reason for both in-rTSA (50%) and (43.2%) on-rTSA rerevision was instability/dislocation. DiscussionRerevision rates of in-rTSA and on-rTSA after aseptic revision are high. The primary rather the revision diagnosis changed rerevision rates in contemporary rTSA surgery. Minor revisions did not reduce rerevision rates for in-rTSA or on-rTSA compared to humeral/glenoid revision. Increased surgical experience of primary rTSA did not change the rate of rerevision of in-rTSA or on-rTSA.

Incidence of patella baja and pseudopatella baja in aseptic revision total knee arthroplasty.

There are two variants regarding the low location of the patella in relation to the tibio-femoral joint line: patella baja (PB) and pseudo-patella baja (PPB). The purpose of this study is to investigate the incidence of PB and PPB in a cohort of patients that underwent revision total knee arthroplasty (rTKA) for aseptic reasons and describe any differences in each group's ROM. This retrospective study included 114 patients that underwent aseptic revision TKA surgery between 2017 and 2022. Patients were revised either for stiffness (Group 1) or aseptic loosening/instability (Group 2). The Insall-Salvati ratio (ISR) and Blackburne-Peel ratio (BPR) were used to evaluate the patellar position. ISR < 0.8 defined PB, while cases with ISR ≥ 0.8 and BPI < 0.54 were defined as PPB. ROM was measured and a subanalysis was conducted to investigate the progression of the values of ISR and BPR. 55 patients comprised Group 1, and 59 patients comprised Group 2. Overall, 13 cases (11.4%) had PB before rTKA and 24 (21%) had PB after rTKA. Cases with PPB were 13 (11.4%) before and 34 (29.9%) after rTKA. Group 1 patients presented with more PB before and after rTKA (12.8% vs 10.2% and 27.3% vs 15.2% respectively). However, after rTKA Group 1 patients presented with less PPB (20%) compared to Group 2 (39%) (p = 0.02). In Group 1, patients with PPB after rTKA had less ROM compared to those without PPB [83.2 (± 21.9) vs 102.1 (± 19.9) (p = 0.025)]. The subanalysis (69 patients) showed a statistically significant decrease in ISR before and after rTKA (p = 0.041), and from the native knee to post-rTKA (p = 0.001). There was a statistically significant decrease in BPR before and after rTKA (p = 0.001) and from the native knee to both pre- and post-rTKA (p < 001). After undergoing rTKA, the incidences of both patella baja (PB) and pseudo-patella baja (PPB) increased. Stiffness in the knee was associated with a higher incidence of PB, while non-stiffness cases showed a significantly higher incidence of PPB. Patients with stiff knees and PPB after rTKA experienced a significant reduction in range of motion (ROM). Additionally, the study revealed a noteworthy decrease in ISR and BPR with each subsequent surgery. This information is crucial for healthcare providers, as it sheds light on potential risks and outcomes of rTKA, allowing for improved patient management and surgical decision-making. III.

Incontinence Is an Independent Risk Factor for Total Hip and Knee Arthroplasty

BackgroundUrinary incontinence has been linked to worse postoperative pain, decreased physical function, and reduced quality of life in patients following total joint arthroplasty. The purpose of this study was to analyze whether incontinence is associated with increased postoperative medical and joint complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). MethodsA retrospective cohort study was conducted using a national insurance database. Thirty-two thousand eight hundred eleven patients with incontinence who underwent primary THA were identified and matched 1:4 with 129,073 patients without incontinence. Ninety-one thousand nine hundred thirty-five patients with incontinence who underwent primary TKA were matched 1:4 with 367,285 patients without incontinence. Medical and joint complication rates at 90 days and 2 years, respectively, were then compared for patient cohorts using multivariable logistic regressions. ResultsPatients who underwent primary THA with incontinence had statistically higher rates of dislocation, periprosthetic fracture, aseptic revisions, and overall joint complications compared to controls. Patients who underwent primary TKA with incontinence had higher rates of mechanical failure, aseptic revision, and all-cause revision compared to controls. ConclusionsThis study demonstrated an association between patients with incontinence and higher rates of dislocation, periprosthetic fractures, aseptic revisions, and overall joint complications following primary THA compared to controls. Patients with incontinence experience higher rates of mechanical failure, aseptic revision, and all-cause revision following TKA compared to controls. As such, perioperative management of urinary incontinence may help mitigate the risk of postoperative complications.

Functional outcomes and survivorship following aseptic revision shoulder arthroplasty

BackgroundRevision shoulder arthroplasty (SA) is a surgical procedure performed to address complications or failures of primary total SA. However, limited evidence exists regarding the functional outcomes and longevity of implants following revision. MethodsA retrospective analysis was conducted on patients who underwent revision SA for failed primary arthroplasty at a single institution between 2009 and 2021 with a minimum of 2-years follow-up. Data was collected from medical records, including type of arthroplasty (anatomic total SA [TSA], reverse total SA [RSA], or hemi-SA [HSA]), demographics and patient-specific information, functional measurements, and implant survival. Patient reported outcomes were obtained during follow-up by phone. ResultsThe mean age at index and revision surgeries was 60.5 ± 12.1 years and 64.8 ± 11.1 years, respectively, and average total follow-up was 5.5 ± 3.5 years. The average time to revision was 4.5 ± 5.2 years (range 0.01–24.5 years). Among 99 revision shoulder arthroplasty procedures, 28 were TSA/HA to TSA/HA, 51 were TSA/HA to RSA, 18 were RSA to RSA, and 2 were RSA to HA. Revision surgery significantly improved functional outcomes in forward elevation (preoperative: 79.8 ± 41.0 vs postoperative: 118.5 ± 38.3; p < 0.001), external rotation (preoperative: 27.8 ± 19.3 vs postoperative: 34.3 ± 16.2; p = 0.028), internal rotation (preoperative: glute vs postoperative: S1; p = 0.002), and forward elevation strength (preoperative: 4+/5 vs postoperative: 5/5; p = 0.002). Postoperative patient reported outcomes included: VAS pain (2.2 ± 2.9), SANE (72.6 ± 21.5), ASES (73.3 ± 20.4), and SST (7.7 ± 2.8) scores. The overall 2-, 5-, and 10-year post-revision implant survival rate was 85.48%, 83.06%, and 79.84%, respectively. Patients who had an initial RSA and were revised to RSA were at higher risk of implant failure and subsequent re-revision (RSA to RSA: 1.5 ± 2.5 years vs. TSA/HA to RSA: 2.5 ± 2.1 years vs. TSA/HA to TSA/HA: 4.0 ± 3.5 years; p = 0.0046) ConclusionRevision shoulder arthroplasty improved patient outcomes post-index arthroplasty failure. Revisions were more likely to be successful when revising from TSA/HA to RSA. Level of evidenceLevel III – retrospective comparative study.

Shoulder Arthroplasty After Previous Nonarthroplasty Surgery: A Systematic Review and Meta-Analysis of Clinical Outcomes and Complications.

Many patients who undergo shoulder arthroplasty (SA) have had at least 1 nonarthroplasty shoulder surgery before the surgery. There is conflicting evidence regarding the effects of previous shoulder surgery on the outcome of SA. A systematic review was conducted to compare functional outcomes and complications between SA patients with and without prior non-SA surgery on the ipsilateral shoulder. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE/PubMed, Embase, Scopus, and Web of Science comprehensively from inception to January 2023. Based on 9,279 records reviewed, 26 comparative studies were included in the meta-analysis consisting of 5,431 shoulders with prior nonarthroplasty procedures (cases) and 55,144 shoulders without previous surgery (controls). Variables such as functional scores, complications, and range of motion were compared between cases and controls using Review Manager Software. In addition, subgroup analysis was conducted based on prior surgery type (rotator cuff repair [RCR], open reduction and internal fixation [ORIF], soft tissue repairs, and not specified) and type of SA (hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty [RTSA]). The results were presented as odds ratios (ORs) or standardized mean differences (SMDs). Except for a higher rate of periprosthetic joint infection (PJI) in patients who had undergone previous arthroscopic surgery (OR, 2.58; 95% confidence interval [CI], 1.66-4.01; p < 0.01), a higher rate of complications was only observed in patients with previous ORIF. These complications included aseptic loosening (OR, 3.43; 95% CI, 2.14-5.50; p < 0.01), shoulder dislocation (OR, 2.25; 95% CI, 1.05-4.84; p = 0.04), overall complication (OR, 3.95; 95% CI, 2.38-6.55; p < 0.01), and revision (OR, 2.52; 95% CI, 1.28-4.97; p = 0.01). Patients with a history of previous surgery demonstrated inferior functional outcomes in comparison with the control group, including American Shoulder and Elbow Surgeons (SMD, -0.39; 95% CI, -0.51 to -0.27; p < 0.01; I2 = 36%), Constant-Murley score (SMD, -0.34; 95% CI, -0.44 to -0.24; p < 0.01; I2 = 0%), abduction (SMD, -0.26; 95% CI, -0.45 to -0.08; p = 0.01; I2 = 54%), and flexion (SMD, -0.33; 95% CI, -0.46 to -0.21; p < 0.01; I2 = 40%). Subgroup analysis by previous type of surgery was not possible regarding functional outcomes. Patients who have had prior fracture surgery are at a higher risk of complications, reoperations, and revisions after SA than controls. The normal shoulder anatomy may be disrupted by prior surgery, which makes arthroplasty technically challenging, particularly when it comes to soft tissue balance. On the other hand, RCR before SA did not negatively affect clinical outcomes after RTSA and did not have a higher rate of overall complications (except PJI). Level III (Treatment Studies). See Instructions for Authors for a complete description of levels of evidence.

The Impact of Obesity on Total Hip Arthroplasty Outcomes When Performed by High-Volume Surgeons—A Propensity Matched Analysis From a High-Volume Urban Center

BackgroundPrevious data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons. MethodsA retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases. ResultsThe MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056). ConclusionsClinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons. Level of EvidenceIII.