Joint Replacement Research Articles

Ti3C2Tx and Mo2TiC2Tx MXenes as additives in synovial fluids - towards an enhanced biotribological performance of 3D-printed implants

Synovial joints, critical for limb biomechanics, rely on sophisticated lubrication systems to minimize wear. Disruptions, whether from injury or disease, often necessitate joint replacements. While additive manufacturing offers personalized implants, ensuring wear resistance remains a challenge. This study delves into the potential of Ti3C2Tx and Mo2TiC2Tx nanosheets in mitigating wear of additively manufactured cobalt-chromium tungsten alloy substrates when incorporated as additives into synovial fluid. The colloidal solutions demonstrate an excellent stability, a crucial factor for reproducible assays and potential clinical applicability. Analysis of contact angles and surface tensions reveals MXene-induced alterations in substrate wettability, while maintaining their general hydrophilic character. Viscosity analysis indicates that MXene addition reduces the dynamic viscosity, particularly at higher concentrations above 5 mg/mL, thus enhancing dispersion and lubrication properties. Friction and wear tests demonstrate a dependency on the MXene concentration, while Ti3C2Tx exhibits stable friction coefficients and up to 77 % wear reduction at 5 mg/mL, which was attributed to the formation of a wear-protecting tribo-film (amorphous carbon and MXene nano-sheets). Our findings suggest that Ti3C2Tx, when supplied in favorable concentrations, holds promise for reducing wear in biotribological applications, offering avenues for future research into optimizing MXene utilization in load-bearing joint replacements and other biomedical devices.

Biomechanical tensile test for capsule repair comparing suturing methods including interrupted, continuous, and barbed sutures

BackgroundCapsule repair plays an important role in total joint arthroplasty. However, no biomechanical studies have indicated the optimal suturing methods and materials in capsule repair. This study aimed to evaluate the effectiveness of the suturing methods (interrupted and continuous sutures) and materials (Vicryl and Stratafix) for capsule repair using porcine skin specimens. MethodsThree groups with eight porcine skin specimens were used as a surrogate for human capsules. The VI group with 1-Vicryl interrupted sutures, VC group with 1-Vicryl continuous sutures, and S group with 1-Stratafix continuous sutures were analyzed by tensile test to investigate the maximum failure load. Eight pieces of 1-Viclyl and nine pieces of 1-Stratafix were used to analyze the suture material's strength. Corrected maximum failure load was calculated by taking the ratio of the mean maximum tensile strengths of Vicryl and Stratafix sutures. FindingsThe maximum failure loads were 275.52 ± 62.45 N, 465.81 ± 57.91 N, and 303.08 ± 37.16 N in VI, VC, and S groups, respectively. Regarding the suture material's strength, 1-Vicryl showed significantly higher maximum failure load than 1-Stratafix (47.37 ± 4.58 N vs 35.62 ± 4.35 N). When normalizing the influence of different suture materials on tensile strength, the corrected maximum failure load was 207.17 ± 46.96 N in VI group and 350.27 ± 43.55 N in VC group. InterpretationOur findings showed that Stratafix, barbed continuous suture, could be an alternative option to conventional Vicryl suture for capsule repair.

Is outpatient joint arthroplasty safe ina high volume academic centre? A retrospective monocentric study using an institutional pathway.

Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice. We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied. 498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters. Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.

Comparison of Biocompatibility of 3D-Printed Ceramic and Titanium in Micropig Ankle Hemiarthroplasty

Background: Ankle arthritis is a common degenerative disease that progresses as cartilage damage in the lower tibia and upper talus progresses, resulting in loss of joint function. In addition to typical arthritis, there is also structural bone loss in the talus due to diseases such as talar avascular necrosis. Total talus replacement surgery is the procedure of choice in end-stage ankle arthritis and consists of a tibial, talar component and an insert. However, in cases of severe cartilage and bone damage to the talar bone with less damage to the tibial cartilage, a talar component hemiarthroplasty may be considered. Although the application of total talus replacement surgery using ceramics has been studied, reports on the application of metal 3D printing technology are limited. We aimed to investigate the feasibility of partial talar components using ceramic and titanium 3D printing technology in terms of biocompatibility and stability through animal experiments. Methods: Preoperative 3D CT was acquired and converted to STL files to fabricate a partial talus component for ankle hemiarthroplasty using ceramic and titanium. Six minipigs with an average age of 17 months were implanted with three ceramic (C-group) and three titanium talar components (T-group) in the hind limb ankle joint. The surgery was performed under anesthesia in a sterile operating room and was performed by two experienced foot and ankle specialist orthopedic surgeons. Blood analysis and CT were performed before surgery and every month for 3 months after surgery to assess the extent of inflammatory response and physical stability, sacrifices were performed 3 months after surgery, and H&E staining and micro-CT analysis were performed to compare histological biocompatibility. A grading score was calculated to semi-quantitative assess and compare the two groups. Results: In the postsurgical evaluation, blood analysis revealed that both groups had increased white blood cell counts on the postoperative day after surgery. The white blood cell count increased more in the titanium group (1.85-fold) than in the ceramic group (1.45-fold). After 3 months, all values normalized. During the study, CT analysis confirmed that all artificial samples were displaced from their initial positions. In micro-CT analysis, the adhesive tissue score of the ceramic artificial sample was better than that of the titanium sample (average threshold = 3027.18 ± 405.92). In histologic and grading scores for the inflammatory reactions, the average inflammation indices of the ceramic and titanium groups were 2.0 and 1.21, respectively. Also, the average grade score confirmed based on the results of fibrous tissue proliferation and new blood vessels was 18.4 in the ceramic application group and 12.3 in the titanium application group. Conclusions: In conclusion, both titanium and ceramics have excellent biocompatibility for artificial joints, and ceramic materials can be used as novel artificial joints. Further research on the strength and availability of these ceramics is required.

Previous Hip or Knee Arthroplasty is Associated With Less Favorable Patient-reported Outcomes of Lumbar Surgery.

Review of cohort studies. To ascertain if previous hip (THA) or knee (TKA) arthroplasty was associated with patients' outcomes assessments of subsequent lumbar surgery, specifically overall satisfaction, less disability due to pain, and an affective appraisal reflecting emotional assessment of results. Hip, knee, and lumbar symptoms often co-exist and increasingly are managed with surgery. Whether previous total joint arthroplasty (TJA) impacts patients' perspectives of results of subsequent lumbar surgery is not known. Identical and systematically acquired preoperative and postoperative data from 3 studies assessing psychosocial characteristics and outcomes of lumbar surgery were pooled. Data obtained during interviews included preoperative demographic and clinical variables and 2-year postoperative global overall assessment (very satisfied/satisfied, neither, dissatisfied/very dissatisfied) and global affective assessment (delighted/pleased, mostly satisfied/mixed/mostly dissatisfied, unhappy/terrible). Patients completed the ODI and preoperative to postoperative change was analyzed according to an MCID (15 points). At 2 years patients also reported any untoward events since surgery (ie, fracture, infection, or repeat lumbar surgery). Associations with outcomes were assessed with multivariable logistic ordinal regression controlling for untoward events. Type of arthroplasty was evaluated in subanalyses. Among 1227 patients (mean: 59y, 50% women), 12% had arthroplasty (+TJA) and 88% did not (-TJA). In multivariable analysis, +TJA was associated with less global satisfaction (OR: 1.9, CI: 1.3-2.7, P=0.0007), worse global affective assessment (OR: 1.6, CI: 1.1-2.2, P=0.009), and not meeting MCID15 (OR: 1.5, CI: 1.0-2.3, P=0.05). Covariables associated with less favorable outcomes were not working, positive depression screen, and prior lumbar surgery. Compared with -TJA, patients with THA had worse affective assessments and patients with TKA had less satisfaction and were less likely to meet MCID15. Previous hip or knee arthroplasty was associated with less favorable patient-reported outcomes of lumbar surgery. Surgeons and patients should discuss differences between procedures preoperatively and during shared postoperative outcome assessment. Level II.

THE USE OF WEARABLES AND SMART PHONE APPS FOR A NON-INFERIOR RECOVERY AFTER LOWER LIMB TOTAL JOINT ARTHROPLASTY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: With an increasing trend toward home-based rehabilitation, it is important to distinguish non-inferior and improved virtual rehabilitation methods. A Systematic review and meta-analysis were conducted to examine the effect of combined digital rehabilitation, including smartphone applications and wearable devices, on quality of life following total joint arthroplasty (TJA), total knee arthroplasty (TKA), and total hip arthroplasty (THA) in comparison to standard of care physical therapy (PT). Methods: A systematic review and single-proportion meta-analysis was conducted employing the PRISMA 2020 guidelines in January 2024. A comprehensive review of the literature was conducted, yielding four randomized controlled trials, encompassing a sample size of 496 patients who underwent combined digital rehabilitation. Results: Differences in quality of life using EQ-5D-5L were non-significant between groups ([Formula: see text] = 0.35, [Formula: see text] = 0.56). In the combined digital group, knee ROM was non-significantly increased ([Formula: see text] = 0.23, [Formula: see text] = 0.63) and KOOS JR was non-significantly decreased ([Formula: see text] = 1.04, [Formula: see text] = 0.31). Conclusions: Adhering to specified inclusion and exclusion criteria, there was limited data available regarding the impact of applications and wearable devices on THA patients. Consequently, our analysis included a single available study that employed the EQ-5D-5L measurement for THA patients. More studies involving wearable devices and digital applications should be considered in order to further test the efficacy of these treatments for TJA compared to standard treatment modalities. Despite this limitation, the findings of this review indicate that at-home treatment using wearable devices and digital applications yields outcomes comparable to those achieved through conventional treatment models for patient rehabilitation. Furthermore, at-home wearable and digital treatments may present a cost-effective and convenient alternative to in-person treatment.

Efficacy of Aspirin in Preventing Venous Thromboembolism in Total Knee and Hip Joint Replacement

Efficacy of Aspirin in Preventing Venous Thromboembolism in Total Knee and Hip Joint Replacement

Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series.

Pain self-efficacy, or the ability to carry out desired activities in the presence of pain, can affect a patient's ability to function before and after orthopaedic surgery. Previous studies suggest that shared decision-making practices such as discussing patient-reported outcome measures (PROMs) can activate patients and improve their pain self-efficacy. However, the ability of PROMs to influence pain self-efficacy in patients who have undergone orthopaedic surgery has yet to be investigated. (1) Is immediately discussing the results of a PROM associated with an increase pain self-efficacy in new patients presenting to the orthopaedic surgery clinic? (2) Is there a correlation between patient resilience or patient involvement in decision-making in changes in pain self-efficacy? This was a prospective, sequential, comparative series completed between February to October 2023 at a single large tertiary referral center at a multispecialty orthopaedic clinic. Orthopaedic subspecialties included total joint arthroplasty, spine, hand, sports, and trauma. The first 64 patients underwent standard care, and the following 64 had a conversation with their orthopaedic surgeon about their PROMs during the initial intake visit. We collected scores from the Pain Self-Efficacy Questionnaire (PSEQ), Brief Resilience Scale (BRS), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function form (PF-SF10a) and data on demographic characteristics before the visit. The PSEQ is a validated PROM used to measure pain self-efficacy, while the BRS measures the ability of patients to recover from stress, and the PROMIS PF-SF10a is used to assess overall physical function. PROMs have been utilized frequently for their ability to report the real-time physical and psychological well-being of patients. In the standard care group, the PROMIS PF-SF10a score was not discussed with the patient. In the PROMs group, the physician discussed the PROMIS PF-SF10a score using a script that gave context to the patient's score. Additional conversation about the patient's score was permitted but not required for all patients. Scores from the Observing Patient Involvement in Decision Making (OPTION-5) instrument were recorded during the visit as a measure of patient involvement in clinical decision-making. After the visit, both groups completed the PSEQ. The primary outcome was change in the PSEQ. Change in pain self-efficacy was recorded as greater or less than the minimum clinically important difference, previously defined at 8.5 points for the PSEQ [10]. The secondary outcomes were correlation between PSEQ change and the BRS or OPTION-5. Between the PROMs and standard care groups, there was no difference in the change in PSEQ scores from before the visit to after (mean ± SD change in control 4 ± 10 versus change in PROMs group 3 ± 7, mean difference 1 [95% confidence interval (CI) -2.0 to 4.0]; p = 0.29). Fifty-six percent (36 of 64) of patients in the standard care group demonstrated an increase in pain self-efficacy (of whom 22% [14 of 64] had clinically important improvements), and 59% (38 of 64) of patients in the PROMs group demonstrated an increase in pain self-efficacy (of whom 19% [12 of 64] had clinically important improvements). In the control group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.13 [95% CI -0.36 to 0.12]; p = 0.30) or patient involvement in decision-making (OPTION-5 r = 0.003 [95% CI -0.24 to 0.25]; p = 0.98). Similarly, in the PROMs group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.10 [95% CI -0.33 to 0.16]; p = 0.45) or patient involvement in decision-making (OPTION-5 r = -0.02 [95% CI -0.26 to 0.23]; p = 0.88). Discussing PROMs results (PROMIS PF-SF10a) at the point of care did not increase pain self-efficacy during one visit. Therefore, surgeons do not need to discuss pain self-efficacy PROM scores in order to influence patient pain self-efficacy. While PROMs remain valuable tools for assessing patient outcomes, further work may assess whether the collection of PROMs itself may increase pain self-efficacy or whether longitudinal discussion of PROMs with patients changes pain self-efficacy. Level II, therapeutic study.

Chronic corticosteroid use does not increase short-term complications following carpometacarpal arthroplasty.

Chronic steroid use has been found to be significantly associated with postoperative complications following total joint arthroplasty. The purpose of this study was to investigate the relationship between chronic steroid and immunosuppressant use and postoperative complications following carpometacarpal (CMC) arthroplasty. The American College of Surgeons National Surgical Quality Improvement Program database was queried for all records of patients who underwent carpometacarpal (CMC) arthroplasty between 2015 and 2020. The initial pool of records was divided into two cohorts: chronic steroid and no chronic steroid use. Patient demographics and comorbidities were compared between cohorts using bivariate logistic regression. A total of 6624 records of CMC arthroplasty were identified in NSQIP from 2015 to 2020. Of the 6432 records remaining after exclusion criteria, 223 (3.5%) were chronic steroid use and 6209 (96.5%) were without chronic steroid use. The patient demographics and comorbidities significantly associated with chronic steroid use were ASA classification ≥ 3 (p < 0.001), insulin-dependent diabetes mellitus (p = 0.032), and COPD (p < 0.001). Compared to no chronic steroid use, chronic steroid use had higher rates of any complication (2.24% vs. 2.01%), superficial incisional SSI (1.35% vs. 0.63%), urinary tract infection (0.45% vs. 0.31%), sepsis (0.45% vs. 0.05%), and mortality (0.45% vs. 0.05%). However, these differences in complication rates were not statistically significant. Chronic preoperative steroid use was not significantly associated with any increased postoperative complication within 30days following CMC arthroplasty. Level III; Retrospective Cohort Comparison; Prognosis Study.

Incidence of local anesthetic systemic toxicity in patients receiving bupivacaine infiltration analgesia for total joint arthroplasty under general anesthesia: a retrospective single-center study

BackgroundLocal infiltration analgesia (LIA) is a crucial component of multimodal analgesia that enhances recovery after total hip arthroplasty (THA) and knee arthroplasty (TKA). However, LIA can cause fatal local anesthetic systemic toxicity (LAST). The incidences of LIA-induced LAST in different surgeries and anesthetic agents have not been well investigated.MethodsThis observational study enrolled 1,267 adult patients who received LIA with bupivacaine for primary THA or TKA under general anesthesia at a single medical center between January 2020 and October 2021. LAST incidence was graded by severity: severe (refractory seizure or arrhythmia requiring lipid rescue), major (seizure or arrhythmia requiring prompt medication), and minor (all other) events. Patient demographics, surgical and anesthesia details, recovery profiles, and LAST incidences were recorded and analyzed.ResultsThe incidence of severe LAST events was 2.41 per 1000 in unilateral THA, 0 in TKA, and 3.16 per 1000 in the entire cohort. The odds ratio of developing major LAST events was 4.35 in patients undergoing unilateral THA compared with those undergoing unilateral TKA in a matched comparison. Patients who underwent bilateral THA had the highest risk of developing LIA-induced LAST. Additionally, patients using propofol infusion for anesthesia maintenance had a lower risk of seizures and tremors than those using sevoflurane inhalation. The odds ratio of major LAST events was 0.47 in matched comparisons.ConclusionsLIA was associated with a significantly higher risk of LAST in the THA group than in the TKA group. Propofol maintenance reduces the likelihood of seizures and tremors compared with sevoflurane inhalation. Exploring strategies to reduce the incidence of LIA-induced LAST is essential to improve perioperative patient safety.

Robotic Assistance Is Not Associated With Decreased Early Revisions in Cementless TKA: An Analysis of the American Joint Replacement Registry.

Previously, we conducted a retrospective study of American Joint Replacement Registry (AJRR) data that examined the 2-year odds of revision between robotic-assisted and nonrobotic-assisted TKA, and we found no benefit to robotic assistance. However, proponents of robotic assistance have suggested that robot platforms confer more accurate bone cuts and precise implant sizing that might promote osteointegration of cementless implants by limiting micromotion at the bone-implant interface that could lead to aseptic loosening. Therefore, it seems important specifically to evaluate the odds of revision among patients with cementless implants only within our previous study population. (1) After controlling for potentially confounding variables, such as surgeon, institution, and patient comorbidity profile, was robotic assistance associated with a decreased odds of 2-year revision of cementless TKA for any reason compared with cementless TKAs performed without robotic assistance? (2) After again controlling for potentially confounding variables, was robotic assistance associated with a decreased odds of 2-year revision of cementless TKA for particular revision indications (such as aseptic loosening, infection, instability, or pain) compared with the cementless TKAs performed without robotic assistance? Using the AJRR, a retrospective cohort of patients ≥ 65 years of age with osteoarthritis who underwent primary TKA with cementless femur and tibial components from January 2017 through March 2020 was identified. Procedures performed with hybrid fixation (cement only on the tibia but not on the femur, or vice versa) were excluded. The AJRR was selected because it is the largest arthroplasty registry in the world by annual procedure volume, and it contains a data linkage with inpatient and outpatient Medicare claims data to ensure near-complete 2-year follow-up. A total of 9220 patients were identified, and robotic assistance was used in 45% (4130) of procedures. Patient age did not differ between groups (72 ± 5 years versus 72 ± 5 years; p = 0.29). However, the robotic-assisted cohort had a slightly higher proportion of female patients (56% [2332 of 4130] versus 53% [2693 of 5090]; p = 0.002) and higher Charlson comorbidity index (CCI) (2.9 ± 0.9 versus 2.8 ± 0.9; p = 0.003). Therefore, a mixed-effects model was used to analyze the ORs for all-cause linked revision with robotic assistance and was adjusted for age, gender, CCI, surgeon, and institution. Subanalyses were performed on indications for revision. A power analysis demonstrated the ability to measure a difference as small as one-half SD between risk of revision within each cohort (specifically, moderate effect sizes based on Cohen d). After controlling for potentially confounding variables, such as surgeon, location of surgery, and patient comorbidity profile, we found no difference regarding odds of all-cause revision between robotic-assisted and nonrobotic-assisted cementless TKA (OR of robotic-assisted versus nonrobotic-assisted cementless TKA 0.8 [95% CI 0.5 to 1.3]; p = 0.41). There were no differences in reasons for revision between robotic-assisted and nonrobotic-assisted cementless TKA, such as mechanical loosening (OR 3.2 [95% CI 0.8 to 12]; p = 0.09) and infection (OR 1.5 [95% CI 0.8 to 2.6]; p = 0.19). We found no evidence that robotic assistance improves the odds of cementless implant survival free from revision at 2 years. Importantly, the differences in odds of revision beyond 2 years as a function of robotic assistance in cementless TKA remains unknown and warrants further population-level investigation, but until or unless robotic assistance proves its value in well-designed studies in terms of endpoints that patients can perceive (such as pain, function, or survivorship), we recommend against widespread adoption until further evidence becomes available. Additionally, we encourage surgeons and healthcare facilities using robotic assistance in cementless TKAs to study its impact on patient outcomes, if any. Level III, therapeutic study.

Evaluating Surgical Approaches for Hemimandibular Hyperplasia Associated with Osteochondroma: A Systematic Literature Review.

Background/Objectives: Hemimandibular hyperplasia (HH) associated with osteochondroma presents complex challenges in maxillofacial surgery, including facial asymmetry, occlusal instability, and temporomandibular joint (TMJ) dysfunction. Surgical interventions vary widely in approach and outcomes, underscoring the need for a systematic evaluation of effectiveness. This systematic review assesses the effectiveness of surgical approaches for managing HH associated with osteochondroma, focusing on techniques including condylectomy, orthognathic surgery, distraction osteogenesis, total joint replacement (TJR), and genioplasty. Methods: Following PRISMA 2020 guidelines, a comprehensive search was conducted in PubMed, Scopus, and Web of Science for studies published from 2000 to 2023. Eligibility criteria were based on the PICO framework, with primary outcomes evaluated for facial symmetry, occlusal correction, mandibular function, and recurrence rates. The Cochrane Risk of Bias Tool assessed study quality, while the GRADE framework evaluated the certainty of evidence. This review was not registered due to exclusion criteria for certain dental topics in PROSPERO. Results: Of 145 studies identified, 18 met inclusion criteria, totaling 214 patients. High and low condylectomy both effectively corrected asymmetry, with high condylectomy reducing recurrence risk but often requiring reconstruction. Orthognathic surgery, combined with condylectomy, significantly enhanced facial symmetry and occlusal function. Distraction osteogenesis proved valuable for mandibular lengthening in cases of severe deformities, while TJR offered definitive solutions for extensive joint involvement. Genioplasty corrected chin asymmetry, contributing to improved facial balance. Limitations included small sample sizes and variable follow-up durations. Conclusions: Surgical approaches tailored to individual patient needs show effectiveness in treating HH associated with osteochondroma, achieving functional and esthetic outcomes. Future studies should prioritize larger cohorts and standardized follow-up protocols to better assess long-term efficacy. Advances in 3D surgical planning and individualized treatment strategies show promise for optimized patient-specific care.

Long-Term Stability in Temporomandibular Joint Replacement: A Review of Related Variables.

Background: The temporomandibular joint (TMJ) is a key component of the stomatognathic system, playing a major role in maintaining mandibular stability and function. Temporomandibular disorders (TMDs) are a prevalent disease in the world, with surgical treatment being reserved for complex cases or end-stage TMJ disease. A narrative review was conducted to describe the quantitative and qualitative factors that affect TMJ prosthesis stability. Methods: Studies with a sample size equal to or greater than 10 subjects who underwent surgical procedures for joint replacement using stock or customized ATM prostheses were included. This narrative review examined some variables that may influence in terms of the longevity of the TMJ prosthesis, highlighting issues to be considered in future research. Results: The current development of TMJ prostheses is benefiting from technological advances, offering a suitable adaptation to the patient's anatomy and superior results in functionality and patient satisfaction. However, the biomechanical complexity of the TMJ shows unique challenges compared to other joints in the body, where anatomical, biomechanical, and functional requirements are high. The stability of the TMJ prosthesis is affected by multiple variables, including the selection of biocompatible materials that resist corrosion and wear, the design of the prosthesis, the diagnosis and indication for its use, and the surgeon's experience. The success of TMJ replacement can be measured by improving the patient's quality of life, reducing pain, restoring mandibular functionality, and recovering suitable facial morphology for the patient's conditions. Conclusion: There is a need for training of maxillofacial surgeons in TMJ surgery and replacement, as well as a greater focus on the research and development of systems to simplify surgical design and procedures and to optimize the results of TMJ replacement.

Becoming Active in Beating osteoarthritiS: study protocol of a randomised controlled trial on the effectiveness of an information campaign in improving the management of osteoarthritis and quality of care in general practices in the Netherlands

IntroductionDespite recommendations, non-surgical treatment modalities in knee and/or hip osteoarthritis (KHOA) are underused. An information campaign was developed targeting patients with early stage KHOA and healthcare professionals (HCPs) to optimise...

Complete Blood Cell Count-Based Ratios Identify Total Joint Arthroplasty Patients Likely to Benefit from Perioperative Dexamethasone

Background: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization. Methods: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles. Results: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of &gt;1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p &lt; 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR &lt;1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of &lt;0.24 (the lowest quartile) (p = 0.039). Conclusions: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Identifying factors associated with persistent opioid use after total joint arthroplasty: A retrospective review.

To identify predictors of persistent opioid use in opioid-naïve individuals undergoing total joint arthroplasty. Retrospective cohort study. Maine Health System. Opioid-naïve patients who underwent at least one total joint arthroplasty (knee, hip, or shoulder) between 2015 and 2020. Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was used to create a predictive model for persistent opioid use after surgery from a US Electronic Health Record dataset in the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) format. 75% of the data was used to build the LASSO model using 10-fold cross-validation and 25% of the data was used to determine the optimal probability threshold for predicting the binary outcome. Out of 6432 patients, 12.3% (792) were identified as having persistent opioid use across combined total joint arthroplasties defined as at least one opioid prescription between 90 days and one year after surgery. Patients with persistent opioid use were more likely to be current smokers (OR 1.65), use antidepressants (OR 1.76), or have a diagnosis of post-traumatic stress disorder (OR 2.07), or a substance related disorder (OR 1.69). Other factors associated with persistent opioid use included back pain (OR 1.43), dementia (OR 1.65), and BMI over 40 (OR 2.50). The probability of persistent opioid use was not associated with age, sex, or ethnicity. This predictive model for persistent opioid use after total joint arthroplasty shows promise as an evidence-based, validated, and standardized tool for identifying high-risk patients before surgery in order to target strategies and interventions to reduce the reliance on opioids for post-operative pain control.

Periprosthetic joint infections – a scoping review

Abstract Periprosthetic joint infections (PJIs) are dramatic complications after primary total joint arthroplasty. Despite increasing research in this field, the diagnosis, classification, and management of PJI remain a challenge. This is mainly due to the heterogenous clinical presentation of PJI in clinical routine and patient-related factors as secondary diagnosis and periprosthetic tissue condition. The early detection of PJI is essential for adequate treatment. However, there is no definition for PJI with 100 % sensitivity or a negative predictive value. This can potentially lead to a delayed or missed diagnosis of PJI. Furthermore, the surgical and antibiotic treatment is among the most discussed topics in PJI literature. There is no international consensus on the treatment of different PJI entities. Concludingly many aspects of PJI diagnostics and treatment remain controversially discussed and current studies are only comparable to a limited extent due to study heterogeneity and limited comparability.

The mononuclear phagocyte system obscures the accurate diagnosis of infected joint replacements

IntroductionDiagnosing infected joint replacements relies heavily on assessing the neutrophil response to bacteria. Bacteria form biofilms on joint replacements. Biofilms are sessile bacterial communities encased in a protective extracellular matrix, making them notoriously difficult to culture, remarkably tolerant to antibiotics, and able to evade phagocytosis. Phagocytized bacteria dramatically alter cytokine production and compromise macrophage antigen presentation. We hypothesize that a subset of joint replacements have a dormant infection that suppresses the neutrophil response to bacteria but can be distinguished from uninfected joint replacements by the response of the mononuclear phagocyte system (MPS) within periarticular tissue, synovial fluid, and circulating plasma.MethodsSingle cell RNASeq transcriptomic and OLink proteomic profiling was performed on matched whole blood, synovial fluid, and periarticular tissue samples collected from 4 joint replacements with an active infection and 3 joint replacements without infection as well as 6 joint replacements with a prior infection deemed “infection-free” by the 2018 Musculoskeletal Infection Society criteria (follow-up of 26 ± 3 months).ResultsThe MPS and neutrophil responses differ by infected state; the cellular distribution of the MPS response in the subset of joints with dormant infections resembled actively infected joints (p = 0.843, Chi-square test) but was significantly different from uninfected joints (p < 0.001, Chi-square test) despite the absence of systemic acute phase reactants and recruitment of neutrophils (p < 0.001, t-test). When compared to no infection, the cellular composition of dormant infection was distinct. There was reduction in classically activated M1 macrophages (p < 0.001, Fischer's test) and alternatively activated M2 macrophages coupled with an increase in classical monocytes (p < 0.001, Fischer’s test), myeloid dendritic cells (p < 0.001, Fischer’s test), regulatory T-cells (p < 0.001, Fischer’s test), natural killer cells (p = 0.009, Fischer’s test), and plasmacytoid dendritic cells (p = 0.005, Fischer’s test). Hierarchical cluster analysis and single-cell gene expression revealed that classically M1 and alternatively M2 activated macrophages as well as myeloid dendritic cells can independently distinguish the dormant and uninfected patient populations suggesting that a process that modulates neutrophil recruitment (C1QA, C1QB, LY86, SELL, CXCL5, CCL20, CD14, ITGAM), macrophage polarization (FOSB, JUN), immune checkpoint regulation (IFITM2, IFITM3, CST7, THBS1), and T-cell response (VISIG4, CD28, FYN, LAT2, FCGR3A, CD52) was occurring during dormant infection. Gene set variation analysis suggested that activation of the TNF (FDR < 0.01) and IL17 (FDR < 0.01) pathways may distinguish dormant infections from the active and uninfected populations, while an inactivation of neutrophil extracellular traps (NETs) may be involved in the lack of a clinical response to a dormant infection using established diagnostic criteria. Synovial inflammatory proteomics show an increase in synovial CXCL5 associated with dormant infection (p = 0.011, t-test), suggesting the establishment of a chronic inflammatory state by the MPS during a dormant infection involved in neutrophil inhibition. Plasma inflammatory proteomics also support a chronic inflammatory state (EGF, GZMN, FGF2, PTN, MMP12) during dormant infection that involves a reduction in neutrophil recruitment (CXCL5, p = 0.006, t-test), antigen presentation (LAMP3, p = 0.047, t-test), and T-cell function (CD28, p = 0.045, t-test; CD70, p = 0.002, t-test) that are also seen during the development of bacterial tolerance.DiscussionAll current diagnostic criteria assume each patient can mount the same neutrophil response to an implant-associated infection. However, the state of the MPS is of critical importance to accurate diagnosis of an implant-associated infection. A reduction in neutrophil recruitment and function mediated by the MPS may allow joint replacements with a dormant infection to be mischaracterized as uninfected, thus limiting the prognostic capabilities of all current diagnostic tests.

Clinical Value of Routine Follow-Up Radiographs in Total Joint Arthroplasty

Clinical Value of Routine Follow-Up Radiographs in Total Joint Arthroplasty

A prospective multicentre study of 82 prosthetic joint infections treated with a standardised debridement and implant retention (DAIR) protocol followed by 6 weeks of antimicrobial therapy: favourable results.

Prosthetic joint infection (PJI) is a much-feared complication in total joint arthroplasty. Debridement, antibiotics, irrigation and implant retention (DAIR) is often the preferred treatment in acute PJIs, but with varying results. The primary aim of this study was to evaluate the outcome of a high quality DAIR procedure performed according to a consistently applied surgical protocol in early postoperative and acute haematogenous PJIs in hip and knee, and secondary to study risk factors associated with failure. We performed a prospective multicentre study to evaluate the effect of a standardised protocol-based surgical management (DAIR) emphasising a thorough debridement, followed by 6 weeks of antimicrobial therapy. Empiric parenteral antimicrobial treatment was administered until the results of susceptibility tests were available. No suppressive antimicrobial therapy was given after the 6-week treatment-period. Primary outcome measure was infection control at the 2-year follow-up. A total of 99 patients from 8 Norwegian hospitals were found eligible and included in the study, and 82 patients were finally analysed. 69 of 82 patients (84% [CI, 76-92%]) were successfully treated with this treatment protocol. We found a reduced success rate when patients were treated with a DAIR procedure following an infected revision arthroplasty compared with an infected primary arthroplasty (11/17 (65 %) versus 58/65 (89 %), respectively (p = 0.02). The success rate of a standardised DAIR procedure with a 6-week antimicrobial treatment was good in PJI following primary arthroplasties. The success rate following PJI in revision arthroplasty was poor, and other treatment options should be considered.