THA Patients Research Articles

Timing of total joint arthroplasty post-COVID-19: an evaluation of the optimal window to minimize perioperative risks

BackgroundTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed orthopedic procedures. This study aimed to evaluate the impact of COVID-19 status on postoperative complications and mortality in patients undergoing THA and TKA.MethodsA total of 110,186 underwent either THA or TKA. Patients were grouped based on their COVID-19 status, gathered from the National COVID-19 Cohort Collaborative (N3C) in the 12 weeks preceding surgery and compared for various variables, including age, sex, BMI, and Charlson Comorbidity Index (CCI) scores. COVID-19 status was defined as a positive test result that was closest to the date of surgery regardless of testing positive previously. Postoperative complications such as venous thromboembolism (VTE), sepsis, surgical site infection, bleeding, acute kidney injury (AKI), 30-day, and 1-year all-cause mortality were examined. To compare the variables, an odds ratio with a 95% confidence interval was calculated with a significant level set at P < 0.05. Logistic regression using R programming was utilized for these calculations.ResultsUnivariate analysis was performed and rates of VTE (1.02% vs. 3.35%), 30-day mortality (0.25% vs. less than 5%), and 1-year mortality (1.42% vs. 5.43%) were higher in the COVID-19-positive group for THA patients (P < 0.001). For TKA patients, only 30-day mortality was significantly higher in the COVID-19-positive group (P = 0.034). Multivariate logistic regression revealed that a positive COVID-19 diagnosis within two weeks of surgery and a CCI score > 3 were significant predictors of postoperative complications and mortality for both TKA and THA.ConclusionsPatients with a positive COVID-19 diagnosis within 12 weeks of THA or TKA carried a significantly higher risk for postoperative complications and mortality. In addition, a CCI score > 3 is also a significant risk factor. These findings emphasize the importance of vigilant preoperative screening and risk stratification in the era of COVID-19.

Low Socioeconomic Status Is Associated with Worse Patient-Reported Outcomes Following Total Joint Arthroplasty: A Systematic Review

BackgroundSocioeconomic status (SES)—an individual or group’s social standing or class, as measured by education, income, and occupation—has been associated with poor surgical outcomes in orthopaedics. Total knee (TKA) and total hip (THA) arthroplasties are the most commonly investigated orthopaedic surgeries regarding SES and patient-reported outcome measures (PROMs), yet the results are contradictory. The aim of this systematic review was to assess the impact of SES on PROMs following total joint arthroplasty (TJA). MethodsWe performed a literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines utilizing MEDLINE (Ovid), EMBASE (Ovid), and Cochrane Library from database inception (1971, 1974, and 1996, respectively) to August 2, 2023, to identify studies investigating SES and PROMs in adults undergoing primary elective TJA. Studies were included if they evaluated one of three SES variables (income, education, or employment status) and reported at least one-year scores using a validated PROM. There were two reviewers who independently screened studies and extracted data. ResultsThere were 16 studies included in this systematic review. A total of 55,875 arthroplasties, including 24,055 TKAs and 31,820 THAs, were analyzed. Of the studies, eight evaluated income, 15 evaluated education, and two evaluated employment status. The majority of studies investigating income found a statistically significant association between lower income and worse postoperative PROMs. There were ten studies, involving 90% of all patients from the included education studies, that found a statistically significant association between education and postoperative PROMs. There were two studies that found unemployed THA patients had lower improvements in PROMs compared to employed and retired patients. ConclusionOur systematic review found several significant associations between income, education, employment, and PROMs after TJA. Providers should pay special attention to lower-income, less educated, and unemployed patients. These patients may benefit from targeted interventions to achieve substantial clinical benefit after TJA.

Clinical outcomes and complications of a non-modular dual-mobility acetabular device, minimum 2 years follow-up.

Non-modular dual-mobility (DM) acetabular bearing constructs are becoming more popular due to their potential advantages for addressing range of motion (ROM) and stability. The objective of this post-market clinical study was to assess clinical outcomes, including patient satisfaction, pain and function, survivorship, and component positioning, in patients ⩾2 years after primary THA using non-modular DM acetabular components. This retrospective, multicentre study evaluated complications and functional outcomes in recipients of non-modular DM acetabular constructs at least 2 years post-THA. Our primary outcomes included the dislocation rate and mean Hip disability and Osteoarthritis Outcomes Score (HOOS). Secondary outcomes included radiographic measurements, patient satisfaction, Forgotten Joint Score (FJS), Harris Hip Score (HHS), and survivorship. 316 eligible patients enrolled in this study across 3 sites, including 168 men (53%) and 148 women (47%). The cohort averaged 5.37 years post-THA (range 2.2-10.1 years) at the study visit. The mean FJS, HHS, and HOOS were good to excellent, with values of 82.3, 90.7, and 92.0, respectively. Patient satisfaction averaged 4.68, between "Very Good" (4) and "Excellent" (5). Minimal radiolucent lines (RLL) surrounded the acetabulum. More RLL surrounded the femur, but most lines were less than 1 mm (4.7% of the study population). There were few adverse events (4 events, 1.3%). Three revisions were performed (0.9%), with one patient requiring removal of the acetabular cup. The high mid- to long-term survivorship and low to no dislocation and reoperation rates indicate this acetabular DM device is a viable option for THA patients. The patient metrics reflect satisfaction, alleviated pain, and restored function with a low risk of adverse outcomes.

Geographical incidence of testosterone supplementation in total hip and knee arthroplasty

IntroductionPrescription testosterone usage in the United States declined after 2013 following reports of its association with myocardial infarction and stroke. However, more recently there has been a documented increase in testosterone prescriptions. Recently, testosterone levels have also been hypothesized to increase infection risk in patients undergoing elective shoulder arthroplasty. Furthermore, testosterone may increase the risk of venous thromboembolism. These complications are perioperative concerns for total hip and knee arthroplasties (THA/TKA). Therefore, the purpose of our study is to identify trends in the incidence of testosterone prescriptions in patients who underwent THA/TKA with respect to geographical population data. MethodsWe retrospectively reviewed 40,711 primary THAs and 50,893 primary TKAs performed in males between 1/1/2016 and 12/31/2021 using a commercial claims database. Records were reviewed for demographics, geographical location, and supplemental testosterone prescriptions within 1 year prior to surgery. Patient Metropolitan Statistical Area (MSA) was assessed with respect to United States Census Population Data. ResultsWe identified 91,604 males who underwent primary THA (n = 40,711) or TKA (n = 50,893). For THA/TKA, patients who were younger had a higher likelihood of having a supplemental testosterone prescription (OR = 0.99, 95 % CI [0.99–1.00], p < 0.001). TKA patients (2,507, 4.9 %) had a higher rate of testosterone prescriptions than THA patients overall (1,413, 3.4 %), (OR = 1.44 95 % CI [1.35, 1.54], p < 0.001) as well as within each year.For THA and TKA patients, patients in the Midwest (OR = 1.61, p < 0.001), South (OR = 3.04, p < 0.001), and West (OR = 2.28, p < 0.001) regions all had higher testosterone prescription rates than the Northeast. Patients living in a city (MSA population ≥200,000) were more likely to be prescribed testosterone (OR = 1.20, p = 0.002). ConclusionSurgeons conducting TKA/THA should be aware that younger patients, those in higher population areas, and those in the Midwest, South, and West regions are more likely to be prescribed testosterone than those in the Northeast.

ABDUCTOR RECONSTRUCTION WITH VASTUS LATERALIS TO GLUTEUS MEDIUS TRANSFER

Few surgical techniques to reconstruct the abductor mechanism of the hip have been reported, with outcomes reported only from case reports and small case series from the centres that described the techniques. As in many of our revision THA patients the gluteus maximus was affected by previous repeat posterior approaches, we opted to reconstruct the abductor mechanism using a vastus lateralis to gluteus medius transfer.We report the results of such reconstructions in seven patients, mean age 66 (range, 53–77), five females, presenting with severe abductor deficiency (MRC grade 1–2). Five patients had previous revision THA, two with a proximal femoral replacement, one patient had a primary THA after a failed malunited trochanteric fracture, and one patient had a native hip with idiopathic fatty infiltration of glutei of &gt;90%. All patients had instrumented gait analysis, and surface electromyography (EMG) of the glutei, TFL, and vastus muscles simultaneously before surgery and at each post-op follow-up. Postoperatively, patients were allowed to weight bear as tolerated and were requested to wear an abduction brace for the first six weeks after surgery to protect the transfer.All patients improved after surgery and reached an abductor power of 3 or more. All patients walked without support six months after surgery and were satisfied with the result. Abductor function continued to improve beyond one year of follow-up, and some patients reached an abductor power of 5. EMG demonstrated that the transferred vastus lateralis started firing synchronously with gluteus medius after three months post-surgery, suggesting adaptation to its new function. No knee extension weakness was recorded. One patient complained of lateral thigh numbness and was dissatisfied with the cosmetic look of her thigh after surgery.Our preliminary results are encouraging and comparable with those achieved by the originators of the technique.

Ultrasonographic Anatomical Changes in the Nasal Vasculature after Rhinoplasty: Analysis of a Series of Cases

It is known that surgical procedures can change the vascularization of the face, and these changes can be related in the course and depth of vessels, increasing the risk for complications with injectable products. The goal of this work is to objectively demonstrate the course and variation of these vascular structures through Doppler ultra-sonographic monitoring. In this research 9 patients were studied, of which 7 completed the study. The presurgical ultrasound study detected anatomical variations like agenesy of the angular artery and dorsal nasal artery in 11.12% of tha patients. The post surgical evaluation detected 85.71% of vascular changes mainly in the nasal arteries. This findings confirm the importance of practicing ultrasonographis evaluation in patients with rhinoplasty, previous to practicing new filler injections in the face.

Readmissions at 30 Days and 1 Year for Implant-Associated Complications Following Primary Total Hip and Knee Arthroplasty: A Population-Based Study of 34,392 Patients Across Austria

BackgroundThe primary aim of this study was to assess 30-day and 1-year rates for unplanned readmission due to implant-associated complications following total hip (THA) or total knee arthroplasty (TKA) in Austria. Secondary endpoints were reasons for readmission and differences in revision risk depending on demographics and hospital size. MethodsData on patients receiving THA (n = 18,508) or TKA (n = 15,884) in orthopaedic and trauma units across Austria within a 1-year period (January 2021 to December 2021) were retrieved from a government-maintained database. The absolute and relative frequencies of unplanned readmissions were calculated. Risk factors for 30-day and 1-year readmission following THA or TKA due to implant-associated complications were investigated. ResultsThe 30-day and 1-year readmission rates for any implant-associated complication were 1.0% (339 of 34,392) and 3.0% (1,024 of 34,392), respectively. Relative to the overall readmission rate for any complication at 30 days (n = 1,952) and 1 year (n = 12,109), readmission rates for implant-associated complications were 17.4 and 8.5%, respectively. The 30-day readmission rates were higher in THA (1.2%) than TKA patients (0.8%; P = 0.001), while it was the opposite at 1 year (THA, 2.7%; TKA, 3.3%; P < 0.001). Mechanical complications (554 of 1,024) were the most common reason for 1-year readmission. Prolonged length of in-hospital stay independently associated with increased 1-year readmission risk in THA and TKA patients. Treatment at large-sized hospitals was associated with a higher 1-year readmission risk in TKA patients. ConclusionsThe 30-day and 1-year readmission rates for implant-associated complications following THA or TKA in Austria are lower than reported in other countries, with similar risk factors and reasons for readmission. Considering that almost 20% of unplanned hospital readmissions following total joint arthroplasty are attributable to implant-associated complications, optimization of in-hospital and postdischarge medical care for these patients is warranted.

Body Mass Index is Not an Appropriate Proxy for the Condition of Peri-Incisional Adiposity in Primary Total Joint Arthroplasty Patients

BackgroundThe American Academy of Orthopaedic Surgeons defined the acceptable threshold for elective safe surgery as a body mass index (BMI) under 40 due to the increased risk of complications. A consequence of this recommendation has been a hard cutoff based on BMI, which restricts access to care for an increasingly large and diverse population. There is an improved understanding that excess adipose tissue confers additional risk for postoperative complications, including infection, through mechanical and physiologic mechanisms. But, it is unclear if BMI is an accurate indicator of adiposity in total joint arthroplasty (TJA) patients and, thus, whether BMI is capturing clinically relevant information in obese patients. Our objective was to determine the relationship between peri-incisional adiposity (PIA) and BMI in a consecutive series of diverse primary TJA patients. MethodsA consecutive series of patients indicated for primary TJA were preoperatively evaluated. For each patient, the following variables were collected: BMI and measures of PIA on radiographs and ultrasounds. ResultsIn THA patients (N = 99), Pearson’s correlation coefficient (r) = 0.436, which indicates a moderate correlation between BMI and adiposity. In total knee arthroplasty patients (N = 271), r = 0.395 for femoral PIA (FPIA) and r = 0.249 for tibial PIA, which indicates a weak correlation between BMI and adiposity measured on radiography. In total knee arthroplasty patients, r = 0.560 for femoral PIA and r = 0.544 for tibial PIA, which indicates a moderate correlation between BMI and adiposity measured on ultrasound. ConclusionsQuantification of obesity has become a common practice in the preoperative evaluation of primary TJA patients. The intent is to determine the magnitude of adipose tissue, which is one of the main drivers of postoperative complications in obesity. The BMI is ubiquitously used as a proxy for obesity due to its simplicity of attainment and calculation. We report that BMI has a weak-to-moderate association with PIA in this population. These findings indicate that BMI may not accurately represent the condition of peri-incisional adipose tissue and, thus, is not capturing the relevant obesity data for preoperative risk stratification in primary TJA patients. Level of evidenceIII.

Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty.

While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.

Early Periprosthetic Joint Infections in Total Hip and Knee Arthroplasty: Microorganisms, Mortality, and Implant Survival Using a Combined Dataset From the Dutch Arthroplasty Register and the Dutch National Nosocomial Surveillance Network

BackgroundPeriprosthetic joint infections (PJIs) can lead to higher re-revision rates and even higher mortality rates that may be associated with the responsible microorganism. We evaluated microorganisms that cause early PJIs in primary total hip and knee arthroplasty (THA and TKA) and examined mortality as well as PJI re-revision rates after these PJIs, using a combined dataset from the Dutch Arthroplasty Register and the Dutch National Nosocomial Surveillance Network (PREZIES). Secondly, the most common microorganisms that cause PJIs were described according to patient and implant survival. MethodsWe included all PREZIES-confirmed PJIs (n = 1,648) from the combined dataset in which primary THAs and TKAs (2012 to 2018) from the Dutch Arthroplasty Register and PREZIES were case-level matched. Kaplan-Meier survival analyses were performed to determine mortality and PJI re-revision rates following PJI revision. ResultsThe most prevalent microorganism in THAs and TKAs was Staphylococcus aureus (THA 34%; TKA 39%), followed by Coagulase-negative staphylococci (THA 20%; TKA 19%), with Staphylococcus epidermidis (THA 12%; TKA 11%) as the most common subtype, and Enterococcus species (THA 8.6%; TKA 5.9%). The 5-year mortality was 15% (95% confidence interval [CI]: 13 to 18) and 18% (CI: 14 to 21) for THA and TKA patients, respectively. The 5-year PJI re-revision rate was 28% (CI: 24 to 34) for THAs and 30% (CI: 24 to 38) for TKAs. In deceased THA patients who had a PJI, Enterococcus species (14%) were more often registered as microorganisms responsible for the PJI than S. epidermidis (8.5%). ConclusionsOver half of the early PJIs in THAs and TKAs in the Netherlands were caused by Staphylococcus aureus and Coagulase-negative staphylococci including Staphylococcus epidermidis. Both 5-year mortality and PJI re-revision rates following PJI were relatively high.

Medial Calcar Density Measured via Opportunistic Computed Tomography Is Well Represented by the Dorr C Classification.

Introduction The canal-to-calcar isthmus (CC) ratio has been previously correlated with proximal femur osteology, but its relationship with bone density is not well established. Our purpose was to assess the relationship between femoral bone density, measured on opportunistic quantitative CT in Hounsfield units (HU), and CC ratio. Methods A total of 148 THA patients were included. The CC ratio was measured on anteroposterior hip radiographs. Using perioperative CT scans, a 1 cm diameter area was identified on a single mid-coronal slice in the medial calcar just proximal to the intertrochanteric ridge. The mean HU was calculated in this region to represent calcar bone density. Results Twenty-four percent (n = 35) of patients were classified as Dorr A (average CC ratio 0.47 [0.45; 0.48]), 67% (n = 96) as Dorr B (0.62 [0.55; 0.68]), and 11% (n = 17) as Dorr C (0.78 [0.77; 0.80]). There was a significant difference between Dorr A and Dorr C femurs (769 (144) vs. 588 (154) HU) as well as between B and C femurs (718 (166) vs. 588 (154) HU). The CC ratio was correlated with calcar bone density on CT (-0.370). Conclusion CC ratio is correlated with bone density determined by HU measurements on an opportunistic quantitative computed tomography scan, and bone density HU values were able to accurately differentiate bone density in Dorr A and B from Dorr C femurs. These findings suggest that the CC ratio is a reliable measurement to predict bone density in Dorr C femurs. Therefore, arthroplasty surgeons can confidently use the Dorr classification for patients with Dorr C femurs when preoperatively planning for THA.

Patients with total hip arthroplasty were more physically active 9.6 years after surgery: a case-control study of 429 hip arthroplasty cases and 29,272 participants from a population-based health study.

Few studies report on long-term levels of physical activity after THA compared with a control population. This case-control study aimed to find the long-term habitual level of leisure-time physical activity after THA and compare it with a large control group. A randomized sample of 856 patients, treated with primary THA, were identified from the Norwegian Arthroplasty Register. 429 (50%) responded to a questionnaire with a mean follow-up time of 9.6 years. We compared them with a control group of 29,272 (64%) from a population-based health study. Physical activity was measured with a questionnaire and categorized into groups according to the general recommendations for physical activity. 245 (63%) of the THA cases reported a level of leisure-time physical activity meeting the general recommendations, compared with 10,803 (39%) in the control group. The difference persisted at all ages (50-90 years). In sex, age, and BMI-adjusted regression models the chance of meeting the physical activity recommendations was higher in the THA group than in the control group (OR 2.9, 95% confidence interval 2.4-3.6). The majority of the patients with THA reported a level of leisure-time physical activity meeting the general recommendations for physical activity. THA patients were more physically active in their leisure time than a control group representing a normal population.

Total hip and knee arthroplasty after lower extremity amputation in a military population

IntroductionThe military includes lower extremity amputees requiring arthroplasty; however, there is little literature on this population. The primary aim of this study was to report demographics and clinical factors in...

Interleukin-1β Polymorphisms Are Genetic Markers of Susceptibility to Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty.

Periprosthetic joint infections (PJIs) are serious complications of prosthetic surgery. The criteria for the diagnosis of PJI integrate clinical and laboratory findings in a complex and sometimes inconclusive workflow. Host immune factors hold potential as diagnostic biomarkers in bone and joint infections. We reported that the humoral pattern-recognition molecule long pentraxin 3 (PTX3) predicts PJI in total hip and knee arthroplasty (THA and TKA, respectively). If and how genetic variation in PTX3 and inflammatory genes that affect its expression (IL-1β, IL-6, IL-10, and IL-17A) contributes to the risk of PJI is unknown. We conducted a case-control study on a Caucasian historic cohort of THA and TKA patients who had prosthesis explant due to PJI (cases) or aseptic complications (controls). Saliva was collected from 93 subjects and used to extract DNA and genotype PTX3, IL-1β, IL-6, IL-10, and IL-17A single-nucleotide polymorphisms (SNPs). Moreover, the concentration of IL-1β, IL-10, and IL-6 was measured in synovial fluid and plasma. No association was found between PTX3 polymorphisms and PJI; however, the AGG haplotype, encompassing rs2853550, rs1143634, and rs1143627 in IL-1β, was linked to the infection (p = 0.017). Also, synovial levels of all inflammatory markers were higher in cases than in controls, and a correlation emerged between synovial concentration of PTX3 and that of IL-1β in cases only (Spearman r = 0.67, p = 0.004). We identified a relationship between rs2853550 and the synovial concentration of IL-1β and PTX3. Our findings suggest that IL-1β SNPs could be used for the early identification of THA and TKA patients with a high risk of infection.

INCIDENTAL FINDINGS AND CLINICAL SIGNIFICANCE OF PREOPERATIVE CT IMAGING FOR THE PLANNING OF ROBOTIC ARTHROPLASTY

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning.The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty.All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation.A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%)Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.

Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis

BackgroundTotal hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu + Ex) programs may reduce the number of THAs needed, but supporting data are limited. This study aimed to estimate the treatment effect of THA versus Edu + Ex on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for hip OA. MethodsPatients who had hip OA who underwent THA or an Edu + Ex program were included in this propensity-matched study. In 778 patients (Edu + Ex, n = 303; THA, n = 475), propensity scores were based on pretreatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference (MD) in change from pretreatment to 3-month and 12-month follow-up using linear mixed models. ResultsThe matched sample consisted of 266 patients (Edu + Ex, n = 133; THA, n = 133) who were balanced on all pretreatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (MD 35.4; 95% confidence interval [CI] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17% and 30% of patients receiving Edu + Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84% and 90% of THA patients. ConclusionsA THA provides greater improvements in pain, function, and quality of life. A notable proportion of Edu + Ex patients had clinically meaningful improvements, suggesting Edu + Ex may result in THA deferral in some patients, but confirmatory trials are needed.

Enhancing postoperative recovery in total hip arthroplasty: the role of pericapsular nerve group and lateral cutaneous nerve block under spinal anaesthesia.

To compare the efficacy of spinal anaesthesia alone versus spinal anesthesia augmented with ultrasound-guided pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in improving perioperative analgesia and functional recovery in patients undergoing THA. In a prospective, randomized clinical trial we included 66 patients scheduled for THA were divided into two groups: one receiving spinal anaesthesia alone (SA group; n = 32) and the other receiving spinal anaesthesia with regional analgesia blocks PENG + LFCN (SRAB group; n = 34). In the SRAB group, PENG followed by LFCN blocks were administered under ultrasound guidance before spinal anaesthesia. There were significant differences between the two groups in the onset of postoperative pain (p < 0.01) and the total amount of analgesics required in the first 36 postoperative hours (p < 0.01). The combined approach of spinal anaesthesia with PENG and LFCN blockade, enables opioid-free analgesia and may contribute to a safer and more comfortable postoperative experience for THA patients.

Dysplastic Hips That Are Too Late for Periacetabular Osteotomy Are Not Too Early for Total Hip Arthroplasty

BackgroundTotal hip arthroplasty (THA) is often performed in symptomatic patients who have hip dysplasia and do not qualify for periacetabular osteotomy. The impact of osteoarthritis (OA) severity on postoperative outcomes in dysplasia patients who undergo THA is not well described. We hypothesized that dysplasia patients who have mild OA have slower initial recovery postoperatively but similar one-year patient-reported outcome measures (PROMs) compared to dysplasia patients who have severe OA. MethodsWe performed a retrospective review at a single academic institution over a 6-year period of patients who have dysplasia who underwent THA compared to patients who have primary OA who underwent THA. There were 263 patients who had dysplasia, compared to 1,225 THA patients who did not have dysplasia. Within the dysplasia cohort, we compared PROMs stratified by dysplasia and OA severity. The diagnosis of dysplasia was verified using the radiographic lateral center edge angle. A minimum one-year follow-up was required. The PROMs were collected through one year postoperatively. Logistic and linear regression models were used, adjusting for age, sex, body mass index, and Charlson comorbidity index. ResultsNo significant differences were found in postoperative PROMs or revision rates (P = .58). When stratified by dysplasia severity, patients who had lower lateral center edge angle had more improvement in physical function scores from preoperative to 2 weeks (P < .01) and higher physical function scores at 2 weeks (P = .03). When stratified by OA severity, patients who had a worse Tönnis score had more improvement in physical function scores from preoperative to 2 weeks (P < .01). Recovery curves in dysplasia patients based on dysplasia and OA severity were not significantly different at 6 weeks, 1 year, and 2 years postoperative. ConclusionsPatients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. We believe that THA is a reasonable surgical intervention for symptomatic dysplasia patients who have mild arthritis and do not qualify for periacetabular osteotomy.

Developing a Computer Vision Model to Automate Quantitative Measurement of Hip-Knee-Ankle Angle in Total Hip and Knee Arthroplasty Patients

BackgroundIncreasing deformity of the lower extremities, as measured by the hip-knee-ankle angle (HKAA), is associated with poor patient outcomes after total hip and knee arthroplasty (THA, TKA). Automated calculation of HKAA is imperative to reduce the burden on orthopaedic surgeons. We proposed a detection-based deep learning (DL) model to calculate HKAA in THA and TKA patients and assessed the agreement between DL-derived HKAAs and manual measurement. MethodsWe retrospectively identified 1,379 long-leg radiographs (LLRs) from patients scheduled for THA or TKA within an academic medical center. There were 1,221 LLRs used to develop the model (randomly split into 70% training, 20% validation, and 10% held-out test sets); 158 LLRs were considered “difficult,” as the femoral head was difficult to distinguish from surrounding tissue. There were 2 raters who annotated the HKAA of both lower extremities, and inter-rater reliability was calculated to compare the DL-derived HKAAs with manual measurement within the test set. ResultsThe DL model achieved a mean average precision of 0.985 on the test set. The average HKAA of the operative leg was 173.05 ± 4.54°; the nonoperative leg was 175.55 ± 3.56°. The inter-rater reliability between manual and DL-derived HKAA measurements on the operative leg and nonoperative leg indicated excellent reliability (intraclass correlation (2,k) = 0.987 [0.96, 0.99], intraclass correlation (2, k) = 0.987 [0.98, 0.99, respectively]). The standard error of measurement for the DL-derived HKAA for the operative and nonoperative legs was 0.515° and 0.403°, respectively. ConclusionsA detection-based DL algorithm can calculate the HKAA in LLRs and is comparable to that calculated by manual measurement. The algorithm can detect the bilateral femoral head, knee, and ankle joints with high precision, even in patients where the femoral head is difficult to visualize.

Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients

BackgroundThe prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states. MethodsWe prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. ResultsSeven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%). ConclusionsThe use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.