Demographics and Early Outcomes of Commercial Antibiotic Cement Usage for Infection Prophylaxis During Primary Total Knee Arthroplasty in Patients Older Than 65 Years: An American Joint Replacement Registry Study.

INTRODUCTION: The use of antibiotic-laden bone cement (ALBC) for infection prophylaxis in the setting of primary total knee arthroplasty (TKA) remains controversial. Using data from the American Joint Replacement Registry (AJRR), (1) we examined the demographics of ALBC usage in the United States and (2) identified the effect of prophylactic commercially available ALBC on early revision and readmission for prosthetic joint infection (PJI) after primary TKA. METHODS: This is a retrospective cohort study of the AJRR from 2017 to 2020. Patients older than 65 years undergoing primary cemented TKA with or without the use of commercially available antibiotic cement were eligible for inclusion (N = 251,506 patients). Data were linked to available Medicare claims to maximize revision outcomes. Demographics including age, sex, race/ethnicity, Charlson Comorbidity Index (CCI), preoperative inflammatory arthritis, region, and body mass index (BMI) class were recorded. Cox proportional hazards regression analysis was used to evaluate the association between the two outcome measures and ALBC usage. RESULTS: Patients undergoing cemented TKA with ALBC were more likely to be Non-Hispanic Black ( P < 0.001), have a CCI of 2 or 3 ( P < 0.001), reside in the South ( P < 0.001), and had a higher mean BMI ( P < 0.001). In the regression models, ALBC usage was associated with increased risk of 90-day revision for PJI (hazards ratio 2.175 [95% confidence interval] 1.698 to 2.787) ( P < 0.001) and was not associated with 90-day all-cause readmissions. Male sex, higher CCI, and BMI >35 were all independently associated with 90-day revision for PJI. DISCUSSION: The use of commercial ALBC in patients older than 65 years for primary TKA in the AJRR was not closely associated with underlying comorbidities suggesting that hospital-level and surgeon-level factors influence its use. In addition, ALBC use did not decrease the risk of 90-day revision for PJI and was not associated with 90-day readmission rates.

Effects of Acetabular Screws on the Initial Stability of Porous Coated Acetabular Implants in Revision Total Hip Arthroplasty.

INTRODUCTION: Revision total hip arthroplasty in the setting of acetabular bone loss remains a challenging clinical entity. Deficiencies of the acetabular rim, walls, and/or columns may limit the bony surface area and initial acetabular construct stability necessary for osseointegration of cementless components. Press-fit acetabular components with supplemental acetabular screw fixation represent a common technique aimed to minimize implant micromotion and allow for definitive osseointegration. Although acetabular screw fixation is commonly practiced in revision hip arthroplasty, few studies to date have examined the screw properties associated with maximal acetabular construct stability. The purpose of the present report is to examine acetabular screw fixation in a pelvis model mimicking Paprosky IIB acetabular bone loss. METHODS: Measuring bone-implant interface micromotion as a surrogate for initial implant stability, experimental models assessed the effect of screw number, screw length, and screw position on construct stability subject to a cyclic loading protocol designed to replicate joint reaction forces of two common daily activities. RESULTS: Trends towards increasing stability were demonstrated with increasing screw number, increasing screw length, and concentrating screws in the supra-acetabular dome. All experimental constructs yielded micromotion levels sufficient for bone ingrowth, except when screws in the dome were moved to the pubis and ischium. CONCLUSIONS: When using a porous coated revision acetabular implant to treat Paprosky IIB defects, screws should be used, and furthermore, increasing number, length, and position within the acetabular dome may help further stabilize the construct.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review.

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty.

Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.

The Impact of Total Hip Arthroplasty Surgical Approach on Patient-Reported Outcomes Measurement Information System Computer Adaptive Tests of Physical Function and Pain Interference.

BACKGROUND: The present study examines Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) scores for domains of physical function (PF) and pain interference (PI) in patients undergoing elective THA from either a direct anterior or posterior surgical approach. METHODS: A total of 1358 patients who underwent THA at our institution from 1/1/2015 to 12/1/2018 were identified. Visual analog scale (VAS) pain scores, PROMIS CAT PF and PI data were collected at the last preoperative visit as well as 6 weeks, 6 months, and 1-2 years postoperatively. Literature-derived minimum clinically important difference (MCID) for PROMIS CAT PF metric with regard to THA was used for data comparison. RESULTS: Four hundred nine patients were included in the final analysis. Fifty-one percent underwent a posterior approach, and 49% underwent a direct anterior approach. Both approaches led to a significant improvement in PROMIS CAT PF and PI scores. Patients undergoing a direct anterior approach had significantly higher preoperative and postoperative PROMIS CAT PF scores as well as significantly lower preoperative PROMIS CAT PI scores. Each approach yielded similar interval improvements of PROMIS CAT PF and PI. One hundred three direct anterior approach THA patients (51%) and 119 posterior approach THA patients (57.5%) achieved PROMIS PF MCID at 1- to 2-year follow-up. CONCLUSION: Neither the direct anterior nor posterior THA surgical approach conferred an advantage to postoperative improvements of PROMIS CAT PF and PI scores. Adult reconstructive surgeons should continue to execute the direct anterior or posterior THA surgical approaches based upon personal preference. Despite surgeon confidence in THA, the potential for further innovation exists given the number of THA patients who failed to achieve PROMIS PF MCID.

Total hip arthroplasty: the mini-posterior approach.

A successful surgical exposure during total hip arthroplasty must not only provide adequate visualization of both the acetabulum and the proximal femur but also avoid injury to critical neurovascular structures and minimize dissection of soft-tissue hip stabilizers. Numerous surgical approaches to the hip have been described and subsequently modified since the advent of modern total hip arthroplasty. Descendent from the standard posterolateral approach, the mini-posterior approach not only satisfies the prerequisites for a successful total hip arthroplasty exposure but also exemplifies a utilitarian approach to the hip, which is applicable to the entire spectrum of reconstructive cases.

Periacetabular osteotomy: intra-articular work.

The goal of periacetabular osteotomy (PAO) is to correct acetabular pathomorphology and restore a more normal interplay between the acetabulum and proximal femur. After PAO, the biomechanically improved hip joint is presumed to better resist the progression of degenerative joint disease. Isolated PAO without intra-articular inspection often will underestimate the extent of hip disease in young adults. If intra-articular inspection is not performed at the time of PAO, chondrolabral injuries and dysplastic hip pathologies associated with femoroacetabular impingement will not be detected. The interaction of the acetabulum with the proximal femur is critical, and the presence of iatrogenic femoroacetabular impingement can be assessed with intra-articular inspection at the time of PAO.

Prevalence and treatment of intraarticular pathology recognized at the time of periacetabular osteotomy for the dysplastic hip.

BACKGROUND: The indication for hip arthrotomy accompanied by intraarticular work during periacetabular osteotomy (PAO) has not been precisely defined. To validate a role for routine hip arthrotomy accompanied by intraarticular work, frequent intraarticular pathology must exist, and the adjunct procedures must not be associated with inferior relief of pain, reduced function, radiographic osteoarthritis progression, or conversion to THA. QUESTIONS/PURPOSES: (1) What is the prevalence of intraarticular pathology at the time of PAO? (2) Does concomitant hip arthrotomy with associated intraarticular work negatively affect PAO as reflected by differences in Harris hip scores (HHS), Tönnis grade, and failure rates? METHODS: We retrospectively reviewed the intraarticular findings in all 151 patients who underwent PAO accompanied by routine hip arthrotomy and intraarticular work from 2002 to 2009. Using multivariate regression models, we compared the HHS and Tönnis grades of patients receiving arthrotomy with a cohort of 39 patients who received PAO alone. RESULTS: The overall prevalence of intraarticular pathology identified during PAO was 89%. Eight (5.3%) failures were identified within the arthrotomy cohort with mean postoperative HHS, postoperative Tönnis grade, postoperative change in HHS, and postoperative change in Tönnis grade of 87.5, 0.7, 29.8, and 0.3, respectively. By contrast, seven (17.9%) failures were identified in the nonarthrotomy cohort. The mean postoperative HHS, postoperative Tönnis grade, postoperative change in HHS, and postoperative change in Tönnis grade for the nonarthrotomy cohort were 83.1, 1.3, 19.0, and 0.3, respectively. CONCLUSIONS: We believe the high prevalence of intraarticular pathology is sufficient to warrant routine joint inspection at the time of PAO. Hip arthrotomy accompanied by intraarticular work at the time of PAO is safe and does not impose additional patient morbidity. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy.

BACKGROUND: The successful treatment of chronic mid-substance Achilles tendinopathy remains elusive. Approximately 25% to 50% of patients fail conservative treatment modalities. Scientific evidence has supported the use of platelet rich plasma (PRP) in the tendon healing process, however despite initial promise there is a paucity of clinical data to validate a role for PRP in the treatment of tendon disorders including chronic midsubstance Achilles tendinopathy. METHODS: As an alternative to operative treatment, our practice offers patients with chronic midsubstance Achilles tendinopathy intratendinous injection of PRP. We retrospectively reviewed all patients treated for Achilles tendinopathy with PRP injection over a 2-year period. Baseline and post injection functional scores including the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Ability Measure - Sports (FAAMS), and the Short Form health survey (SF-8) were examined. Patients also underwent post-injection magnetic resonance imaging (MRI), which were compared to available pre-injection MRI data. RESULTS: Ten patients were identified for this study. Pre- and postinjection functional outcome scores were available for eight of ten patients. The average SF-8 score improved from 24.9 to 30.0, the average FAAM score improved from 55.4 to 65.8, and the average FAAMS score improved from 14.8 to 17.4. Complete MRI data was available for six patients. Only one in six Achilles tendons demonstrated qualitative MRI improvement post-injection. CONCLUSION: Patients who received PRP injection demonstrated modest improvement in functional outcome measures, however MRI appearance of diseased Achilles tendons remained largely unchanged following PRP injection.