The Growing Role of Artificial Intelligence and Technology in Hip and Knee Arthroplasty.

Artificial intelligence and technology have continued to evolve over recent decades, and their utility in hip and knee arthroplasty is growing with interest and enthusiasm. A multitude of technologies are available to assist surgeons in the intraoperative execution of hip and knee arthroplasty, ranging from robotics and augmented reality to artificial intelligence-powered fluoroscopy. The purpose of this review is to provide a framework for arthroplasty surgeons to understand the concept of artificial intelligence and the advancements in technologies that impact the perioperative care of patients undergoing hip and knee arthroplasty.

Robotic-arm-assisted conversion of unicompartmental knee arthroplasty to total knee arthroplasty.

Introduction: The purpose of this study was to describe a novel robotic-arm-assisted UKA to TKA conversion technique and evaluate the patient reported and clinical outcomes in these patients. Methods: A retrospective review between 2017 and 2022 was conducted of patients that underwent robotic-arm-assisted UKA to TKA conversion. Charts were reviewed for patient demographics, indications for conversion from UKA to TKA, operative technique, implants used, postoperative complications, and patient-reported outcome measures (PROMs). The surgical technique resembles that of primary TKA, with the major exception of registering the robotic arm with retained UKA implants and removing the implants only when verification is complete. There were 44 robotic-arm-assisted UKAs in 41 patients were included in the study. Indications for UKA conversion to TKA included: 33 patients who had osteoarthritis progression (75%), 7 aseptic loosening (16%), 2 unspecified pain (4.5%), 1 polyethylene wear (2.3%), and 1 prosthetic joint infection (2.3%). Uncemented cruciate-retaining (CR) implants were used in 38 of the 44 robotic-arm-assisted TKAs (86.5%). The other six utilized cemented implants: four CR femurs (9.1%), six tibial baseplates (13.6%), four tibial stems (9.1%), and four medial tibial augments (9.1%). Results: The PROMs significantly improved at 1-year follow-up, with the average KOOS JR score increasing from 48.1 to 68.7 (P < 0.001), and the r-WOMAC score decreasing from 25.7 to 10.6 (P = 0.003). Two patients developed prosthetic joint infections (4.5%), one developed aseptic loosening of the femoral component (2.3%), and one developed a superficial surgical site infection requiring superficial irrigation and debridement (2.3%). Overall survivorship was 93.18% at 1.8 years, and aseptic survivorship was 97.73%. Conclusion: Robotic-arm-assisted UKA to TKA conversion exhibited improved patient-reported outcomes and low revision and complication rates. Improved implant placement achieved with robotic-arm-assistance may improve the functional and clinical outcomes following these surgeries.

The Role of a New Hinged Total Knee Arthroplasty System for Use in a Variety of Complex Knee Scenarios: A Case Series.

Hinged knee arthroplasties are commonly used in scenarios where there are major ligament deficiencies or bone loss around the knee. They are applicable in native knees with major deformities and during revisions. They can also be used as a salvage procedure after distal femoral resection. The new modular hinged device system, namely the Triathlon Hinge Knee (THK) System (Stryker, Mahwah, New Jersey), reflects the advancements of third-generation design and enhances surgical flexibility by allowing streamlined integration with the Triathlon Total Stabilized (TS) System (Stryker, Mahwah, New Jersey) and the Global Modular Replacement System (GMRS, Stryker, Mahwah, New Jersey). Additionally, the Triathlon Revision Tibial Baseplate (Stryker, Mahwah, New Jersey) has been launched as part of THK and is compatible with the Modular Rotating Hinge (MRH , Stryker, Mahwah, New Jersey) femur, which allows the Revision Baseplate to replace the existing tibial component while leaving the existing MRH Femoral Component in place. The Triathlon Revision Tibial Baseplate enables orthopaedic surgeons to use constrained or hinged prostheses, including both distal and total femoral replacement options, without changing the Tibial Baseplate. This is because the TS, MRH, THK, and GMRS femurs are compatible with the new Triathlon Revision Tibial Baseplate. Additionally, the system can be augmented with metaphyseal cone constructs to help provide a stable foundation for reconstruction. This report explores the application of a new modular hinged device system in various scenarios, starting with (1) complex primary hinged knee arthroplasty, followed by revision hinged knee arthroplasty cases including (2) failed TKA with medial collateral ligament (MCL) dysfunction, (3) severe arthrofibrosis post-TKA, (4) revisions for prosthetic joint infection, (5) extensor mechanism deficiency, and (6) arthrofibrosis with extensor mechanism disruption, concluding with a case of (7) distal femoral arthroplasty for periprosthetic fracture post-failed TKA.

The Effect of Insurance Type on Length of Stay Following Total Knee Arthroplasty.

INTRODUCTION: With the expansion of the Affordable Care Act in 2014, there has been a growing interest in how the Medicaid population will affect postoperative outcomes following total knee arthroplasty (TKA). Studies have shown that lower socioeconomic status, non-Caucasian race, women, cardiac and renal disorders, and younger age have been associated with increased lengths of stay (LOS) after TKA. The primary purpose of our study was to compare total complications and LOS among patients undergoing TKA who have cash, commercial, government, Medicaid, and Medicare insurances. METHODS: We queried a national, all-payer administrative claims database from 2016 to 2022 among patients undergoing TKA who had cash (n = 3,923), commercial (n = 966,169), government (n = 25,644), Medicaid (n = 56,184), and Medicare (n = 524,034) insurances. We compared and analyzed various baseline demographics, total complications, and LOS (< 1 day, 1 to 2 days, 3 to 4 days, and > 4 days), between the insurance types. RESULTS: Medicaid and Medicaid insurance types had patients who had the most comorbidities at baseline, including a comorbidity index > 3 (P < 0.0001), women, alcohol abuse, diabetes, obesity, tobacco use, chronic kidney disease, and congestive heart disease (all P < 0.0001). In accounting for comorbidities, Medicaid was the biggest risk factor for total complications (P < 0.001) as well as increased LOS after TKA at 4 to 6 days, 7 to 9 days, and > 9 days (P < 0.0001). CONCLUSION: Medicaid insurance is a risk factor for increased total complications and LOS following TKA. Appropriate preoperative and perioperative management of these patients is essential in order to mitigate the risk and burden on the healthcare system in this population.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

INTRODUCTION: In orthopaedic surgery, particularly total knee arthroplasty (TKA), the management of surgical wounds is critical for optimal wound healing and successful patient outcomes. Despite advances in surgical techniques, challenges persist in effectively managing surgical wounds to prevent complications and infections. This study aimed to identify and address the critical evidence gaps in wound management in TKA, including preoperative optimization, intraoperative options, and for the avoidance of postoperative complications. These are important issues surrounding wound management, which is essential for improving patient recovery and the overall success of the surgery. METHODS: Utilizing the Delphi method, this study brought together 20 experienced orthopaedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 specific statements about wound management in TKA based on a comprehensive literature review. During these three stages and after further panel review, an alternative goal of the Delphi panel was to also identify critical evidence gaps in the current understanding of wound management practices for TKA. RESULTS: While the panel reached consensus on various wound management practices, they highlighted several major evidence gaps. Also, there was general consensus on issues such as wound closure methods including the use of mesh-adhesive dressings, skin glue, staples, sutures (including barbed sutures),and negative-pressure wound therapy (NPWT). However, it was deemed necessary that further evidence needs to be generated to address the cost-effectiveness of each and develop best practices for promoting patient outcomes. The identification of these gaps points to areas requiring more in-depth research and improvements to enhance wound care in TKA. DISCUSSION: The identification of these major evidence gaps underscores the need for targeted research in wound management surrounding TKA. Addressing these evidence gaps is crucial for the future development of more effective, efficient, and patient-friendly wound care strategies. Future research should prioritize these areas, focusing on comparative effectiveness studies and further developing clear guidelines for the use of emerging technologies. Bridging these gaps has the potential to improve patient outcomes, reduce complications, and elevate the overall success rate of TKA surgeries.

Phase 1 study of the pharmacokinetics and clinical proof-of-concept activity of a biofilm-disrupting human monoclonal antibody in patients with chronic prosthetic joint infection of the knee or hip.

We report the results of a first-in-human phase 1 clinical study to evaluate TRL1068, a native human monoclonal antibody that disrupts bacterial biofilms with broad-spectrum activity against both Gram-positive and Gram-negative species. The study population consisted of patients with chronic periprosthetic joint infections (PJIs) of the knee or hip, including both monomicrobial and polymicrobial infections, that are highly resistant to antibiotics due to biofilm formation. TRL1068 was administered via a single pre-surgical intravenous infusion in three sequentially ascending dose groups (6, 15, and 30 mg/kg). Concomitant perioperative antibiotics were pathogen-targeted as prescribed by the treating physician. In this double-blinded study, 4 patients were randomized to receive placebo and 11 patients to receive TRL1068 on day 1, as well as targeted antibiotics for 7 days prior to the scheduled removal of the infected implant and placement of an antibiotic-eluting spacer as the first stage of the standard of care two-stage exchange arthroplasty. No adverse events attributable to TRL1068 were reported. TRL1068 serum half-life was 15-18 days. At day 8, the concentration in synovial fluid was approximately 60% of the blood level and thus at least 15-fold above the threshold for biofilm-disrupting activity in vitro. Explanted prostheses were sonicated to release adherent bacteria for culture, with elimination of the implant bacteria observed in 3 of the 11 patients who received TRL1068, which compares favorably to prior PJI treatments. None of the patients who received TRL1068 had a relapse of the original infection by the end of the study (day 169). CLINICAL TRIALS: This study is registered with ClinicalTrials.gov as NCT04763759.

An Advanced Knee Simulator Model Can Reproducibly Be Used for Ligament Balancing Training during Total Knee Arthroplasty.

A critical and difficult aspect of total knee arthroplasty (TKA) is ligamentous balancing for which cadavers and models have played a large role in the education and training of new arthroplasty surgeons, although they both have several shortcomings including cost, scarcity, and dissimilarity to in vivo ligament properties. An advanced knee simulator (AKS) model based on computed tomography (CT) scans was developed in the setting of these challenges with cadavers and previous models. In this study, we compared the ligament balancing between AKS and human cadaveric knees to assess the validity of using the AKS for ligament balancing training during TKA. A CT scan of a TKA patient with varus deformity was used to design the AKS model with modular components, using three-dimensional printing. Three fellowship-trained arthroplasty surgeons used technology-assisted TKA procedure to plan and balance three cadaver knees and the AKS model. Medial and lateral laxity data were captured using manual varus and valgus stress assessments for cadavers and the model in an extension pose (10 degrees of flexion from terminal extension) and between 90 and 95 degrees for flexion. After preresection assessments, surgeons planned a balanced cruciate-retaining TKA. Following bony cuts and trialing, extension and flexion ligament laxity values were recorded in a similar manner. Descriptive statistics and Student's t-tests were performed to compare the cadavers and model with a p-value set at 0.05. Preresection medial/lateral laxity data for both extension and flexion were plotted and showed that the highest standard deviation (SD) for the cadavers was 0.67 mm, whereas the highest SD for the AKS was 1.25 mm. A similar plot for trialing demonstrated that the highest SD for the cadavers was 0.6 mm, whereas the highest SD for the AKS was 0.61 mm. The AKS trialing data were highly reproducible when compared with cadaveric data, demonstrating the value of the AKS model as a tool to teach ligament balancing for TKA and for future research endeavors.

Improved Pain and Function With Triamcinolone Acetonide Extended-Release and Cryoneurolysis for Knee Osteoarthritis: Use of a New Real-World Registry.

BACKGROUND: Knee osteoarthritis (OA) affects 19% of American adults aged more than 45 years and costs $27+ billion annually. A wide range of nonoperative treatment options are available. This study compared 6 treatments: cryoneurolysis with deep genicular nerve block (Cryo-Deep/Both), cryoneurolysis with superficial nerve block (Cryo-Superficial), intra-articular hyaluronic acid (IA-HA) injections, nonsteroidal anti-inflammatory drug injections (IA-NSAIDs), IA-corticosteroids (IA-CS) injections, or IA-triamcinolone extended release (IA-TA-ER) injections over 4 months for: (1) pain severity and analgesic use; and (2) physical function (from Knee Injury and Osteoarthritis Outcome Score for Joint Replacement). METHODS: Patients who had unilateral knee OA and received nonoperative intervention were enrolled in the Innovations in Genicular Outcomes Research registry, a novel, multicenter real-world registry, between September 2021 and February 2024. A total of 480 patients were enrolled. Both pain and functional outcomes were assessed at baseline, weekly, and monthly, which were analyzed by overall trend, magnitude changes pretreatment to post-treatment, and distribution-based minimally clinically important difference (MCID) score. Multivariate linear regressions with adjustments for 7 confounding factors were used to compare follow-up outcomes among 6 treatment groups. RESULTS: Use of IA-TA-ER injections was associated with the lowest pain, greatest pain reduction, and highest prevalence of patients achieving MCID relative to other treatments (P < .001). Deep/Both-Cryo and IA-CS were associated with a higher prevalence of achieving MCID than IA-HA, IA-NSAIDs, and Cryo-Superficial (P ≤ .001). Use of IA-TA-ER was also associated with the greatest functional score, improvement from baseline, and highest prevalence of patients achieving MCID than other treatments (P ≤ .003). CONCLUSIONS: The IA-TA-ER appears to outperform other treatments in terms of pain relief and functional improvement for up to 4 months following treatment. In addition, outcomes in the novel cryoneurolysis and conventional IA-CS were similar to one another and better than those in IA-HA and IA-NSAIDs.

Cryoneurolysis Associated With Improved Pain, Function, and Sleep in Patients Following total Knee Arthroplasty: Use of a New Real-World Registry.

BACKGROUND: Total knee arthroplasty (TKA) is performed on approximately 790,000 patients annually in the United States and is projected to increase to 1.5 million by 2050. This study aimed at assessing the use of preoperative cryoneurolysis on patients undergoing TKA by analyzing: (1) pain severity; (2) opioid use; (3) functional status; and (4) sleep disturbance (SD) over 6 months following discharge. METHODS: Patients enrolled in the Innovations in Genicular Outcomes Registry between September 2021 and February 2024 were followed for 6 months. Our analyses included patients undergoing unilateral primary TKA with no preoperative opioid prescription, who either received cryoneurolysis, or did not. Baseline patient demographics were collected before TKA and tabulated. Pain management was assessed via the Brief Pain Inventory-Short Form instrument for pain severity. SD was measured using the patient-reported outcomes measurement information system questionnaire. Each outcome measure was assessed prior to TKA, weekly, and at monthly follow-up. Data were analyzed by a generalized linear mixed-effect regression model to compare cryoneurolysis versus control patients, with a P < .05 as significant. RESULTS: There were 80 patients who were treated with preoperative cryoneurolysis, while 60 control patients did not have treatment. Patients receiving cryoneurolysis experienced significantly lower pain severity and SD over the 6-month follow-up than control patients (P = .046). Cryoneurolysis was also associated with a trend toward greater functional improvement that did not reach statistical significance (P = .061). Further, patients who underwent cryoneurolysis were 72% less likely than control group patients to take opioids over 6 months following discharge (P < .001). CONCLUSIONS: Preoperative cryoneurolysis therapy in opioid-naive patients undergoing TKA is associated with improved pain, decreased opioid use, and improved SD for 6 months postoperatively. Cryoneurolysis, a nonopioid pain relief modality administered preoperatively, demonstrated substantial benefits in patients who underwent TKA.

Total Knee Arthroplasty in Human Immunodeficiency Virus Patients: A Literature Review.

Background: Total knee arthroplasty (TKA) has become a common surgical intervention for human immunodeficiency virus (HIV)-positive patients who develop osteonecrosis of the knee. This paper summarized existing literature regarding the outcomes of HIV-positive patients undergoing TKA in 4 subsections: (1) complications; (2) survivorship analyses; (3) patient-reported outcomes; and (4) infections. Methods: A review of PubMed was performed, searching for articles focused on HIV-positive patients undergoing TKA. There were 6 reports selected, containing 4765 HIV-positive patients, and data regarding the various domains was tabulated and analyzed. To ensure article quality, a methodology score and level of evidence were determined for selected studies. Results: Complication rates for HIV-positive patients were low, with a larger study reporting that 7.8% of HIV-positive patients developed a complication in comparison to 8% of HIV-negative patients. Survivorship analyses showed similar results, with a study reporting implant survivorship of 98% for HIV-positive and 99% for HIV-negative patients. There were no differences in patient-reported outcomes; HIV-positive patients improved from baseline with respect to the mean Knee Society objective and mean Knee Society functional scores, and the University of California, Los Angeles self-reported activity levels. The infection rate for HIV-positive patients was low, with a larger database study reporting that 0.6% of HIV-positive patients developed a wound infection in comparison to 0.4% of HIV-negative patients. Conclusions: A TKA is an effective treatment for HIV-positive patients who develop osteonecrosis of the knee. Results showed similar patient-reported outcomes, implant survivorships, revisions, and complication rates when compared to non-HIV patients.

Oxidation and Damage Mechanisms of Second-Generation Highly Cross-Linked Polyethylene Tibial Inserts.

BACKGROUND: After clinical introduction in 2005, sequentially annealed, highly cross-linked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices of SA HXLPE and conventional gamma inert-sterilized (Gamma Inert) ultra-high-molecular-weight polyethylene tibial inserts implanted for >5 years. METHODS: There were 74 total knee arthroplasty tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for >5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semiquantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials 2102. Differences between cohorts were assessed with Mann-Whitney U-tests. RESULTS: Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = .022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = .002) and anterior-posterior faces (P = .023). No difference was observed at the backside surface (P = .060). CONCLUSIONS: Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years.

Patients with Osteoporosis Are at Higher Risk for Periprosthetic Femoral Fractures and Aseptic Loosening Following Total Hip Arthroplasty.

This report provides an updated analysis for patients with osteoporosis following total hip arthroplasty (THA). The comorbidities of alcohol abuse, chronic kidney disease, cerebrovascular disease, obesity, and rheumatoid arthritis continue to be significant risk factors for periprosthetic femur fracture (PPFFx) and aseptic loosening in the population with osteoporosis. Patients with dual-energy x-ray absorptiometric (DEXA) scans were at risk for PPFFx regardless of femoral fixation method, and patients with DEXA scans with cementless fixation were at risk of aseptic loosening after THA. The patient population with severe osteoporosis may have higher risks for aseptic loosening and PPFFx than previously recognized.

Total Knee Arthroplasty With or Without Prior Bariatric Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Studies comparing the outcomes of bariatric surgery followed by total knee arthroplasty (TKA) versus TKA alone in obese patients have disparate results. This systematic review and meta-analysis sought to compare TKA with and without prior bariatric surgery in obese patients. METHODS: MEDLINE, PubMed, and Embase were searched from inception to April 9, 2023. There were twelve included studies that yielded 2,876,547 patients, of whom 62,818 and 2,813,729 underwent TKA with and without prior bariatric surgery, respectively. Primary outcomes were medical complications (ie, urinary tract infection, pneumonia, renal failure, respiratory failure, venous thromboembolism [VTE], arrhythmia, myocardial infarction, and stroke); surgical complications (ie, wound complications [eg, infection, hematoma, dehiscence, delayed wound healing, and seroma], periprosthetic joint infection, mechanical complications, periprosthetic fracture, knee stiffness, and failed hardware); revision, and mortality. Secondary outcomes were blood transfusion, length of stay (day), and readmission. RESULTS: The odds ratios (OR) of 90-day VTE (OR = 0.75 [0.66, 0.85], P < .00001), 90-day stroke (OR = 0.58 [0.41, 0.81], P = .002), and 1-year periprosthetic fracture (OR = 0.74 [0.55, 0.99], P = .04) were lower in those who underwent bariatric surgery before TKA. Although the mean difference in hospital stays (-0.19 days [-0.23, -0.15], P < .00001) was statistically less in those who underwent bariatric surgery before TKA, it was not clinically relevant. The other outcomes were similar between the groups. CONCLUSIONS: Bariatric surgery before TKA is beneficial in terms of a lower risk of VTE, stroke, and periprosthetic fracture. This analysis suggests surgeons consider discussing bariatric surgery before TKA in obese patients, especially those who are at risk of VTE and stroke.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

INTRODUCTION: The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. METHODS: A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). RESULTS: The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). CONCLUSION: Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

How-To Create an Orthopaedic Systematic Review: A Step-by-step Guide Part II: Study Execution.

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: (1) design, (2) execute, and (3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Nonrandomized Studies criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines is recommended and standard in all scientific literature, including that of orthopedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (eg, publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review.

The effect of fixation type on periprosthetic fractures in high-risk patients who have osteoporosis undergoing total joint arthroplasty.

Introduction: Minimizing the burden of periprosthetic fractures (PFF) following total joint arthroplasty (TJA) with regard to morbidity and mortality remains an outcome of interest. Patient and surgical risk factors, including osteoporosis and fixation type, have not truly been optimized in patients undergoing TJA as a means to reduce the risk of PFF. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA? Methods: We queried an all-payer, national database from April 1, 2016 to December 31, 2021, to identify high-risk and low-risk patients who underwent TJA with a cementless or cemented fixation. High-risk patients met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years old who have the following: tobacco use, alcohol abuse, body mass index <18.5, prior fragility fracture, chronic systemic corticosteroids, or genetic condition affecting sex hormones or bone mineral density. Exclusion criteria were a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and a minimum follow-up of less than 2 years. Results: There were 384,783 patients (67.1 %) who underwent cementless TKA and 67,774 patients (11.8 %) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9 %) who underwent cemented THA and 58,667 patients (10.2 %) who underwent cementless THA and were considered high risk. The cementless cohort had a 5-year periprosthetic fracture risk following TKA of 7.8 % (95 % CI, 5.56 to 10.98) in comparison to 4.30 % in the cemented cohort (85 % CI, 3.98 to 4.65), P < 0.0001. The high-risk cementless cohort had a 5-year periprosthetic fracture risk following THA of 7.9 % (95 % confidence interval (CI), 6.87 to 9.19) in comparison to 7.78 % in the cemented cohort (85 % CI, 6.77 to 8.94), P < 0.0001. Conclusion: There is an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but no clinically meaningful difference between the two groups. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate patients for TJA based on bone quality and fracture risk can help expedite the process of improving the current state of practice.