Is a Failed Spinal Attempt Associated with a Worse Clinical Course Following Primary Total Hip and Knee Arthroplasty?

INTRODUCTION: Spinal anesthesia (SA) is the preferred anesthesia modality for total joint arthroplasty (TJA). However, studies establishing SA as preferential may be subject to selection bias given that general anesthesia (GA) is often selectively utilized on more difficult, higher-risk operations. The optimal comparison group, therefore, is the patient converted to GA due to a failed attempt at SA. The purpose of this study was to determine risk factors and outcomes following failed SA with conversion to GA during primary total hip (THA) or knee arthroplasty (TKA). METHODS: A consecutive cohort of 4,483 patients who underwent primary TJA at our institution was identified (2,004 THA and 2,479 TKA). Of these patients, 3,307 underwent GA (73.8%), 1,056 underwent SA (23.3%), and 130 patients failed SA with conversion to GA (2.90%). Primary outcomes included rescue analgesia requirement in the post-anesthesia care unit (PACU), time to ambulation, pain scores in the PACU, estimated blood loss (EBL), and 90-day complications. RESULTS: Risk factors for SA failure included older age and a higher comorbidity burden. Failure of SA was associated with increased EBL, rescue intravenous (IV) opioid use, and time to ambulation when compared to the successful SA group in both THA and TKA patients (P < 0.001). The anesthesia modality was not associated with significant differences in PACU pain scores. The 90-day complication rate was similar between the failed SA and GA groups. There was a higher incidence of post-operative pain prompting unplanned visits and thromboembolism when comparing failed SA to successful SA in both THA and TKA patients (P < 0.05). CONCLUSION: In our series, patients who had failed SA demonstrated inferior outcomes to patients receiving successful SA and similar outcomes to patients receiving GA who did not have an SA attempt. This emphasizes the importance of success in the initial attempt at SA for optimizing outcomes following TJA.

The wake- and sleep-modulating neurons of the lateral hypothalamic area demonstrate a differential pattern of degeneration in Alzheimers disease.

BACKGROUND: Sleep-wake dysfunction is an early and common event in Alzheimer's disease (AD). The lateral hypothalamic area (LHA) regulates the sleep and wake cycle through wake-promoting orexinergic neurons (OrxN) and sleep-promoting melanin-concentrating hormone or MCHergic neurons (MCHN). These neurons share close anatomical proximity with functional reciprocity. This study investigated LHA OrxN and MCHN loss patterns in AD individuals. Understanding the degeneration pattern of these neurons will be instrumental in designing potential therapeutics to slow down the disease progression and remediate the sleep-wake dysfunction in AD. METHODS: Postmortem human brain tissue from donors with AD (across progressive stages) and controls were examined using unbiased stereology. Formalin-fixed, celloidin-embedded hypothalamic sections were stained with Orx-A/MCH, p-tau (CP13), and counterstained with gallocyanin. Orx or MCH-positive neurons with or without CP13 inclusions and gallocyanin-stained neurons were considered for stereology counting. Additionally, we extracted RNA from the LHA using conventional techniques. We used customized Neuropathology and Glia nCounter (Nanostring) panels to study gene expression. Wald statistical test was used to compare the groups, and the genes were considered differentially expressed when the p-value was <.05. RESULTS: We observed a progressive decline in OrxN alongside a relative preservation of MCHN. OrxN decreased by 58% (p=0.03) by Braak stages (BB) 1-2 and further declined to 81% (p=0.03) by BB 5-6. Conversely, MCHN demonstrated a non-statistical significant decline (27%, p=0.1088) by BB 6. We observed a progressive increase in differentially expressed genes (DEGs), starting with glial profile changes in BB2. While OrxN loss was observed, Orx-related genes showed upregulation in BB 3-4 compared to BB 0-1. GO and KEGG terms related to neuroinflammatory pathways were mainly enriched. CONCLUSIONS: To date, OrxN loss in the LHA represents the first neuronal population to die preceding the loss of LC neurons. Conversely, MCHN shows resilience to AD p-tau accumulation across Braak stages. The initial loss of OrxN correlates with specific neuroinflammation, glial profile changes, and an overexpression of HCRT, possibly due to hyperexcitation following compensation mechanisms. Interventions preventing OrxN loss and inhibiting p-tau accumulation in the LHA could prevent neuronal loss in AD and, perhaps, the progression of the disease.

Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations. METHODS: This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed. RESULTS: There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2). CONCLUSIONS: With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.

Cemented dual-mobility constructs in uncemented revision acetabular components.

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

Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty?

The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.

Glucagon-like Peptide-1 Agonists: What the Orthopaedic Surgeon Needs to Know.

¼ Orthopaedic surgeons are increasingly likely to encounter patients with obesity and/or type 2 diabetes taking glucagon-like peptide-1 (GLP-1) agonists for weight loss.¼ GLP-1 agonists are an effective treatment for weight loss with semaglutide and tirzepatide being the most effective agents. Randomized controlled trials using these agents have reported weight loss up to 21 kg (46 lb).¼ The use of GLP-1 agonists preoperatively can improve glycemic control, which can potentially reduce the risk of postoperative complications. However, multiple cases of intraoperative aspiration/regurgitation have been reported, potentially related to the effect of GLP-1 agonists on gastric emptying.¼ While efficacious, GLP-1 agonists may not produce sufficient weight loss to achieve body mass index cutoffs for total joint arthroplasty depending on individual patient factors, including starting bodyweight. Multifactorial approaches to weight loss with focus on lifestyle modification in addition to GLP-1 agonists should be considered in such patients.¼ Although GLP-1 agonists are efficacious agents for weight loss, they may not be accessible or affordable for all patients. Each patient's unique circumstances should be considered when creating an ideal weight loss plan during optimization efforts.

Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome.

PURPOSE: To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting. CASE REPORT: A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging. CONCLUSION: It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids.

BACKGROUND: Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve. METHODS: Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared. RESULTS: A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not. CONCLUSION: Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Total Hip Arthroplasty Following Operative Fixation of Acetabular Fracture: A Contemporary Series.

BACKGROUND: Total hip arthroplasty (THA) is the operation of choice for salvage of post-traumatic arthritis following acetabular fracture. While high failure rates have been reported for these procedures, existing literature reports mainly on historical implant designs and techniques. We aimed to describe implant survivorships, complications, radiographic results, and clinical outcomes of contemporary THA following prior open reduction internal fixation (ORIF) of an acetabular fracture. METHODS: We identified 104 patients undergoing THA following prior ORIF of an acetabular fracture from 2000 to 2015 via our institutional total joint registry. Mean age at THA was 50 years (range, 18 to 79 years), 71% were men, and mean body mass index was 27 (range, 18 to 52). All patients were implanted with uncemented acetabular components, and 89% had uncemented stems. Some hardware from prior fixation was retained in 94% of cases. Mean follow-up was 10 years (range, 2 to 21 years). RESULTS: The 10-year survivorships free of any revision and any reoperation were 98% and 97%, respectively. There were 4 revisions: 1 each for psoas tendonitis, dislocation, acetabular aseptic loosening, and periprosthetic joint infection. There were 9 complications that did not lead to reoperation: 5 dislocations, 2 periprosthetic femur fractures, 1 sciatic nerve palsy, and 1 case of symptomatic heterotopic ossification. All unrevised components appeared radiographically well-fixed. Mean Harris Hip Score improved from mean 50 preoperatively to mean 82 at 5 years (P < .001). CONCLUSIONS: In this series of contemporary THAs following prior acetabular fracture ORIF, revision-free survivorship was excellent with only a single case of acetabular aseptic loosening. These results are encouraging and suggest that contemporary implants and techniques have notably improved on historic results. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Central Sensitization: The Missing Link Between Psychological Distress and Poor Outcome Following Primary Total Knee Arthroplasty.

BACKGROUND: While preoperative psychological distress is known to predict risk for worse total knee arthroplasty (TKA) outcomes, distress may be too broad and nonspecific a predictor in isolation. We tested whether there are distinct preoperative TKA patient types based jointly on psychological status and measures of altered pain processing that predict adverse clinical outcomes. METHODS: In 112 TKA patients, we preoperatively assessed psychological status (depression, anxiety, and catastrophizing) and altered pain processing via a simple quantitative sensory testing protocol capturing peripheral and central pain sensitization. Outcomes (pain, function, opioid use) were prospectively evaluated at 6 weeks and 6 months after TKA. Cluster analyses were used to empirically identify TKA patient subgroups. RESULTS: There were 3 distinct preoperative TKA patient subgroups identified from the cluster analysis. A low-risk (LR) group was characterized by low psychological distress and low peripheral and central sensitization. In addition, 2 subgroups with similarly elevated preoperative psychological distress were identified, differing by pain processing alterations observed: high-risk centralized pain and high-risk peripheral pain. Relative to LR patients, high-risk centralized pain patients displayed significantly worse function and greater opioid use at 6 months after TKA (P values <.05). The LR and high-risk peripheral pain patient subgroups had similar 6-month outcomes (P values >.05). CONCLUSIONS: Among patients who have psychological comorbidity, only patients who have central sensitization were at elevated risk for poor functional outcomes and increased opioid use. Central sensitization may be the missing link between psychological comorbidity and poor TKA clinical outcomes. Preoperative testing for central sensitization may have clinical utility for improving risk stratification in TKA patients who have psychosocial risk factors.

Removing Cemented Dual Mobility Liners From Acetabular Components: A Technical Tip for a Challenging Surgical Problem.

Dislocation remains the leading cause of failure following revision total hip arthroplasty. Dual mobility (DM) constructs, including monoblock cups designed for cementation, reduce but do not eliminate this risk. Cemented DM constructs offer several unique advantages in revision total hip arthroplasty, and as such, they have gained popularity. Despite their advantages, a portion of these implants will require revision for infection or recurrent dislocation. Removal of a cemented DM cup presents numerous challenges, and there is no effective published technique. Here, we present an effective technique for the safe removal of one design of cemented DM cup.

Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction.

Purpose: To characterize contemporary pain management strategies after anterior cruciate ligament reconstruction (ACLR) within the US and international orthopaedic community. Methods: This was a cross-sectional survey-based study disseminated to a consortium of expert orthopaedic surgeons in the management of anterior cruciate ligament injuries. The survey was a 27-question, multiple choice-style questionnaire with question topics ranging from demographic characteristics and practice characteristics to surgeon-specific pain management strategies in the postoperative period after ACLR. Specific topics of interest included the use of preoperative opioid education and/or counseling sessions, implementation of standardized pain management regimens, use of pain tracking systems, and use of any adjunct non-narcotic analgesic modalities. Results: A total of 34 completed surveys were collected, representing a 73.9% response rate. Over 85% of respondents reported prescribing opioids as a standardized postoperative regimen after ACLR. Surgeons reported prescribing 5- to 10-mg doses, with the tablet count ranging anywhere from fewer than 10 tablets to more than 20 tablets, often instructing their patients to stop opioid use 2 to 4 days postoperatively. Prescribed dosages remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents reported using standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Conclusions: Over 85% of respondents prescribe opioids as a standardized postoperative regimen after ACLR, with only 15% providing non-narcotic pain regimens. However, prescribed dosages have remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents use standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Clinical Relevance: The ongoing opioid epidemic has created an urgent need to identify the most effective pain management strategies after orthopaedic procedures, especially ACLR. This study provides important information about current pain management practices for patients who have undergone ACLR.

Sleep quality is a predictor of muscle mass, strength, quality of life, anxiety and depression in older adults with obesity.

We aimed to investigate associations between sleep quality with selected quantitative and qualitative parameters of health in older individuals with obesity. Cross-sectional assessment (n = 95 men/women; ≥ 65 years; BMI ≥ 30 kg/m2) of sleep quality, body composition, handgrip strength, quality-of-life, anxiety/depression. Mean PSQI score was 6.3. Poor sleepers (n = 49) presented lower appendicular lean mass (ALM) (16.2 vs 17.8 kg; p = 0.0273), ALM/BMI (0.47 vs 0.53 kg/BMI; p = 0.0085), fat mass (48.6 vs 46.6%; p = 0.0464), handgrip strength (19.7 vs 22.0 kgf; p = 0.0542) and handgrip/BMI (0.57 vs 0.66 kgf/BMI; p = 0.0242) than good sleepers. They also had higher anxiety (8.6 vs 5.6; p = 0.0100) and depression (4.8 vs 3.2; p = 0.0197) scores, worse health-related quality-of-life and lower scores in mental (62.8 vs 73.0; p = 0.0223) and physical (52.9 vs 67.3; p = 0.0015) domains. Adjusted models showed that PSQI was negatively associated with ALM (ß = - 0.13, 95% CI - 0.25; - 0.01) and health-related quality of life on physical (ß = - 2.76, 95% CI - 3.82; - 1.70) and mental (ß = - 2.25, 95% CI - 3.38; - 1.12) domains, and positively associated with anxiety (ß = 0.57; 95% CI 0.26; 0.87) and depression (ß = 0.31; 95% CI 0.13; 0.49). Poor sleep quality associates with impaired selected quantitative and qualitative parameters of health. Additionally, sleep quality was shown as an independent predictor of ALM, health-related quality-of-life, anxiety and depression in older individuals with obesity.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty.

BACKGROUND: The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA). METHODS: Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics. CONCLUSIONS: The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

Assessment of the Efficacy of a Low-Dose Iron Supplement in Restoring Iron Levels to Normal Range among Healthy Premenopausal Women with Iron Deficiency without Anemia.

(1) Background: Iron deficiency without anemia (IDWA) is a prevalent health concern in premenopausal women. Oral supplementation of iron may be a viable solution to improve blood-iron status in women; however, the effects of a high-dose iron-supplement regimen have been associated with gastrointestinal side effects. Therefore, the purpose of the present study was to evaluate the effectiveness of a low-dose liquid fermented iron-bisglycinate supplement (LIS) on improving blood-iron status in premenopausal women with IDWA without increasing constipation or gastrointestinal distress. (2) Methods: 85 premenopausal women with IDWA (ferritin < 70 ng/dL and hemoglobin > 11.0 g/dL) took a LIS (27 mg) or a placebo (PLA) for 8 weeks. Blood draws were taken at Wk0 and Wk8 of the study to measure serum-iron markers. In addition, surveys of gastrointestinal distress were administered at Wk0, Wk4, and Wk8 while the profile of mood states (POMS) was surveyed at Wk0 and Wk8. (3) Results: Compared to the placebo, the LIS was able to increase serum ferritin (p = 0.03), total serum iron (p = 0.03), and mean corpuscular volume (p = 0.02), while exhibiting no significant interaction in subjective gastrointestinal distress (p > 0.05). No significant effects were detected for POMS (p > 0.05). (4) Conclusions: Supplementing with LIS appears to improve blood-iron status without causing significant gastrointestinal distress in premenopausal women with IDWA.

Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial.

BACKGROUND: Suicide is a leading cause of death in adolescents and adults in the US. Follow-up support delivered when patients return home after an emergency department (ED) or primary care encounter can significantly reduce suicidal ideation and attempts. Two follow-up models to augment usual care including the Safety Planning Intervention have high efficacy: Instrumental Support Calls (ISC) and Caring Contacts (CC) two-way text messages, but they have never been compared to assess which works best. This protocol for the Suicide Prevention Among Recipients of Care (SPARC) Trial aims to determine which model is most effective for adolescents and adults with suicide risk. METHODS: The SPARC Trial is a pragmatic randomized controlled trial comparing the effectiveness of ISC versus CC. The sample includes 720 adolescents (12-17 years) and 790 adults (18+ years) who screen positive for suicide risk during an ED or primary care encounter. All participants receive usual care and are randomized 1:1 to ISC or CC. The state suicide hotline delivers both follow-up interventions. The trial is single-masked, with participants unaware of the alternative treatment, and is stratified by adolescents/adults. The primary outcome is suicidal ideation and behavior, measured using the Columbia Suicide Severity Rating Scale (C-SSRS) screener at 6 months. Secondary outcomes include C-SSRS at 12 months, and loneliness, return to crisis care for suicidality, and utilization of outpatient mental health services at 6 and 12 months. DISCUSSION: Directly comparing ISC and CC will determine which follow-up intervention is most effective for suicide prevention in adolescents and adults.

Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

BACKGROUND: Registry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty. Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach triple-tapered uncemented stem designs may provide comparable results to cemented stems. METHODS: From 2000 to 2018, 5,809 primary total hip arthroplasties were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75 years of age. Statistical weighting accounted for baseline cohort differences. RESULTS: At 10 years, there was a trend toward higher all-cause revision (hazards ratio (HR) 1.6, P = .053) and higher all-cause reoperation (HR 1.6, P = .02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P < .001) but no difference in postoperative fractures (HR 0.99, P = .96). The same was true in patients ≥75 years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years. CONCLUSION: Compared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75 years, was associated with more intraoperative fractures but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

Comparative Survival of Contemporary Cementless Acetabular Components Following Revision Total Hip Arthroplasty.

BACKGROUND: The advent of highly porous ingrowth surfaces and highly crosslinked polyethylene has been expected to improve implant survivorship in revision total hip arthroplasty. Therefore, we sought to evaluate the survival of several contemporary acetabular designs following revision total hip arthroplasty. METHODS: Acetabular revisions performed from 2000 to 2019 were identified from our institutional total joint registry. We studied 3,348 revision hips, implanted with 1 of 7 cementless acetabular designs. These were paired with highly crosslinked polyethylene or dual-mobility liners. A historical series of 258 Harris-Galante-1 components, paired with conventional polyethylene, was used as reference. Survivorship analyses were performed. For the 2,976 hips with minimum 2-year follow-up, the median follow-up was 8 years (range, 2 to 35 years). RESULTS: Contemporary components with adequate follow-up had survivorship free of acetabular rerevision of ≥95% at 10-year follow-up. Relative to Harris-Galante-1 components, 10-year survivorship free of all-cause acetabular cup rerevision was significantly higher in Zimmer Trabecular Metarevision (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.2-0.45), Zimmer Trabecular MetaModular (HR 0.34, 95% CI 0.13-0.89), Zimmer Trilogy (HR 0.4, 95% CI 0.24-0.69), DePuy Pinnacle Porocoat (HR 0.24, 95% CI 0.11-0.51), and Stryker Tritanium revision (HR 0.46, 95% CI 0.24-0.91) shells. Among contemporary components, there were only 23 rerevisions for acetabular aseptic loosening and no rerevisions for polyethylene wear. CONCLUSION: Contemporary acetabular ingrowth and bearing surfaces were associated with no rerevisions for wear and aseptic loosening was uncommon, particularly with highly porous designs. Therefore, it appears that contemporary revision acetabular components have dramatically improved upon historical results at available follow-up.

The Fate of the Patient With Superficial Dehiscence Following Direct Anterior Total Hip Arthroplasty.

BACKGROUND: Direct anterior approach (DAA) total hip arthroplasty (THA) has been associated with higher rates of superficial incisional dehiscence. However, limited data are available regarding the outcomes following initial treatment of this complication. This study aimed to evaluate patient risk factors, reoperations, and revisions in those who developed superficial wound dehiscence following DAA THA. METHODS: We identified 3,687 patients who underwent a primary DAA THA between 2010 and 2019 from our enterprise total joint registry. Of these, 98 (2.7%) patients developed a superficial wound dehiscence requiring intervention [irrigation and debridement (n = 42) or wound care with or without antibiotics (n = 56)]. Dehiscence was noted at a median of 27 (range, 2-105) days. These patients were compared to patients who did not have a superficial wound complication (n = 3,589). Landmark survivorship analysis was performed to account for immortal time bias with a 45-day landmark time. RESULTS: Patients who had superficial wound dehiscence compared to those who did not, were more often women (64 versus 53%, P = .02) and had increased mean body mass index (33 versus 29, P < .001). There was no difference in 4-year survivorship free from any revision between cohorts (97 versus 98%, respectively, P = .14). There were 2 (2.0%) revisions in the superficial dehiscence group: 1 for periprosthetic joint infection and 1 for aseptic femoral loosening. CONCLUSION: Superficial wound dehiscence following DAA THA was associated with higher body mass index and was more common in women. Fortunately, with proper index management, the risk of revision THA and periprosthetic joint infection was not increased for these patients.