Excellent results of restricted kinematic alignment total knee arthroplasty at a minimum of 10 years of follow-up.

PURPOSE: While restricted kinematic alignment (rKA) total knee arthroplasty (TKA) with cemented implants has been shown to provide a similar survivorship rate to mechanical alignment (MA) in the short term, no studies have reported on the long-term survivorship and function. METHODS: One hundred four consecutive cemented cruciate retaining TKAs implanted using computer navigation and following the rKA principles proposed by Vendittoli were reviewed at a minimum of 10 years after surgery. Implant revisions, reoperations and clinical outcomes were assessed using knee injury and osteoarthritis outcome score (KOOS), forgotten joint score (FJS), patients' satisfaction and joint perception questionnaires. Radiographs were analyzed to identify signs of osteolysis and implant loosening. RESULTS: Implant survivorship was 99.0% at a mean follow-up of 11.3 years (range: 10.3-12.9) with one early revision for instability. Patients perceived their TKA as natural or artificial without limitation in 50.0% of cases, and 95.3% were satisfied or very satisfied with their TKA. The mean FJS was 67.6 (range: 0-100). The mean KOOS were as follows: pain 84.7 (range: 38-100), symptoms 85.5 (range: 46-100), function in daily activities 82.6 (range: 40-100), function in sport and recreation 35.2 (range: 0-100) and quality of life 79.1 (range: 0-100). No radiological evidence of implant aseptic loosening or osteolysis was identified. CONCLUSION: Cemented TKA implanted with the rKA alignment protocol demonstrated excellent long-term implant survivorship and is a safe alternative to MA to improve patient function and satisfaction. LEVEL OF EVIDENCE: IV, continuous case series with no comparison group.

Challenges of Hip and Knee Arthroplasty in Patients With Osteopetrosis.

Osteopetrosis is a rare metabolic bone disease, characterized by dysfunction of osteoclasts, resulting in increased bone density and brittleness leading to pathological fractures and bone deformities. Hip and knee osteoarthritis (OA) are common long-term complications in patients with osteopetrosis. Joint arthroplasty surgery remains an effective and recommended treatment for these patients with an end-stage OA because it provides favorable outcomes. However, in osteopetrosis, joint arthroplasty surgery carries an increased risk of complications, and specific preoperative and perioperative considerations are required to deal with the technical challenges related to the disease. The aim of this article was to review some of the key aspects of osteopetrosis, provide technical recommendations, and answer clinically relevant questions related to hip and knee arthroplasty surgery.

Clinical Outcomes of Total Knee Arthroplasty in Patients Who Have Hemophilic Arthropathy: A Prospective Study.

BACKGROUND: Total knee arthroplasty (TKA) is considered the gold standard treatment for patients who have advanced hemophilic knee arthropathy. However, special considerations are required for these patients. This prospective study reports on the need for soft-tissue procedures, implant types, complication rates, mean 53.3 months implant survivorship, and patient-reported outcome measures of TKA in hemophilic patients. METHODS: There were twenty primary TKAs that were performed on 15 hemophilic patients from 2012 to 2023. The mean follow-up was 53.3 months (range, 6 to 128). The necessity for additional soft tissue procedures, implant type, complications, and revision rates were recorded. Knee Injury and Osteoarthritis Outcome Score, Knee Society Score, Hemophilia-specific Quality of Life Questionnaire for Adults, Hemophilia Activities List, and range of motion, were compared preoperatively and at the last follow-up. RESULTS: At the last follow-up, implant survivorship was 90%. There were 2 revisions: one for aseptic loosening and one for periprosthetic joint infection. Additional soft tissue procedures included 2 quadriceps snips (10%). Tibial augments, tibial stubby stems, and both tibial and femoral traditional stems were used in one (5%), 4 (20%), and one (5%) TKAs, respectively. A constrained posterior-stabilized bearing was necessary in one case. Clinically and statistically significant improvements were found between the preoperative and final follow-up values of all patient-reported outcome measures, knee flexion (73 versus 108 °, P < 0.001), and flexion contracture (11 versus 4 °, P = 0.002). CONCLUSIONS: This study showed that TKA, in patients who have hemophilic knee arthropathy, is a reliable treatment option that improves knee function and patients' quality of life with acceptable implant survival rates at midterm follow-up (mean 53.3 months). Standard implants and approaches can be used in most cases. Despite good outcomes, hemophilic patients carry additional risks for complications that require specific considerations. It is paramount for these patients to be treated in specialized centers by experienced surgeons to achieve good results.

Excellent Results of Large-Diameter Ceramic-On-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-Up.

BACKGROUND: This study reports the minimum 10 years results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head ceramic-on-ceramic bearing. METHODS: Of the 276 THAs included in this study, there were eleven deaths and 27 patients lost to follow up (11%) during the follow-up, leaving 237 (85%) hips available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up. RESULTS: After a minimum of 10 years, implant survivorship was 98.7%. There were 3 revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. All patients (100%) were satisfied or very satisfied. Since implantation, 43% of patients reported hearing a squeaking noise from the prosthesis. But all patients who reported squeaking were satisfied with the surgery. The mean titanium level was 2.2 µg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation. CONCLUSIONS: A large-diameter head ceramic-on-ceramic THA provides outstanding long-term (minimum 10 years) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Total hip arthroplasty with monobloc press-fit acetabular components and large-diameter bearings for atypical acetabula is safe: a consecutive case series of 125 hips with mean follow-up of 9 years.

BACKGROUND: Large-diameter head (LDH) total hip arthroplasty (THA) with a monobloc acetabular component improves hip stability. However, obtaining initial press-fit stability is quite challenging in atypical acetabula. The purpose of this study was to assess primary and secondary fixation of monobloc cups in atypical acetabula. METHODS: In this consecutive case series, the local arthroplasty database was used to retrospectively identify patients with secondary osteoarthritis who underwent primary hip replacement with press-fit only LDH monobloc acetabular components between 2005 and 2018 and who had a minimum of 2 years of follow-up. Radiographic evaluation was performed at last follow-up, and patient-reported outcome measures (PROMs) were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Forgotten Joint Score (FJS), and the Patient's Joint Perception (PJP) question. RESULTS: One hundred and six LDH THAs and 19 hip resurfacings were included in the study. Preoperative diagnoses included hip dysplasia (36.8%), Legg-Calve-Perthes disease (32.0%), osteoarthritis with acetabular deficiency (17.6%), periacetabular osteotomy (8.0%), arthrodesis (4.0%), and osteopetrosis (1.6%). After a mean follow-up of 9.2 years, no aseptic loosening of the acetabular component was recorded nor observed on radiologic review. There were 13 (10.4%) revisions unrelated to the acetabular component fixation. The mean WOMAC and FJS scores were 9.2 and 80.9, respectively. In response to the PJP question, 49.4% of the patients perceived their hip as natural, 19.1% as an artificial joint with no restriction, 31.5% as an artificial joint with restriction, and none as a non-functional joint. CONCLUSION: Primary press-fit fixation of monobloc acetabular components with LDH implanted in atypical acetabula led to secondary fixation in all cases with low revision and complication rates and great functional outcomes. With careful surgical technique and experience, systematic use of supplemental screw fixation is not essential in THA with atypical acetabula.

Primary total knee arthroplasty in hemophilic arthropathy.

Advanced hemophilic knee arthropathy is a frequent and devastating manifestation of severe hemophilia with significant implications for activities of daily living. Hemophilic arthropathy is caused by repeated bleeding, resulting in joint degeneration, pain, deformity and disability. In patients with hemophilia and advanced disease, total knee arthroplasty (TKA) has proven to be the most successful intervention, improves physical function and reduces knee pain. Hemophilic patients carry additional risks for complications and required specific pre/postoperative considerations. Expert treatment center should be used to improve patient outcome. Hemophilic patients present significant surgical challenges such as joint destruction, bone loss, severe ankylosis and oligoarticular involvement. The surgeon performing the arthroplasty must be experienced to manage such problems.

Monobloc press-fit cups with large-diameter bearings are safe in revision total hip arthroplasty.

BACKGROUND: Instability is a major cause of failure of revision total hip arthroplasty (THA) which can be avoided with the use of monobloc press-fit cups with large diameter heads (LDH). OBJECTIVE: This consecutive case series analyses whether LDH monobloc components are a safe and clinically beneficial option for revision THA. METHODS: This consecutive case series includes 47 revision THA with LDH monobloc acetabular cup. Acetabular bone defects were Paprosky type I (42), type IIA (2) and type IIC (3). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS) and the Patient's Joint Perception (PJP) scores were analysed and a radiographic evaluation for signs of implant dysfunction was performed. RESULTS: After a mean follow-up of 4.5 years, there were 5 (10.6%) acetabular cup re-revisions: 2 loss of primary fixation and 3 instabilities. Implant survivorship at 4-years was 89.4% (95% CI: 89.3 to 89.5). Recurrent hip dislocation was reported in 1 patient (2.1%) and remains under conservative treatment. The mean WOMAC and FJS were 19.5 (16.8; 0.0 to 58.3) and 57.3 (28.9; 6.3 to 100.0), respectively. Regarding the PJP, 3 (8.8%) patients perceived their hip as natural, 8 (23.5%) as an artificial joint with no restriction, 14 (41.2%) with minor restriction and 9 (26.5%) with major restriction. CONCLUSION: In cases of revision THA with limited bone loss, press-fit primary fixation with LDH monobloc acetabular components are valuable options that offer excellent mid-term out-comes with low re-revision and joint instability rates.

Delayed discharge after total hip arthroplasty is associated with an increased risk of complications.

BACKGROUND: The purpose of this study was to evaluate the influence of discharge timing on 30-day complication rates following total hip arthroplasty. METHODS: We identified patients who underwent total hip arthroplasty between 2011 and 2017 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Using propensity score matching, we matched patients who were discharged from the hospital on the day of surgery to those discharged on postoperative days 1, 2, 3 and 4, respectively. We used multivariable logistic regression to determine if the rates of complications and readmission differed depending on length of stay. RESULTS: We identified 141 594 patients who underwent total hip arthroplasty (average age 64.7 [standard deviation (SD) 11.4] yr) from the NSQIP database. The average length of stay was 2.3 days and decreased from 2.8 (SD 0.7) days in 2011 to 1.9 (0.9) days in 2017. The adjusted odds of a major complication increased by 1.33 (1.09-1.61) and 1.41 (1.05-2.21) for patients discharged on postoperative day 3 and 4, respectively, compared with patients discharged on postoperative day 2. Similarly, the adjusted odds of a minor complication increased by 1.22 (1.03-1.43) and 1.58 (1.11-2.26) for patients discharged on postoperative days 3 and 4, respectively, compared with those discharged on postoperative day 2. We found no difference in the risk of major or minor complications between patients discharged on the day of surgery or postoperative day 1 compared with patients discharged on postoperative day 2. We also found that a length of stay of 3 or 4 days increased the risk of readmission (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03-1.29, and OR 1.18, 95% CI 1.08-1.85, respectively) compared with a length of stay of 2 days. CONCLUSION: Our data suggest that discharge on postoperative days 0-2 is associated with the lowest risk of 30-day complications following total hip arthroplasty. These findings support early discharge after total hip arthroplasty; however, more prospective clinical data are required to determine the optimal length of stay following total hip arthroplasty.

Prolonged surgical time increases the odds of complications following total knee arthroplasty.

Background: The aim of this study was to evaluate the influence of operating time on complications and readmission within 30 days of total knee arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes. Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients 18 years of age and older who underwent TKA between 2006 and 2017, using procedural codes. Patient demographic characteristics, operation length and 30-day major and minor complication and readmission rates were captured. We used multivariable regression to determine if the rates of complications and readmission differed depending on the length of the operation, while adjusting for relevant covariables. Results: A total of 263 174 patients who underwent TKA were identified from the database. Their mean age was 66.8 (standard deviation 9.7) years. Within 30 days of the index procedure, 5700 patients (2.2%) experienced a major complication, 5185 (2.0%) experienced a minor complication and 7730 (3.1% of 249 746 patients from 2011 to 2017) were readmitted. Mean operation length was 91.7 minutes (range 30­240 min). After adjustment for relevant covariables, an operating time of 90 minutes or more was a significant predictor of major and minor complications as well as readmission. There was no difference in the odds of complications or readmission for operations lasting 30­49, 50­69 or 70­89 minutes (p > 0.05). Conclusion: Our data suggest that operating times of 90 minutes or more may be associated with an increase in the 30-day odds of complications and readmission following TKA. Further studies are needed to confirm our findings and determine the influence of surgical time on outcomes when there is increased case complexity.

Contexte: Cette étude avait pour but d'évaluer l'influence de la durée opératoire sur les taux de complications et de réadmission dans les 30 jours suivant une arthroplastie totale du genou (ATG) et de déterminer si certaines durées étaient associées à des issues défavorables. Méthodes: Nous avons interrogé la base de données du National Surgical Quality Improvement Program de l'American College of Surgeons pour repérer, à l'aide de codes d'acte, les patients de 18 ans et plus ayant subi une ATG entre 2006 et 2017. Les caractéristiques démographiques des patients, la durée opératoire et les taux de complications mineures et majeures et de réadmission dans les 30 jours suivant l'intervention ont été relevés. Nous nous sommes servis d'une régression logistique multivariée pour déterminer si les taux de complications et de réadmission variaient selon la durée opératoire, tout en tenant compte des covariables pertinentes. Résultats: Au total, 263 174 patients ayant subi une ATG ont été repérés dans la base de données. L'âge moyen était de 66,8 ans (écart type : 9,7 ans). Dans les 30 jours suivant l'intervention de référence, 5700 patients (2,2 %) ont présenté une complication majeure et 5185 (2,0 %), une complication mineure; 7730 patients (3,1 % des 249 746 patients ayant subi une ATG entre 2011 et 2017) ont été réhospitalisés. La durée opératoire moyenne était de 91,7 minutes (plage 30­240 minutes). Après la prise en compte des covariables pertinentes, une durée opératoire de 90 minutes ou plus était un facteur prédictif significatif de complications mineures ou majeures et de réadmission. Aucune différence n'a été constatée quant à la probabilité de complications ou de réadmission pour les chirurgies durant de 30­49 minutes, de 50­69 minutes et de 70­89 minutes (p > 0,05). Conclusion: Ces données laissent croire qu'une durée opératoire de 90 minutes ou plus peut être associée à une hausse des taux de complications et de réadmission dans les 30 jours suivant une ATG. D'autres études sont nécessaires pour confirmer ces résultats et déterminer l'influence de la durée opératoire sur les issues des patients au cas complexe.

The economic impact of periprosthetic infection in total knee arthroplasty.

Background: Currently, the gold standard treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is 2-stage revision, but few studies have looked at the economic impact of PJI on the health care system. The objective of this study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in TKA and to assess the economic impact of PJI after TKA compared to uncomplicated primary TKA. Methods: We identified consecutive patients in our institutional database who had undergone 2-stage revision TKA for PJI between 2010 and 2014 and matched them on age and body mass index with patients who had undergone uncomplicated primary TKA over the same period. We calculated all costs associated with the 2 procedures and compared mean costs, length of stay, clinical visits and readmission rates between the 2 groups. Results: There were 73 patients (mean age 68.8 [range 48-91] yr) in the revision TKA cohort and 73 patients (mean age 65.9 [range 50-86] yr) in the primary TKA cohort. Two-stage revision surgery was associated with a significantly longer hospital stay (mean 22.7 d v. 3.84 d, p < 0.001), more outpatient clinic visits (mean 8 v. 3, p < 0.001), more readmissions (29 v. 0, p < 0.001) and higher overall cost (mean $35 429.97 v. $6809.94, p < 0.001) than primary TKA. Conclusion: Treatment for PJI after TKA has an enormous economic impact on the health care system. Our data suggest a fivefold increase in expenditure in the management of this complication compared to uncomplicated primary TKA.

Contexte: À l'heure actuelle, le traitement par excellence d'une infection de prothèse articulaire (IPA) survenant après une arthroplastie totale du genou (ATG) est l'arthroplastie de révision en 2 étapes. Toutefois, peu d'études se sont penchées sur les répercussions économiques de l'IPA sur le système de santé. La présente étude visait donc à estimer de façon précise le coût de prise en charge de l'IPA par les établissements, ainsi qu'à évaluer les répercussions économiques de l'IPA après une ATG, comparativement à celles d'une ATG primaire sans complications. Méthodes: Nous avons recensé, dans la base de données de notre établissement, tous les patients consécutifs ayant subi une ATG de révision en 2 étapes pour une IPA entre 2010 et 2014, puis les avons jumelés en fonction de l'âge et de l'indice de masse corporelle avec des patients ayant subi une ATG primaire sans complications durant la même période. Nous avons calculé tous les coûts associés aux 2 interventions, et avons comparé la moyenne des coûts, de la durée d'hospitalisation, des visites cliniques et des réadmissions entre les 2 groupes. Résultats: On comptait 73 patients (âge moyen 68,8 ans [plage 48­91 ans]) dans la cohorte d'ATG de révision, et 73 patients (âge moyen 65,9 ans [plage 50­86 ans]) dans la cohorte d'ATG primaire. L'ATG de révision en 2 étapes, comparativement à l'ATG primaire, a été associée à une durée d'hospitalisation significativement plus longue (moyenne 22,7 j c. 3,84 j; p < 0,001), à un plus grand nombre de visites en clinique externe (moyenne 8 visites c. 3 visites; p < 0,001), à un taux plus élevé de réadmission (29 réadmissions c. 0 réadmission; p < 0,001) et à des coûts globaux plus élevés (moyenne 35 429,97 $ c. 6809,94 $; p < 0,001). Conclusion: Le traitement de l'IPA après une ATG a d'énormes répercussions économiques sur le système de santé. Selon nos données, les dépenses liées à la prise en charge de cette complication pourraient être 5 fois plus élevées que celles liées à une ATG primaire sans complications.