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Monoblock ceramic cups are designed to accommodate large-diameter femoral heads. This has the potential to offer the advantages of an increased range of motion and enhanced joint stability. These features could benefit younger and high-demand patients in need of total hip arthroplasty. The aim of this study was to assess the survival rate and the reasons for revision of the DeltaMotion cup. Data from the AOANJRR were analyzed for all patients who had undergone a primary conventional THA performed between January 1, 2001 and December 31, 2021. Only prostheses with ceramic/ceramic, ceramic/XLPE, metal/XLPE, or CM/XLPE bearing surfaces were included. The primary outcome measure was the cumulative percent revision for all causes. Secondary outcome measures were revision for dislocation/instability, ceramic breakage, or noise. A subanalysis for cup size was also performed. There were 486,946 primary conventional THA procedures undertaken for any reason. Of these, 4,033 used the DeltaMotion cup and 482,913 were modular designs. The DeltaMotion cup had the lowest CPR for all diagnoses compared to the modular bearings at all time points, had a significantly lower revision rate for prosthesis dislocation and no revisions for squeaking compared to other modular bearings. There were 175 ceramic breakages recorded in the modular bearing group and 1 ceramic breakage in the DeltaMotion group. The DeltaMotion cup had a low rate of all-cause revision, and for dislocation, ceramic breakage, and noise. Although this cup is no longer manufactured, ongoing follow-up of newer monoblock ceramic cups will determine their suitability for younger and more active patients. [ABSTRACT FROM AUTHOR]

There is growing interest in the perioperative management of patients who have indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, poorly controlled diabetes, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients who have modifiable risk factors. The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via SurveyMonkey. There were 77 responses received, representing a response rate of 64%. The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients who have modifiable risk factors. There were 72% restricting access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. While 49% of surgeons believed that current payment systems did not impair their ability to achieve good outcomes, 58% believed that certain arthroplasty patients would benefit from additional intervention, based on their socioeconomic status. Over 90% of surgeons who responded address modifiable risk factors prior to surgery. This finding aligns with the practice patterns of AAHKS members, despite differences in healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA).Methods: PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics.Results: All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively.Conclusion: Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit. [ABSTRACT FROM AUTHOR]

Background: Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty.Methods: A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed.Results: In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA.Conclusion: Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities. [ABSTRACT FROM AUTHOR]

Background: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.Methods: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).Results: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.Conclusion: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition. [ABSTRACT FROM AUTHOR]

Background: The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes.Methods: Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact.Results: Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn.Conclusion: Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects. [ABSTRACT FROM AUTHOR]

Background: Distal femoral replacement (DFR) is a potential treatment option following periprosthetic fracture (PPF) of a total knee arthroplasty (TKA). However, there is limited literature regarding implant survivorship and complication rates. The aim of this study was to examine patient demographics and trends in usage, implant survivorship and modes of failure, and patient mortality following DFR for PPF captured by a national joint replacement registry.Methods: A retrospective registry review was performed using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). In total, 306 DFR were performed for PPF of a known primary TKA. Eighty-five percent of patients were female, and the mean age was 76.4 years. Kaplan-Meier estimates of implant and patient survivorship were performed.Results: The number of DFR performed for PPF has doubled over the past five years. The cumulative percent second revision rate at six years was 12%. The most common indications for revision were infection (37%) and aseptic loosening (33%). Patient survivorship after DFR was 97% and 83% at five and ten years, respectively.Conclusion: A national registry review has identified the increasing prevalence of DFR for PPF after primary TKA and demonstrated implant survivorship of 88% at midterm follow-up. Surgeons may consider DFR as an acceptable and durable treatment option.Level Of Evidence: Level III - Case Series. [ABSTRACT FROM AUTHOR]

Background: Data assessing femoral stems may be influenced by grouping together matt and polished stems, despite their differing reported survivorship. The aim of this study is to assess the difference in revision rates between commonly used cemented and cementless stems when polished tapered stems are assessed independently of matt stems.Methods: Australian Orthopaedic Association National Joint Replacement Registry data from 1999 to 2019 were used to assess difference in revision rates between the 5 most commonly implanted femoral cemented and cementless stems for osteoarthritis. Cemented matt femoral stems, stems using line-to-line cementing techniques and procedures using non-cross-linked polyethylene, large head (>32 mm) metal-on-metal bearing surfaces or exchangeable necks were excluded. Cumulative percent revision was used to help compare survivorship between stems.Results: There were 201,889 total hip replacements meeting the inclusion criteria, of which 50.0% were cemented and 50.0% cementless. Cemented stems had a lower rate of revision at all time points compared to cementless stems. This was most significant during the first 2 weeks (hazard ratio 0.48, 95% confidence interval 0.40-0.58, P < .001) compared to 2 weeks postoperatively and onwards (hazard ratio 0.85, 95% confidence interval 0.81-0.90, P < .001). A subanalysis of head size, bearing type, and surgeon volume further supported the use of a cemented stem.Conclusion: Commonly used cemented polished tapered stems have a lower revision rate when compared to commonly used cementless prostheses, and are recommended in all age groups for both low-volume and high-volume surgeons especially when head size 32 mm or smaller is used. [ABSTRACT FROM AUTHOR]

Background: In order to reduce the incidence of total hip joint replacement revision for wear, multiple advanced materials and alloys targeting hip replacement tribology have been introduced. Ion implantation of chromium-cobalt heads is thought to reduce wear due to increased surface hardness and lower friction. These advances in technology result in additional manufacturing costs. However, it is unclear whether these attributes result in a decreased rate of revision for wear and when used with modern highly crosslinked polyethylene (XLPE). The aim of this study is to compare the survivorship of stainless steel and ion-implanted chromium-cobalt femoral heads in order to determine whether ion implantation has a lower risk of revision.Methods: Data from the Australian Orthopedic Association National Joint Replacement Registry included all stainless steel and low-friction ion-treated (LFIT) femoral heads used in conjunction with a primary Exeter/Trident hip replacement combination and XLPE liners performed for osteoarthritis. Kaplan-Meier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazard models, with adjustment for age and gender, were used to compare revision rates between the 2 groups.Results: There were 40,468 total hip replacements that met the inclusion criteria. Stainless steel heads had a lower revision rate compared to LFIT chromium-cobalt heads (HR 0.87, 95% confidence interval 0.76-1.00, P = .048). The difference in the rate of revision was even greater when 32-mm heads were used (HR 0.72, 95% confidence interval 0.58-0.89, P = .002). There was no difference in revision for loosening between head alloys or when stratified by age.Conclusion: Given the increased costs associated with LFIT implants and the lower rate of revision for stainless steel heads, we recommend the use of a stainless steel heads when using an Exeter/Trident hybrid hip with an XLPE liner. [ABSTRACT FROM AUTHOR]

Background: Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH).Methods: A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness.Results: Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs.Conclusion: Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI. [ABSTRACT FROM AUTHOR]

Background: Recent case series have reported early failure with the use of high-viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk after TKA with HVC compared with medium-viscosity cement (MVC) in a large cohort.Methods: We conducted a cohort study using data from Kaiser Permanente's Total Joint Replacement Registry. Patients who underwent fully cemented primary TKA for osteoarthritis were identified (2001-2018). Only posterior-stabilized, fixed-mobility designs of the 3 highest-volume implant systems (DePuy PFC, Zimmer NexGen, and Zimmer Persona) were included to mitigate confounding from implant characteristics. Palacos (Zimmer/Heraeus) and Simplex (Stryker) cements comprised the HVC and MVC exposure groups, respectively. Propensity score-weighted Cox proportional hazards regression was used to evaluate risk for any revision during follow-up and risk for revision from aseptic loosening specifically.Results: The final cohort comprised 76,052 TKAs, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC, respectively. In propensity score-weighted Cox models, MVC compared with HVC had a lower risk of any revision (hazard ratio = 0.82, 95% confidence interval = 0.70-0.95) while no difference was observed for revision from aseptic loosening (hazard ratio = 0.80, 95% confidence interval = 0.56-1.13).Conclusion: While we observed a lower risk for any revision with the use of Simplex MVC compared with Palacos HVC, we did not observe a difference in revision for aseptic loosening specifically. Given the widespread use of HVC, additional research to investigate other HVC and potential mechanisms for failure outside of loosening is warranted.Level Of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: Prosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).Methods: Baseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness.Results: The use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200.Conclusion: The use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA. [ABSTRACT FROM AUTHOR]

Background: Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies.Methods: The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR.Results: Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment.Conclusion: Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections. [ABSTRACT FROM AUTHOR]

Background: Outcomes following 1-surgeon single-anesthetic sequential bilateral total knee arthroplasty (seq-BTKA) compared to 2-surgeon single-anesthetic simultaneous bilateral total knee arthroplasty (sim-BTKA) are largely unknown. The current study compared revision rates and all-cause mortality following seq-BTKA vs sim-BTKA using data from the Australian Orthopedic Association National Joint Replacement Registry.Methods: Seq-BTKA and sim-BTKA procedures recorded within the registry between September 1, 1999 and December 31, 2018 were analyzed for subsequent revision and patient mortality. Cumulative percent revision and cumulative percent survival were determined using the Kaplan-Meier method. Revision and mortality rates for sim-BTKA and seq-BTKA were compared using Cox proportional hazards models, adjusting for age and gender.Results: Included in the analysis were 27,480 seq-BTKAs and 471 sim-BTKAs. There was no difference in the cumulative percent revision between the 2 groups (hazard ratio 1.23, 95% confidence interval 0.82-1.85). Cumulative percent patient survival was not significantly different between the 2 groups (hazard ratio 1.20, 95% confidence interval 0.93-1.54).Conclusion: Revision rates and mortality were similar for seq-BTKA and sim-BTKA. Investigation of additional outcomes such as complications not requiring revision, pain, function, and cost is required to comprehensively understand the relative merits of each procedure. [ABSTRACT FROM AUTHOR]

Background: The cementless Corail is one of the most commonly used stems in total hip arthroplasty (THA). The aim of this study was to investigate whether there was a difference in revision rate for smaller stems.Methods: All primary THA procedures recorded by the Australian Joint Replacement Registry from September 1999 to December 2017 performed for osteoarthritis using the Corail stem, a cementless acetabular cup, modern bearing surfaces (ceramic/ceramic, ceramic/cross-linked polyethylene, and metal/cross-linked polyethylene), and 28 mm, 32 mm, and 36 mm head sizes were included. The primary outcome measure was femoral component revision. Data were analyzed and adjusted for age, gender, and head size. Further analysis investigated the effects of surgical approach.Results: There was 41,265 primary THAs recorded. The cumulative percent revision (CPR) at 13 years was 7.7% (5.5, 10.7) for stem sizes 8 and 9 and 3.0% (2.4, 3.8) for sizes 10-20 (P < .001). When adjusted for age and gender, the sizes 8 and 9 collared (hazard ratio [HR]: 6.22 [3.84-10.06], P < .001) and collarless (HR: 3.28 [2.41-4.45], P < .001) had a higher CPR than the collared and collarless size 10-20. The size 8 and 9 stems performed with an anterior approach had the highest CPR (HR: 14.44 [6.21-33.56], P < .001). The main reason for revision of size 8 and 9 femoral stems was loosening (65.2%, compared to 31.5% for 10-20 femoral stems).Conclusions: Smaller Corail stems have 4 times the rate of revision compared with the larger femoral sizes with loosening being the most common diagnosis. This is most evident when using an anterior approach. [ABSTRACT FROM AUTHOR]

Background: The declining popularity of cemented acetabular components is incongruous, given the published results of prostheses implanted using contemporary techniques. The outcome of arthroplasty has previously been demonstrated to correlate with surgeon experience and volume of practice. We aim to explore if surgeon volume alters outcomes of cemented acetabular components based on survivorship data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).Methods: An observational study was undertaken using a cohort of 22,956 patients with a primary diagnosis of osteoarthritis in the period 2003-2016 in whom cemented acetabular components were implanted. The cohort was stratified by age (greater than or less than 65 years) and annualized surgical volume of ≤10, >10-≤25, and >25 cases.Results: Stratified by age and volume, there was a protective benefit against revision conveyed at volume thresholds of 10 cases per annum and 25 cases per annum for patients ≥65 years of age and <65 years of age, respectively.Conclusion: Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data. This survivorship is further improved if surgeons perform a higher volume of cases, with >25 cases conferring the greatest benefit. The AOANJRR data set is used to define best practice; surgeons who choose to utilize cemented acetabular fixation should be encouraged to perform this technique in adequate volumes to minimize revision risk and ensure the preservation of this important surgical skill set. [ABSTRACT FROM AUTHOR]

While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time. In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods. The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia. While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed. [ABSTRACT FROM AUTHOR]

Cementless total hip arthroplasty (THA) femoral stems are the most commonly selected prostheses in the United States. Optimal stem geometry remains controversial with excellent survivorship reported for many designs. We compared cause-specific stem revision of single-wedge versus double-wedge designs from a multicenter US cohort. Data from an integrated healthcare network's total joint replacement registry were used to conduct a cohort study. Primary elective cementless THAs were identified (2001 to 2018). Implant exposure groups were classified by design geometry using the system proposed by Khanuja et al. Type 1 single-wedge (n = 11,082) and type 2 double-wedge (n = 32,380) designs were compared, and other design types were excluded; the final study cohort comprised 43,462 THAs. Cause-specific multivariable Cox regressions were used to evaluate risk for revision due to infection or aseptic reasons, including loosening, instability, periprosthetic fracture, or other reasons. After adjustment for covariates, a higher aseptic revision risk was observed for type 1 when compared to type 2 designs (hazard ratio = 1.91, 95% confidence interval = 1.33-2.75). When looking at specific revision reasons, revision for aseptic loosening (hazard ratio = 3.46, 95% confidence interval = 2.24-5.34) was higher for type 1 versus type 2 designs. No differences were found for septic revision, instability, periprosthetic fracture, or revisions for other reasons. Type 1 single-wedge designs were found to have a higher risk of revision due to aseptic loosening relative to type 2 double-wedge designs. Femoral stem geometry should be considered when selecting a cementless femoral implant. Level III. [ABSTRACT FROM AUTHOR]

Background: Matt and polished femoral stems have been historically grouped together in registry assessment of the outcome of cemented femoral stems in total hip arthroplasty. This is despite differences in the mode of fixation and biomechanics of loading. The aims of this study are to compare the survivorship of polished tapered stems with matt finished cemented stems.Methods: Data on primary total hip arthroplasty undertaken for a diagnosis of osteoarthritis from September 1999 to December 2014 were included from a National Joint Registry. Revision rates of the 2 different types of femoral components were compared.Results: There were 96,315 cemented femoral stems included, of which 82,972 were polished tapered and 13,343 matt finish. The cumulative percent revision at 14 years of polished stems was 3.6% (3.0-4.2) compared to 4.9% (4.1-5.7) for matt finish stems. Polished tapered stems had a significantly lower revision rate of femoral revision (hazard ratio 0.56, P < .001). This difference is evident in patients aged <75, and becomes apparent in the mid-term and continues to increase with time. Aseptic loosening accounts for 75% of revisions of matt finish stems compared to 20% for polished tapered stems.Conclusion: Although both polished and matt finish stems have excellent early to mid-term results, the long-term survivorship of polished stems is significantly better, with aseptic loosening becoming an issue with matt finish stems. In the future reports of cement fixation for femoral stems may benefit from separate analysis of polished and matt finish. [ABSTRACT FROM AUTHOR]

Background: Constrained acetabular components have a mechanism to lock in the femoral head. They have been developed to control postoperative dislocation, particularly in revision total hip arthroplasty (THA). Although these components may reduce dislocation, there are durability concerns: with reports of locking mechanism failures and loosening. We wanted to determine the outcome of constrained components in controlling dislocation, and if these components had a higher rate of second revision when compared with standard nonconstrained components.Methods: Revision THA procedures from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) with a recorded primary procedure and initial diagnosis of osteoarthritis were used to compare constrained and standard nonconstrained components. Kaplan-Meier estimates of survivorship were calculated, and hazard ratios using Cox proportional hazard models were used to compare groups.Results: There were 9509 THA first-revision procedures and 700 constrained components. Constrained components had a significantly higher revision rate after 3 months when large-head metal-on-metal components were included (hazard ratio = 1.37; P = .005). When large-head metal-on-metal components were excluded, there was no difference in the rate of second revision between the 2 groups. When the analysis was limited to first revision for dislocation, constrained components had a higher second revision rate for further dislocation after 9 months.Conclusion: Constrained acetabular components had similar second-revision rates when compared with standard nonconstrained components, both for all first-revision reasons and when used to treat dislocation. Although possibly used for the more difficult unstable hips, constrained components had a higher rate of second revision for further dislocation. [ABSTRACT FROM AUTHOR]

Background: Dislocation is a leading cause of revision after primary total hip arthroplasty (THA). Although more common in the first few years after the procedure, dislocation can occur at any time. This study investigated the difference in late dislocation in ceramic-on-ceramic (CoC) bearings compared with metal-on-polyethylene and ceramic-on-polyethylene bearings in THA.Methods: Data were used from the Australian Orthopaedic Association National Joint Replacement Registry, and the cumulative percent revision for dislocation was estimated using the Kaplan-Meier method for the different bearing surfaces. There were 192,275 THAs included in the study with 101,915 metal-on-cross-linked polyethylene (MoXLPE), 30,256 ceramic-on-cross-linked polyethylene (CoXLPE), and 60,104 CoC.Results: The cumulative percent revision for dislocation at 13 years for MoXLPE, CoXLPE, and CoC groups was 1.2 (95% confidence interval [CI], 1.1-1.3), 1.0 (95% CI, 0.7-1.4), and 0.9 (95% CI, 0.8-1.1), respectively. There was an increased risk of revision for dislocation for MoXLPE compared with CoXLPE and CoC. When stratified for head size, there was no difference in the risk of revision for dislocation between MoXLPE, CoXLPE, and CoC in the 28- and 32-mm head sizes. With a head size of 36 mm, MoXLPE had a higher rate of dislocation compared with other materials.Conclusion: Bearing surface has little impact on revision for dislocation. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) systems permit a degree of femoro-tibial component size mismatch. The effect of mismatched components on revision rates has not been evaluated in a large study. We reviewed 21,906 fixed-bearing PFC Sigma primary TKAs using the Australian Orthopaedic Association National Joint Replacement Registry, dividing patients into three groups: no femoro-tibial size mismatch, tibial component size > femoral component size, and femoral component > tibial component. Revision rates were higher when the femoral size was greater than the tibia, compared to both equal size (HR = 1.20 (1.00, 1.45), P = 0.047) and to tibial size greater than femoral (HR = 1.60 (1.08, 2.37), P = 0.019). Potential mechanisms to explain these findings include edge loading of polyethylene and increased tibial component stresses. [ABSTRACT FROM AUTHOR]

Background: The clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery.Methods: A 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology.Results: Most respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery.Conclusion: The public's unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals. [ABSTRACT FROM AUTHOR]

Background: Many U.S. health systems are grappling with how to safely resume elective surgery amid the COVID-19 pandemic. We used online crowdsourcing to explore public perceptions and concerns toward resuming elective surgery during the pandemic, and to determine factors associated with the preferred timing of surgery after health systems reopen.Methods: A 21-question survey was completed by 722 members of the public using Amazon Mechanical Turk. Multivariable logistic regression analysis was performed to determine factors associated with the timing of preferred surgery after health systems reopen.Results: Most (61%) participants were concerned with contracting COVID-19 during the surgical process, primarily during check-in and in waiting room areas, as well as through excessive interactions with staff. Overall, 57% would choose to have their surgery at a hospital over an outpatient surgery center. About 1 in 4 (27%) would feel comfortable undergoing elective surgery in the first month of health systems reopening. After multivariable adjustment, native English speaking (OR, 2.6; 95% CI, 1.04-6.4; P = .042), male sex (OR, 1.9; 95% CI, 1.3-2.7; P < .001), and Veterans Affairs insurance (OR, 4.5; 95% CI, 1.1-18.7; P = .036) were independent predictors of preferring earlier surgery.Conclusion: Women and non-native English speakers may be more hesitant to undergo elective surgery amid the COVID-19 pandemic. Despite concerns of contagion, more than half of the public favors a hospital setting over an outpatient surgery center for their elective surgery. Concerted efforts to minimize patient congestion and unnecessary face-to-face interactions may prove most effective in reducing public anxiety and concerns over the safety of resuming elective care. [ABSTRACT FROM AUTHOR]