248 results on '"Della Valle CJ"'
Search Results
2. Bisphosphonate Use in Patients Who Have Osteoporosis Does Not Increase the Risk of Periprosthetic Fracture Following Total Knee Arthroplasty.
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Forlenza EM, Serino J 3rd, Acuña AJ, Terhune EB, Behery OA, and Della Valle CJ
- Abstract
Background: The purpose of this study was to evaluate the effect of preoperative bisphosphonate use in patients who have osteoporosis on the risk of complications following primary total knee arthroplasty (TKA)., Methods: An administrative claims database was queried for patients who have osteoporosis undergoing primary TKA between 2010 and 2019 with a minimum of 2-year follow-up. Bisphosphonate naïve patients and bisphosphonate users, defined as patients who had a continuous prescription for bisphosphonates for a minimum of six months preoperatively, were matched 1:1 based on age, sex, and comorbidity burden. Patients undergoing non-elective TKA on chronic glucocorticoid therapy or receiving any other pharmacologic treatment for osteoporosis were excluded. The final cohort included 21,058 matched pairs of patients. The incidence of postoperative complications was identified via International Classification of Disease (ICD) coding and compared between matched groups. A subgroup analysis was performed to examine outcomes amongst patients who underwent cemented and cementless TKA., Results: There was no difference in the incidence of periprosthetic fracture on univariate (0.7 versus 0.8%, P = 0.068) or multivariate testing (OR [odds ratio]: 1.24, 95% CI [confidence interval] [0.99 to 1.56]; P = 0.060). Bisphosphonate users were statistically less likely to undergo all-cause revision TKA at 2 years (OR: 0.84 [0.72 to 0.97]; P = 0.021). Patients who had osteoporosis were found to have an increased risk of periprosthetic fracture when TKA was performed with cementless implants (1.6 versus 0.4%; P = 0.033). However, when treated with bisphosphonates, patients who have osteoporosis demonstrated equivalent fracture rates regardless of implant type (1.3 versus 1.0%; P = 1.000)., Conclusions: While bisphosphonate use in patients who have osteoporosis did not decrease the risk of periprosthetic fracture, it did significantly lower the incidence of all-cause revision at 2 years although the difference identified was small. Consideration should be given to performing cemented TKA in patients who have untreated osteoporosis, given the higher rate of periprosthetic fracture when cementless implants were utilized., (Copyright © 2024. Published by Elsevier Inc.)
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- 2024
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3. Total Knee Arthroplasty in Patients with Cerebral Palsy: A Large Database Analysis.
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Acuña AJ, Burnett RA, Jones CM, Forlenza EM, Levine BR, and Della Valle CJ
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- Humans, Female, Male, Middle Aged, Aged, Reoperation, Retrospective Studies, Risk Factors, Arthroplasty, Replacement, Knee adverse effects, Cerebral Palsy complications, Postoperative Complications etiology, Databases, Factual
- Abstract
Cerebral palsy (CP) is a neurodevelopmental condition that can result in altered gait biomechanics, joint dysfunction, and imbalance. The complications associated with total knee arthroplasty (TKA) in patients with CP have not yet been well described. Therefore, our analysis sought to compare the 90-day and 2-year complications following TKA in patients with and without CP. The PearlDiver Mariner database was utilized to identify patients with CP undergoing primary TKA between 2010 and 2020. This cohort was matched 1:4 to a control cohort without neurodegenerative disorders based on age, sex, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 3,257 patients (657 CP patients 2,600 controls) were included in our final analysis. A multivariable logistic regression analysis was utilized to determine the risk of CP on medical and surgical complications at 90 days and all-cause revision rates at 2 years. Patients with CP had an increased risk of acute kidney injury (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.07-2.5; p = 0.019), pneumonia (OR: 5.63; 95% CI: 3.69-8.67; p < 0.001), urinary tract infection (OR: 5.01; 95% CI: 3.85-6.52; p < 0.001), and transfusion (OR: 2.21; 95% CI: 1.50-3.23; p < 0.001). CP patients additionally had a higher incidence of emergency department (ED) visits (OR: 5.24; 95% CI: 3.76-7.32; p < 0.001) and readmissions (OR: 5.24; 95% CI: 2.57-4.96; p < 0.001). There were no differences in rates of periprosthetic joint infection (PJI; OR: 1.23; 95% CI: 0.69-2.10; p = 0.463), surgical site infection (SSI; OR: 0.51; 95% CI: 0.12-1.46; p = 0.463), and reoperation (OR: 1.35; 95% CI: 0.71-2.43; p = 0.339) at 90 days postoperatively. The all-cause revision rates at 2 years were comparable (OR: 1.02; 95% CI: 0.67-1.51; p = 0.927). In this database review, we found that CP patients have a higher risk of medical complications in the acute postoperative period following TKA. The 90-day surgical complication and 2-year revision rates in CP patients were comparable to matched controls., Competing Interests: None declared., (Thieme. All rights reserved.)
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- 2024
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4. The Impact of Travel Distance on Patient-Reported Outcomes Following Primary Total Hip Arthroplasty.
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Jones CM, Forlenza EM, Spaan JC, Levine BR, Karas V, and Della Valle CJ
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Background: Total hip arthroplasties (THAs) are increasingly being performed at high-volume centers, causing some patients to travel further distances to receive care. Concerns remain that increased travel distance limits follow-up, which may impact outcomes and early return to the hospital. The purpose of this study is to evaluate the impact of travel distance on 90-day patient-reported outcomes (PROs) and 90-day complication rates., Methods: Patients undergoing inpatient primary THA at a single center by one of three surgeons between 2017 and 2021 were retrospectively reviewed. Patients whose local and distant medical records were available were included. Patients who lived ≥ 40 miles from the location or follow-up were labeled as "travelers," and those < 40 miles were "locals." Primary outcomes included PROs as measured by Veterans Rand 12 Item Health Survey, Harris Hip Score, and Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement. Secondary outcomes included rates of 90-day medical complications, emergency department visits, unplanned readmissions, and reoperations., Results: A total of 413 patients were analyzed at a mean of 897.1 days (range, 92 to 2,196) including 96 travelers. Travelers averaged 96.1 miles for follow-up (range, 40.1 to 678 miles), and locals averaged 14.1 miles for follow-up (range, 0.3 to 39.8 miles). There were no differences in the percentage of patients achieving minimal clinically important difference in PROs. There was no difference in the rate of 90-day medical complications, 90-day readmissions, and reoperations. Local patients were significantly more likely to have unplanned postoperative emergency department visits (travelers = 0%, locals = 7.4%, P = 0.003)., Conclusions: Travelers did not demonstrate any significant differences with respect to rates of achieving minimal clinically important difference in PROs or 90-day complication rates. These data suggest that increased travel distance to treatment centers does not impact outcomes following primary THA., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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5. Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership.
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Hannon CP, Hamilton WG, Della Valle CJ, and Fillingham YA
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Background: The purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time., Methods: A survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018., Results: There were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%., Conclusions: Since 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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6. Fragility Index Analysis of the 2018 Clinical Practice Guidelines on Tranexamic Acid Use in Total Joint Arthroplasty.
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Hohmann AL, Wilson AE, Schulte DM, Casambre FD, Della Valle CJ, Lonner JH, and Fillingham YA
- Abstract
Background: The 2018 American Association of Hip and Knee Surgeons clinical practice guideline (CPG) 'tranexamic acid use in total joint arthroplasty' evaluated the efficacy and safety of tranexamic acid in primary total joint arthroplasty. The following review assessed the statistical fragility of the randomized controlled trial (RCT) outcomes on which the CPG recommendations were based using a fragility analysis., Methods: All dichotomous outcomes from the RCTs used to guide the CPG from its associated network, and direct meta-analyses were analyzed. Fragility and reverse fragility indices (FI and rFI) and quotients were calculated for each outcome. The mean indices and quotients were calculated for each guideline question, outcome category, and comparison of tranexamic dose, formulation, and administration timing., Results: This review evaluated 403 dichotomous outcomes on transfusion and complication rates associated with tranexamic acid (TXA) administration. The mean FI of significant outcomes of the CPG was 5.23, and the mean rFI of nonsignificant outcomes was 5.80. Outcomes assessing complication rates had a mean rFI of 6.48. Most outcomes on transfusion in categories comparing TXA to placebo administration had higher mean FIs than rFIs, and all outcomes comparing transfusion risk associated with different TXA formulations and doses had higher mean rFIs than FI or no associated significant outcomes., Conclusions: The rFI and FIs calculated for this CPG are comparable to or higher than mean values reported across orthopaedic literature, indicating the relative statistical stability of its included outcomes. As we learn more about fragility analyses and their potential applications, this type of statistical analysis shows promise as a useful tool to incorporate into future guidelines to assess the quality of RCTs and evaluate the strength of recommendations., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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7. Unicompartmental knee arthroplasty in octogenarians: An analysis of 1,466 patients with 2-year follow-up.
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Acuña AJ, Forlenza EM, Serino J 3rd, Morgan VK, Gerlinger TL, and Della Valle CJ
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Introduction: Unicompartmental knee arthroplasty (UKA) has been shown to improve pain and function in appropriately selected patients. Limited data exists regarding outcomes and complication rates following UKA among octogenarians., Methods: The PearlDiver Mariner database was queried for patients undergoing primary UKA between 2010-2022. Patients < 80 years old were matched 4:1 to the octogenarian cohort (≥80 years old) by sex, year, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 1,334 octogenarians and 5,313 controls were included in our analysis. Multivariate logistic regression was utilized to compare medical complications at 90-days post-operatively and surgical complications at 1- and 2-years post-operatively. Our regression analysis controlled for sex, ECI, tobacco use, obesity, and diabetes., Results: Octogenarians had an increased risk of acute kidney injury (OR: 2.306, 95% CI: 1.393-3.749; p < 0.001), pneumonia (OR: 2.367, 95% CI: 1.301-4.189; p = 0.003), UTI (OR: 1.846, 95% CI: 1.304-2.583; p < 0.001), ED visits (OR: 2.229, 95% CI: 1.586-3.105; p < 0.001), and any complication (OR: 1.575, 95% CI: 1.304-1.895; p < 0.001) at 90-days post-operatively. Octogenarians had lower odds of all-cause revision at 2-years (OR: 0.607, 95% CI: 0.382-0.923; p = 0.026). No differences were demonstrated between cohorts in rates of PJI (OR: 0.832, 95% CI: 0.334-1.796; p = 0.664), periprosthetic fracture (OR: 0.516, 95% CI: 0.120-1.520; p = 0.289), or aseptic loosening (OR: 0.285, 95% CI: 0.045-1.203; p = 0.088) at 2-years., Discussion: These findings suggest that despite an increased risk of certain medical complications within the acute post-operative period, octogenarians undergoing UKA experienced similar rates of surgical complications to younger matched controls at 2-year follow-up., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [CDV reports the following disclosures: Royalties (BD, Smith & Nephew, Wolters Kluwer), Paid consultant (Depuy, Zimmer), Stock or stock options (Parvizi Surgical Innovations), Researchs support (Smith & Nephew, Zimmer, Stryker), Other financial support (Wolters Kluwer Health, SLACK incorporated), and Board/Committee member (Arthritis Foundation, Knee Society, Orthopedics Today, MidAmerica Orthopaedic Association). TG reports the following disclosures: IP Royalties (Smith & Nephew), Paid consultant (Smith & Nephew), and research support (Smith & Nephew). AJA, EF, JS, and VM. have nothing to disclose.]., (Copyright © 2024 Elsevier B.V. All rights reserved.)
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- 2024
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8. Advanced Concepts in Outpatient Joint Arthroplasty.
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Sershon RA, Ast MP, DeCook CA, Della Valle CJ, and Hamilton WG
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- Humans, Arthroplasty, Replacement, Perioperative Care, Patient Satisfaction, Patient Selection, Robotic Surgical Procedures, Ambulatory Surgical Procedures
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As the adoption and utilization of outpatient total joint arthroplasty continues to grow, key developments have enabled surgeons to safely and effectively perform these surgeries while increasing patient satisfaction and operating room efficiency. Here, the authors will discuss the evidence-based principles that have guided this paradigm shift in joint arthroplasty surgery, as well as practical methods for selecting appropriate candidates and optimizing perioperative care. There will be 5 core efficiency principles reviewed that can be used to improve organizational management, streamline workflow, and overcome barriers in the ambulatory surgery center. Finally, future directions in outpatient surgery at the ASC, including the merits of implementing robot assistance and computer navigation, as well as expanding indications for revision surgeries, will be debated., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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9. Fretting and Tribocorrosion of Modular Dual Mobility Liners: Role of Design, Microstructure, and Malseating.
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Terhune EB, Serino J 3rd, Hall DJ, Nam D, Della Valle CJ, Jacobs JJ, and Pourzal R
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- Humans, Corrosion, Aged, Middle Aged, Female, Male, Aged, 80 and over, Titanium, Adult, Retrospective Studies, Hip Prosthesis, Prosthesis Design, Arthroplasty, Replacement, Hip instrumentation, Prosthesis Failure, Chromium Alloys
- Abstract
Background: Modular dual mobility (DM) bearings have a junction between a cobalt chrome alloy (CoCrMo) liner and titanium shell, and the risk of tribocorrosion at this interface remains a concern. The purpose of this study was to determine whether liner malseating and liner designs are associated with taper tribocorrosion., Methods: We evaluated 28 retrieved modular DM implants with a mean in situ duration of 14.6 months (range, 1 to 83). There were 2 manufacturers included (12 and 16 liners, respectively). Liners were considered malseated if a distinct divergence between the liner and shell was present on postoperative radiographs. Tribocorrosion was analyzed qualitatively with the modified Goldberg Score and quantitatively with an optical coordinate-measuring machine. An acetabular shell per manufacturer was sectioned for metallographic analysis., Results: There were 6 implants (22%) that had severe grade 4 corrosion, 6 (22%) had moderate grade 3, 11 (41%) had mild grade 2, and 5 (18.5%) had grade 1 or no visible corrosion. The average volumetric material loss at the taper was 0.086 ± 0.19 mm
3 . There were 7 liners (25%) that had radiographic evidence of malseating, and all were of a single design (P = .01). The 2 liner designs were fundamentally different from one another with respect to the cobalt chrome alloy type, taper surface finish, and shape deviations. Malseating was an independent risk factor for increased volumetric material loss (P = .017)., Conclusions: DM tribocorrosion with quantifiable material loss occurred more commonly in malseated liners. Specific design characteristics may make liners more prone to malseating, and the interplay between seating mechanics, liner characteristics, and patient factors likely contributes to the shell/liner tribocorrosion environment., Level of Evidence: Level III., (Copyright © 2024 Elsevier Inc. All rights reserved.)- Published
- 2024
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10. Revision Hip Arthroplasty Performed by Fellowship-Trained Versus Non-Fellowship-Trained Surgeons: A Comparison of Perioperative Management and Complications.
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Burnett RA, Dobson CB, Turkmani A, Sporer SM, Levine BR, and Della Valle CJ
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- Humans, Male, Female, Middle Aged, Aged, Perioperative Care, Retrospective Studies, Anticoagulants therapeutic use, Analgesics, Opioid therapeutic use, Arthroplasty, Replacement, Hip, Reoperation statistics & numerical data, Fellowships and Scholarships, Postoperative Complications etiology, Postoperative Complications epidemiology
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Background: Successful revision hip arthroplasty (rTHA) requires major resource allocation and a surgical team adept at managing these complex cases. The purpose of this study was to compare the results of rTHA performed by fellowship-trained and non-fellowship-trained surgeons., Methods: A national administrative database was utilized to identify 5,880 patients who underwent aseptic rTHA and 1,622 patients who underwent head-liner exchange for infection by fellowship-trained and non-fellowship-trained surgeons from 2010 to 2020 with a 5-year follow-up. Postoperative opioid and anticoagulant prescriptions were compared among surgeons. Patients treated by fellowship-trained and non-fellowship-trained surgeons had propensity scores matched based on age, sex, comorbidity index, and diagnosis. The 5-year surgical complications were compared using descriptive statistics. Multivariable analysis was performed to determine the odds of failure following head-liner exchange when performed by a fellowship-trained versus non-fellowship-trained surgeon., Results: Aseptic rTHA patients treated by fellowship-trained surgeons received fewer opioids (132 versus 165 milligram morphine equivalents per patient) and nonaspirin anticoagulants (21.4 versus 32.0%, P < .001). Fellowship-training was associated with lower dislocation rates (9.9 versus 14.2%, P = .011), fewer postoperative infections, and fewer periprosthetic fractures and re-revisions (15.2 versus 21.3%, P < .001). Head-liner exchange for infection performed by fellowship-trained surgeons was associated with lower odds of failure (31.2 versus 45.7%, odds ratio 0.76, 95% confidence interval 0.62 to 0.91, P < .001)., Conclusions: rTHA performed by adult reconstruction fellowship-trained surgeons results in fewer re-revisions in aseptic cases and head-liner exchanges. Variations in resources, volumes, and perioperative protocols may account for some of the differences., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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11. Body Mass Index Does Not Drive the Risk for Early Postoperative Instability After Total Hip Arthroplasty: A Matched Cohort Analysis.
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Acuña AJ, Forlenza EM, Serino J 3rd, Terhune EB, and Della Valle CJ
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- Humans, Female, Middle Aged, Male, Aged, Risk Factors, Adult, Reoperation statistics & numerical data, Cohort Studies, Retrospective Studies, Arthroplasty, Replacement, Hip adverse effects, Body Mass Index, Joint Instability etiology, Joint Instability epidemiology, Osteoarthritis, Hip surgery, Postoperative Complications epidemiology, Postoperative Complications etiology
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Background: Instability remains the leading cause of revision following total hip arthroplasty (THA). The objective of the present investigation was to determine whether an elevated body mass index (BMI) is associated with an increased risk of instability after primary THA., Methods: An administrative claims database was queried for patients undergoing elective, primary THA for osteoarthritis between 2010 and 2022. Patients who underwent THA for a femoral neck fracture were excluded. Patients who had an elevated BMI were grouped into the following cohorts: 25 to 29.9 (n = 2,313), 30 to 34.9 (n = 2,230), 35 to 39.9 (n = 1,852), 40 to 44.9 (n = 1,450), 45 to 49.9 (n = 752), and 50 to 59.9 (n = 334). Patients were matched 1:1 based on age, sex, and Elixhauser Comorbidity Index, as well as a history of spinal fusion, neurodegenerative disorders, and alcohol abuse, to controls with a normal BMI (20 to 24.9). A multivariate logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and additional risk factors for dislocation was used to evaluate dislocation rates at 30 days, 90 days, 6 months, 1 year, and 2 years. Rates of revision for instability were similarly compared at 1 year and 2 years postoperatively., Results: No significant differences in dislocation rate were observed between control patients and each of the evaluated BMI classes at all evaluated postoperative intervals (all P values > .05). Similarly, the risk of revision for instability was comparable between the normal weight cohort and each evaluated BMI class at 1 year and 2 years postoperatively (all P values > .05)., Conclusions: Controlling for comorbidities and known risk factors for instability, the present analysis demonstrated no difference in rates of dislocation or revision for instability between normal-weight patients and those in higher BMI classes., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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12. Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence.
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Forlenza EM, Higgins JDD, Keating TC, Berger RA, Della Valle CJ, and Sporer SM
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- Humans, Retrospective Studies, Female, Male, Aged, Middle Aged, Radiography, Aged, 80 and over, Treatment Outcome, Intraoperative Complications etiology, Reoperation statistics & numerical data, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Hip instrumentation, Hip Prosthesis adverse effects
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Background: Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared., Methods: We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated., Results: A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort)., Conclusions: The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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13. The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial.
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Abdel MP, Salmons HI, Larson DR, Austin MS, Barnes CL, Bolognesi MP, Della Valle CJ, Dennis DA, Garvin KL, Geller JA, Incavo SJ, Lombardi AV Jr, Peters CL, Schwarzkopf R, Sculco PK, Springer BD, Pagnano MW, and Berry DJ
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- Humans, Male, Female, Aged, Middle Aged, Postoperative Complications etiology, Treatment Outcome, Awards and Prizes, Anti-Inflammatory Agents administration & dosage, Physical Therapy Modalities, Knee Joint surgery, Knee Joint physiopathology, Arthroplasty, Replacement, Knee, Celecoxib administration & dosage, Range of Motion, Articular drug effects, Dexamethasone administration & dosage, Osteoarthritis, Knee surgery
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Background: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes., Methods: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov., Results: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points., Conclusions: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted., Level of Evidence: Level 1, RCT., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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14. Strikingly High Rates of Periprosthetic Joint Infection Following Revision Surgery for Periprosthetic Fractures Regardless of Surgery Timing.
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Heckmann ND, Yang J, Ong KL, Lau EC, Fuller BC, Bohl DD, and Della Valle CJ
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- Humans, Male, Female, Aged, Aged, 80 and over, Time Factors, United States epidemiology, Medicare, Retrospective Studies, Hip Prosthesis adverse effects, Middle Aged, Periprosthetic Fractures etiology, Periprosthetic Fractures surgery, Periprosthetic Fractures epidemiology, Reoperation statistics & numerical data, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Hip instrumentation, Prosthesis-Related Infections etiology, Prosthesis-Related Infections epidemiology
- Abstract
Background: Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA., Methods: The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery., Results: Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing., Conclusions: The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)
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- 2024
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15. Chat Generative Pretrained Transformer (ChatGPT) and Bard: Artificial Intelligence Does not yet Provide Clinically Supported Answers for Hip and Knee Osteoarthritis.
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Yang J, Ardavanis KS, Slack KE, Fernando ND, Della Valle CJ, and Hernandez NM
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- Humans, Artificial Intelligence, Reproducibility of Results, Language, Osteoarthritis, Knee therapy, Osteoarthritis, Hip therapy
- Abstract
Background: Advancements in artificial intelligence (AI) have led to the creation of large language models (LLMs), such as Chat Generative Pretrained Transformer (ChatGPT) and Bard, that analyze online resources to synthesize responses to user queries. Despite their popularity, the accuracy of LLM responses to medical questions remains unknown. This study aimed to compare the responses of ChatGPT and Bard regarding treatments for hip and knee osteoarthritis with the American Academy of Orthopaedic Surgeons (AAOS) Evidence-Based Clinical Practice Guidelines (CPGs) recommendations., Methods: Both ChatGPT (Open AI) and Bard (Google) were queried regarding 20 treatments (10 for hip and 10 for knee osteoarthritis) from the AAOS CPGs. Responses were classified by 2 reviewers as being in "Concordance," "Discordance," or "No Concordance" with AAOS CPGs. A Cohen's Kappa coefficient was used to assess inter-rater reliability, and Chi-squared analyses were used to compare responses between LLMs., Results: Overall, ChatGPT and Bard provided responses that were concordant with the AAOS CPGs for 16 (80%) and 12 (60%) treatments, respectively. Notably, ChatGPT and Bard encouraged the use of non-recommended treatments in 30% and 60% of queries, respectively. There were no differences in performance when evaluating by joint or by recommended versus non-recommended treatments. Studies were referenced in 6 (30%) of the Bard responses and none (0%) of the ChatGPT responses. Of the 6 Bard responses, studies could only be identified for 1 (16.7%). Of the remaining, 2 (33.3%) responses cited studies in journals that did not exist, 2 (33.3%) cited studies that could not be found with the information given, and 1 (16.7%) provided links to unrelated studies., Conclusions: Both ChatGPT and Bard do not consistently provide responses that align with the AAOS CPGs. Consequently, physicians and patients should temper expectations on the guidance AI platforms can currently provide., (Copyright © 2024 Elsevier Inc. All rights reserved.)
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- 2024
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16. Bisphosphonate Use May be Associated With an Increased Risk of Periprosthetic Hip Fracture.
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Serino J 3rd, Terhune EB, Harkin WE, Weintraub MT, Baim S, and Della Valle CJ
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- Humans, Diphosphonates adverse effects, Risk Factors, Reoperation, Retrospective Studies, Periprosthetic Fractures epidemiology, Periprosthetic Fractures etiology, Arthroplasty, Replacement, Hip adverse effects, Hip Fractures epidemiology, Hip Fractures etiology, Hip Fractures surgery, Osteoporosis complications, Osteoporosis drug therapy, Osteoporosis epidemiology
- Abstract
Background: Osteoporosis is common among patients undergoing primary total hip arthroplasty (THA). This study aimed to evaluate the effect of bisphosphonate treatment on osteoporotic patients undergoing primary THA., Methods: Using a national database, 30,137 patients who had osteoporosis before primary elective THA were identified during 2010 to 2020. Patients undergoing nonelective THA and those using corticosteroids or other medications for osteoporosis were excluded. Bisphosphonate users and bisphosphonate naïve patients were matched 1:1 based on age, sex, Elixhauser comorbidity index, and a history of obesity, rheumatoid arthritis, tobacco use, and alcohol abuse. Kaplan-Meier and multivariate analyses were used to compare 2-year outcomes between groups., Results: Among matched cohorts of 9,844 patients undergoing primary THA, bisphosphonate use was associated with a significantly higher 2-year rate of periprosthetic fracture (odds ratio 1.29, 95% confidence interval 1.04 to 1.61, P = .022). There was a trend toward increased risk of any revision with bisphosphonate use (odds ratio 1.19, confidence interval 1.00 to 1.41, P = .056). Rates of infection, aseptic loosening, dislocation, and mortality were not statistically different between bisphosphonate users and bisphosphonate-naïve patients., Conclusion: In osteoporotic patients, bisphosphonate use before primary THA is an independent risk factor for periprosthetic fracture. Additional longer-term data are needed to determine the underlying mechanism for this association and identify preventative measures., (Copyright © 2023 Elsevier Inc. All rights reserved.)
- Published
- 2024
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17. The Ideal Timing of Bilateral Total Knee Arthroplasty: Simultaneous Versus Staged.
- Author
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Serino JM, Terhune EB, Burnett RA, Higgins JDD, Jacobs JJ, Della Valle CJ, and Nam D
- Abstract
Objectives: The ideal timing for patients undergoing bilateral total knee arthroplasty (TKA) remains unknown. The purpose of this study was to compare 90-day outcomes between unilateral, simultaneous bilateral, and staged bilateral TKA., Methods: The PearlDiver database was used to retrospectively identify 231,119 patients undergoing primary TKA during 2015-2020, of which 67,956 (29.4%) were bilateral. Bilateral TKA patients were divided into cohorts of simultaneous bilateral TKA and staged bilateral TKA at 1-14 days, 15-30 days, 31-90 days, and 91-365 days. Each bilateral TKA cohort underwent one-to-one matching with unilateral TKA patients based on age, gender, year, Elixhauser Comorbidity Index (ECI), and a history of obesity, diabetes, and tobacco use. Ninety-day outcomes were compared between matched groups via univariate and multivariate analysis. In staged bilateral TKA groups, outcomes were collected beginning after the second TKA., Results: Compared to unilateral TKA, simultaneous bilateral TKA was associated with higher rates of venous thromboembolism (VTE; odds ratio [OR] 1.28, 95% confidence interval [CI] 1.07-1.54, p=0.007), acute kidney injury (AKI; OR 1.47, CI 1.17-1.84, p=0.001), blood transfusion (OR 6.81, CI 5.43-8.65, p<0.001), and any complication (OR 1.63, CI 1.49-1.78, p<0.001). Staged bilateral TKA at any time interval studied was associated with a similar or decreased risk of individual complications, emergency department visits, readmissions, reoperations, and any complication relative to unilateral TKA., Conclusion: Simultaneous bilateral TKA is associated with an increased risk of adverse events compared to unilateral TKA. However, bilateral TKA staged at a short interval appears safe in appropriately selected patients., Competing Interests: None
- Published
- 2024
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18. Intra-articular corticosteroids associated with increased risk of total hip arthroplasty at 5 years.
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Angotti ML, Burnett RA, Khalid S, Terhune EB, and Della Valle CJ
- Subjects
- Humans, Adrenal Cortex Hormones adverse effects, Pain chemically induced, Arthralgia diagnosis, Injections, Intra-Articular adverse effects, Injections, Intra-Articular methods, Arthroplasty, Replacement, Hip adverse effects, Osteoarthritis etiology
- Abstract
Background: Intra-articular corticosteroid injections are commonly administered for hip pain. However, guidelines are conflicting on their efficacy, particularly in patients without arthritis. This study assessed for an association of corticosteroid injections and the incidence of total hip arthroplasty at 5 years., Methods: Patients with a diagnosis of hip pain without femoroacetabular osteoarthritis who were administered an intra-articular corticosteroid injection of the hip within a 2-year period were identified from the Mariner PearlDiver database. Patient were matched to patients with a diagnosis of hip pain who did not receive an injection. 5-year incidence of total hip arthroplasty was compared between matched patients who received an intra-articular corticosteroid injection and those who did not., Results: 2,540,154 patients diagnosed with hip pain without femoroacetabular arthritis were identified. 25,073 (0.9%) patients received a corticosteroid injection and were matched to an equal number of control patients. The incidence of total hip arthroplasty (THA) at 5-year-follow up was significantly higher for the corticosteroid cohort compared to controls (1.1% vs. 0.5%; p < 0.001). The incidence and risk of THA increased along with number of injections (1 injection: 0.8%, OR 1.37; 95% CI, 1.34-1.42; p < 0.001, 2 injections: 1.1%; OR 1.45; CI, 1.40-1.50; p < 0.001, ⩾3 injections: 1.5%; OR 1.48; CI, 1.40-1.56; p < 0.001)., Conclusions: There may be a dose-dependent association of corticosteroid injections and a greater risk of total hip arthroplasty at 5 years. These results along with the conflicting guidelines on the efficacy of intra-articular steroids for hip pain should prompt physicians to consider osteoarthritis progression that may occur in the setting of corticosteroid injections in non-arthritic hips.
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- 2023
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19. Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020.
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Burnett RA, Serino J, Hur ES, Higgins JDD, Courtney PM, and Della Valle CJ
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- Humans, Retrospective Studies, Patient Discharge, Regression Analysis, Postoperative Complications epidemiology, Postoperative Complications etiology, Length of Stay, Outpatients, Arthroplasty, Replacement, Knee adverse effects
- Abstract
Background: The number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA., Methods: Patients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients., Results: The incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84)., Conclusions: Complications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA., Level of Evidence: Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)
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- 2023
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20. Elective Joint Arthroplasty Should be Delayed by One Month After COVID-19 Infection to Prevent Postoperative Complications.
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Forlenza EM, Serino J 3rd, Weintraub MT, Burnett RA 3rd, Karas V, and Della Valle CJ
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- Humans, Postoperative Complications epidemiology, Postoperative Complications prevention & control, Postoperative Complications etiology, Retrospective Studies, Risk Factors, COVID-19 epidemiology, Arthroplasty, Replacement, Knee adverse effects, Arthroplasty, Replacement, Hip adverse effects, Venous Thrombosis epidemiology, Venous Thrombosis etiology, Venous Thrombosis prevention & control
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Background: It remains unclear whether a history of recent COVID-19 infection affects the outcomes and risks of complications of total joint arthroplasty (TJA). The purpose of this study was to compare the outcomes of TJA in patients who have and have not had a recent COVID-19 infection., Methods: A large national database was queried for patients undergoing total hip and total knee arthroplasty. Patients who had a diagnosis of COVID-19 within 90-days preoperatively were matched to patients who did not have a history of COVID-19 based on age, sex, Charlson Comorbidity Index, and procedure. A total of 31,453 patients undergoing TJA were identified, of which 616 (2.0%) had a preoperative diagnosis of COVID-19. Of these, 281 COVID-19 positive patients were matched with 281 patients who did not have COVID-19. The 90-day complications were compared between patients who did and did not have a diagnosis of COVID-19 at 1, 2, and 3 months preoperatively. Multivariate analyses were used to further control for potential confounders., Results: Multivariate analysis of the matched cohorts showed that COVID-19 infection within 1 month prior to TJA was associated with an increased rate of postoperative deep vein thrombosis (odds ratio [OR]: 6.50, 95% confidence interval: 1.48-28.45, P = .010) and venous thromboembolic events (odds ratio: 8.32, confidence interval: 2.12-34.84, P = .002). COVID-19 infection within 2 and 3 months prior to TJA did not significantly affect outcomes., Conclusion: COVID-19 infection within 1 month prior to TJA significantly increases the risk of postoperative thromboembolic events; however, complication rates returned to baseline after that time point. Surgeons should consider delaying elective total hip arthroplasty and total knee arthroplasty until 1 month after a COVID-19 infection., (Copyright © 2023 Elsevier Inc. All rights reserved.)
- Published
- 2023
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21. Ultrasound-Guided Iliopsoas Bursal Injections for Management of Iliopsoas Bursitis After Total Hip Arthroplasty.
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Weintraub MT, Barrack TN, Burnett RA 3rd, Serino J 3rd, Bhanot SS, and Della Valle CJ
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- Humans, Retrospective Studies, Psoas Muscles diagnostic imaging, Psoas Muscles surgery, Pain surgery, Adrenal Cortex Hormones therapeutic use, Ultrasonography, Interventional adverse effects, Treatment Outcome, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Hip methods, Bursitis drug therapy, Bursitis etiology, Bursitis surgery, Tendinopathy drug therapy, Tendinopathy etiology, Tendinopathy surgery
- Abstract
Background: Iliopsoas tendonitis can cause persistent pain after total hip arthroplasty (THA). Nonoperative management of iliopsoas tendonitis includes anti-inflammatory drugs and image-guided corticosteroid injections. This study evaluated the efficacy of ultrasound-guided corticosteroid injections (US-CSIs) for iliopsoas tendonitis following THA., Methods: We retrospectively reviewed 42 patients who received an US-CSI for iliopsoas tendonitis after primary THA between 2009 and 2020 at a single institution. Outcomes including reoperation, groin pain at last follow-up, additional intrabursal injection, and Harris Hip Score (HHS) were evaluated at a minimum of 1 year. Cross-table lateral radiographs (36 patients) or computed tomography scans (6 patients) were reviewed to determine if anterior cup overhang was present, indicating a mechanical etiology of iliopsoas tendonitis. Descriptive statistics and univariate comparison of HHS preinjection and postinjection were performed, with alpha < 0.05., Results: Among the 22 patients who did not have cup overhang, four (18.2%) had persistent groin pain at mean follow-up of 40 months (range, 14-94) after US-CSI. Three patients had a second injection; none had groin pain at most recent follow-up. No patients required acetabular revision. Mean HHS improved from 74 points (range, 52-94 points) to 91 points (range, 76-100 points; P < .001) at last follow-up. Among the 20 patients who had anterior cup overhang, five underwent acetabular revision after only temporary pain relief from injection. Groin pain was resolved in all revised patients at mean follow-up of 43 months (range, 12-60) after revision. Of the remaining 15 patients, five had persistent groin pain at mean follow-up of 35 months (range, 12-83). Mean HHS improved from 69 points (range, 50-96 points) preinjection to 81 (range, 56-98 points; P = .007) at last follow-up., Conclusion: Resolution of groin pain was demonstrated in 78.6% of patients in the cohort; however, those who did not have acetabular overhang had higher rates of success. The overall revision rate was 11.9%. US-CSI appears to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary THA., Level of Evidence: Level IV, Therapeutic Study., (Copyright © 2022 Elsevier Inc. All rights reserved.)
- Published
- 2023
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22. Invasive Gastrointestinal Endoscopy Following Total Joint Arthroplasty Increases the Risk for Periprosthetic Joint Infection.
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Forlenza EM, Terhune EB, Higgins JDD, Jones C, Geller JA, and Della Valle CJ
- Subjects
- Humans, Retrospective Studies, Endoscopy, Gastrointestinal adverse effects, Risk Factors, Prosthesis-Related Infections etiology, Prosthesis-Related Infections complications, Arthroplasty, Replacement, Knee adverse effects, Arthroplasty, Replacement, Hip adverse effects, Arthritis, Infectious surgery
- Abstract
Background: The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI)., Methods: Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) versus total hip arthroplasty (THA)), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKAs and 45,251 THAs) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Preoperative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P < .05., Results: Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (odds ratio (OR): 1.29 [1.08-1.53]; P = .004; OR: 1.41 [1.01-1.90]; P = .033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI., Conclusion: These data suggest that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI., (Copyright © 2023 Elsevier Inc. All rights reserved.)
- Published
- 2023
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23. Contralateral Total Hip Arthroplasty Staged Within Six Weeks Increases the Risk of Adverse Events Compared to Unilateral Surgery.
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Serino J 3rd, Terhune EB, Burnett RA 3rd, Guntin JA, Della Valle CJ, and Nam D
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- Humans, Postoperative Complications epidemiology, Postoperative Complications etiology, Retrospective Studies, Comorbidity, Blood Transfusion, Risk Factors, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Hip methods
- Abstract
Background: The ideal timing for bilateral total hip arthroplasty (THA) remains controversial. This study compared 90-day outcomes after simultaneous bilateral THA and contralateral surgery in staged bilateral THA to a matched cohort of unilateral procedures., Methods: Patients undergoing primary, elective THA during 2015 to 2020 were reviewed in a national database. Of the 273,281 patients identified, 39,905 (14.6%) were bilateral. Patients were divided into cohorts of unilateral THA, simultaneous bilateral THA, and staged bilateral THA at 1 to 14 days, 15 to 42 days, 43 to 90 days, and 91 to 365 days. Bilateral THA cohorts were matched with unilateral THA patients based on demographics and comorbidities. Ninety-day outcomes after the second THA were compared between matched groups., Results: Simultaneous bilateral THA resulted in higher rates of transfusion (odds ratio [OR] 4.43, 95% confidence interval 2.31-2.63, P < .001), readmission (OR 2.60, 2.01-3.39, P < .001), and any complication (OR 1.86, 1.55-2.24, P < .001) compared to unilateral THA. Contralateral THA staged at 1 to 14 days increased the risk of readmission (OR 1.83, 1.49-2.24, P < .001) and any complication (OR 1.45, 1.26-1.66, P < .001) relative to unilateral THA. Contralateral THA staged at 15 to 42 days increased the risk of periprosthetic joint infection (OR 3.15, 1.98-5.19, P < .001), readmission (OR 1.92, 1.55-2.39, P < .001), and any complication (OR 1.70, 1.46-1.97, P < .001). Contralateral THA staged beyond 42 days resulted in similar or decreased rates of adverse events relative to unilateral THA., Conclusions: Bilateral THA should be staged a minimum of 6 weeks apart in appropriately selected patients to avoid an increased risk of adverse events after the second THA compared to unilateral THA., (Copyright © 2022 Elsevier Inc. All rights reserved.)
- Published
- 2023
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24. Dual-Mobility versus Large Femoral Heads in Revision Total Hip Arthroplasty: Interim Analysis of a Randomized Controlled Trial.
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Weintraub MT, DeBenedetti A, Nam D, Darrith B, Baker CM, Waren D, Schwarzkopf R, Courtney PM, and Della Valle CJ
- Subjects
- Humans, Femur Head surgery, Reoperation, Prosthesis Design, Prosthesis Failure, Arthroplasty, Replacement, Hip, Hip Prosthesis, Hip Dislocation etiology, Hip Dislocation surgery, Joint Dislocations surgery
- Abstract
Background: This multicenter randomized controlled trial evaluated if dual-mobility bearings (DM) lower the risk of dislocation compared to large femoral heads (≥36 mm) for patients undergoing revision total hip arthroplasty (THA) via a posterior approach., Methods: A total of 146 patients were randomized to a DM (n = 76; 46 mm median effective head size, range 36 to 59 mm) or a large femoral head (n = 70; twenty-five 36 mm heads [35.7%], forty-one 40 mm heads [58.6%], and four 44 mm heads [5.7%]). There were 71 single-component revisions (48.6%), 39 both-component revisions (26.7%), 24 reimplantations of THA after 2-stage revision (16.4%), seven isolated head and liner exchanges (4.8%), four conversions of hemiarthroplasty (2.7%), and 1 revision of a hip resurfacing (0.7%). Power analysis determined that 161 patients were required in each group to lower the dislocation rate from 8.4 to 2.2% (power = 0.8, alpha = 0.05)., Results: At a mean of 18.2 months (range, 1.4 to 48.2), there were three dislocations in the large femoral head group compared to two in the DM cohort (4.3 versus 2.6%; P = .67). One patient in the large head group and none in the DM group were successfully treated with closed reduction without subsequent revision., Conclusion: Interim analysis of this randomized controlled trial found no difference in the risk of dislocation between DM and large femoral heads in revision THA, although the rate of dislocation was lower than anticipated and continued follow-up is needed., (Copyright © 2023. Published by Elsevier Inc.)
- Published
- 2023
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25. Cementless Total Knee Arthroplasty is Associated With Early Aseptic Loosening in a Large National Database.
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Forlenza EM, Serino J 3rd, Terhune EB, Weintraub MT, Nam D, and Della Valle CJ
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- Humans, Prosthesis Failure, Prosthesis Design, Bone Cements, Reoperation, Treatment Outcome, Arthroplasty, Replacement, Knee adverse effects, Knee Prosthesis
- Abstract
Background: Despite excellent longevity demonstrated in institutional studies, outcomes after cementless total knee arthroplasty (TKA) on a population level remain unknown. This study compares 2-year outcomes between cemented and cementless TKA using a large national database., Methods: A large national database was used to identify 294,485 patients undergoing primary TKA from January 2015 to December 2018. Patients who had osteoporosis or inflammatory arthritis were excluded. Cementless and cemented TKA patients were matched one-to-one based on age, Elixhauser Comorbidity Index, sex, and year yielding matched cohorts of 10,580 patients. Outcomes at 90 days, 1 year, and 2 years postoperatively were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survival rates., Results: At 1 year postoperatively, cementless TKA was associated with an increased rate of any reoperation (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.12-1.92, P = .005) compared to cemented TKA. At 2 years postoperatively, there was an increased risk of revision for aseptic loosening (OR 2.34, CI 1.47-3.85, P < .001) and any reoperation (OR 1.29, CI 1.04-1.59, P = .019) after cementless TKA. Two-year revision rates for infection, fracture, and patella resurfacing were similar between cohorts., Conclusion: In this large national database, cementless fixation is an independent risk factor for aseptic loosening requiring revision and any reoperation within 2 years after primary TKA., (Copyright © 2023 Elsevier Inc. All rights reserved.)
- Published
- 2023
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26. High rate of failure after revision extensor mechanism allograft reconstruction.
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Weintraub MT, Bailey Terhune E, Serino J 3rd, Della Valle E, and Della Valle CJ
- Subjects
- Humans, Retrospective Studies, Transplantation, Homologous adverse effects, Reoperation, Allografts surgery, Treatment Outcome, Range of Motion, Articular, Knee Joint surgery, Arthroplasty, Replacement, Knee adverse effects
- Abstract
Background: Patients who fail initial extensor mechanism allograft (EMA) reconstruction for extensor mechanism disruption after total knee arthroplasty (TKA) are left with few options. This study evaluated outcomes in patients that underwent revision EMA reconstruction following a failed EMA., Method: Ten patients that underwent revision EMA for failed index EMA with minimum 1-year follow-up were retrospectively reviewed. Patients receiving fresh-frozen EMA (quadriceps tendon, patella, patellar tendon, and tibial tubercle) at index and revision EMA were included. The primary outcome was EMA failure defined as revision surgery, extensor lag > 30°, or Knee Society Score (KSS) < 60 at last follow-up. Descriptive statistics were performed, with p < 0.05., Results: Mean extensor lag improved from 55.6°±26.7° pre-revision to 32.8°±29.6° (p = 0.13) at mean follow-up of 43.8 months (range, 12-124 months). Mean KSS improved from 41.0 ± 9.5 pre-revision to 73.4 ± 14.5 at last follow-up (p < 0.001). All patients required assistive devices for ambulation at final follow-up: one (10.0%) required a wheelchair, five (50.0%) required a walker, and four (40.0%) required a cane. Seven (70.0%) patients experienced EMA failure at a mean of 33.6 months (range, 2-124) following revision EMA: three (30.0%) were revised for periprosthetic joint infection (one of which also had extensor lag > 30°), three (30.0%) additional patients had extensor lag > 30°, and one (10.0%) patient had KSS < 60 (this patient developed PJI and was treated nonoperatively with chronic antibiotic suppression)., Conclusions: Revision EMA reconstruction fails at a high rate despite leading to improvements in KSS. Further research is needed to develop effective prevention and treatment strategies for failure after initial EMA reconstruction., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)
- Published
- 2023
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27. Vitamin D 3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial.
- Author
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Weintraub MT, Guntin J, Yang J, DeBenedetti A, Karas V, Della Valle CJ, and Nam D
- Subjects
- Humans, Postural Balance, Time and Motion Studies, Vitamin D therapeutic use, Dietary Supplements adverse effects, Double-Blind Method, Cholecalciferol therapeutic use, Cholecalciferol adverse effects, Arthroplasty, Replacement, Knee adverse effects
- Abstract
Background: The purpose of this randomized controlled trial was to determine if a one-time dose of vitamin D
3 prior to total knee arthroplasty improves function and patient-reported outcomes, while decreasing complications., Methods: One hundred seven patients undergoing primary total knee arthroplasty were randomized to receive 50,000 international units vitamin D3 (57 patients) or placebo (50 patients) on the morning of surgery. Power analysis determined 45 patients were required in each cohort to detect a minimal clinically important difference of 6 points in the functional component of the 2011 version of the Knee Society Score (KSS), assuming an alpha of 0.05 and power of 80%. KSS and a Timed Up and Go Test (TUGT) were measured preoperatively and at 3 and 6 weeks postoperatively., Results: There was no difference in improvement of KSS at 3 weeks (+4.8 points vitamin D3 versus +3.0 points placebo; P = .6) or 6 weeks (+14.5 points vitamin D3 versus +12.4 points placebo; P = .5) from baseline. There was no difference in change in TUGT at 3 weeks (+1.2 seconds vitamin D3 versus +0.6 seconds placebo; P = .6) or 6 weeks (-0.3 seconds vitamin D3 versus -0.9 seconds placebo; P = .6) from baseline. There were 4 complications in the placebo cohort within the first 90 days postoperatively and 5 complications in the vitamin D3 cohort (P = 1.0)., Conclusion: Supplementation with 50,000 international units vitamin D3 on the day of surgery failed to demonstrate statistical significant differences in functional KSS, TUGT times, or complications in the early postoperative period compared to placebo., Level of Evidence: Level I, therapeutic study., (Copyright © 2022 Elsevier Inc. All rights reserved.)- Published
- 2023
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28. Over Half of All Medicare Total Knee Arthroplasty Patients Are Now Classified as an Outpatient-Three-Year Impact of the Removal From the Inpatient-Only List.
- Author
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Burnett RA, Barrack TN, Terhune EB, Della Valle CJ, Shah RP, and Courtney PM
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- Humans, Aged, United States, Outpatients, Medicare, Length of Stay, Patient Readmission, Inpatients, Arthroplasty, Replacement, Knee
- Abstract
Background: In 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates., Methods: Using a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions., Results: In 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001)., Conclusion: Over half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA., (Copyright © 2022 Elsevier Inc. All rights reserved.)
- Published
- 2023
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29. The Microbiome of Osteoarthritic Hip and Knee Joints: A Prospective Multicenter Investigation.
- Author
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Goswami K, Clarkson S, Tipton C, Phillips CD, Dennis DA, Klatt BA, O'Malley M, Smith EL, Gililland J, Pelt CE, Peters CL, Malkani AL, Palumbo BT, Lyons ST, Bernasek TL, Minter J, Goyal N, Purtill W, McDonald JF 3rd, Cross MB, Prieto HA, Lee GC, Hansen EN, Bini SA, Ward DT, Zhao N, Shohat N, Higuera CA, Nam D, Della Valle CJ, and Parvizi J
- Abstract
Background: Recent advances in high-throughput DNA sequencing technologies have made it possible to characterize the microbial profile in anatomical sites previously assumed to be sterile. We used this approach to explore the microbial composition within joints of osteoarthritic patients., Methods: This prospective multicenter study recruited 113 patients undergoing hip or knee arthroplasty between 2017 and 2019. Demographics and prior intra-articular injections were noted. Matched synovial fluid, tissue, and swab specimens were obtained and shipped to a centralized laboratory for testing. Following DNA extraction, microbial 16S-rRNA sequencing was performed., Results: Comparisons of paired specimens indicated that each was a comparable measure for microbiological sampling of the joint. Swab specimens were modestly different in bacterial composition from synovial fluid and tissue. The 5 most abundant genera were Escherichia, Cutibacterium, Staphylococcus, Acinetobacter, and Pseudomonas. Although sample size varied, the hospital of origin explained a significant portion (18.5%) of the variance in the microbial composition of the joint, and corticosteroid injection within 6 months before arthroplasty was associated with elevated abundance of several lineages., Conclusions: The findings revealed that prior intra-articular injection and the operative hospital environment may influence the microbial composition of the joint. Furthermore, the most common species observed in this study were not among the most common in previous skin microbiome studies, suggesting that the microbial profiles detected are not likely explained solely by skin contamination. Further research is needed to determine the relationship between the hospital and a "closed" microbiome environment. These findings contribute to establishing the baseline microbial signal and identifying contributing variables in the osteoarthritic joint, which will be valuable as a comparator in the contexts of infection and long-term arthroplasty success., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H489)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)
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- 2023
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30. Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty.
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Hur ES, Bohl DD, Della Valle CJ, Villalobos F, and Gerlinger TL
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- Humans, Postoperative Complications etiology, Postoperative Complications epidemiology, Serum Albumin analysis, Risk Factors, Retrospective Studies, Treatment Outcome, Arthroplasty, Replacement, Knee adverse effects, Hypoalbuminemia complications
- Abstract
Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA., Competing Interests: None declared., (Thieme. All rights reserved.)
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- 2023
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31. A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty.
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Hannon CP, Fillingham YA, Gililland JM, Sporer SM, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, and Della Valle CJ
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- Humans, Aged, Analgesics, Opioid, Pain Management, Pain, Postoperative drug therapy, Ketamine therapeutic use, Arthroplasty, Replacement, Knee adverse effects, Arthroplasty, Replacement, Hip adverse effects
- Abstract
Background: Ketamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA)., Methods: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses., Results: High-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92)., Conclusion: High-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2023
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32. Complications and costs of patellofemoral arthroplasty versus total knee arthroplasty.
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Serino J 3rd, Weintraub MT, Burnett RA 3rd, Angotti ML, Courtney PM, and Della Valle CJ
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- Humans, Retrospective Studies, Treatment Outcome, Arthroplasty, Replacement, Knee methods, Osteoarthritis, Knee surgery, Patellofemoral Joint surgery
- Abstract
Background: Patellofemoral arthroplasty (PFA) is an alternative to total knee arthroplasty (TKA) for the treatment of patellofemoral arthritis. Although PFA may preserve native kinematics and accelerate recovery, it has been associated with higher revision rates. The purpose of this study is to compare complication rates and costs between PFA and TKA., Methods: Using the PearlDiver database, 6,179 patients with isolated patellofemoral arthritis treated with PFA or TKA from 2010-2015 were retrospectively reviewed with 5-year follow up. PFA and TKA patients were matched by age, sex, and Elixhauser Comorbidity Index via a 1:1 stepwise algorithm. Five-year costs and complications were compared between matched cohorts. The lifetime costs of PFA and TKA were evaluated with Markov decision modeling., Results: Compared to TKA, PFA was associated with fewer Emergency Department (ED) visits (6.1% vs 3.9%, p = 0.004) but a higher 5-year revision rate (9.9% vs 4.2%, p < 0.001). After multivariate regression, PFA was independently more likely to require revision (odds ratio 2.60, 95% confidence interval 1.32-4.71, p = 0.003). PFA was associated with lower total healthcare costs at every time point between 3 months ($18,014 vs $26,473, p < 0.001) and 5 years ($20,837 vs $27,942, p < 0.001). On average, the lifetime cost of PFA per patient was $5,235 less than for TKA ($26,343 vs $31,578)., Conclusions: PFA is a less expensive alternative to TKA with a similar risk of medical complications but is associated with a significantly higher 5-year revision rate. Future studies should examine the reasons for PFA failure and methods to mitigate this risk., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [The two senior authors (PMC and CDV) receive financial support from companies that manufacture orthopedic devices; however these specific devices were not explicitly identified or evaluated in the present study.], (Copyright © 2022 Elsevier B.V. All rights reserved.)
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- 2023
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33. Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial.
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Weintraub MT, Yang J, Nam D, Greenspoon JA, DeBenedetti A, Karas V, Mehta N, and Della Valle CJ
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- Humans, Male, Female, Urinary Catheterization adverse effects, Postoperative Complications prevention & control, Postoperative Complications etiology, Catheters adverse effects, Urinary Catheters adverse effects, Urinary Retention etiology, Urinary Retention prevention & control, Arthroplasty, Replacement, Knee adverse effects, Arthroplasty, Replacement, Hip adverse effects, Urinary Tract Infections prevention & control, Urinary Tract Infections complications
- Abstract
Background: The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA)., Methods: Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05., Results: Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis., Conclusions: The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR., Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H369 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)
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- 2023
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34. Intra-articular corticosteroid injections are associated with a dose-dependent risk of total knee arthroplasty at 5 years.
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Burnett RA 3rd, Khalid S, DeBenedetti A, Terhune EB, Angotti ML, and Della Valle CJ
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- Humans, Adrenal Cortex Hormones adverse effects, Knee Joint surgery, Injections, Intra-Articular adverse effects, Pain surgery, Arthroplasty, Replacement, Knee adverse effects, Osteoarthritis, Knee drug therapy, Osteoarthritis, Knee surgery, Osteoarthritis, Knee etiology
- Abstract
Purpose: Intra-articular corticosteroid injections (CSI) are used commonly for the non-operative management of patients with knee pain. Recent literature has raised concern for chondrotoxicity of CSI. The purpose of the present study is to evaluate for any dose-dependent association between CSI in non-osteoarthritic knees and subsequent total knee arthroplasty (TKA)., Methods: The Pearl Diver database identified patients with a diagnosis of knee pain without concomitant osteoarthritis who were administered CSI over a 2-year period. Patients were compared to matched and unmatched cohorts. The primary endpoint was the incidence of TKA at 5 years. Multivariable regression analysis was used to assess CSI quantity as an independent risk factor., Results: 49,443 of 986,162 (5.0%) Patients diagnosed with knee pain without concomitant knee osteoarthritis who received at least one CSI were identified. At 5 years, there was a higher incidence of TKA in the matched injection cohort relative to the non-injection matched cohort (0.26 vs 0.13%; p < 0.001) and unmatched cohort (0.26 vs. 0.10%, p < 0.001). The quantity of CSI corresponded with an increased probability of TKA at 5 years; one injection: 0.22% (OR 1.23, 95% CI [0.87-1.74], p = 0.236); two injections: 0.39% (OR 1.98 CI [1.06-3.67], p = 0.03, three or more injections: 0.49% (OR 3.22 CI [1.60-6.48], p = 0.001). The average time to TKA after one CSI was 3.03 ± 2.29 years. This time was nearly halved with three CSI (1.78 ± 0.80 years, p < 0.001)., Conclusions: Intra-articular corticosteroid injections in patients without knee osteoarthritis at the time of injection are associated with a dose-dependent risk of TKA at 5 years. CSI may not be as benign of a treatment modality as previously thought., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)
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- 2023
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35. Hot Topics and Current Controversies in Total Knee Arthroplasty.
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Maloney WJ, Barrack RL, Berend KR, Berry DJ, Della Valle CJ, Chen AF, Dalury DF, Haddad FS, Lieberman JR, Mayman DJ, Nelson CL, and Pagnano MW
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- Humans, Biomechanical Phenomena, Knee Joint surgery, Lower Extremity surgery, Arthroplasty, Replacement, Knee, Knee Prosthesis, Osteoarthritis, Knee surgery
- Abstract
Total knee arthroplasty continues to evolve. It is important to review some of the current controversies and hot topics in arthroplasty. Optimal knee alignment strategy is now just a matter of debate. Mechanical, kinematic, and functional alignment and the role of robotics in achieving optimum alignment are important topics, along with fixation and outpatient knee arthroplasty.
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- 2023
36. Hypoalbuminemia Increases Mortality after Two-Stage Revision Total Joint Arthroplasty.
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Guntin J, Serino J, Rossi D, Boniello A, Gusho CA, and Della Valle CJ
- Abstract
Objectives: This study aimed to evaluate the effect of hypoalbuminemia on failure rates and mortality after a two-stage revision for PJI., Methods: 199 Patients (130 knees and 69 hips) with a mean age of 64.7 ± 10.7 years who underwent a two-stage exchange were retrospectively reviewed at a mean of 51.2 ± 39.7 months. Failure of treatment was defined as any revision within the follow-up period, failure to undergo reimplantation, or death within one year of initiating treatment., Results: There were 71 failures (35.7%), including 38 septic failures (19.1%). We found no differences between successful revisions and failures regarding hypoalbuminemia (43% vs. 42% prior to stage 1, P=1 and 32% vs. 29% prior to stage 2, P=0.856). There were also no differences in hypoalbuminemia rates between septic failures and the rest of the cohort (42% vs. 43% prior to stage 1, P=1.0 and 34% vs. 30% prior to stage 2, P=0.674). Hypoalbuminemia prior to stage 2 was a significant predictor of mortality based on multivariate analysis (odds ratio 5.40, CI 1.19-24.54, P=0.029). Hypoalbuminemia was independently associated with a greater length of stay by 2.2 days after stage 1 (P=0.002) and by 1.0 days after the second stage reimplantation (P=0.004)., Conclusion: Preoperative hypoalbuminemia is a significant predictor of mortality and increased length of stay following two-stage revision but is not a predictor of failure of PJI treatment. Further study is required to understand if hypoalbuminemia is a modifiable risk factor or a marker for poor outcomes., Competing Interests: The authors do not have any potential conflicts of interest for this manuscript.
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- 2023
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37. Can images crowdsourced from the internet be used to train generalizable joint dislocation deep learning algorithms?
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Wei J, Li D, Sing DC, Yang J, Beeram I, Puvanesarajah V, Della Valle CJ, Tornetta P 3rd, Fritz J, and Yi PH
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- Algorithms, Humans, Internet, Crowdsourcing, Deep Learning, Joint Dislocations
- Abstract
Objective: Deep learning has the potential to automatically triage orthopedic emergencies, such as joint dislocations. However, due to the rarity of these injuries, collecting large numbers of images to train algorithms may be infeasible for many centers. We evaluated if the Internet could be used as a source of images to train convolutional neural networks (CNNs) for joint dislocations that would generalize well to real-world clinical cases., Methods: We collected datasets from online radiology repositories of 100 radiographs each (50 dislocated, 50 located) for four joints: native shoulder, elbow, hip, and total hip arthroplasty (THA). We trained a variety of CNN binary classifiers using both on-the-fly and static data augmentation to identify the various joint dislocations. The best-performing classifier for each joint was evaluated on an external test set of 100 corresponding radiographs (50 dislocations) from three hospitals. CNN performance was evaluated using area under the ROC curve (AUROC). To determine areas emphasized by the CNN for decision-making, class activation map (CAM) heatmaps were generated for test images., Results: The best-performing CNNs for elbow, hip, shoulder, and THA dislocation achieved high AUROCs on both internal and external test sets (internal/external AUC): elbow (1.0/0.998), hip (0.993/0.880), shoulder (1.0/0.993), THA (1.0/0.950). Heatmaps demonstrated appropriate emphasis of joints for both located and dislocated joints., Conclusion: With modest numbers of images, radiographs from the Internet can be used to train clinically-generalizable CNNs for joint dislocations. Given the rarity of joint dislocations at many centers, online repositories may be a viable source for CNN-training data., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)
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- 2022
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38. The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis.
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, and Della Valle CJ
- Subjects
- Adrenal Cortex Hormones adverse effects, Analgesics, Opioid adverse effects, Dexamethasone adverse effects, Humans, Nausea, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Pain, Postoperative prevention & control, Vomiting drug therapy, Vomiting etiology, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Knee adverse effects
- Abstract
Background: Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management., Methods: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids., Results: Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA., Conclusion: Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2022
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39. The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis.
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Fillingham YA, Hannon CP, Kopp SL, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Austin MS, Casambre FD, Woznica A, Nelson N, Hamilton WG, and Della Valle CJ
- Subjects
- Analgesics, Analgesics, Opioid, Humans, Pain, Postoperative drug therapy, Pain, Postoperative prevention & control, Anesthetics, Arthroplasty, Replacement, Hip, Nerve Block methods
- Abstract
Background: Regional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management., Methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks., Results: An initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption., Conclusion: Local periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2022
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40. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis.
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, and Della Valle CJ
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- Analgesics, Opioid therapeutic use, Bupivacaine, Clonidine therapeutic use, Epinephrine therapeutic use, Humans, Injections, Intra-Articular, Ketorolac therapeutic use, Morphine therapeutic use, Pain Management, Pain Measurement, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Pain, Postoperative prevention & control, Ropivacaine therapeutic use, Anesthetics, Local, Arthroplasty, Replacement, Knee adverse effects
- Abstract
Background: Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine., Methods: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI., Results: Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine., Conclusion: Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2022
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41. The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis.
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Fillingham YA, Hannon CP, Kopp SL, Austin MS, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Woznica A, Casambre FD, Nelson N, Hamilton WG, and Della Valle CJ
- Subjects
- Analgesics, Opioid, Anesthetics, Local, Femoral Nerve, Humans, Pain, Postoperative prevention & control, Anesthetics, Arthroplasty, Replacement, Knee, Nerve Block
- Abstract
Background: Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management., Methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks., Results: Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective., Conclusion: Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2022
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42. Detecting total hip arthroplasty dislocations using deep learning: clinical and Internet validation.
- Author
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Wei J, Li D, Sing DC, Yang J, Beeram I, Puvanesarajah V, Della Valle CJ, Tornetta P 3rd, Fritz J, and Yi PH
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- Humans, Internet, Neural Networks, Computer, Retrospective Studies, Arthroplasty, Replacement, Hip, Deep Learning, Joint Dislocations
- Abstract
Objective: Periprosthetic dislocations of total hip arthroplasty (THA) are time-sensitive injuries, as the longer diagnosis and treatment are delayed, the more difficult they are to reduce. Automated triage of radiographs with dislocations could help reduce these delays. We trained convolutional neural networks (CNNs) for the detection of THA dislocations, and evaluated their generalizability by evaluating them on external datasets., Methods: We used 357 THA radiographs from a single hospital (185 with dislocation [51.8%]) to develop and internally test a variety of CNNs to identify THA dislocation. We performed external testing of these CNNs on two datasets to evaluate generalizability. CNN performance was evaluated using area under the receiving operating characteristic curve (AUROC). Class activation mapping (CAM) was used to create heatmaps of test images for visualization of regions emphasized by the CNNs., Results: Multiple CNNs achieved AUCs of 1 for both internal and external test sets, indicating good generalizability. Heatmaps showed that CNNs consistently emphasized the THA for both dislocated and located THAs., Conclusion: CNNs can be trained to recognize THA dislocation with high diagnostic performance, which supports their potential use for triage in the emergency department. Importantly, our CNNs generalized well to external data from two sources, further supporting their potential clinical utility., (© 2022. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)
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- 2022
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43. An Enhanced Understanding of Culture-Negative Periprosthetic Joint Infection with Next-Generation Sequencing: A Multicenter Study.
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Goswami K, Clarkson S, Phillips CD, Dennis DA, Klatt BA, O'Malley MJ, Smith EL, Gililland JM, Pelt CE, Peters CL, Malkani AL, Palumbo BT, Lyons ST, Bernasek TL, Minter J, Goyal N, McDonald JF 3rd, Cross MB, Prieto HA, Lee GC, Hansen EN, Bini SA, Ward DT, Shohat N, Higuera CA, Nam D, Della Valle CJ, and Parvizi J
- Subjects
- High-Throughput Nucleotide Sequencing, Humans, Propionibacterium acnes, Retrospective Studies, Arthritis, Infectious diagnosis, Arthroplasty, Replacement, Hip adverse effects, Arthroplasty, Replacement, Knee adverse effects, Prosthesis-Related Infections etiology
- Abstract
Background: The challenges of culture-negative periprosthetic joint infection (PJI) have led to the emergence of molecular methods of pathogen identification, including next-generation sequencing (NGS). While its increased sensitivity compared with traditional culture techniques is well documented, it is not fully known which organisms could be expected to be detected with use of NGS. The aim of this study was to describe the NGS profile of culture-negative PJI., Methods: Patients undergoing revision hip or knee arthroplasty from June 2016 to August 2020 at 14 institutions were prospectively recruited. Patients meeting International Consensus Meeting (ICM) criteria for PJI were included in this study. Intraoperative samples were obtained and concurrently sent for both routine culture and NGS. Patients for whom NGS was positive and standard culture was negative were included in our analysis., Results: The overall cohort included 301 patients who met the ICM criteria for PJI. Of these patients, 85 (28.2%) were culture-negative. A pathogen could be identified by NGS in 56 (65.9%) of these culture-negative patients. Seventeen species were identified as common based on a study-wide incidence threshold of 5%. NGS revealed a polymicrobial infection in 91.1% of culture-negative PJI cases, with the set of common species contributing to 82.4% of polymicrobial profiles. Escherichia coli, Cutibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus ranked highest in terms of incidence and study-wide mean relative abundance and were most frequently the dominant organism when occurring in polymicrobial infections., Conclusions: NGS provides a more comprehensive picture of the microbial profile of infection that is often missed by traditional culture. Examining the profile of PJI in a multicenter cohort using NGS, this study demonstrated that approximately two-thirds of culture-negative PJIs had identifiable opportunistically pathogenic organisms, and furthermore, the majority of infections were polymicrobial., Level of Evidence: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H102 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)
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- 2022
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44. Ketamine in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society.
- Author
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Hannon CP, Fillingham YA, Gililland JM, Sporer SM, Hamilton WG, and Della Valle CJ
- Subjects
- Analgesics therapeutic use, Arthroplasty, Humans, Pain, United States, Anesthesia, Conduction, Arthroplasty, Replacement, Hip, Ketamine therapeutic use, Orthopedic Surgeons, Surgeons
- Published
- 2022
- Full Text
- View/download PDF
45. Regional Nerve Blocks in Primary Total Knee Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society.
- Author
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Fillingham YA, Hannon CP, Austin MS, Kopp SL, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Hamilton WG, and Della Valle CJ
- Subjects
- Humans, Pain, United States, Anesthesia, Conduction, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Nerve Block, Orthopedic Surgeons
- Published
- 2022
- Full Text
- View/download PDF
46. Regional Nerve Blocks in Primary Total Hip Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society.
- Author
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Fillingham YA, Hannon CP, Kopp SL, Sershon RA, Stronach BM, Austin MS, Meneghini RM, Abdel MP, Griesemer ME, Hamilton WG, and Della Valle CJ
- Subjects
- Humans, Pain, United States, Anesthesia, Conduction, Arthroplasty, Replacement, Hip, Nerve Block, Orthopedic Surgeons
- Published
- 2022
- Full Text
- View/download PDF
47. Multimodal Analgesia and Anesthesia: Enabling Safe and Rapid Recovery for Total Joint Arthroplasty Patients.
- Author
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Hannon CP, Fillingham YA, Hamilton WG, and Della Valle CJ
- Subjects
- Analgesics, Opioid, Arthroplasty, Humans, Pain Management, Pain, Postoperative etiology, Analgesia, Anesthesia
- Published
- 2022
- Full Text
- View/download PDF
48. Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society.
- Author
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Hamilton WG, and Della Valle CJ
- Subjects
- Arthroplasty, Humans, Injections, Intra-Articular, Pain, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Pain, Postoperative prevention & control, United States, Anesthesia, Conduction, Arthroplasty, Replacement, Hip, Orthopedic Surgeons
- Published
- 2022
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49. Use of a monoblock dual-mobility acetabular component in primary total hip arthroplasty in patients at high risk of dislocation.
- Author
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Yang J, Bryan AJ, Drabchuk R, Tetreault MW, Calkins TE, and Della Valle CJ
- Subjects
- Acetabulum diagnostic imaging, Acetabulum surgery, Follow-Up Studies, Humans, Prosthesis Design, Prosthesis Failure, Reoperation adverse effects, Retrospective Studies, Arthroplasty, Replacement, Hip adverse effects, Femoral Fractures surgery, Hip Dislocation etiology, Hip Dislocation surgery, Hip Prosthesis adverse effects, Joint Dislocations surgery, Periprosthetic Fractures complications, Periprosthetic Fractures diagnostic imaging, Periprosthetic Fractures surgery
- Abstract
Introduction: Dislocation is amongst the most common complications following total hip arthroplasty (THA). Dual-mobility bearings have been suggested as one way to reduce the risk of dislocation, particularly among patients at increased risk. The purpose of this study was to determine the outcomes of a monoblock dual-mobility shell for patients at high risk for dislocation following primary THA., Methods: A total of 155 primary THAs with a monoblock, cementless dual-mobility acetabular component were performed in patients at high risk for dislocation. Two patients died prior to their two-year follow-up. The remaining 153 THAs were followed for a mean of 5.1 years (range: 2.1 to 9.3)., Results: There were no dislocations; however, four patients underwent revision surgery: one for an early periprosthetic acetabular fracture, one for an early periprosthetic femoral fracture, one for a late periprosthetic femoral fracture, and one for leg-length discrepancy. Intraoperative complications included one periprosthetic acetabular fracture treated with protected weight-bearing and one intraoperative proximal femoral fracture treated with cerclage wiring. Harris Hip Scores improved from a mean of 42.4 points preoperatively to a mean of 82.4 points postoperatively ( p < 0.001). No cups were radiographically loose. At a mean follow-up of 5.1 years, survivorship of the acetabular component was 99.3% (95% CI, 98.1-100%) and survivorship without any reoperation was 97.4% (95% CI, 95.9-100%)., Discussion: Although there were no dislocations in this high-risk population, periprosthetic fractures of the femur and acetabulum were common with the implants utilised.
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- 2022
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50. Corticosteroids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society.
- Author
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Hamilton WG, and Della Valle CJ
- Subjects
- Adrenal Cortex Hormones, Humans, Pain, United States, Anesthesia, Conduction, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Orthopedic Surgeons, Surgeons
- Published
- 2022
- Full Text
- View/download PDF
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