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Perioperative medical management during total hip arthroplasty (THA) is continuously improving, allowing an increasing number of medically complex patients to undergo total joint arthroplasty. This study examined mortalities, medical complications, implant survivorships, and clinical outcomes of THA in patients who have pulmonary hypertension (HTN).We identified 638 patients who had pulmonary HTN and underwent 508 primary THAs and 191 revision THAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analyses were used for reporting mortality, reoperation, and revision with death as a competing risk.The 90-day mortality was 1.8 and 3.1% for primary and revision THAs, respectively. The risk of death was approximately two-fold higher compared to primary (HR 2.69) and revision (HR 2.04) THA patients who did not have pulmonary HTN. Rate of medical complications within 90 days from surgery were 6.2 and 13.1% in primary and revision THAs, respectively. The 10-year cumulative incidence of any revision was 9 and 14% following primaries and revisions, respectively.Patients who had pulmonary HTN undergoing primary and revision THAs had increased risk of death and experienced a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to medical centers expert at managing complex medical problems should be considered.

AimsThe purpose of this study was to assess mid-term survivorship following primary total knee arthroplasty (TKA) with Optetrak Logic components and identify the most common revision indications at a single institution.MethodsWe identified a retrospective cohort of 7,941 Optetrak primary TKAs performed from January 2010 to December 2018. We reviewed the intraoperative findings of 369 TKAs that required revision TKA from January 2010 to December 2021 and the details of the revision implants used. Kaplan-Meier analysis was used to determine survivorship. Cox regression analysis was used to examine the impact of patient variables and year of implantation on survival time.ResultsThe estimated survivorship free of all-cause revision was 98% (95% confidence interval (CI) 97% to 98%), 95% (95% CI 95% to 96%), and 86% (95% CI 83% to 88%) at two, five, and ten years, respectively. In 209/369 revisions there was a consistent constellation of findings with varying severity that included polyethylene wear and associated synovitis, osteolysis, and component loosening. This failure mode, which we refer to as aseptic mechanical failure, was the most common revision indication. The mean time from primary TKA to revision for aseptic mechanical failure was five years (5 months to 11 years).ConclusionIn this series of nearly 8,000 primary TKAs performed with a specific implant, we identified a lower-than-expected mid-term survivorship and a high number of revisions with a unique presentation. This study, along with the recent recall of the implant, confirms the need for frequent monitoring of patients with Optetrak TKAs given the incidence of polyethylene failure, osteolysis, and component loosening.Cite this article: Bone Joint J 2023;105-B(3):277–283.

The objective of this study was to evaluate the reoperation and complication rate following trochanteric plate fixation of greater trochanter (GT) periprosthetic femur fractures associated with total hip arthroplasty and to identify risk factors for subsequent reoperation, nonunion, and hardware failure (plate/cable breakage or migration).Between 2010 and 2020, 44 patients who had 44 periprosthetic greater trochanter fractures at mean follow up of 2 years were retrospectively reviewed. Initial injury radiographs as well as immediate and final follow-up radiographs were evaluated. Subsequent reoperations, nonunion, and cases of hardware failure were identified. There were 22 (50%) Vancouver B2 fractures and 22 (50%) Vancouver A fractures.The 2-year cumulative probability of any subsequent reoperation was 20%. There were 9 total subsequent reoperations. The trochanteric fracture went on to nonunion in 14 patients (39%), and hardware failure occurred in 10 (28%) patients. A trochanteric bolt was used in addition to the trochanteric plate in 6 patients (14%), of which 4 (67%) patients had trochanteric plate displacement and 3 (50%) patients had trochanteric nonunion. Displacement of the greater trochanter prior to fixation was a predictor of subsequent nonunion (77% versus 23%, P = .02).In this large contemporary series, there was a high incidence of reoperation (20%) with in the first 2-years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%), and hardware failure (28%). Displacement of the GT prior to plating predicted nonunion.Level IV, retrospective observational study.

The recreational and medical use of cannabis is being legalized worldwide. Its use has been linked to an increased risk of developing opioid use disorders. As opioids continue to be prescribed after total hip arthroplasty (THA), the influence that preoperative cannabis use may have on postoperative opioid consumption remains unknown. The purpose of this study was to assess the relationship between preoperative cannabis use and opioid utilization following primary THA.We identified all patients over the age of 18 who underwent unilateral, primary THA for a diagnosis of osteoarthritis at a single institution from February 2019 to April 2021. Our cohort was grouped into current cannabis users (within 6 months of surgery) and those who reported never using cannabis. One hundred and fifty-six current users were propensity score matched 1:6 with 936 never users based on age, sex, BMI, history of chronic pain, smoking status, history of anxiety/depression, ASA classification and type of anesthesia. Outcomes included inpatient and postdischarge opioid use in morphine milligram equivalents.Total inpatient opioid utilization, opioids refilled, and total opioids used within 90 postoperative days were similar between the groups.In propensity score matched analyses, preoperative cannabis use was not independently associated with an increase in inpatient or outpatient, 90-days opioid consumption following elective THA.

There is a relative paucity of literature on the outcomes after revision total hip arthroplasty (rTHA) in young patients. This study reports the survivorship and risk factors for re-revision in patients aged ≤55 years.We identified 354 patients undergoing aseptic nononcologic rTHA at mean follow-up of 5 years after revision, with mean age of 48 years, body mass index of 28 kg/mSixty-two patients (18%) underwent re-revision THA at the mean time of 2.5 years, most commonly for instability (37%), aseptic loosening (27%), and prosthetic joint infection (15%). The rTHA survivorship from all-cause re-revision and reoperation was 83% and 79% at 5 years, respectively. Multivariate analysis demonstrated that patients undergoing femoral component only (hazard ratio 4.8, P = .014) and head/liner exchange rTHA (hazard ratio 2.5, P = .022) as risk factors for re-revision THA.About 1 in 5 patients aged ≤55 years undergoing rTHA required re-revision THA at 5 years, most commonly for instability. The highest risk group included patients undergoing head/liner exchanges and isolated femoral component revisions.

Preoperative opioid use increases opioid consumption postoperatively, but the effect of tramadol is poorly understood.We retrospectively reviewed 11,667 patients undergoing primary unilateral THA and TKA at a single institution. Preoperatively, there were 8,201 opioid-naïve patients (70.3%), 1,315 on tramadol (11.3%), 1,408 on narcotics (12.1%) and 743 on narcotics and tramadol (6.3%). We compared morphine milligram equivalents (MMEs) used during hospitalization, prescribed at discharge, and refilled during the first 90 days. We used multivariate analysis to assess whether preoperative tramadol use was associated with increased number of refills and total refilled MMEs.Total in-hospital MMEs and daily MMEs was lowest for the opioid naïve patients and significantly increased for the remaining three groups (total in-hospital use: 119, 152, 211, and 196 MMEs, respectively-P.001) (daily in-hospital use: 66, 74, 100, and 86 MMEs, respectively-P.001). Opioid refill rate was significantly higher for all patients who were not opioid naïve (32%, 42%, 41%, and 52%, respectively-P.001). Total MMEs prescribed after discharge was lowest for opioid naïve patients (477, 528, 590 and 658, respectively-P.001). Logistic and linear regression controlling for age, sex, history of anxiety/depression revealed that THA patients taking tramadol preoperatively were 2.5 times more likely to require post-discharge refills and refilled 80 additional MMEs than opioid naïve patients (P.001).Tramadol is not recommended for pain beforeTKA or THA, and surgeons and patients should be aware that it is associated with a substantial increase in postoperative opioid use.

There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion.We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis.Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P.001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb12 had an elevated risk of transfusion at 37.5% (15/40 patients).With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (12 g/dL) had the highest risk of transfusion at 37.5%.

Background: Several studies have reported lower perioperative complications with unicompartmental knee arthroplasty (UKA) than with total knee arthroplasty (TKA). However, there is a paucity of data analyzing the incidence of periprosthetic joint infection (PJI) in similar patients undergoing UKA and TKA. As such, we sought to analyze the incidence of UKA and TKA PJI in a large matched population. Material and Methods: The Mariner data set of the PearlDiver database was queried for all patients undergoing UKA or TKA during 2010-2017. Included patients were required to have at least 2 years of database inclusion after surgery. Patients were then matched at a 1:3 ratio (UKA:TKA) on age, gender, Elixhauser Comorbidity Index, tobacco use, and obesity. Rates of PJI requiring operative intervention within 90 days and 1 year were calculated. Results: In total, 5636 patients having undergone UKA were matched to 16,890 patients having undergone TKA. Fifteen (0.27%) after UKA and 79 (0.47%) after TKA had a PJI surgically managed within 90 days (risk ratio = 0.57, 95% confidence interval = 0.33-0.99, P = .04). Thirty (0.53%) after UKA and 136 (0.81%) after TKA had a PJI surgically managed within 1 year (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = .04). Conclusions: In a large group of rigorously matched patients, UKA was associated with a significantly lower rate of surgically managed PJI than TKA at 90 days and 1 year; however, the rate of PJI in both groups remained low at

Background There is a paucity of data on the outcomes of distal femoral replacements (DFRs) in patients with total knee arthroplasty (TKA) periprosthetic fractures. We sought to characterize these patients’ survivorship free from rerevision. Methods We retrospectively identified 49 patients, including 34 after primary TKA (primary cohort), 9 after revision TKA, and 6 conversions for failed open reduction and internal fixation (revision cohort) that underwent DFR for a periprosthetic femur fracture. The mean age was 76 years, and 40 patients (82%) were female. The mean follow-up was 4 years. Femoral fixation included 44 cemented stems (90%) and 5 cementless stems (10%). Survivorship free from rerevision was characterized by the Kaplan–Meier method; cox proportional regression was used to analyze the risk factors for rerevision. Results Survivorship free from any rerevision at 5 years in the primary and revision cohort was 93% and 18%, respectively. The revision cohort had a 5.3× higher risk of re-revision (P = .008). Survivorship free from re-revision for aseptic loosening at 5 years in the primary and revision cohort was 93% and 53%, respectively. Two of the 3 patients with cementless stems in the primary cohort underwent early rerevision for aseptic loosening, but patients with prior primary TKAs treated with cemented femoral fixation (n = 31) had a 97% 5-year survivorship free from re-revision. Conclusion Patients with periprosthetic fractures around prior primary TKAs treated with DFRs with cemented femoral fixation had a 97% 5-year survivorship free from any re-revision. DFRs for periprosthetic femur fractures around revision TKAs or conversions of failed open reduction and internal fixations have a 5× increased risk of rerevision.

Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0–520 ml) versus 92.3 ml (0–600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250–1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

AimsSurgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture, which leads to femoral joint line elevation. There is a paucity of data describing the effect of joint line elevation on mid-flexion stability and knee kinematics. Thus, the goal of this study was to quantify the effect of joint line elevation on mid-flexion laxity.MethodsSix computational knee models with cadaver-specific capsular and collateral ligament properties were implanted with a posterior-stabilized (PS) TKA. A 10° flexion contracture was created in each model to simulate a capsular contracture. Distal femoral resections of + 2 mm and + 4 mm were then simulated for each knee. The knee models were then extended under a standard moment. Subsequently, varus and valgus moments of 10 Nm were applied as the knee was flexed from 0° to 90° at baseline and repeated after each of the two distal resections. Coronal laxity (the sum of varus and valgus angulation with respective maximum moments) was measured throughout flexion.ResultsWith + 2 mm resection at 30° and 45° of flexion, mean coronal laxity increased by a mean of 3.1° (SD 0.18°) (p < 0.001) and 2.7° (SD 0.30°) (p < 0.001), respectively. With + 4 mm resection at 30° and 45° of flexion, mean coronal laxity increased by 6.5° (SD 0.56°) (p < 0.001) and 5.5° (SD 0.72°) (p < 0.001), respectively. Maximum increased coronal laxity for a + 4 mm resection occurred at a mean 15.7° (11° to 33°) of flexion with a mean increase of 7.8° (SD 0.2°) from baseline.ConclusionWith joint line elevation in primary PS TKA, coronal laxity peaks early (about 16°) with a maximum laxity of 8°. Surgeons should restore the joint line if possible; however, if joint line elevation is necessary, we recommend assessment of coronal laxity at 15° to 30° of knee flexion to assess for mid-flexion instability. Further in vivo studies are warranted to understand if this mid-flexion coronal laxity has negative clinical implications. Cite this article: Bone Joint J 2021;103-B(6 Supple A):87–93.

Instability remains one of the most frequent complications requiring revision surgery after primary total hip arthroplasty (THA). Elevated liners are often utilized to reduce the risk of dislocation; however, the literature is inconclusive, with no systematic reviews summarizing the data. Thus, this systematic review aimed to establish a consensus for the efficacy of elevated liners in primary THA by determining rates of overall revision and revision specifically for recurrent dislocation. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies reporting on the use of elevated liners in primary total hip arthroplasty were identified through May 2020. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. Eight studies met inclusion criteria, and overall, 26,507 patients undergoing primary THA with use of an elevated liner were included. In aggregate, the most common cause of revision was recurrent hip dislocation (1.3%, N = 82/6,267) followed by joint infection (1.2%, N = 45/3,772) and acetabular loosening (0.3%, N = 10/3,772). Notably, elevated liners were associated with a lower risk of revision for recurrent dislocation compared to neutral liners (HR: 0.74; 95% CI: 0.55–1.00; p = 0.048). This review found that after primary THA with the use of elevated liners, hip dislocation and prosthetic joint infection continued to be the most frequent reasons for revision surgery. However, elevated liners had a lower risk of revision for recurrent dislocation compared to neutral liners.

The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA. The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “cross-linked”, “polyethylene”, “HXLPE”, “conventional”, “total knee arthroplasty”, “TKA”, “total knee replacement” and “TKR” combined with Boolean operators AND and OR. Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39–1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20–1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31–0.39; I2: 0.0%). The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/mOne hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb12.5 (OR = 3.99, P.0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P.001).Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.

Background The COVID-19 pandemic significantly altered medical practice and public behavior in the USA. In spring of 2020, elective surgery including most joint replacement was suspended and much of the public asked to stay at home. As elective surgery resumes, it is unknown how the public will respond. Questions/Purposes We sought to describe public interest in knee replacement during the onset of the COVID-19 pandemic. Methods Google Trends was used to obtain the daily number of searches for “knee replacement,” “coronavirus,” and “knee pain” from December 19, 2019, to May 14, 2020. The number is on a term-specific scale weighted to the highest number of daily searches for that term. Seven-day weighted averages were used to smooth the data. Results The number of daily searches for “knee replacement” was stable until around March 8, 2020, after which it decreased through late March, plateauing at less than half the number of searches. At the same time, searches for “coronavirus” spiked. By early May, searches for “knee replacement” had not meaningfully increased, though at the end of the search period the slope turned positive and coronavirus searches decreased. Searches for “knee pain” initially followed a similar pattern to “knee replacement,” though the decline was not as steep, and by late April searches for “knee pain” had meaningfully increased. Conclusion Public interest in knee replacement, assessed through internet search queries, decreased during the onset of the COVID-19 pandemic. While interest in pain has returned, the continued decreased level of interest in surgery may represent a fear of surgery among the general public in the setting of COVID-19. Surgeons may wish to focus outreach and education efforts on the safety and efficacy of knee replacement. Electronic supplementary material The online version of this article (10.1007/s11420-020-09794-0) contains supplementary material, which is available to authorized users.

Background There are little data on the outcomes of primary total hip arthroplasties (THAs) in patients with a prior surgically treated hip or knee periprosthetic joint injection (PJI). The goal of this study was to compare the risk of infection in this population with matched controls. Methods We retrospectively reviewed 48 patients whom underwent 50 primary THAs from 2000 to 2014 with a history of a PJI in a total knee arthroplasty or contralateral THA. Thirteen patients (27%) were on chronic antibiotic suppression at the time of primary THA. Mean age was 67 years, and mean body mass index was 35 kg/m2. Mean follow-up was 6 years. We 1:3 matched (age, sex, body mass index, cemented vs cementless femoral fixation, and surgical year) these cases to 150 primary THAs. Competing risk analysis, with death as the competing risk, was performed. Results The cumulative incidence of PJI with death as a competing risk was 1.5-fold higher in the study cohort (2.0%) compared with matched controls (1.4%) (hazards ratio, 1.5; P = .75). The cumulative incidence of any infection with death as a competing risk was 2-fold higher in the study cohort (4.0%) compared with matched controls (2.1%) (hazards ratio, 2.0; P = .45). However, these were both statistically similar given the relatively small cohort. The overall complication rate, including infections and reoperations, was 17% in the study cohort. Conclusion Patients undergoing a clean primary THA with a history of a total knee arthroplasty or contralateral THA PJI in another joint have a 2% and 4% risk of PJI and any infection, respectively. Moreover, nearly 1 in 5 patients experience at least 1 complication.

Introduction Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy’s PP washout protocol, Betadine has known tissue toxicity. Aim We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin. Methods We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed. Main Outcome Measure The primary outcome was rate of PP infection before and after change of intraoperative irrigation. Results From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy. Conclusions Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine. Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422–427.

Aims Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m2 (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175.

PURPOSE OF THE REVIEW: The utilization of technology has increased over the last decade across all surgical specialties. Robotic-assisted surgery, among the most advanced surgical technology, applied to hip and knee arthroplasty has experienced rapid growth in utilization, surgical applications, and robotic platforms. The goal of this study is to provide a comprehensive review of the most commonly utilized robotic platforms for hip and knee arthroplasty and the most up to date literature on the benefits and limitations of robotic arthroplasty. RECENT FINDINGS: Studies consistently demonstrate that that robotic-assisted surgery during total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) improves component position and alignment. There is also growing evidence that robotic-assisted UKA improves clinical outcomes and implant survivorship and, therefore, may be cost-effective. However, there remains to be convincing evidence that robotic-assisted arthroplasty improves clinical outcome measures or reduces revision rates for THA and TKA. Potential disadvantages of robotic arthroplasty remain, including a learning curve, potential for additional radiation exposure preoperatively, and the financial costs. SUMMARY: Robotic hip and knee arthroplasty remains attactive as studies show that it consistently improves implant position and alignment over conventional techniques. There is growing evidence that robotic UKA may improve patient outcomes and reduce revision rates, but further study is needed. In addition, further and longer-term studies are needed to determine if improved component position and alignment in TKA and THA leads to improved clinical outcomes and reduced revision rates.

BACKGROUND Hemochromatosis can result in metabolic bone pathology (due to excessive iron absorption) and degenerative joint disease, leading to total joint arthroplasties. The aim of this study is to analyze the survivorship, complications, radiographic results, and clinical outcomes of patients with hemochromatosis who received either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA). METHODS We identified 34 lower extremity arthroplasties in 29 patients with hemochromatosis performed between 2000 and 2016. There were 17 primary THAs in 15 patients and 17 primary TKAs in 14 patients. Mean age at arthroplasty was 63 years with 76% being male. The mean body mass index was 28 kg/m2. Mean follow-up was 5 years. RESULTS The survivorship free from any revision for THAs was 94% at 10 years. One patient was revised for aseptic loosening of the femoral stem at 6 months. In THA patients, no infections, no other complications, and no radiographic evidence of aseptic loosening were identified. Harris Hip Scores improved from a mean of 55 preoperatively to 94 postoperatively (P < .001). The survivorship free from any revision for TKAs was 100% at 10 years. Two patients (12%) developed acquired idiopathic stiffness postoperatively; no infections were identified. There was no radiographic evidence of aseptic loosening in any TKA. Knee Society Scores improved from a mean of 61 preoperatively to 94 postoperatively (P < .001). CONCLUSION This study found excellent survivorship, significant improvements in clinical outcomes, and a very low complication profile for both THA and TKA in patients with hemochromatosis.

Background: Recreational and medicinal cannabis use is becoming increasingly popular, but there are little data on its effect on postoperative pain and opioid consumption after primary total knee arthroplasty (TKA). Purpose: We sought to evaluate the relationship between self-reported preoperative cannabis use and postoperative opioid consumption and post-discharge opioid prescriptions following elective primary TKA. Methods: We identified all patients who underwent unilateral, primary TKA for a diagnosis of osteoarthritis at a single institution between February 1, 2019, and April 30, 2021, and subdivided them into current cannabis users and non-users based on self-reported data. Regular users were propensity score-matched 1:6 with non-users using logistic regression on age, sex, body mass index (BMI), history of chronic pain, smoking status, history of anxiety/depression, American Society of Anesthesiology (ASA) classification, and type of anesthesia. Outcomes of interest included median inpatient (total, daily, and hourly) morphine milligram equivalents (MMEs), discharge MMEs, and outpatient MMEs within 90 days after surgery. Results: A cohort of 70 current cannabis users was matched with 420 non-users. There were no significant differences in opioid use in inpatient MMEs (hourly, daily, or total), discharge MMEs, or outpatient MMEs between cohorts. Also, there was no significant difference in hospital stay between cohorts. Conclusion: In this retrospective propensity score–matched model, preoperative cannabis use did not independently increase opioid use post-TKA in the inpatient or outpatient setting when compared with non-use. More rigorous, prospective study is warranted.

Surgeons may resect additional distal femur during primary posterior-stabilized (PS) total knee arthroplasty (TKA) to correct a flexion contracture. However, the resultant joint line elevation (JLE) increases mid-flexion laxity. We determined whether a mid-level constraint (MLC) insert reduced mid-flexion laxity after JLE.Six computational knee models were developed using computed tomography scans and average soft tissue properties yielding balanced extension gaps but with a 10° flexion contracture. Distal femoral resections of +2 and +4 mm were simulated with PS and MLC inserts. Varus-valgus ±10 Nm moments were applied at 30°, 45°, and 60° of flexion. Coronal laxity (the sum of varus-valgus angulation) and coupled axial rotation (the sum of internal/external rotation) were measured and compared between insert models.At 30° of flexion, coronal laxities with the PS insert at the +2 and +4 mm resections averaged 7.9° ± 0.6° and 11.3° ± 0.6°, respectively, and decreased by 0.8° (P = .06) and 1.0° (P = .07), respectively, with the MLC insert. PS rotational laxities at the +2 and +4 mm resections averaged 11.1° ± 3.9° and 12.5° ± 4.6°, respectively, and decreased by 5.6° (P = .01) and 7.1° (P = .02), respectively, with the MLC insert. Similar patterns were observed at 45° and 60° of flexion.With additional distal femoral resections to alleviate a flexion contracture, utilizing an MLC insert substantially reduced coupled axial rotation but had a minimal impact on coronal laxity compared to a PS insert. Efforts should be taken to avoid JLE in primary total knee arthroplasty as even MLC inserts may not mitigate coronal laxity.

Tibial slope in total knee arthroplasty (TKA) impacts knee flexion, balance, and ligament strain. Implants were initially designed with tibial slope recommendations based on the intramedullary axis. However, technology-assisted TKA, such as robotics or navigation, determines slope from the ankle-knee axis connecting the center of the transmalleolar line to the proximal exit point of the tibial shaft axis. We sought to quantify the difference in tibial slope between the traditional intramedullary and transmalleolar sagittal tibial axes.We retrospectively identified 40 TKAs with preoperative computed tomography scans. We reconstructed the 3-dimensional geometry of the tibia and fibula and determined the intramedullary axis as the best fit cylinder to the tibial shaft. We defined the transmalleolar axis according to accepted industry standards. We measured the angular difference between both axes in the sagittal plane.The transmalleolar axis was radiographically posterior to the intramedullary axis in 39 knees. Utilizing the transmalleolar axis to set posterior tibial slope would reduce the posterior tibial slope by a mean of 1.9° ± 1.3° compared to the intramedullary axis. Furthermore, the posterior slope would be reduced between 0° and 2° in 24 knees (60%), between 2° and 4° in 10 knees (25%), and more than 4° in 5 knees (13%).Tibial components implanted with technology assistance referencing the transmalleolar axis to set posterior slope will show an average of 1.9° less posterior slope when measured in sagittal plain radiographs, potentially concerning for knee kinematics.

Background: Periacetabular osteotomy (PAO) can be used for joint preservation in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI). 1 of the most common procedures following PAO is hardware removal. The aims of this study were to determine the rate of hardware removal and patient characteristics associated with this outcome following PAO. Methods: Data from a prospectively-collected registry was retrospectively reviewed at one institution managing DDH or FAI patients with PAO from July 2008–December 2015. Patients who completed preoperative and postoperative patient reported outcome (PRO) questionnaires with minimum 1-year follow-up were evaluated, resulting in 221 patients followed for a mean of 2.8 years (range 1.0–7.7 years). There were 80% women, mean age was 25 years and mean body mass index (BMI) was 25 kg/m2. Fully-threaded 4.5-mm screws were used for internal fixation. Results: Hardware removal occurred in 30 patients (13.6%) at a mean of 1.0 years after PAO. Patients undergoing hardware removal were younger (mean age 20.4 vs. 26.3 years), thinner (mean BMI 22.2 vs. 25.1), had less severe dysplasia (DDH patients only: mean lateral centre-edge angle 21.0 vs. 16.2, mean Tönnis angle 12.9 vs. 16.8), and were more likely to have PAO for FAI (33% vs. 11%) compared to patients with retained hardware. At final follow-up, multivariable analysis demonstrated a trend toward inferior patient reported outcomes in the hardware removal group. Conclusions: This study defines the incidence and characteristics of patients undergoing hardware removal after PAO and demonstrates similar outcomes to patients who do not require hardware removal.

Two-stage revision total knee arthroplasty remains the gold standard for management of chronic periprosthetic joint infection in North America. Static cement antibiotic spacers used after knee resection to deliver high-dose antibiotics lack primary stability, potentially leading to spacer migration or dislocation, additional bone loss, extensor mechanism erosion, and even knee subluxation or frank dislocation. A custom brace or cast is often required to augment knee stability, which is time-consuming, costly, and prevents monitoring or wound care of the soft tissues. An external fixator arthrodesis antibiotic spacer can provide primary stability without a brace or cast, allowing for soft-tissue monitoring and care, and minimizes potential spacer complications. We present the technique for implanting and removing this specific external fixator arthrodesis antibiotic spacer. Keywords: Total knee arthroplasty, Infection, Periprosthetic joint infection, Antibiotic spacer, Static spacer