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Unlabelled: Although the published studies on the outcomes of total hip arthroplasty (THA) performed with currently available ceramic components show high survivorship and low bearing wear at midterm followup, concern over ceramic fracture and squeaking persist. For these reasons, the use of ceramic is limited. Recently, a new alumina matrix composite material (Delta ceramic) with improved material properties was developed to address these concerns. We report the early outcomes and complications of a prospective, randomized, multicenter trial of 263 patients (264 hips) at eight centers, comparing a Delta ceramic-on-ceramic (COC) articulation with a Delta ceramic head-crosslinked polyethylene bearing combination (COP). There were 177 COC hips and 87 COP hips. Complications were reported for all patients, whereas clinical and radiographic results were provided for the 233 patients with minimum 2-year followup (average, 31.2 months; range, 21-49 months). The Harris hip scores and clinical, radiographic, and survivorship outcomes were similar in both groups. There were four (2%) revisions in the COC group and two (2%) in the COP group. We encountered three intraoperative ceramic liner-related events. In addition, one patient receiving the COC underwent revision for chipping of the ceramic liner, and a second had ceramic fragmentation on followup radiographs but has not undergone revision. These liner related complications remain a concern. No patient reported squeaking in either group; this leaves us hopeful the new material will lessen the frequency of squeaking. In the short term, the Delta COC articulation provided similar functional scores and survivorship and complication rates with the ceramic head mated with crosslinked polyethylene.Level Of Evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Unlabelled: The valgus, osteoarthritic knee is challenging technically and it is unknown whether and how technical and implant variables influence outcomes. We therefore determined the influence of surgical technique of soft tissue balancing and patient and implant factors from 100 unselected cruciate-retaining TKAs for valgus osteoarthritis in patients younger than 75 years of age. From 1987 to 1990, lateral soft tissue balancing was done with an outside-in progression in which the lateral collateral ligament and popliteus were typically released from the femur. From 1991 to 1994, an inside-out technique was use in which the lateral collateral ligament and/or popliteus were typically preserved. The minimum followup was 0.1 year (mean, 8.2 years; range, 0.1-18.2 years). Fourteen of 16 revisions were for wear and/or instability. Popliteus release, lateral collateral ligament release, or greater polyethylene shelf age increased the risk of revision. At 10 postoperative years, survival (end point, revision) was 89% (100 knees), 94% when the shelf age was less than 1 year (n = 73 knees), 97% when the popliteus or lateral collateral ligament was not released (n = 57 knees), and 100% when both conditions were met (n = 39 knees). Cruciate-retaining implants can be successfully used in knees with any degree of valgus osteoarthritis and survival is improved when the surgeon preserves at least one of the structures providing lateral stability in flexion and uses polyethylene with a short shelf life.Level Of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

We retrospectively reviewed the office records of the senior author -- which include two national ballet companies -- and identified 35 dancers who sustained distal shaft fractures of the fifth metatarsal. The usual fracture pattern is a spiral, oblique fracture starting distal-lateral and running proximal-medial. Treatment consisted of open reduction and internal fixation for 2 patients, closed reduction and percutaneus fixation for 2 patients, short leg weightbearing cast for 7 patients, and an elastic wrap and treatment of symptoms for 24 patients. Patients with marked displacement of the fracture underwent internal fixation early in the study period; but more recent treatment emphasized nonoperative means, even for displaced fractures. The average time to pain free walking was 6.1 weeks (range, 0 to 16); return to barre exercises, 11.6 weeks (range, 4 to 48); and return to performance, 19 weeks (range, 6 to 52). There was one delayed union (7 months) and one refracture (2 months) that subsequently healed. All patients returned to professional performance without limitation and no patient reported pain with performance at followup. Spiral fractures of the distal shaft of the fifth metatarsal are common injuries and can usually be treated nonoperatively for these high performance athletes without long-term functional sequelae. [ABSTRACT FROM AUTHOR]

Twenty-eight principal dancers and soloists from America's two most famous ballet companies were examined for anthropometric measurements, including flexibility, muscle strength, and joint range of motion. Both male and female dancers were flexible, but not hypermobile, and did not differ significantly from each other. Marked differences were found between the range of motion of the hip and ankle in the dancers and the norms for the general population. The increased external rotation of the hip in women was accompanied by a loss in internal rotation, resulting in an increased range of motion with an externally rotated orientation. The men, however, lost more internal rotation than they gained in external rotation. These data raise the possibility of a torsional component to the turned-out hip position in elite female professional ballet dancers. In addition, significant anatomic differences separate elite dancers of both sexes from the normal population. [ABSTRACT FROM AUTHOR]

Ballet is an exquisitely sophisticated and elegant art form. However its seeming ease and gracefulness belie the underlying physical stress. Much of a dancer's ability is reliant on favourable anatomy, strength and flexibility. Their foot mechanics, training and performing techniques are unique and thus they present with particular injury patterns. The following paper aims to address these differences and provide an approach to assessing and treating foot and ankle injuries in the ballet dancer. [ABSTRACT FROM AUTHOR]

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.)

Aims: The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution., Methods: Prospectively collected data were reviewed for all primary cemented medial UKAs performed by seven surgeons from January 2006 to December 2022. A total of 2,999 UKAs were identified, including 2,315 FB and 684 MB cases. The primary outcome measure was implant survival. Secondary outcomes included 90-day and cumulative complications, reoperations, component revisions, conversion arthroplasties, range of motion, and patient-reported outcome measures. Overall mean age at surgery was 65.7 years (32.9 to 94.3), 53.1% (1,593/2,999) of UKAs were implanted in female patients, and demographics between groups were similar (p > 0.05). The mean follow-up for all UKAs was 3.7 years (0.0 to 15.6)., Results: Using revision for any reason as an endpoint, five-year survival for FB UKAs was 97.2% (95% CI 96.4 to 98.1) compared to 96.0% for MB (95% CI 94.1 to 97.9; p = 0.008). The FB group experienced fewer component revisions (14/2,315, 0.6% vs 12/684, 1.8%; p < 0.001) and conversion arthroplasties (38/2315, 1.6% vs 24/684, 3.5%; p < 0.001). A greater number of MB UKAs underwent revision due to osteoarthritis progression (FB = 21/2,315, 0.9% vs MB = 16/684, 2.3%; p = 0.003). In the MB group, 12 (1.8%) subjects experienced bearing dislocations which required revision surgery. There were 15 early periprosthetic tibia fractures (0.6%) in the FB group compared to 0 for MB (p = 0.035)., Conclusion: In similar patient populations, FB UKAs demonstrated slightly higher survival than a commonly used MB design. Adverse event profiles differed by bearing type, with an increased risk of bearing dislocation and OA progression with MB designs, and early periprosthetic tibia fractures for FB designs., Competing Interests: K. B. Fricka reports IP Royalties, payment as a presenter and speaker, and research support from Smith & Nephew, as well as consulting fees and research support from Zimmer Biomet, all unrelated to this study. W. G. Hamilton reports research support from Zimmer Biomet, not related to this study. R. A. Sershon reports consulting fees from Zimmer Biomet, not related to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

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.)

Background: Intraoperative calcar fractures (IOCFs) are an established complication of cementless total hip arthroplasty (THA). Prompt recognition and management may prevent subsequent postoperative complications. This study aimed to evaluate the outcomes and revision rates of THAs with IOCFs identified and managed intraoperatively., Methods: There were 11,438 primary cementless THAs performed at a single institution from 2009 to 2022. Prospectively collected data on cases with an IOCF was compared to cases without the complication. The fracture group had a lower body mass index (26.9 versus 28.9 kg/m 2 ; P = .01). Patient age, sex, and mean follow-up (3.2 (0 to 12.8) versus 3.5 years (0 to 14); P = .45) were similar between groups., Results: An IOCF occurred in 62 of 11,438 (0.54%) cases. The THAs done via a direct anterior approach experienced the lowest rate of fractures (31 of 7,505, 0.4%) compared to postero-lateral (27 of 3,759, 0.7%; P = .03) and lateral (4 of 165, 2.4%; P < .01) approaches. Of the IOCFs, 48 of 62 (77%) were managed with cerclage cabling, 4 of 62 (6.5%) with intraoperative stem design change and cabling, 4 of 62 (6.5%) with restricted weight-bearing, and 6 of 62 (9.7%) with no modification to the standard postoperative protocol. The IOCF group experienced one case of postoperative component subsidence. No subjects in the IOCF cohort required revision, and rates were similar between groups (0 of 62, 0% versus 215 of 11,376, 1.9%; P = .63). Postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement scores were comparable (85.7 versus 86.4; P = .80)., Conclusions: Cementless THA complicated by IOCF had similar postoperative revision rates and patient-reported outcome measures at early follow-up when compared to patients not experiencing this complication. Surgeons may use these data to provide postoperative counseling on expectations and outcomes following these rare intraoperative events., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Advances in total hip arthroplasty (THA) have resulted in evolving revision indications and intraoperative techniques, which can influence the exposure of trainees to complex cases. We report 3 decades of revision experience from a tertiary referral center that trains fellows, comparing the reasons for revision and the complexity of revisions over time., Methods: We retrospectively reviewed all revision THAs performed at our institution from 1990 to 2022. Revision diagnoses, components revised, types of revision implants used, and exposure techniques were collected. A "complex" revision was defined as a case that involved an extended trochanteric osteotomy, triflange and cup-cage construct, or acetabular augment., Results: A total of 3,556 THA revisions were identified (108 revisions/year). Aseptic loosening was the most common indication in 1990 to 1999 (45 per year), but decreased to 28.3/year in 2010 to 2019. From 1990 to 1999 and 2010 to 2019, fracture increased from 3.1 to 7.3 per year, infection from 2.9/year to 16.9/year, and metallosis from 0.1 to 13.2 per year. Both component revision were common from 1990 to 1994 (42.6 per year), while polyethylene exchange was most common in 2010 to 2019 (43.3 per year). A decrease was observed in "complex" cases over time: 14.8 extended trochanteric osteotomies/year in 2000 to 2004 compared to 5.4 per year in 2018 to 2022, 4.5 triflange and cup-cage constructs/year in 2004 to 2007 compared to 0.8 per year in 2018 to 2022, and 4 acetabular augments per year in 2009 to 2012 compared to 1 per year in 2018 to 2022., Conclusions: Indications for revision have changed over the decades, while the number of "complex" revisions has gradually decreased, presumably due to advances in implants and materials. If this trend extends to other training institutions, the next generation of arthroplasty surgeons will have less exposure to complex revisions during their training., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Same-day discharge (SDD) following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) started increasing prior to 2020. The purpose of this study was to evaluate the change in the rate of SDD after the pandemic and determine whether those changes became permanent., Methods: The annual rate of SDD for 15,208 primary THA and TKA cases performed between January 1, 2015, and September 9, 2022, at a single institution was determined. We also examined changes in SDD patient demographics as well as differences in the 90-day complication rates of SDD and overnight patients., Results: In 2015, the rate of SDD for primary arthroplasty was 24%, which grew annually to 29% in 2019. Postpandemic, the rate of SDD jumped above 50% and continued up to 64% by 2022. The biggest increase was in TKA, which went from under 10% SDD prepandemic to 50% by 2022. The average age and body mass index of SDD cases prepandemic increased significantly to 62 ± 9 years and 29.4 ± 5.3 (P < .01). Overnight patients had higher rates of 90-day postoperative complications (8.4 versus 4.2%, P < .00001)., Conclusions: The pandemic caused major changes in the rate of SDD for primary THA and TKA, increasing in subsequent years. The SDD patients became older and heavier due to the expanded criteria for SDD cases. The 90-day postoperative complication rate was lower for SDD patients since higher risk patients were kept overnight. At the prepandemic rate, 29% of patients currently being sent home would have stayed overnight., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Recent expansion in the indications for outpatient total joint arthroplasty has led to debates over patient selection. The purpose of this study was to compare early clinical outcomes and complications of same-day discharge (SDD) hip and knee arthroplasties from a high-volume institution based on the American Society of Anesthesiologists (ASA) physical status classification., Methods: Prospectively collected data were reviewed for all SDD primary joint arthroplasties between January 2013 and August 2023. There were 8 surgeons who performed 7,258 cases at hospital outpatient (n = 4,288) or ambulatory surgery centers (n = 2,970). This included 3,239 total hip arthroplasties, 1,503 total knee arthroplasties, and 2,516 unicompartmental knee arthroplasties. The ASA 1 group comprised 506 subjects, compared to 5,005 for ASA 2 and 1,736 for ASA 3. The primary outcomes included emergency department (ED) visits, readmissions, complications, and revisions within 24 hours and 90 days of surgery. The ASA 3 group was older (ASA 1 = 55 versus ASA 2 = 63 versus ASA 3 = 66 years; P < .01) and had a higher body mass index (ASA 1 = 25.4 versus ASA 2 = 28.5 versus ASA 3 = 32.7; P < .01)., Results: There were no differences between ASA groups in joint-related ED visits, readmissions, and complications within 24 h and 90 days of surgery (P > .05). Subjects in the ASA 3 group experienced greater 90-day revisions compared to the other groups (ASA 1 = 1 of 506, 0.2% versus ASA 2 = 15 of 5,005, 0.3% versus ASA 3 = 15 of 1,736, 0.9%; P = .01). Regarding systemic events, ASA 1 subjects experienced significantly greater 24-hour complications (8 of 506, 1.6%) and ED visits (5 of 506, 1.0%), and the ASA 3 subjects had a higher incidence of 90-day readmissions (19 of 1,736, 1.1%) compared to the other groups (P < .05). Within 24 hours of discharge, urinary retention and syncope were the most frequent complications that required additional health care utilization., Conclusions: Medically optimized patients categorized as ASA 3 can safely undergo SDD hip and knee arthroplasty without increased risk of 24-hour or 90-day complications. Patient preference for outpatient care, reliable social support, and independent functional status are imperative for a successful outpatient program., (Copyright © 2024 Elsevier Inc. All rights reserved.)

We describe the technique of total hip arthroplasty via a direct anterior approach using the Depuy Synthes (Raynham, MA) VELYS™ Hip Navigation system This technique allows one to accurately set the acetabular component position as well as recreate leg length and offset to meet the goals of hip reconstruction in a precise and efficient manner.

Background: Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training., Methods: Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated., Results: Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group., Conclusion: In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Literature suggests that outpatient arthroplasty may result in low rates of complications and readmissions. There is, however, a dearth of information on the relative safety of total knee arthroplasty (TKA) performed at stand-alone ambulatory surgery centers (ASCs) versus hospital outpatient (HOP) settings. We aimed to compare safety profiles and 90-day adverse events of these 2 cohorts., Methods: Prospectively collected data were reviewed on all patients who underwent outpatient TKA from 2015 to 2022. The ASC and HOP groups were compared, and differences in demographics, complications, reoperations, revisions, readmissions, and emergency department (ED) visits within 90 days of surgery were analyzed. There were 4 surgeons who performed 4,307 TKAs during the study period, including 740 outpatient cases (ASC = 157; HOP = 583). The ASC patients were younger than HOP patients (ASC = 61 versus HOP = 65; P < .001). Body mass index and sex did not differ significantly between groups., Results: Within 90 days, 44 (6%) complications occurred. No differences were observed between groups in rates of 90-day complications (ASC = 9 of 157, 5.7% versus HOP = 35 of 583, 6.0%; P = .899), reoperations (ASC = 2 of 157, 1.3% versus HOP = 3 of 583, 0.5%; P = .303), revisions (ASC = 0 of 157 versus HOP = 3 of 583, 0.5%; P = 1), readmissions (ASC = 3 of 157, 1.9% versus HOP = 8 of 583, 1.4%; P = .625), and ED visits (ASC = 1 of 157, 0.6% versus HOP = 3 of 583, 0.5%; P = .853)., Conclusion: These results suggest that in appropriately selected patients, outpatient TKA can be safely performed in both ASC and HOP settings with similar low rates of 90-day complications, reoperations, revisions, readmissions, and ED visits., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: During manual broaching (MB) in total hip arthroplasty (THA), off-axis forces delivered to the proximal femur and broach malalignment can lead to fractures and cortical perforations. Powered broaching (PB) is a novel alternative that delivers consistent impaction forces and reduces workload. This is the first large-scale study to compare intraoperative and 90-day rates of periprosthetic femur fractures (PFFs) and perforations in THA performed using MB vs PB., Methods: Our institutional database was reviewed for all patients undergoing primary cementless direct anterior THA from 2016 to 2021. Three surgeons performing 2048 THAs (MB = 800; PB = 1248) using the same stem design were included. PFFs and perforations within 90 days of the index procedure were compared. Differences in length of surgery and demographics were assessed., Results: Calcar fractures occurred in <1% of patients (PB [0.96%, 12/1248] vs MB [0.25%, 2/800]; P  = .06). Rates of trochanteric fractures did not differ (PB = 0.32% [4/1248] vs MB = 0.38% [3/800]; P  = .84). Cortical perforations occurred in 0.24% (3/1248) of the PB cohort and in 0.75% (6/800) of the MB cohort ( P  = .09). No revisions due to aseptic loosening or PFF occurred within 120 days of surgery., Conclusions: Our single-center experience with powered femoral broaching in THA demonstrates PB is a safe and efficient means of performing direct anterior THA. Low rates (<1%) of PFF, perforation, and revision can be achieved. Given our positive experience with PB, all surgeon authors utilize PB nearly exclusively for elective primary direct anterior THA., (© 2023 The Authors.)

Background: There is limited literature on motor nerve palsy in modern total hip arthroplasty (THA). The purpose of this study was to establish the incidence of nerve palsy following THA using the direct anterior (DA) and postero-lateral (PL) approaches, identify risk factors, and describe the extent of recovery., Methods: Using our institutional database, we examined 10,047 primary THAs performed between 2009 and 2021 using the DA (6,592; 65.6%) or PL (3,455; 34.4%) approach. Postoperative femoral (FNP) and sciatic/peroneal nerve palsies (PNP) were identified. Incidence and time to recovery was calculated, and association between surgical and patient risk factors and nerve palsy were evaluated using Chi-square tests., Results: The overall rate of nerve palsy was 0.34% (34/10,047) and was lower with the DA approach (0.24%) than the PL approach (0.52%), P = .02. The rate of FNPs in the DA group (0.20%) was 4.3 times more than the rate of PNPs (0.05%), while in the PL group the rate of PNPs (0.46%) was 8 times more than that of FNPs (0.06%). Higher rates of nerve palsy were observed with women, shorter patients, and nonosteoarthritis preoperative diagnoses. Full recovery of motor strength occurred in 60% of cases with FNP and 58% of cases with PNP., Conclusion: Nerve palsy is rare after contemporary THA through the PL and DA approaches. The PL approach was associated with a higher rate of PNP, whereas the DA approach was associated with a higher rate of FNP. Femoral and sciatic/peroneal palsies had similar rates of complete recovery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The study evaluates the technology of fluoroscopy-based hip navigation that has shown to improve implant positioning in total hip arthroplasty (THA)., Methods: Premier Healthcare data for patients undergoing manual THA or fluoroscopy-based hip navigation THA between 1 January 2016-30 September 2021, were analyzed 90- and 365-day post-THA. The primary outcome was inpatient readmission. Secondary outcomes were operating room (OR) time, length of stay, discharge status, and hospital costs. Baseline covariate differences were balanced using fine stratification and analyzed using generalized linear models., Results: Among 4,080 fluoroscopy-based hip navigation THA and 429,533 manual THA balanced patients, hip-related readmission rates were statistically significantly lower for the fluoroscopy-based hip navigation THA cohort vs. manual THA for both 90-day (odd ratio [95% CI]: 0.69 [0.52 to 0.91] and 365-day (0.63 [0.49 to 0.81] follow-up. OR time was higher with fluoroscopy-based hip navigation THA vs. manual THA (134.65 vs. 132.04 minutes); however, fluoroscopy-based hip navigation THA patients were more likely to be discharged to home (93.73% vs. 90.11%) vs. manual THA. Hospital costs were not different between cohorts at 90- and 365-day post-operative., Conclusions: Fluoroscopy-based hip navigation THA resulted in fewer readmissions, greater discharge to home, and similar hospital costs compared to manual THA.

Background: Short-acting spinal anesthetics enable rapid recovery after hip and knee arthroplasty; however, concerns with transient neurological symptoms (TNS) cause some to avoid using lidocaine. Postoperative urinary retention (POUR) is also a concern with spinal anesthesia. We sought to study the comparative rates of TNS and POUR between lidocaine, mepivacaine, and bupivacaine in a high-volume hip and knee arthroplasty setting., Methods: Data for 1,217 primary THA, TKA, and unicompartmental knee arthroplasty cases were reviewed and grouped by spinal anesthetic agent (lidocaine, mepivacaine, or bupivacaine). Of the 1,217 cases, utilization was 523 lidocaine, 573 mepivacaine, and 121 bupivacaine. The incidence of TNS and POUR requiring catheterization was measured both by clinical evaluation as well as a questionnaire sent to patients 14 days postoperatively., Results: The overall rate of TNS was 8%. With the numbers available, there was no difference in rates of TNS between groups (6.9% lidocaine, 9.2% mepivacaine, and 4.1% bupivacaine; P = .297). There was no difference in rates of TNS or POUR between THA and TKA/unicompartmental knee arthroplasty. Bupivacaine had a significantly higher rate of urinary retention (9.1%; P < .001) than mepivacaine (2.8%) or lidocaine (1.5%)., Conclusion: This study showed no difference in the rate of TNS between the 3 common agents used in spinal anesthesia. Short-acting spinal anesthetics such as lidocaine and mepivacaine can lower the rate of POUR requiring catheterization, helping to enable rapid recovery after hip and knee arthroplasty., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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.)

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.)

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.)

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.)

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.)

Background: Cortical perforation during femoral preparation is a recognized complication of total hip arthroplasty (THA) but the incidence, patient characteristics, management, and outcome have not been described for the direct anterior approach (DAA)., Methods: A database query of all primary and conversion DAA THAs performed by a single surgeon from 2009 to 2021 was used to identify hips that sustained a recognized intraoperative femoral perforation. Radiographs were used to assess stem subsidence, Dorr femur type, and Canal Flare Index., Results: Among 3,973 THAs, 16 patients (0.4%) sustained perforations during broaching including 8 males and 8 females with a mean age at surgery of 65.6 (range 41-81) years and a mean body mass index of 31.0 (range 19.0-44.4). Two hips were converted to longer primary cementless stems to bypass the perforation. For the remaining 14, the broach was redirected and the same primary stem was implanted. Limited weight-bearing (6 patients) or protected weight-bearing as tolerated with a walker/cane (10 patients) was advised postoperatively. At a mean follow-up of 18.7 (range 4-105) months, all stems were stable with no fractures, subsidence, or revisions. Factors associated with perforation included difficulty with exposure (body mass index >40 or a contracture), measurable osteoporosis (Canal Flare Index <3.0), and abnormal proximal femoral anatomy due to prior trauma, retained hardware, or Perthes disease., Conclusion: In this case series, isolated perforation of an otherwise intact femur during DAA was successfully managed with redirection of the broach, implantation of a primary stem that achieved axial/rotational stability, and protected weight-bearing., Level of Evidence: IV, Case Series., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Debate still exists regarding the benefits of unicompartmental (UKA) versus total knee arthroplasty (TKA) for the treatment of medial compartment osteoarthritis. The purpose of this randomized trial is to compare the early outcomes of UKA versus TKA., Methods: One-hundred and seven candidates for UKA were randomized at two centers; 57 candidates received UKA and 50 received TKA. Six-week and 6-month outcome measures including Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), Knee Society Score (KSS), Forgotten Joint Score (FJS), and VR-12 global health scores were obtained. No demographic or baseline patient reported outcome (PRO) differences were present suggesting successful randomization (P > .05)., Results: UKA demonstrated shorter operative times (UKA = 65 minutes, TKA = 74 minutes; P < .001) and length of stay (UKA = 0.7 nights, TKA = 1.2 nights; P < .01). At 6 weeks, there were no differences in KOOS, JR (P = .755), KSS (P = .754), FJS (P = .664), or PRO change from preoperative scores (P = .468). There were three surgical complications within 90 days in each group. The duration of opioid consumption (UKA = 33.8 days, TKA = 28.5 days; P = .290) and return to work (UKA = 57.1 days, TKA = 47.3 days; P = .346) did not differ between groups., Conclusion: Data suggest no clinically significant differences between UKA and TKA in the early postoperative period in regards to patient-reported outcome measures, duration of opioid use, or return to work. Patients undergoing UKA can anticipate a shorter length of stay and greater early range of motion. All-cause short-term complications may be more prevalent with TKA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to determine whether pharmacogenetic testing could be used to effectively customize postoperative pain medicine following total joint replacement., Methods: Buccal swabs were collected preoperatively from 107 patients. Pharmacogenetic testing was performed for genetic variants on a panel of 16 genes, including CYP2D6, CYP2C9, OPRM1, and CYP1A2, which affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and many opioids. Patients were randomized to a control group or custom group and blinded to their group. The control group was prescribed oxycodone, tramadol, and celecoxib for postoperative pain management. If any of those were not normally metabolized, they were not prescribed to the patients in the custom group, who were given an alternative drug (hydromorphone for narcotics, meloxicam for non-steroidal anti-inflammatory drugs). Patients recorded their pain level (0-10 numeric scale) and all medications taken daily for the first 10 days following surgery. Medication was converted to milligram morphine equivalents (MMEs)., Results: Genetic variations to medications in our standard postoperative pain management protocol occurred in 24 of the 107 patients (22.4%). The 10-day MME consumed by patients in the control group with genetic variants was 162.6 mg. Patients with variants who had custom postoperative medication consumed only 86.7 MME in the same timeframe (P = .126). The control group demonstrated a higher 10-day average pain level of 4.2 vs the custom group pain level of only 3.1 (P < .05)., Conclusion: With custom postoperative pain prescriptions based on pharmacogenetic testing, patients were able to achieve lower pain levels while reducing the consumption of pain medication., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The procedure of total hip arthroplasty (THA) is rapidly evolving. Patients undergoing THA are younger and more active, and they demand an earlier return to their daily activities. All of these factors increase both the early forces on uncemented femoral stems and the risk for complications. Consequently, surgeons must choose implants that provide immediate primary stability. This has led to renewed interest in the use of uncemented collared stems, which have benefits including increased primary stability, decreased risk of subsidence and periprosthetic fracture, and improved load transfer to the proximal femur. [ Orthopedics . 2022;45(3):e122-e126.].

Background: One purported benefit of the direct anterior approach (DAA) for total hip arthroplasty (THA) is a lower rate of postoperative dislocation., Methods: An institutional database was used to identify 8840 primary THAs performed from 2003 to 2020 including 5065 (57%) performed using the DAA and 3775 (43%) performed via the posterior approach (PA). Direction and mechanism of dislocation were determined from chart review. Outcomes were compared using Kaplan-Meier survivorship with dislocation as the endpoint and a Cox multivariate regression was used to investigate factors associated with dislocation. The mean follow-up was 1.7 ± 2.0 years for the DAA and 3.1 ± 3.3 years for the PA., Results: The 0.5% (26/5065) incidence of dislocation among DAA hips was significantly less than the 3.3% (126/3775) among PA cases (P < .001). The majority of dislocations were posterior (DAA 57%, PA 79%) and occurred during activities of daily living (DAA 82%, PA 77%). Five-year survivorship was significantly higher for the DAA group compared to the PA group (99.1% vs 95.4%, P < .001). Dislocation risk was 4.9 times higher for the PA compared to the DAA (hazard ratio = 4.9, 95% confidence interval = 3.2-7.5, P < .001). Increasing head diameter reduced the risk (hazard ratio = 0.70, 95% confidence interval = 0.57-0.86, P < .001). The 0.2% incidence (10/5065) of revision for instability among the DAA group was significantly lower than the 1.1% (43/3775) rate for the PA group (P < .001)., Conclusion: Compared to primary THAs performed with the PA, DAA cases had a lower risk of dislocation, higher survivorship with dislocation as an endpoint, and a lower risk of revision for instability in this single institution cohort., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Revision total hip arthroplasty with modular component exchange can limit morbidity by retaining well-fixed components but dislocation has been a relatively frequent postoperative complication. This study evaluated the effect of surgical approach on dislocation rate in a modern revision cohort., Methods: From 2010 to 2020, 248 aseptic head and liner exchanges were performed at a single institution. The mean patient age at revision was 64.9 ± 10.4 years and 50% (123/248) were performed among males. Indications for revision included 140 (56%) for polyethylene wear, 68 (27%) for failed metal-on-metal components, and 40 (16%) for instability. The mean follow-up after revision was 2.3 years., Results: Thirty (12%) hips dislocated at a mean of 0.6 years (range 0.01-4.6) postoperatively. The dislocation rate by revision approach was 17% (9/54) for the direct anterior, 6% (5/80) for the direct lateral, and 14% (16/114) for the posterolateral approach (P = .13). Hips revised by the direct anterior approach that dislocated were more abducted (51 ± 8 vs 45 ± 8, P = .05) and more anteverted (26 ± 9 vs 20 ± 7, P = .04) than non-dislocators. Among all 248 hips, cups with more than 48° of abduction were 2.6 times more likely to dislocate (P = .01). Head diameter, neck length, patient age, and gender were not associated with dislocation (P ≥ .20)., Conclusion: Dislocation remains a common complication after head and liner exchange regardless of approach. Cup position is associated with postoperative instability and must be critically evaluated during preoperative planning., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: This study evaluated total knee arthroplasty (TKA) outcomes for an Existing-TKA versus New-TKA from the same manufacturer., Methods: TKA outcomes for 752 with Existing-TKA versus 1129 subjects with New-TKA were followed through 2 years using patient-reported outcome measures (PROMs). Responders were assessed per Outcome Measures in Rheumatology-Osteoarthritis Research Society International criteria. Kaplan-Meier implant survivorship was estimated. Radiographs had an independent radiographic review., Results: Two-year follow-up was 84.6% (636/752) for Existing-TKA and 82.5% (931/1129) for New-TKA. Two-year PROMs mean outcomes for New-TKA versus Existing-TKA at 2 years were: Knee Injury and Osteoarthritis Outcome Score (ADL: 89.0 versus 86.8, P = 0.005; pain: 88.9 versus 87.1, P = 0.019; symptoms: 84.1 versus 82.2, P = 0.017; Sport/Rec: 63.9 versus 58.8, P = 0.001; and QOL: 77.0 versus 73.5, P = 0.003), Patient's Knee Implant Performance (overall: 76.5 versus 73.5, P = 0.003; confidence: 8.4 versus 8.1, P = 0.004; stability: 8.6 versus 8.3, P = 0.006; satisfaction: 8.3 versus 8.1, P = 0.042; and modifying activities: 6.6 versus 6.4, P = 0.334), Oxford Knee Score (41.9 versus 41.1, P = 0.027), and EQ5D-3L (0.88 versus 0.88, P = 0.737). Two-year responder rates using WOMAC were 93.9% versus 90.6% (P = 0.018) for New-TKA versus Existing-TKA. Independent radiographic review showed that tibial and femoral radiolucencies ≥2 mm were similar (P ≥ 0.05) or favored New-TKA. Implant survivorship was similar between groups (log-rank P = 0.9994)., Discussion: New-TKA versus Existing-TKA demonstrated slightly better PROMs with similar radiographic and implant survivorship outcomes., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: The custom triflange acetabular component is used during revision THA to address severe acetabular bone loss. Midterm results are promising, with low rates of loosening and triflange revision reported. However, reoperation and overall complication rates remain high. We aim to investigate our institution's custom triflange experience over 20 years by evaluating implant survivorship, reoperations, complications, and clinical outcomes., Methods: Prospectively collected data were reviewed for 50 patients undergoing revision THA with the use of a triflanged component from January 2000 to December 2018. 94% among these cases had a known outcome or minimum two year follow-up. Outcomes related to the triflange component were recorded, including revisions, reoperations, surgical complications, medical complications, Harris hip scores, and patient satisfaction. Phone interviews were conducted with patients whose recent follow-up exceeded 2 years. Radiographic review was performed to define implants as either stable or unstable., Results: The average Harris hip scores improved 24 points (49 to 73; P < .001). 91% of eligible patients were satisfied at follow-up. One patient was scheduled for revision at an outside institution during the study period. There were 2 reoperations (1 acute infection and 1 screw removal). One patient died due to pulmonary thromboembolism. A Trendelenberg gait was present in 46% (23/50) of patients. There were 14 major complications (28%). Dislocation (12%) was the most common complication., Conclusion: Custom triflange components provide a reliable solution for managing complex acetabular defects in revision THA. Patients should be counseled on magnitude of surgery and the high incidence of complications, specifically infection and dislocation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/G523).

Background: The COVID-19 pandemic caused an abrupt disruption in residency and fellowship training, with most in-person teaching ceasing in March 2020. The AAHKS (American Association of Hip and Knee Surgeons) Board of Directors quickly initiated an online lecture series named the Fellows Online COVID-19 AAHKS Learning initiative. The purpose of this study is to illustrate the impact that this educational platform had on residents and adult hip and knee reconstruction fellows., Methods: Between March 31, 2020 and June 25, 2020 an online educational platform was simultaneously developed and delivered. Adult hip and knee reconstruction fellows and residents were invited to participate in the free, live, online education sessions. Faculty from well-respected institutions from around the United States volunteered their time to host the initiative, choosing topics to present, ranging from hip (13 lectures) and knee (9 lectures), to practice management/miscellaneous (12 lectures). Attendee registrations were tracked via the online platform and the maximum number of attendees per session was recorded. A survey was administered to attendees for feedback., Results: Thirty-four, 1-hour virtual lectures were delivered in real time by 79 different faculty members from 20 different institutions. A total of 4746 registrations for the 34 lectures were received, with 2768 registrants (58.3%) attending. The average attendance was 81 viewers per session (range 21-143), with attendance peaking mid-April 2020. A survey administered to lecture participants showed that 104/109 (95.4%) attended live lectures and 93/109 (85.3%) watched recorded sessions. About 92.5% of attendees responded that they wanted the lectures to continue after clinical responsibilities resumed., Conclusion: Amid a pandemic with cessation of in-person training, AAHKS delivered a robust virtual training alternative, exposing residents and fellows to a variety of renowned faculty and topics. Attendance with the program was very high, along with continued interest to continue this initiative. These worldwide lectures may lead to future opportunities in virtual residency and fellowship education., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Periprosthetic femur fracture (PFF) remains a common reason for failure after total hip arthroplasty (THA). For over 10 years, our institution has performed both anterior approach (AA) and posterolateral (PL) approaches for primary THA with multiple stem designs. The aim of this study is to determine the 90-day relative risk of PFF with regard to approach and stem design., Methods: A retrospective review of our institutional database was performed on all patients undergoing primary THA from 2007 to 2018 using AA or PL approaches. Five surgeons performing 6309 THAs (AA = 4510; PL = 1799) using single-wedge taper (n = 2417) or fit-and-fill (n = 3892) stems were included. PFF occurring within 90 days of the index procedure were analyzed. Differences in PFF rates, fracture location, stem type, and treatment method were assessed. Comparisons were made using a Cox regression analysis., Results: The 90-day revision rate for fracture was 0.3%. Clinically significant fractures requiring cerclage cabling, stem change, revision, or open reduction internal fixation occurred in 0.9% of patients (intraoperative = 37, 0.6%; postoperative = 17, 0.3%). Cox regression found PFF risk was significant for female patients (P = .008), patients older than age 65 (P < .01), single-wedge taper stems (P = .05), and for cases with collarless stems (P = .04). Among PFF cases that required surgical intervention, risk factors were female sex, age older than 65, and body mass index under 25 (P < .05). Collarless stems were 2.6 times more likely to result in PFF than collared stems (P = .04). Single-wedge taper stems were 2.3 times more likely to result in PFF than fit-and-fill stems (P = .05). Approach was not found to be an independent risk factor for PFF (P = .85)., Conclusion: Our single-center experience demonstrates the risk of periprosthetic fracture within 90 days of surgery is significantly lower with collared stems and fit-and-fill stem designs. Female sex, age over 65, and body mass index below 25 nearly double the PFF risk. Surgical approach did not influence fracture rates., (Copyright © 2021 Elsevier Inc. All rights reserved.)