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Background: Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors. Methods: This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution. Results: Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training. Conclusions: This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Background: Semipermanent functional spacers are now utilized for prosthetic joint infection in an attempt to avoid another surgery with 2-stage treatment. This study evaluates the results of metal-on-polyethylene articulating spacers for the treatment of chronic native septic knee arthritis. Methods: This is a retrospective review of 18 patients treated with metal-on-polyethylene articulating antibiotic spacers constructed with all-polyethylene tibial components or with polyethylene inserts (PIs) with Steinmann pins or screws for chronic native knee infection. Demographic information, spacer construct type, prior knee surgery, complications, infecting organisms, infection eradication, and functional results were analyzed. Results: Of 18, 8 (44%) spacers were all-polyethylene tibial components and 10 (56%) were PI. Of 18 patients, 5 (28%) experienced spacer complications. Of 18 patients, 12 (67%) underwent a second reimplantation surgery (mean 106 days), while 6 (33%) retained their spacer (average duration 425 days). The PI group performed better in Knee Injury and Osteoarthritis Outcome score for Joint Replacement according to minimum clinically important difference and patient acceptable symptom state (PASS) criteria. The overall reimplantation group achieved Knee Injury and Osteoarthritis Outcome score for Joint Replacement PASS criteria and minimum clinically important difference criteria, while the maintained articulating spacer group did not achieve PASS criteria; however, they did reach minimum clinically important difference. Conclusions: Functional articulating spacers are a viable treatment for chronic, native knee septic arthritis. The PI patient group had a greater improvement in Knee Injury and Osteoarthritis Outcome score for Joint Replacement scores and had no significant difference in reimplantation rate as the all-polyethylene tibial components patient group. Both planned 2-stage reimplantation and longer-term spacer retention show promising results for this difficult clinical problem.

Background: There has been a shift toward same-day discharge (SDD) in total joint arthroplasty (TJA) in recent years. Our clinical standard had been next-day discharge, but the COVID pandemic led to a hospital bed shortage, causing us to shift to SDD directly from the Post-Anesthesia Care Unit (PACU). The aim of our project was to investigate if the SDD protocol was successful and if it changed complications or 90-day readmission rates. Our secondary aim was to investigate if the protocol created disparities in patient selection. Methods: A retrospective review compared the first 100 patients intended to discharge from PACU to the 100 patients prior to the SDD protocol undergoing elective primary TJA procedures at our academic institution from September 1, 2020, to March 23, 2021. The SDD protocol started on November 19, 2020. Results: During this SDD period, 98% (98/100) of patients were successfully discharged from the PACU. The 90-day readmission rate changed from 0% to 2% (P = .4975), and the overall complication rate changed from 2% to 5% (P = .4448). Most complications were manipulation under anesthesia to improve range of motion. Manipulations under anesthesia changed from 1% to 4% (P = .3687). Conclusions: The transition to same SDD in TJA at our academic institution was successfully implemented without markedly increasing complications, readmissions, or changing patient selection. The COVID-19 pandemic likely influenced the recovery of patients before and after the protocol. Future studies are needed to validate this data during the post-COVID era.

Background: Robotic total knee arthroplasty (R-TKA) utilization and marketing continue to rise. We examined the marketing on surgeon websites regarding R-TKA benefits and sought to determine if the claims were supported by existing literature. Methods: A Google search identified 10 physician websites from each of the 5 largest U.S. markets by population with the term “robotic total knee arthroplasty city, state.” Claims on websites about R-TKA were categorized. Literature from 2012-2022 was reviewed for data “for” or “against” each claim. Level of evidence for each publication was collected. Results: Fifty websites were captured that included 59 surgeons. A specific R-TKA platform was mentioned on 68% of websites. Website claims about robotics were placed into 8 major categories. Literature review supported the claims of more precise/accurate, reduced injury to tissue, and less pain with more literature “for” than “against” the claims. Conclusions: Claims made on physician websites regarding the benefits of R-TKA are variable and not definitively supported by existing literature. Most available data can be categorized into levels of evidence III, IV, and V. There is a paucity of level I evidence to support the various marketing statements. Physicians should be cognizant of both the claims made on their websites and the literature that could be used to support or refute those specific claims.

The 2023 report represents a full decade of published annual reports of the American Joint Replacement Registry (AJRR). The number of cases being captured continues to rapidly grow, as are over 3.2 million patients included in AJRR. Matched-pair primary and revision data is more robust with 10-year survivorship being available. Similarly, implant-specific survivorship has been included for common implants being used in the United States. The data mined from the AJRR have led to numerous publications and presentations. Numerous trends have emerged, and others have been reinforced with the most recent data. The authors encourage readers to more thoroughly review the full report at the following link: https://www.aaos.org/registries/publications/ajrr-annual-report/.

Background: Inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) practices were dramatically affected in the United States in 2020 as elective surgeries were paused in response to the COVID-19 pandemic. This study sought to provide an updated estimate of inpatient total joint arthroplasty (TJA) case volumes in the United States in 2020. Methods: A retrospective cohort study was performed by identifying all adult patients who underwent primary, elective TJA from January 1st, 2017 to December 31st, 2020, using the National Inpatient Sample. Monthly and annual case volumes were reported with descriptive statistics. Baseline case volumes were established by taking the average number of monthly cases performed in 2017, 2018, and 2019. These monthly averages were compared to 2020 values. Results: From 2017 to 2019, the average case volume was 1,056,669 cases per year (41.0% THA, 59.0% TKA) and 88,055 cases per month. In 2020, 535,441 cases were identified (45.4% THA, 54.6% TKA), corresponding to a 49.3% reduction from the 2017-2019 annual average. Monthly cases decreased to 4515 in April during the “first wave” of COVID-19, corresponding to a 94.8% decrease from prior years. In June, cases rebounded to 55,520 before decreasing again in July to 50,100 during the “second wave” of COVID-19. During the “third wave,” COVID-19 cases decreased month-over-month from October through December (56.5% decrease). Conclusions: This updated estimate identified a 49.3% decrease in inpatient TJA cases in 2020 compared to prior years. This is similar to the 46.5-47.7% decrease in case volume previously reported.

Denosumab is an anti-RANKL Ab that potently suppresses bone resorption, increases bone mass, and reduces fracture risk. Discontinuation of denosumab causes rapid rebound bone resorption and bone loss, but the molecular mechanisms are unclear. We generated humanized RANKL mice and treated them with denosumab to examine the cellular and molecular conditions associated with rebound resorption. Denosumab potently suppressed both osteoclast and osteoblast numbers in cancellous bone in humanized RANKL mice. The decrease in osteoclast number was not associated with changes in osteoclast progenitors in bone marrow. Long-term, but not short-term, denosumab administration reduced osteoprotegerin (OPG) mRNA in bone. Localization of OPG expression revealed that OPG mRNA is produced by a subpopulation of osteocytes. Long-term denosumab administration reduced osteocyte OPG mRNA, suggesting that OPG expression declines as osteocytes age. Consistent with this, osteocyte expression of OPG was more prevalent near the surface of cortical bone in humans and mice. These results suggest that new osteocytes are an important source of OPG in remodeling bone and that suppression of remodeling reduces OPG abundance by reducing new osteocyte formation. The lack of new osteocytes and the OPG they produce may contribute to rebound resorption after denosumab discontinuation.

Introduction A negative correlation exists between functional outcomes and leg length discrepancy (LLD) following hip fracture repair. We have assessed the effects of LLD following hip fracture repair in elderly patients on 3-meter walking time, standing time, activities of daily living (ADL), and instrumental activities of daily living (IADL). Methods One hundred sixty-nine patients enrolled in the STRIDE trial were identified with femoral neck, intertrochanteric, and subtrochanteric fractures that were treated with partial hip replacement, total hip replacement, cannulated screws, or intramedullary nail. Baseline patient characteristics recorded included age, sex, body mass index Charlson comorbidity index (CCI) score. ADL, IADL, grip strength, sit-to-stand time, 3-meter walking time and return to ambulation status were measured at 1 year after surgery. LLD was measured on final follow-up radiographs by either the sliding screw telescoping distance or the difference from a trans-ischial line to the lesser trochanters, and was analyzed as a continuous variable using regression analysis. Results Eighty eight patients (52%) had LLD 10 mm. Age, sex, BMI, Charlson score, and ambulation status had no significant impact on LLD occurrence. Type of procedure and fracture type did not correlate with severity of LLD. Having a larger LLD was not found to have a significant impact on post-operative ADL ( P = .60), IADL ( P = .08), sit-to-stand time ( P = .90), grip strength ( P = .14) and return to former ambulation status ( P = .60), but did have a statistically significant impact on 3-meter walking time ( P = .006). Discussion LLD after hip fracture was associated with reduced gait speed but did not affect many parameters associated with recovery. Continued efforts to restore leg length after hip fracture repair are likely to be beneficial.

The 2022 American Joint Replacement Registry Annual Report includes data from over 2.8 million hip and knee procedures from over 1,250 institutions that encompass all 50 states and the District of Columbia. This represents a cumulative registered procedural volume growth of 14% compared to the previous year, making the American Joint Replacement Registry the largest arthroplasty registry by volume in the world.

Articulating hip spacers for periprosthetic joint infection (PJI) offer numerous advantages over static spacers such as improved patient mobilization, hip functionality, and soft tissue tension. Our study aimed to determine complication rates of a functional articulating spacer using a constrained liner to determine the role of acetabular cementation mantle and bone loss on the need for second-stage surgery. A retrospective review of 103 patients was performed and demographic information, spacer components and longevity, spacer-related complications, reinfection rates, and grade of bone loss and acetabular cement mantle quality were determined. There was no significant difference in spacer-related complications or reinfection rate between PJI and native hip infections. 33 of 103 patients (32.0%) elected to retain their spacers. Between patients who retained their initial spacer and those who underwent reimplantation surgery, there was not a significant difference in cement mantle grade (p = 0.52) or degree of bone loss (p = 0.78). Functional articulating antibiotic spacers with cemented constrained acetabular liners demonstrate promising early results in the treatment of periprosthetic and native hip infections. The rate of dislocation events was low. Further efforts to improve cement fixation may help decrease the need for second-stage reimplantation surgery.

Introduction Certain titanium alloy stems have been shown to be susceptible to failure at the neck with catastrophic trunnion failure. Failure has been particularly noted in the single wedge Accolade 1 stem design. Other stems also used this alloy including the anatomic designed Citation stem. Methods This case series details 3 catastrophic failures of the TMZF version of the Citation femoral stem. Results Each of these failures appear to be attributed to cyclical wear of the TMZF trunnion against the cobalt chromium femoral head. Wear resulted in ultimate implant failure and significant metal debris in the joint capsule at the time of revision surgery. Discussion While surgeons are aware of the risk of catastrophic failure for the Accolade 1 stem, failure may similarly happen in the TMZF Citation stem. Surgeons should monitor these implants with care and discuss the potential for trunnion failure with their patients.

Background: Orthopaedic surgery trainees who aim to specialize in total joint arthroplasty commonly complete an additional year of fellowship training. Limited information regarding individual programs is readily available to potential applicants. The purpose of this study is to determine what information applicants value when considering an adult reconstruction fellowship program. Methods: An anonymous survey was distributed to all 470 junior members of AAHKS. The 12-question survey gathered demographic information as well as average weighted scores (1-10) of various components regarding fellowship education, recruitment, and experiences. Subgroup analysis was performed on survey responses based on the following 3 different categories: Gender, year of training, and geographical location. Results: A total of 135 respondents completed the survey (135 of 470, 28.7% response rate). Sixty-two (45.9%) participants held the position of postgraduate year 5, 43 (31.9%) participants held the position of postgraduate year 4. Exposure to operative techniques in revision surgery (9.62), exposure to operative techniques in primary surgery (9.51), and ability to obtain desired job opportunity after fellowship (8.89) were the 3 most considered components. Higher level trainees valued information regarding average number of hours worked relative to junior trainees (P = .046). Geographic differences were noted in the following 3 variables: the number of cases performed (P = .010), whether fellows had a dedicated clinic and/or operating room (P = .002), and the average number of hours worked (P = .020). Conclusions: Amongst the 3 domains studied, applicants most valued educational components, such as exposure to various techniques surrounding total joint arthroplasty. There is a need for a centralized, comprehensive database that contains information applicants value most and this database should be customizable toward training level and location.

Background: Extensor mechanism disruption (EMD) combined with periprosthetic joint infection (PJI) after total knee arthroplasty are life-changing complications. The literature suggests many eventually receive above-knee amputation and lose ambulatory function. An alternative is modular knee fusion (KF), but little is known about its outcomes and biomechanical function. We report early term results on a case series of patients. Methods: A retrospective review was conducted of patients who underwent 2-stage reconstruction with modular KF for combined EMD and PJI. Patient-reported outcomes at 1 year after arthrodesis and complications of surgery were recorded. Biomechanical analysis was conducted on 6 patients >1 year after surgery to measure gait speed and balance. Results: Fifteen patients received a modular KF. At the most recent follow-up visit (average 25.7 months), 12 patients had their modular KFs in place and were ambulatory while 2 had died. Six patients used a walker; 4, a cane; and 2, unassisted. Gait analysis of 6 of these patients showed variation in patterns and speed. Balance was better than historical controls treated with above-knee amputation. Average Knee Injury and Osteoarthritis Outcome Score Junior was 76 ± 11. Conclusion: Modular KF for EMD and PJI can result in successful outcomes in terms of preventing additional operations and maintaining ambulation. While speed is variable, physical testing shows this method for limb salvage may allow patients to ambulate with a gait aid although further studies are needed to evaluate midterm and long-term results.

Background: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States. Methods: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed. Results: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital. Conclusion: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume.

Background: The COVID-19 pandemic has had a severe impact on the practices of adult reconstruction surgeons, primarily due to the elective nature of hip and knee arthroplasty. Methods: To capture the impact of COVID-19 on its members, the American Association of Hip and Knee Surgeons sent 6 surveys over a span of 7 months from late March until September of 2020 querying its members regarding the effects of COVID on the health and well-being of their personal, financial, and clinical practice. Results: Ninety-two percent of surgeons reported a cessation of elective inpatient cases during the height of the crisis. The reduction was greatest for surgeries performed in hospital-based sites of care. Ninety-one percent reported a drop in clinic volume. At the final surveys, these numbers where 7% and 59%, respectively. In addition, there was a widespread increase in the use of telemedicine during this period. Only a small number of orthopedic practices permanently closed because of COVID-19; 68% of surgeons, however, sought federal funding to offset their loss of revenue because of the restrictions placed on elective surgeries. Finally, once elective surgeries were reinstated, most surgeons reported no restrictions with surgical cases and that they believed they were adapting to the challenges of COVID successfully. Conclusions: The impact of COVID-19 in 2020 on the practice of arthroplasty resulted in nearly universal loss of volume and significant financial stress. Recovery has been consistent but incomplete for most practices. Continued monitoring of the members of American Association of Hip and Knee Surgeons will be needed in 2021 to measure the strength of the demonstrated adaptive recovery of 2020.

Patients with malignancy are often profoundly immunocompromised due to chemotherapy, placing them at potential increased risk for periprosthetic joint infection (PJI). However, there is little information regarding PJI management in these patients. We describe 4 patients with a history of primary total knee arthroplasty followed by diagnosis of multiple myeloma or Waldenström macroglobulinemia who received chemotherapy within 4 months prior to PJI. The Musculoskeletal Infection Society major and minor criteria and either debridement, antibiotics, and implant retention or a 2-stage approach appear to be effective for acute or chronic PJI, respectively. We recommend an anticoagulant be administered concomitantly with antineoplastics that significantly increase deep vein thrombosis risk, and we recommend long-term oral suppressive antibiotics postoperatively, especially if chemotherapy will be resumed. Additional studies are needed to investigate risks and benefits of PJI prophylaxis during chemotherapy and long-term suppressive antibiotics after PJI treatment.

Introduction Corneal abrasion (CA) is the most common ocular complication in patients undergoing nonocular surgery. Corneal abrasions can be caused by a variety of mechanisms, the most common being drying of the cornea due to reduced tear secretions, loss of eyelid reflex, and the loss of pain recognition during surgery. Though CA heals well with eye lubricants, it can result in significant ocular pain and some cases may go on to develop ocular complications. With the current switch to outpatient total joint replacement, CA could potentially lead to discharge delays. Materials and Methods We examined the results of a quality improvement project to reduce CA during general anesthesia to determine the rates of CA during hip and knee total joint replacement. We compared rates of CA for 6 months before and 6 months after the intervention. Results A total of 670 hip and knee arthroplasty procedures were performed during this period. Two events of CA occurred, one occurred before and one after the intervention to decrease eye injuries. Both incidences occurred during total hip arthroplasty (THA) procedures with the patient in the lateral decubitus position and recovered without long-term deficit. Discussion Surgeons and anesthesiologists alike should be cognizant of this avoidable complication and take precaution to protect the eyes during surgery, especially during THA when the patient is placed in the lateral decubitus position. Conclusion Corneal abrasion during total joint arthroplasty is a rare complication and is infrequently addressed in the literature. CA is mostly self-limiting, however, but may lead to patient dissatisfaction and to delays if same-day discharge is attempted. Preventative measures and attentive care may help reduce the incidence of CA in patients undergoing total joint arthroplasty. The lateral decubitus position and longer surgeries times are risk factors for CA.

Introduction: Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost. Methods: Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost. Results: Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs ( P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost. Conclusion: Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Introduction: With the increase in knee and hip implants, these periprosthetic fractures will become more common especially as the population ages. Open periprosthetic fractures are rare and severe injuries and are more likely to be seen in high-energy injuries. They present challenges to the treating physician due to soft tissue damage, contamination of the existing implants, and the effects of polytrauma in the geriatric patient. Methods: Case review report and review of literature . Results A 72-year-old woman was involved in a motor vehicle collision with multiple injuries including an open periprosthetic tibia and femur fracture. This was treated with initial washout and removal of loose tibial component with placement of a cement spacer. The knee was treated with staged revision using a protocol like that used after prosthetic joint infection. After complete soft tissue healing, the patient underwent successful revision with a megaprosthesis. The literature on open periprosthetic fractures is reviewed. Discussion and Conclusion: Open periprosthetic fractures present multiple challenges to the orthopedic surgeon. In the presences of poly trauma and soft tissue injury, we present an approach using staged surgery like that used for prosthetic joint infection.

Tibial bone loss is a common scenario encountered during revision total knee arthroplasty. Reconstructive options depend on the amount and location of bone loss, but few good solutions exist to address large, uncontained tibial defects where cortical support is lost in the metadiaphyseal region. We describe a novel technique using acetabular augments to buttress a revision tibial component and recreate a hemiplateau during tibial revision total knee arthroplasty. In selected scenarios, this construct can create a biomechanically friendlier surface onto which to support the tibial tray and a less expensive option when compared to traditional stacked augments or cones. Level of Evidence: IV–Case series. Keywords: Revision total knee arthroplasty, Acetabular augment, Tibial bone loss, Uncontained defect

Consensus regarding femoral stem fixation options in revision total knee arthroplasty remains controversial. Tapered, modular, fluted titanium (TMFT) stems have an excellent track record in total hip arthroplasty for their ability to provide axial and rotational stability in situations of compromised host bone. We present 3 successfully treated cases in which the Food & Drug Administration granted permission to use custom TMFT stems in situations of failed femoral fixation in multiple revised knees. These stems hold promise to achieve stable fixation in revision total knee arthroplasty where host metadiaphyseal bone is deficient. Implant manufactures should consider dedicating future resources to create adapters that can link existing successful TMFT stems currently used in hip arthroplasty to revision total knee components when host bone is severely compromised.