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Background: The risk of noise-induced hearing loss (NIHL) to orthopedic surgeons due to occupational exposures is unknown. A level of 85 decibels (dB) over an 8-hour time-weighted average (TWA) is considered hazardous. Question/Purpose: We sought to identify whether manual and/or robotic arthroplasty procedures increase surgeons' risk of developing NIHL. Methods: At our institution, we prospectively collected intraoperative recordings with a microphone attached to the surgeon during manual total knee arthroplasty (TKA), manual total hip arthroplasty (THA), and robotic-assisted total knee arthroplasty (RTKA). Recordings taken in the operating room without operating room staff present served as baseline controls. The 172 recordings consisted of 46 baseline, 42 THA, 40 TKA, and 44 RTKA recordings. Decibel levels were reported as "maximum dB level" (the highest sound pressure level using an A-weighted dB scale), "LAeq" (the equivalent continuous sound level), "LCpeak" (the peak sound pressure level using a C-weighted dB scale), and "TWA" (the average dB level projected over an 8-hour period). The percentage of allowable daily noise dose was reported as "dose" and the measured dose projected over 8 hours as "projected dose." Results: The recordings of surgeries had average maximum dB levels ranging from 106.0 to 108.0 dB, all significantly greater than controls. Robotic-assisted total knee arthroplasties had the highest average dose (18.7%) and average projected dose (252.0%). Conclusions: Our review of recordings at a single institution found that noise levels of RTKAs surpassed projected doses of 100%. Orthopedic surgeons performing more than 2 RTKAs per day may be at increased risk of NIHL. Further research is needed to assess the effectiveness of measures such as ear protection to minimize surgeons' exposure. [ABSTRACT FROM AUTHOR]

Background: Noise-induced hearing loss (NIHL) is a serious concern for orthopedic surgeons. The National Institute for Occupational Safety and Health (NIOSH) sets the safe exposure limit at 85 dB for 8 hours, yet operating rooms often surpass this limit. This study investigated if using an automated broaching system exposes orthopedic surgeons to dangerous decibel (dB) levels. Materials and Methods: A prospective study analyzed 138 intraoperative sound recordings from 92 total hip arthroplasty (THA) surgeries and 46 baseline measurements at an academic-affiliated private practice, using the NIOSH Sound Level Meter (SLM) application and a microphone. The surgeries were categorized into manual and automated broaching. Key metrics measured included maximal dB level (MDL), peak sound pressure (LCpeak), average continuous sound (LAeq), and average weighted sound in an 8-hour period (TWA), along with dose representations, to identify hazardous noise levels. Results: Of the 92 THA sound recordings, 50 used manual broaching and 42 employed automated broaching. Automated broaching exhibited higher noise levels, with an average MDL of 109.92 dBA, a LAeq of 86.09 dBA, a TWA of 76.48 dBA, and a projected noise dose of 137.74%. In contrast, manual broaching exhibited an average MDL of 105.87 dBA, a LAeq of 83.06 dBA, a TWA of 72.82 dBA, and a projected noise dose of 82.02%. Conclusion: This study highlights the auditory risks from automated broach and manual THA surgeries that orthopedic surgeons experience. Manufacturers should focus on reducing instrument noise when designing surgical tools and orthopedic surgeons and operating room staff should take measures to protect themselves from NIHL during surgery. [Orthopedics. 2024;47(6):349–354.] [ABSTRACT FROM AUTHOR]

Background: Patients being evaluated for revision total joint arthroplasty (RTJA) are often referred to tertiary care centers, which may decrease their access to adequate health care and overburden these health care systems. The purpose of this study was to evaluate the feasibility and effectiveness of RTJA patient evaluation via telehealth. Materials and Methods: We identified a consecutive series of patients newly evaluated for a symptomatic TJA by two academic surgeons during a 1-year period. Clinical records, radiographs, and laboratory values were reviewed to determine whether the patient was indicated for RTJA. Efficiency was determined by calculating the percentage of patients who could have been adequately evaluated with telehealth. We then used the modalities required for diagnosis in each RTJA case to determine the feasibility of evaluating such patients through telehealth. Results: Of the 381 patients evaluated for RTJA candidacy, 154 (40.4%) were indicated for revision surgery. All 152 patients evaluated for possible hip revision could have been evaluated and diagnosed via telehealth, demonstrating a telehealth efficiency of 100%. Of 229 patients evaluated for possible knee revision, 183 were able to be evaluated and diagnosed via telehealth. The 46 remaining patients were indicated for revision secondary to instability, which would require an in-office examination for diagnosis. The efficiency of telehealth for potential knee revision patients was 79.9%. Conclusion: Telehealth may be useful in evaluating patients with symptomatic TJA. It may increase the efficiency of in-office evaluations and reduce potential barriers to health care access. [Orthopedics. 2024;47(6):372–376.] [ABSTRACT FROM AUTHOR]

Background: Selective genicular artery embolization (GAE) has shown promise as a minimally invasive treatment option for persistent symptomatic recurrent effusions (REs) following total knee arthroplasty (TKA). Purpose: We sought to investigate the radiographic and clinical success of GAE for RE after TKA. Methods: We performed a retrospective review of prospectively collected data on primary and revision TKA patients with RE, both hemorrhagic and non-hemorrhagic, who underwent GAE between 2019 and 2021 with a minimum of 6-month follow-up. All embolization procedures were performed by a single interventional radiologist. Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and visual analog scale (VAS) scores were collected prior to GAE and at 1, 3, and 6 months post-procedure. Recurrence of effusion following GAE was assessed at 6 months using ultrasound. Results: Seventeen patients, 10 female and 7 male, with 18 TKAs and a mean (SD) age of 63.1 (8.6) years were included. We saw a mean (SD) of 36.1 (24.4) and 3.3 (3.0) point improvement in WOMAC and VAS scores, respectively. In addition, 14 of the 18 TKAs (77.8%) seen at final follow-up had complete resolution of effusion confirmed by ultrasound. Conclusion: Our retrospective review found that a majority of patients showed significant clinical improvement and resolution of effusion following GAE. These findings suggest that GAE may be an effective minimally invasive treatment option for RE following TKA and should be further investigated. [ABSTRACT FROM AUTHOR]

Background: Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose: We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods: We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results: Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion: In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations. [ABSTRACT FROM AUTHOR]

Background: While many studies have examined the impact of comorbidities on the success of same calendar day discharge (SCDD) in total joint arthroplasty (TJA), literature surrounding the impact of social determinants is lacking. Purpose: We sought to investigate the relationship between various social determinants and success of SCDD after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: We conducted a retrospective review of 1160 THA and 1813 TKA performed at a single academic institution between November 2020 and August 2022. Social factors including substance use, occupation, marital status, income, and participation in physical exercise were included. In addition, aspects of discharge planning were reviewed such as living situation and transportation details. Results: Overall, 952 (32%) patients had successful SCDD, whereas 2021 (68%) patients were discharged on postoperative day 1 (POD1) or greater. Successful SCDD patients were more likely to have health care (4.8% vs 2.5%) and active (5.4% vs 4.6%) rather than sedentary occupations, be married (79.6% vs 67.4%), have access to transportation (95.6% vs 92.9%), live in a higher median income area ($64,044 [16,183] vs $61,572 [14,594]), and exercise weekly (62.6% vs 23.9%). Interestingly, the successful patients had more stories in their homes (1.62 [0.56] vs 1.43 [0.53]), more stairs to enter their homes (5.19 [5.22] vs 4.60 [5.24]), lived farther from the hospital (43.3 [138.0] vs 32.0 [75.9] miles), and a higher prevalence of alcohol use (60.7% vs 44.7%) and tobacco use (19.3% vs 17.3%). Conclusion: These findings may help arthroplasty surgeons to better understand the social factors that contribute to successful SCDD in TJA patients, ultimately aiding in patient selection and preoperative counseling. [ABSTRACT FROM AUTHOR]

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6–e12.] [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infection (PJI) is an important cause of failure in total knee arthroplasty. Irrigation and debridement including liner exchange (I&D/L) success rates have varied for acute PJI. The purpose of this study is to present results of a specific protocol for I&D/L with retention of total knee arthroplasty components.Methods: Sixty-seven consecutive I&D/L patients were retrospectively evaluated. Inclusion criteria for I&D/L were as follows: fewer than 3 weeks of symptoms, no immunologic compromise, intact soft tissue sleeve, and well-fixed components. I&D/L consisted of extensive synovectomy; irrigation with 3 L each of betadine, Dakin's, bacitracin, and normal saline solutions; and exchange of the polyethylene component. Postoperatively, all patients were treated with intravenous antibiotics. Infection was considered eradicated if the wound healed without persistent drainage, there was no residual pain or evidence of infection.Results: Forty-six patients (68.66%) had successful infection eradication regardless of bacterial strain. Those with methicillin-resistant Staphylococcus aureus (MRSA) had an 80% failure rate and those with Pseudomonas aeruginosa had a 66.67% failure rate. The success rate for bacteria other than MRSA and Pseudomonas was 85.25%.Conclusion: Our protocol for I&D/L was successful in the majority of patients who met strict criteria. We recommend that PJI patients with MRSA or P aeruginosa not undergo I&D/L and be treated with 2-stage revision. For nearly all other patients, our protocol avoids the cost and patient morbidity of a 2-stage revision. [ABSTRACT FROM AUTHOR]

Background Total joint arthroplasty (TJA) patients on preoperative anticoagulation therapy present a challenge for adult reconstruction surgeons. The goal in managing such patients is to limit bleeding complications associated with administering the medications while preventing medical complications from withholding them. At our institution, we began a protocol in 2017 that utilizes a half-dose direct oral anticoagulant (DOAC) regimen for one week followed by resuming of the full-dose regimen in select patients who underwent TJA. This study investigated the 90-day safety profile associated with this protocol compared to previous literature. Methodology A retrospective review of 898 patients from a single institution was conducted including all patients receiving a half-dose DOAC protocol for one week followed by resuming of the full-dose regimen after total knee and total hip arthroplasty between 2017 and 2022. Data were collected on patient demographics, type of surgery, and DOAC dosage. Ninety-day complications were collected and separated into reduced dose complications of DOAC (such as cerebrovascular accidents (CVAs) or venothrombotic events (VTEe)) and DOAC therapy-related complications (including wound and bleeding complications). Results In the total hip arthroplasty (THA) subgroup (n = 396, 44.10%), there were four major VTE occurrences, aligning with the range seen in historical protocols. Deep vein thrombosis (DVT) and pulmonary embolism (PE) incidents were three and one, respectively, both within the historical range. In the total knee arthroplasty (TKA) subgroup of 502 (55.90%) patients, there were seven major VTE events, with five DVTs and two PEs, also aligning with historical ranges. Medical complications in the THA group included no CVA events and one myocardial infarction, with the latter slightly higher than the historical range. In the TKA group, there were two medical complications, both being CVAs. Regarding bleeding complications, THA patients showed four major bleeding incidents, two blood transfusions, and two hemorrhages, with these numbers comparable to or lower than historical ranges. There were seven minor bleeding events. For TKA, there were two major bleeding events, two blood transfusions, no hemorrhages, and five minor bleeding events. Wound complications in THA included five surgery-related complications, two cases of wound dehiscence, and three infections. TKA patients experienced 17 surgery-related complications, six cases of wound dehiscence, and 11 infections. Conclusions This study suggests that the half-dose DOAC protocol in patients undergoing TJA is non-inferior to historical full-dose DOAC protocols warranting further investigation to generalize across broader populations., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Patrizio et al.)

Introduction The canal-to-calcar isthmus (CC) ratio has been previously correlated with proximal femur osteology, but its relationship with bone density is not well established. Our purpose was to assess the relationship between femoral bone density, measured on opportunistic quantitative CT in Hounsfield units (HU), and CC ratio. Methods A total of 148 THA patients were included. The CC ratio was measured on anteroposterior hip radiographs. Using perioperative CT scans, a 1 cm diameter area was identified on a single mid-coronal slice in the medial calcar just proximal to the intertrochanteric ridge. The mean HU was calculated in this region to represent calcar bone density. Results Twenty-four percent (n = 35) of patients were classified as Dorr A (average CC ratio 0.47 [0.45; 0.48]), 67% (n = 96) as Dorr B (0.62 [0.55; 0.68]), and 11% (n = 17) as Dorr C (0.78 [0.77; 0.80]). There was a significant difference between Dorr A and Dorr C femurs (769 (144) vs. 588 (154) HU) as well as between B and C femurs (718 (166) vs. 588 (154) HU). The CC ratio was correlated with calcar bone density on CT (-0.370). Conclusion CC ratio is correlated with bone density determined by HU measurements on an opportunistic quantitative computed tomography scan, and bone density HU values were able to accurately differentiate bone density in Dorr A and B from Dorr C femurs. These findings suggest that the CC ratio is a reliable measurement to predict bone density in Dorr C femurs. Therefore, arthroplasty surgeons can confidently use the Dorr classification for patients with Dorr C femurs when preoperatively planning for THA., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Atlanticare Regional Medical Center Institutional Review Board issued approval 2023-1162. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Zachary Post declare(s) personal fees from Ortho Development . Alvin Ong declare(s) personal fees from Smith and Nephew. Alvin Ong, Fabio Orozco declare(s) personal fees from Stryker. Zachary Post, Danielle Ponzio, Hope Thalody declare(s) personal fees from Depuy. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lutz et al.)

Background: The risk of noise-induced hearing loss (NIHL) to orthopedic surgeons due to occupational exposures is unknown. A level of 85 decibels (dB) over an 8-hour time-weighted average (TWA) is considered hazardous., Question/purpose: We sought to identify whether manual and/or robotic arthroplasty procedures increase surgeons' risk of developing NIHL., Methods: At our institution, we prospectively collected intraoperative recordings with a microphone attached to the surgeon during manual total knee arthroplasty (TKA), manual total hip arthroplasty (THA), and robotic-assisted total knee arthroplasty (RTKA). Recordings taken in the operating room without operating room staff present served as baseline controls. The 172 recordings consisted of 46 baseline, 42 THA, 40 TKA, and 44 RTKA recordings. Decibel levels were reported as "maximum dB level" (the highest sound pressure level using an A-weighted dB scale), "LA eq " (the equivalent continuous sound level), "LC peak " (the peak sound pressure level using a C-weighted dB scale), and "TWA" (the average dB level projected over an 8-hour period). The percentage of allowable daily noise dose was reported as "dose" and the measured dose projected over 8 hours as "projected dose.", Results: The recordings of surgeries had average maximum dB levels ranging from 106.0 to 108.0 dB, all significantly greater than controls. Robotic-assisted total knee arthroplasties had the highest average dose (18.7%) and average projected dose (252.0%)., Conclusions: Our review of recordings at a single institution found that noise levels of RTKAs surpassed projected doses of 100%. Orthopedic surgeons performing more than 2 RTKAs per day may be at increased risk of NIHL. Further research is needed to assess the effectiveness of measures such as ear protection to minimize surgeons' exposure., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SAK DO, RWL DO, AJS DO, and VWL DO declare no potential conflicts of interest. ACO, MD, reports relationships with Stryker and Smith and Nephew. GKD, MD, reports relationships with Zimmer Biomet, Synthes, CD Diagnostics, Biostar Ventures, Trice, JBJS, and JOA., (© The Author(s) 2024.)

Total hip arthroplasty (THA) is a common procedure that has become increasingly prevalent in a younger patient population. With improvements in prostheses and materials, the survivorship of implants has increased. Historically, the excellent wear characteristics of ceramic-on-ceramic (CoC) implants made them an appealing choice compared to other bearing options. Yet, the potential benefits of the bearing longevity related to the wear characteristics have been combated by their unique causes of failure such as implant fracture and squeaking. Metal-backed ceramic liners were developed to minimize impingement-related chipping at the periphery of the implant that may propagate to catastrophic implant fracture. We report a case involving a fracture of a metal-backed ceramic liner that presented with months of pain and crepitus with no overt signs of fracture on imaging., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Diciurcio et al.)

In patients who undergo femoral fracture fixation with a cephalomedullary nail, the breakage of one or more of the distal interlocking screws is a well-described phenomenon. The presence of a broken interlocking screw in patients who require the removal of their cephalomedullary nail presents a unique challenge. The broken interlocking screw may be retrieved, or the screw may be retained if it is not engaged within the nail and the nail can safely be removed while leaving the broken screw fragment behind. We report a hip conversion arthroplasty case with a broken interlocking screw where the nail was removed with ease and the broken screw was assumed to have been left behind. Cerclage wires were placed for an apparent proximal femoral fracture. Postoperative X-rays demonstrated a large lucency tracking from the prior location of the distal interlocking screw to the calcar region. This finding made it evident that the broken screw had been retained in the nail and was dragged up the femur upon nail removal, causing a large gouge spanning the entire femur., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Panchal et al.)