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Background: Current literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads. Methods: A 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598). Results: There were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012). Conclusions: A minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Background: Prior studies have shown that the majority of re-infections following two-stage revisions are due to organisms different from the initial organisms identified. It remains unknown whether these new organisms were susceptible to the antibiotics given (indicating the patient likely developed another infection following successful treatment) or not susceptible (indicating these organisms may have been initially present, but were not identified, and thus, inadequately treated). The purpose of this study was to determine if bacteria identified at time of re-infection following two-stage revisions were susceptible to the antibiotics administered during treatment of the index infection, in order to understand if these are new infections or from organisms that were present but not initially identified. Methods: Thirty failures (19 knees and 11 hips) following two-stage revisions from four institutions were identified. Cultures and antibiotic sensitivities were used to determine whether the re-infectious organisms were new and if they were susceptible to the antibiotics initially given. Results: Twenty-five (83.3%) re-infections were due to new organisms. Of these re-infections from new organisms, 16 (64.0%) were susceptible to the antibiotics previously administered, suggesting they were new infections rather than persistent infections from organisms that were not detected during initial treatment. No statistically significant differences in demographics or time to revision were observed when comparing by organism type (new vs. repeat) or by antibiotic susceptibility. Conclusions: Failures following two-stage revisions are frequently due to organisms different than those identified prior to two-stage revision and are likely new infections rather than persistent infections from undetected organisms.

Background: There is considerable disparity in institutional practices surrounding routine pathologic examination of femoral heads removed during total hip arthroplasty (THA). Multiple groups have studied the merits of routine femoral head pathology in THA, without clear consensus. We sought to further investigate the existing evidence on routine pathologic examination of femoral heads retrieved during THA to determine if this practice provides additional clinical value and is cost-effective. Material and methods: To conduct a systematic review of the literature, a medical librarian was consulted to develop and perform comprehensive searches in PubMed (1809-present), Embase (embase.com 1974-present), CINAHL (EBSCO, 1937-present), and the Cochrane Central Register of Controlled Trials (Wiley). Final searches resulted in 727 references. Through multiple reviewer screenings and assessments of eligible full-text articles, we included 14 articles for review. Results: Our systematic review yielded pathologic examination results from 17,388 femoral head specimens collected during THA. In 0.85% of cases, the pathologic diagnosis differed in a meaningful way from the preoperative clinical diagnosis. Routine pathology changed patient management in approximately 0.0058% of cases. The average cost for pathologic examination of each specimen was $126.38. Conclusion: Routine pathologic examination of femoral heads retrieved during THA has limited impact on patient management. With an estimated 500,000 THAs performed in 2019, the economic feasibility of routine femoral head pathology is limited at an annual cost of up to $63,000,000 and cost per quality-adjusted life-year approaching infinity. However, surgeon discretion on a patient-specific or practice-specific basis should be used to make the final determination on the need for femoral head pathology.

Background: There is a paucity of data to guide management of the patella in revision total knee arthroplasty (RTKA). The purpose of this study was to review our experience with patellar management in RTKA. Methods: We retrospectively reviewed 422 consecutive RTKAs at a minimum of 2 years (mean, 42 months). Patellar management was guided by a classification that considered stability, size, and position of the implanted patellar component, thickness/quality of remaining bone stock, and extensor mechanism competence. Results: Management in 304 aseptic revisions included retention of a well-fixed component in 212 (69.7%) and revision using an all-polyethylene component in 46 (15.1%). Patella-related complications included 5 extensor mechanism ruptures (1.6%), 3 cases of patellar maltracking (1.0%), and 2 periprosthetic patellar fractures (0.7%). Of 118 2-stage revisions for infection, an all-polyethylene component was used in 88 (74.6%), patelloplasty in 20 (16.9%), and patellectomy in 7 (5.9%). Patella-related complications included 4 cases of patellar maltracking (3.4%), 3 extensor mechanism ruptures (2.5%), and 1 periprosthetic patellar fracture (0.8%). Conclusions: Septic revisions required concomitant lateral releases more frequently (38.1% vs 10.9%; P < .02) but had a similar rate of patellar complications (6.8% vs 3.3%; P = .40). No cases required rerevision specifically for failure of the patellar component. Patients who had a patelloplasty had worse postoperative Knee Society functional scores than those with a retained or revised patellar component. In most aseptic RTKAs, a well-fixed patellar component can be retained. If revision is required, a standard polyethylene component is sufficient in most septic and aseptic revisions. Rerevisions related to the patellar component are infrequent. Keywords: Patella, Revision total knee arthroplasty, Revision TKA, Extensor mechanism, TKA

We report a case of bead shedding from a cylindrical extensively porous-coated cementless femoral component with concomitant taper corrosion at the modular head-neck junction of a metal-on-polyethylene total hip prosthesis. The patient presented with chronic thigh pain 4 years after primary total hip arthroplasty, and radiographs revealed significant osteolysis and metallic debris around the femoral stem. Intraoperatively, the patient had a grossly loose femoral component with debonding of sintered beads from the femoral stem, as well as evidence of taper corrosion. We identify a failure of a modern beaded femoral component in conjunction with taper corrosion. Keywords: Total hip arthroplasty, Bead shedding, Taper corrosion