Publications by authors named "Antonia F Chen"

252 Publications

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

J Arthroplasty 2021 May 26. Epub 2021 May 26.

Department of Orthopedics, Rothman Orthopedics, Philadelphia, PA.

Background: Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.

Methods: A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.

Results: Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.

Conclusion: Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.
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http://dx.doi.org/10.1016/j.arth.2021.05.032DOI Listing
May 2021

Can the Knee Outcome and Osteoarthritis Score (KOOS) Function Subscale Be Linked to the PROMIS Physical Function to Crosswalk Equivalent Scores?

Clin Orthop Relat Res 2021 Jun 11. Epub 2021 Jun 11.

Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: An increased focus on patient-reported outcome measures (PROMs) has led to a proliferation of these measures in orthopaedic surgery. Mandating a single PROM in clinical and research orthopaedics is not feasible given the breadth of data already collected with older measures and the emergence of psychometrically superior measures. Creating crosswalk tables for scores between measures allows providers to maintain control of measure choice. Furthermore, crosswalk tables permit providers to compare scores collected with older outcome measures with newly collected ones. Given the widespread use of the newer Patient-reported Outcome Measure Information System Physical Function (PROMIS PF) and the established Knee Outcome and Osteoarthritis Score (KOOS), it would be clinically useful to link these two measures.

Question/purpose: Can the KOOS Function in Activities of Daily Living (ADL) subscale be robustly linked to the PROMIS PF to create a crosswalk table of equivalent scores that accurately reflects a patient's reported physical function level on both scales?

Methods: We sought to establish a common standardized metric for collected responses to the PROMIS PF and the KOOS ADL to develop equations for converting a PROMIS PF score to a score for the KOOS-ADL subscale and vice versa. To do this, we performed a retrospective, observational study at two academic medical centers and two community hospitals in an urban and suburban healthcare system. Patients 18 years and older who underwent TKA were identified. Between January 2017 and July 2020, we treated 8165 patients with a TKA, 93% of whom had a diagnosis of primary osteoarthritis. Of those, we considered patients who had completed a full KOOS and PROMIS PF 10a on the same date as potentially eligible. Twenty-one percent (1708 of 8165) of patients were excluded because no PROMs were collected at any point, and another 67% (5454 of 8165) were excluded because they completed only one of the required PROMs, leaving 12% (1003 of 8165) for analysis here. PROMs were collected each time they visited the health system before and after their TKAs. Physical function was measured by the PROMIS PF version 1.0 SF 10a and KOOS ADL scale. Analyses to accurately create a crosswalk of equivalent scores between the measures were performed using the equipercentile linking method with both unsmoothed and log linear smoothed score distributions.

Results: Crosswalks were created, and adequate validation results supported their validity; we also created tables to allow clinicians and clinician scientists to convert individual patients' scores easily. The mean difference between the observed PROMIS PF scores and the scores converted by the crosswalk from the KOOS-ADL scores was -0.08 ± 4.82. A sensitivity analysis was conducted, confirming the effectiveness of these crosswalks to link the scores of two measures from patients both before and after surgery.

Conclusion: The PROMIS PF 10a can be robustly linked to the KOOS ADL measure. The developed crosswalk table can be used to convert PROMIS PF scores from KOOS ADL and vice versa.

Clinical Relevance: The creation of a crosswalk table between the KOOS Function in ADL subscale and PROMIS PF allows clinicians and researchers to easily convert scores between the measures, thus permitting greater choice in PROM selection while preserving comparability between patient cohorts and PROM data collected from older outcome measures. Creating a crosswalk, or concordance table, between the two scales will facilitate this comparison, especially when pooling data for meta-analyses.
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http://dx.doi.org/10.1097/CORR.0000000000001857DOI Listing
June 2021

Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections.

J Bone Jt Infect 2021 26;6(6):189-198. Epub 2021 May 26.

Brigham & Women's Hospital, Department of Orthopedics, Boston, MA, 02115, USA.

Irrigation and debridement in the treatment of periprosthetic joint infection (PJI) serve an integral role in the eradication of bacterial burden and subsequent re-infection rates. Identifying the optimal irrigation agent, however, remains challenging, as there is limited data on superiority. Direct comparison of different irrigation solutions remains difficult because of variability in treatment protocols. While basic science studies assist in the selection of irrigation fluids, in vitro results do not directly translate into clinical significance once implemented in vivo. Dilute povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid, sodium hypochlorite, hypochlorous acid, and preformed combination solutions all have potential against a broad spectrum of PJI pathogens with their own unique advantages and disadvantages. Future clinical studies are needed to identify ideal irrigation solutions with optimal bactericidal properties and low cytotoxicity for PJI treatment.
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http://dx.doi.org/10.5194/jbji-6-189-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182666PMC
May 2021

Floating Biofilm Formation and Phenotype in Synovial Fluid Depends on Albumin, Fibrinogen, and Hyaluronic Acid.

Front Microbiol 2021 29;12:655873. Epub 2021 Apr 29.

Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.

Biofilms are typically studied in bacterial media that allow the study of important properties such as bacterial growth. However, the results obtained in such media cannot take into account the bacterial localization/clustering caused by bacteria-protein interactions and the accompanying alterations in phenotype, virulence factor production, and ultimately antibiotic tolerance. We and others have reported that methicillin-resistant or methicillin-susceptible (MRSA or MSSA, respectively) and other pathogens assemble a proteinaceous matrix in synovial fluid. This proteinaceous bacterial aggregate is coated by a polysaccharide matrix as is characteristic of biofilms. In this study, we identify proteins important for this aggregation and determine the concentration ranges of these proteins that can reproduce bacterial aggregation. We then test this protein combination for its ability to cause marked aggregation, antibacterial tolerance, preservation of morphology, and expression of the phenol-soluble modulin (PSM) virulence factors. In the process, we create a viscous fluid that models bacterial behavior in synovial fluid. We suggest that our findings and, by extension, use of this fluid can help to better model bacterial behavior of new antimicrobial therapies, as well as serve as a starting point to study host protein-bacteria interactions characteristic of physiological fluids.
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http://dx.doi.org/10.3389/fmicb.2021.655873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117011PMC
April 2021

Response to Letter to the Editor on "Disparities Among Leading Publishers of Arthroplasty Research".

J Arthroplasty 2021 05;36(5):e48-e49

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1016/j.arth.2020.12.052DOI Listing
May 2021

The Charlson and Elixhauser Scores Outperform the American Society of Anesthesiologists Score in Assessing 1-year Mortality Risk After Hip Fracture Surgery.

Clin Orthop Relat Res 2021 04 29. Epub 2021 Apr 29.

N. H. Varady, S. M. Gillinov, C. M. Yeung, S. S. Rudisill, A. F. Chen, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated.

Question/purpose: Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era?

Methods: A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%.

Results: The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days.

Conclusion: Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001772DOI Listing
April 2021

Causal Language in Observational Orthopaedic Research.

J Bone Joint Surg Am 2021 Apr 22. Epub 2021 Apr 22.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Abstract: With the increasing availability of large clinical registries and administrative data sets, observational (i.e., nonexperimental) orthopaedic research is being performed with increased frequency. While this research substantially advances our field, there are fundamental limitations to what can be determined through a single observational study. Avoiding overstatements and misstatements is important for the sake of accuracy, particularly for ensuring that clinical care is not inadvertently swayed by how an observational study is written up and described. We have noticed that causal language is frequently misused in observational orthopaedic research-that is, language that says or implies that 1 variable definitively causes another, despite the fact that causation can generally only be determined with randomization. In this data-backed commentary, we examine the prevalence of causal language in a random sample of 400 observational orthopaedic studies; we found that causal language was misused in 60% of them. We discuss the implications of these results and how to report observational findings more accurately: the word "association" (and its derivatives) can almost always replace or reframe a causal phrase.
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http://dx.doi.org/10.2106/JBJS.20.01921DOI Listing
April 2021

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

Clin Orthop Relat Res 2021 06;479(6):1179-1189

A. J. Acuña, T. K. Jella, L. T. Samuel, S. H. Jeong, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.

Background: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions.

Question/purpose: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States?

Methods: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively.

Results: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth.

Conclusion: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains.

Clinical Relevance: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.
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http://dx.doi.org/10.1097/CORR.0000000000001724DOI Listing
June 2021

Out-of-Network Facility Charges for Patients Undergoing Outpatient Total Joint Arthroplasty.

J Arthroplasty 2021 Jul 5;36(7S):S128-S133. Epub 2021 Mar 5.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA.

Background: The utilization of outpatient (OP) total joint arthroplasty (TJA) is increasing. Although many arthroplasty surgeons and hospitals have longstanding agreements with insurance companies, it may take time for ambulatory surgery centers (ASCs) to establish in-network agreements. The purposes of this study are to investigate trends in out-of-network facility charges for OP-TJA, as well as compare rates of out-of-network facilities between ASC and hospital outpatient department (HOPD) OP-TJA.

Methods: This is a retrospective study of the MarketScan commercial claims database of OP-TJAs (same-day discharge) performed at ASCs or HOPDs from 2007 to 2017. Detailed demographic, geographic, operative, insurance, temporal, and financial details were collected. Out-of-network facility utilization was trended over time. Adjusted regressions compared the prevalence of out-of-network facilities between ASCs and HOPDs.

Results: There were 13,031 OP-TJA patients (58.8% total knee arthroplasty). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (P < .001); however, this was non-linear with a significant increase in 2013-2015 corresponding to rising use of out-of-network ASCs. Patients treated at ASCs were significantly more likely to be out-of-network than those treated at HOPDs (odds ratio 4.88, 95% confidence interval 4.28-5.57, P < .001; odds ratio 7.70, 95% confidence interval 6.42-9.25, P < .001 among the 11,870 patients with in-network surgeons). About 10.4% of patients with in-network surgeons were treated at out-of-network facilities.

Conclusion: Although the utilization of out-of-network facilities has decreased, over 10% of patients with in-network surgeons face out-of-network facility charges, which may often come as a surprise. Efforts are warranted to reduce the out-of-network facility burden for OP-TJA patients, including accelerating insurance contracting and reviewing patients' coverage statuses.
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http://dx.doi.org/10.1016/j.arth.2021.03.001DOI Listing
July 2021

External Validation Demonstrates Limited Clinical Utility of a Preoperative Prognostic Calculator for Periprosthetic Joint Infection.

J Arthroplasty 2021 Jul 3;36(7):2541-2545. Epub 2021 Mar 3.

Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN.

Background: Preoperative calculation of treatment failure risk in patients undergoing surgery for periprosthetic joint infection (PJI) is imperative to allow for medical optimization and targeted prevention. A preoperative prognostic model for PJI treatment failure was previously developed, and this study sought to externally validate the model.

Methods: A retrospective review was performed of 380 PJIs treated at two institutions. The model was used to calculate the risk of treatment failure, and receiver operating characteristic curves were generated to calculate the area under the curve (AUC) for each institution.

Results: When applying this model to institution 1, an AUC of 0.795 (95% confidence interval [CI]: 0.693-0.897) was found, whereas institution 2 had an AUC of 0.592 (95% CI: 0.502-0.683). Comparing all institutions in which the model had been applied to, we found institution 2 represented a significantly sicker population and different infection profile.

Conclusion: In this cohort study, we externally validated the prior published model for institution 1. However, institution 2 had a decreased AUC using the prior model and represented a sicker and less homogenous cohort compared with institution 1. When matching for chronicity of the infection, the AUC of the model was not affected. This study highlights the impact of comorbidities and their distributions on PJI prognosis and brings to question the clinical utility of the algorithm which requires further external validation.
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http://dx.doi.org/10.1016/j.arth.2021.02.067DOI Listing
July 2021

Tranexamic acid in patients with current or former cancer undergoing hip and knee arthroplasty.

J Surg Oncol 2021 May 13;123(8):1811-1820. Epub 2021 Mar 13.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background And Objectives: While tranexamic acid (TXA) is an excellent mechanism to reduce blood loss in arthroplasty, its safety in cancer patients-who could potentially benefit the most from blood conservation-is unknown.

Methods: A multicenter, retrospective review of current or former cancer patients undergoing hip/knee arthroplasty from 2014 to 2019 was performed. The use of intravenous TXA, indication (oncologic/degenerative), cancer state, cancer type, surgical factors, demographics, and comorbidities were collected. The association between TXA use and 90-day/1-year complications was analyzed with multivariable logistic regressions.

Results: We identified 282 patients with current (87.9%) or former (12.1%) malignancies undergoing arthroplasty (73.0% oncologic/27.0% degenerative). About 74 (26.2%) patients received TXA (52.7% had oncologic indications, 74.3% had active cancer). In adjusted analysis, TXA was not associated with increased risk of venous thromboembolism within 90-days (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.16-2.16, p = 0.43) or 1-year (OR 0.47; 95%CI 0.15-1.44, p = 0.19), with a trend towards lower risk. Similar results were seen for mortality and wound complications, and when stratifying by indication.

Conclusion: TXA was not associated with increased complications in current or former cancer patients undergoing arthroplasty. Future randomized studies of TXA in arthroplasty should include cancer patients; in the interim, clinicians should weigh the theoretical risks of TXA with the known benefits of reduced blood loss in oncology patients.
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http://dx.doi.org/10.1002/jso.26448DOI Listing
May 2021

Are Growing Rates of Total Joint Arthroplasty in Younger Patients of Concern?

Pain Med 2021 Feb 15. Epub 2021 Feb 15.

The Department of Orthopaedic Surgery, The University of Pennsylvania, Philadelphia, PA.

Total joint arthroplasty (TJA) is being used more frequently now than in the past for younger patients who may not have radiographic evidence of severe osteoarthritis. This change is problematic. We will present evidence that younger patients, and those with early-stage osteoarthritis, benefit less from TJA than do older patients with late-stage osteoarthritis. The reasons for the increase in TJA among younger, healthier patients are complex and have economic and ethical implications. Outcomes of TJA are poorly studied in patients less than 55 years, and it is unclear whether many younger patients who undergo TJA have arthritis severe enough to warrant the procedure. TJA may be inappropriate for patients who have minimal pain and disability related to osteoarthritis and higher functional demands that stress the replaced joint. In this viewpoint, we discuss reasons for the increase in TJA among these patients and make ethics-based recommendations for avoiding inappropriate and costly TJA.
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http://dx.doi.org/10.1093/pm/pnab064DOI Listing
February 2021

Randomized Trial of Static and Articulating Spacers for Treatment of the Infected Total Hip Arthroplasty.

J Arthroplasty 2021 Jun 21;36(6):2171-2177. Epub 2021 Jan 21.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Background: The purpose of this randomized clinical trial is to compare perioperative and postoperative variables between static and articulating spacers for the treatment of chronic periprosthetic joint infection (PJI) complicating total hip arthroplasty (THA).

Methods: Fifty-two patients undergoing resection arthroplasty as part of a 2-stage exchange for PJI at 3 centers were randomized to either a static (n = 23) or articulating spacer (n = 29). The primary endpoint was operative time of the second-stage reimplantation and power analysis determined that 22 patients per cohort were necessary to detect a 20-minute difference. Seven patients were lost to follow-up, 4 were never reimplanted, and one died before discharge after reimplantation. Forty patients were followed for a mean 3.2 years (range 2.0-7.1).

Results: There were no differences in operative time at second-stage reimplantation (143 minutes static vs 145 minutes articulating, P = .499). Length of hospital stay was longer in the static cohort after stage 1 (8.6 vs 5.4 days, P = .006) and stage 2 (6.3 vs 3.6 days, P < .001). Although it did not reach statistical significance with the numbers available for study, nearly twice as many patients in the static cohort were discharged to an extended care facility after stage 1 (65% vs 30%, P = .056).

Conclusion: This randomized trial demonstrated that the outcomes of static and articulating spacers are similar in the treatment of THA PJI undergoing 2-stage exchange arthroplasty. The significantly longer length of hospital stay associated with the use of static spacers may have important economic implications for the health care system.
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http://dx.doi.org/10.1016/j.arth.2021.01.031DOI Listing
June 2021

Adult Hip and Knee Reconstruction Education during the COVID-19 Pandemic.

J Arthroplasty 2021 Jul 21;36(7S):S395-S399. Epub 2021 Jan 21.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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.
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http://dx.doi.org/10.1016/j.arth.2021.01.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825893PMC
July 2021

Comparing the Efficacy of Articulating Spacer Constructs for Knee Periprosthetic Joint Infection Eradication: All-Cement vs Real-Component Spacers.

J Arthroplasty 2021 Jul 21;36(7S):S320-S327. Epub 2021 Jan 21.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY.

Background: The most common treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a 2-stage revision. Few studies have compared different articulating spacer constructs. This study compares the outcomes of real-component and all-cement articulating spacers for TKA PJI treatment.

Methods: This retrospective observational study examined the arthroplasty database at 3 academic hospitals for articulating spacers placed for TKA PJIs between April 2011 and August 2020. Patients were categorized as receiving a real-component or an all-cement articulating spacer. Data on demographics, surgical information, and outcomes were collected.

Results: One-hundred sixty-four spacers were identified: 72 all-cement and 92 real-component spacers. Patients who received real-component spacers were older (67 ± 10 vs 63 ± 12 years; P = .04) and more likely to be former smokers (50.0% vs 28.6%; P = .02). Real-component spacers had greater range of motion (ROM) after Stage 1 (84° ± 28° vs 58° ± 28°; P < .01) and shorter hospital stays after Stage 1 (5.8 ± 4.3 vs 8.4 ± 6.8 days; P < .01). There was no difference in time to reimplantation, change in ROM from pre-Stage 1 to most recent follow-up, or reinfection. Real-component spacers had shorter hospital stays (3.3 ± 1.7 vs 5.4 ± 4.9 days; P < .01) and operative times during Stage 2 (162.2 ± 47.5 vs 188.0 ± 66.0 minutes; P = .01).

Conclusion: Real-component spacers had improved ROM after Stage 1 and lower blood loss, shorter operative time, and shorter hospital stays after Stage 2 compared to all-cement articulating spacers. The 2 spacer constructs had the same ultimate change in ROM and no difference in reinfection rates, indicating that both articulating spacer types may be safe and effective options for 2-stage revision TKA.

Level Of Evidence: III, retrospective observational analysis.
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http://dx.doi.org/10.1016/j.arth.2021.01.039DOI Listing
July 2021

Does Cup Position at the High Hip Center or Anatomic Hip Center in THA for Developmental Dysplasia of the Hip Result in Better Harris Hip Scores and Revision Incidence? A Systematic Review.

Clin Orthop Relat Res 2021 05;479(5):1119-1130

M.-R. Viamont-Guerra, F. Laude, Ramsay Santé, Clinique du Sport Paris V, Paris, France.

Background: One goal of THA is to restore the anatomic hip center, which can be achieved in hips with developmental dysplasia by placing cups at the level of the native acetabulum. However, this might require adjuvant procedures such as femoral shortening osteotomy. Another option is to place the cup at the high hip center, potentially reducing surgical complexity. Currently, no clear consensus exists regarding which of these cup positions might offer better functional outcomes or long-term survival.

Question/purpose: We performed a systematic review to determine whether (1) functional outcomes as measured by the Harris hip score, (2) revision incidence, and (3) complications that do not result in revision differ based on the position of the acetabular cup (high hip center versus anatomic hip center) in patients undergoing THA for developmental dysplasia of the hip (DDH).

Methods: We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, including studies comparing the functional outcomes, revision incidence, and complications of primary THA in dysplastic hips with acetabular cups placed at the high hip center versus those placed at the anatomic hip center, over any time frame. The review protocol was registered with PROSPERO (registration number CRD42020168183) before commencement. Of 238 records, eight comparative, retrospective nonrandomized studies of interventions were eligible for our systematic review, reporting on 207 hips with cups placed at the high hip center and 268 hips with cups at the anatomic hip center. Risk of bias within eligible studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. Due to low comparability between studies, data could not be pooled, so these studies were assessed without summary effects.

Results: Six studies compared Harris hip scores, two of which favored high hip center cup placement and three of which favored anatomic hip center cup placement, although none of the differences between cohorts met the minimum clinically important difference. Five studies reliably compared revision incidence, which ranged from 2% to 9% for high hip center at 7 to 15 years and 0% to 5.9% for anatomic hip center at 6 to 16 years. Five studies reported intra- and postoperative complications, with the high hip center being associated with higher incidence of dislocation and lower incidence of neurological complications. No clear difference was observed in intraoperative complications between the high hip center and anatomic hip center.

Conclusion: No obvious differences could be observed in Harris hip score or revision incidence after THA for osteoarthritis secondary to DDH between cups placed at the anatomic hip center and those placed at the high hip center. Placement of the acetabular cup in the high hip center may lead to higher risk of dislocation but lower risk of neurologic complications, although no difference in intraoperative complications was observed. Surgeons should be able to achieve satisfactory functional scores and revision incidence using either technique, although they should be aware of how their choice influences hip biomechanics and the need for adjunct procedures and associated risks and operative time. These recommendations should be considered with respect to the several limitations in the studies reviewed, including the presence of serious confounding factors and selection biases, inconsistent definitions of the high hip center, variations in dysplasia severity, small sample sizes, and follow-up periods. These weaknesses should be addressed in well-designed future studies.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001618DOI Listing
May 2021

Effect of Manual versus Robotic-Assisted Total Knee Arthroplasty on Cervical Spine Static and Dynamic Postures.

J Knee Surg 2021 Jan 28. Epub 2021 Jan 28.

Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York.

This study compared surgeon cervical (C) spine postures and repetitive motions when performing traditional manual total knee arthroplasty (MTKA) versus robotic-assisted TKA (RATKA). Surgeons wore motion trackers on T3 vertebra and the occiput anatomical landmarks to obtain postural and repetitive motion data during MTKA and RATKA performed on cadavers. We assessed (1) flexion-extension at T3 and the occiput anatomical landmarks, (2) range of motion (ROM) as the percentage of time in the flexion-extension angle, (3) repetition rate, defined as the number of the times T3 and the occiput flexion-extension angle exceeded ±10°; and (4) static posture, where T3 or occiput postures exceed 10° for more than 30 seconds. The average T3 flexion-extension angle for MTKA cases was 5-degree larger than for RATKA cases (19 ± 8 vs. 14 ± 8 degrees). The surgeons who performed MTKA cases spent 15% more time in nonneutral C-spine ROM than those who performed RATKA cases (78 ± 25 vs. 63 ± 36%,  < 0.01). The repetition rate at T3 was 4% greater for MTKA than RATKA (14 ± 5 vs. 10 ± 6 reps/min). The percentage of time spent in static T3 posture was 5% greater for overall MTKA cases than for RATKA cases (15 ± 3 vs. 10 ± 3%). In this cadaveric study, we found differences in cervical and thoracic ergonomics between manual and robotic-assisted TKA. Specifically, we found that RATKA may reduce a surgeon's ergonomic strain at both the T3 and occiput locations by reducing the time the surgeon spends in a nonneutral position.
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http://dx.doi.org/10.1055/s-0040-1721412DOI Listing
January 2021

Diagnosis and Management of Intraoperative Fractures in Primary Total Hip Arthroplasty.

J Am Acad Orthop Surg 2021 May;29(10):e497-e512

From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Siddiqi, Piuzzi), the Department of Orthopedics Atrium, OrthoCarolina Hip and Knee Center, Musculoskeletal Institute, Charlotte, NC (Springer), and the Department of Orthopedics, Brigham and Women's Hospital, Boston, MA (Chen).

Intraoperative periprosthetic fractures are challenging complications that may affect implant stability and survivorship. Periprosthetic acetabular fractures are uncommon and infrequently are the focus of studies. Acetabular fractures are occasionally recognized after patients report unremitting groin pain weeks postoperatively. The widespread use of cementless acetabular cups might lead to higher number of fractures than is clinically detectable. Conversely, the incidence of intraoperative periprosthetic femoral fractures are more common and encompass a broad spectrum, ranging from a small cortical perforation to displaced fractures with an unstable prosthesis. Appropriate recognition, including mindfulness of preoperative patient and surgical risk factors, is critical to the successful management of acetabular and femoral complications. This comprehensive review article focuses on the incidence, patient and surgical risk factors, diagnosis, management, and clinical outcomes associated with intraoperative acetabular and femur fractures in primary total hip arthroplasty.
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http://dx.doi.org/10.5435/JAAOS-D-20-00818DOI Listing
May 2021

Thalamic neurometabolite alterations in patients with knee osteoarthritis before and after total knee replacement.

Pain 2021 Jul;162(7):2014-2023

Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.

Abstract: The weak association between disability levels and "peripheral" (ie, knee) findings suggests that central nervous system alterations may contribute to the pathophysiology of knee osteoarthritis (KOA). Here, we evaluated brain metabolite alterations in patients with KOA, before and after total knee arthroplasty (TKA), using 1H-magnetic resonance spectroscopy (MRS). Thirty-four presurgical patients with KOA and 13 healthy controls were scanned using a PRESS sequence (TE = 30 ms, TR = 1.7 seconds, voxel size = 15 × 15 × 15 mm). In addition, 13 patients were rescanned 4.1 ± 1.6 (mean ± SD) weeks post-TKA. When using creatine (Cr)-normalized levels, presurgical KOA patients demonstrated lower N-acetylaspartate (NAA) (P < 0.001), higher myoinositol (mIns) (P < 0.001), and lower Choline (Cho) (P < 0.05) than healthy controls. The mIns levels were positively correlated with pain severity scores (r = 0.37, P < 0.05). These effects reached statistical significance also using water-referenced concentrations, except for the Cho group differences (P ≥ 0.067). Post-TKA patients demonstrated an increase in NAA (P < 0.01), which returned to the levels of healthy controls (P > 0.05), irrespective of metric. In addition, patients demonstrated postsurgical increases in Cr-normalized (P < 0.001), but not water-referenced mIns, which were proportional to the NAA/Cr increases (r = 0.61, P < 0.05). Because mIns is commonly regarded as a glial marker, our results are suggestive of a possible dual role for neuroinflammation in KOA pain and post-TKA recovery. Moreover, the apparent postsurgical normalization of NAA, a putative marker of neuronal integrity, might implicate mitochondrial dysfunction, rather than neurodegenerative processes, as a plausible pathophysiological mechanism in KOA. More broadly, our results add to a growing body of literature suggesting that some pain-related brain alterations can be reversed after peripheral surgical treatment.
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http://dx.doi.org/10.1097/j.pain.0000000000002198DOI Listing
July 2021

Introduction for the Journal of Orthopaedic Research Special Issue on musculoskeletal infection.

J Orthop Res 2021 02 17;39(2):225-226. Epub 2021 Jan 17.

Department of Orthopaedic Surgery Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1002/jor.24981DOI Listing
February 2021

Opioid Use Following Inpatient Versus Outpatient Total Joint Arthroplasty.

J Bone Joint Surg Am 2021 Mar;103(6):497-505

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Although the risks of continued opioid use following inpatient total joint arthroplasty (TJA) have been well-studied, these risks in the outpatient setting are not well known. The purpose of the present study was to characterize opioid use following outpatient compared with inpatient TJA.

Methods: In this retrospective cohort study, opioid-naïve patients who underwent inpatient or outpatient (no overnight stay) primary, elective TJA from 2007 to 2017 were identified within a large national commercial-claims insurance database. For inclusion in the study, patients had to have been continuously enrolled in the database for ≥12 months prior to and ≥6 months after the TJA procedure. Multivariable analyses controlling for demographics, geography, procedure, year, and comorbidities were utilized to determine the association between surgical setting and risk of persistent opioid use, defined as the patient still filling new opioid prescriptions >90 days postoperatively.

Results: We identified a total of 92,506 opioid-naïve TJA patients, of whom 57,183 (61.8%) underwent total knee arthroplasty (TKA). Overall, 7,342 patients (7.9%) underwent an outpatient TJA procedure, including 4,194 outpatient TKAs. Outpatient TJA was associated with reduced surgical opioid prescribing (78.9% compared with 87.6% for inpatient procedures; p < 0.001). Among the 80,393 patients (86.9%) who received surgical opioids, the total amount of opioids prescribed (in morphine milligram equivalents) was similar between inpatient (median, 750; interquartile range, 450 to 1,200) and outpatient procedures (median, 750; interquartile range, 450 to 1,140; p = 0.47); however, inpatient TJA patients were significantly more likely to still be taking opioids after 90 days postoperatively (11.4% compared with 9.0% for outpatient procedures; p < 0.001). These results persisted in adjusted analysis (adjusted odds ratio, 1.13; 95% confidence interval, 1.03 to 1.24; p = 0.01).

Conclusions: Outpatient TJA patients who received opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient TJA procedures, but were significantly less likely to become persistent opioid users, even when controlling for patient factors. Outpatient TJA, as compared with inpatient TJA, does not appear to be a risk factor for new opioid dependence, and these findings support the continued transition to the outpatient-TJA model for lower-risk patients.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01401DOI Listing
March 2021

Elevated Body Mass Index Is a Risk Factor for Failure to Achieve the Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form Minimal Clinically Important Difference Following Total Knee Arthroplasty.

J Arthroplasty 2021 05 15;36(5):1626-1632. Epub 2020 Dec 15.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA.

Background: The aims of this study are (1) to assess the association between body mass index (BMI) and failure to achieve the 1-year Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) minimal clinically important difference (MCID) for total knee arthroplasty (TKA) patients and (2) to determine if there is a BMI threshold beyond which the risk of failing to achieve the MCID is significantly increased.

Methods: A regional arthroplasty registry was queried for TKA patients from 2016 to 2019 with completion of preoperative and 1-year postoperative KOOS-PS. The MCID threshold was derived using a distribution-based approach. Demographic and patient-reported outcome measure variables were collected. BMI was analyzed continuously and categorically using cutoffs defined by the Centers for Disease Control and Prevention. The association between failure to achieve 1-year MCID and BMI was analyzed using multiple logistic regression. A BMI threshold was determined using the Youden index and receiver operating characteristic curve.

Results: In total, 1059 TKAs were analyzed. BMI assessed continuously was significantly associated with failure to achieve the KOOS-PS MCID (odds ratio 1.03, 95% confidence interval 1.00-1.05, P = .025). Analysis of BMI categorically revealed that "overweight" (25-30 kg/m), "obese class I" (30-35 kg/m), "obese class II" (35-40 kg/m), and "obese class III" (>40 kg/m) patients faced 77%, 76%, 83%, and 106% greater risk, respectively, of failing to achieve the KOOS-PS MCID compared to "normal BMI" (<25 kg/m) patients.

Conclusion: Elevated BMI was associated with an increased risk of failure to achieve the 1-year KOOS-PS MCID following TKA.
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http://dx.doi.org/10.1016/j.arth.2020.12.019DOI Listing
May 2021

Comparing the performance of a deep convolutional neural network with orthopedic surgeons on the identification of total hip prosthesis design from plain radiographs.

Med Phys 2021 May 23;48(5):2327-2336. Epub 2021 Mar 23.

Department of Orthopaedic, Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, MA, USA.

Purpose: A crucial step in the preoperative planning for a revision total hip replacement (THR) surgery is the accurate identification of the failed implant design, especially if one or more well-fixed/functioning components are to be retained. Manual identification of the implant design from preoperative radiographic images can be time-consuming and inaccurate, which can ultimately lead to increased operating room time, more complex surgery, and increased healthcare costs.

Method: In this study, we present a novel approach to identifying THR femoral implants' design from plain radiographs using a convolutional neural network (CNN). We evaluated a total of 402 radiographs of nine different THR implant designs including, Accolade II (130 radiographs), Corail (89 radiographs), M/L Taper (31 radiographs), Summit (31 radiographs), Anthology (26 radiographs), Versys (26 radiographs), S-ROM (24 radiographs), Taperloc Standard Offset (24 radiographs), and Taperloc High Offset (21 radiographs). We implemented a transfer learning approach and adopted a DenseNet-201 CNN architecture by replacing the final classifier with nine fully connected neurons. Furthermore, we used saliency maps to explain the CNN decision-making process by visualizing the most important pixels in a given radiograph on the CNN's outcome. We also compared the CNN's performance with three board-certified and fellowship-trained orthopedic surgeons.

Results: The CNN achieved the same or higher performance than at least one of the surgeons in identifying eight of nine THR implant designs and underperformed all of the surgeons in identifying one THR implant design (Anthology). Overall, the CNN achieved a lower Cohen's kappa (0.78) than surgeon 1 (1.00), the same Cohen's kappa as surgeon 2 (0.78), and a slightly higher Cohen's kappa than surgeon 3 (0.76) in identifying all the nine THR implant designs. Furthermore, the saliency maps showed that the CNN generally focused on each implant's unique design features to make a decision. Regarding the time spent performing the implant identification, the CNN accomplished this task in ~0.06 s per radiograph. The surgeon's identification time varied based on the method they utilized. When using their personal experience to identify the THR implant design, they spent negligible time. However, the identification time increased to an average of 8.4 min (standard deviation 6.1 min) per radiograph when they used another identification method (online search, consulting with the orthopedic company representative, and using image atlas), which occurred in about 17% of cases in the test subset (40 radiographs).

Conclusions: CNNs such as the one developed in this study can be used to automatically identify the design of a failed THR femoral implant preoperatively in just a fraction of a second, saving time and in some cases improving identification accuracy.
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http://dx.doi.org/10.1002/mp.14705DOI Listing
May 2021

Intra-Articular Corticosteroid or Hyaluronic Acid Injections Are Not Associated with Periprosthetic Joint Infection Risk following Total Knee Arthroplasty.

J Knee Surg 2021 Jan 3. Epub 2021 Jan 3.

Department of Biomedical Engineering, Exponent Inc., Philadelphia, Pennyslavania.

This study evaluated whether the preoperative use and timing of the use of hyaluronic acid (HA) and/or corticosteroid (CS) injections were associated with an increased risk of periprosthetic joint infections (PJIs) following primary total knee arthroplasty (TKA). We tested the hypothesis that preoperative injection of HA or CS within 3 months prior to primary TKA was associated with an increased risk of PJI by specifically evaluating the association between PJI risk and (1) injection type; (2) timing; (3) patient demographic factors; and (4) surgery-related factors, such as surgeon injection volume, knee arthroscopy (pre- and postoperative), and hospital length of stay. The 5% Medicare part B claims database was queried for patients who received CS and/or HA injections. Cox proportional hazards regressions evaluated the risk of PJIs after TKA, adjusting for patient and clinical factors, as well as propensity scores. The unadjusted incidence of PJI at 2-year post-TKA was 0.75% for the CS group, 0.89% for the HA group, 0.96% for both CS and HA group, and 0.75% for those who did not use HA or CS in the 12 months before TKA. For patients who used HA and/or CS within 3 months prior to TKA, the unadjusted incidence of PJI at 2-year post-TKA was 0.75% for the CS group, 1.07% for the HA group, and 1.00% for both CS and HA group, compared with 0.77% for those who did not use HA or CS. The number of injections performed per year was inconsistently associated with PJI risk. Overall, we found that intra-articular injections given within the 4-month period prior to TKA were not associated with elevated PJI risk (evaluated at 1, 3, 12, and 24 months after the index TKA) within the elderly Medicare patient population.
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http://dx.doi.org/10.1055/s-0040-1721128DOI Listing
January 2021

Prevalence of Undiagnosed Subchondral Insufficiency Fractures of the Knee in Middle Age Adults with Knee Pain and Suspected Meniscal Tear.

Osteoarthr Cartil Open 2020 Dec 19;2(4). Epub 2020 Aug 19.

Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA.

Objective: Symptomatic knee osteoarthritis (OA) and meniscal tear are often treated with weight-bearing exercises and without ordering advanced imaging (e.g. MRI). This may lead to missed diagnoses of subchondral insufficiency fracture of the knee (SIFK). Failure to diagnose SIFK has treatment implications, as patients with SIFK are typically managed with a period of reduced weight-bearing. The primary objective of this study is to determine the prevalence of undiagnosed SIFK among persons treated non-operatively for knee pain and suspected meniscal tear(s).

Methods: The randomized controlled trial, TeMPO (Treatment of Meniscal Problems and Osteoarthritis), enrolls subjects whose clinicians suspect concomitant meniscal tear and knee OA. TeMPO participants undergo MRI ordered by the study to confirm meniscal tear. All study-ordered MRIs revealing a fracture were reviewed by two study radiologists who noted features of the fracture and joint. We report prevalence of SIFK and clinical and imaging features on these subjects with 95% confidence intervals.

Results: Ten of the 340 study-ordered MRIs had SIFK, resulting in an estimated prevalence of 2.94% (95% CI: 1.15%, 4.71%). Eight of the ten participants with SIFK had fractures located medially. The femur was involved in five of these participants, tibia in four, and both in one. Five of the ten participants did not have meniscal tears.

Conclusions: This is the only reported estimate of undiagnosed SIFK in adults with knee pain, to our knowledge. Approximately 3% of patients managed with weight-bearing exercise for suspected meniscal tear may have SIFK, a diagnosis typically treated with reduced weight-bearing approaches.
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http://dx.doi.org/10.1016/j.ocarto.2020.100089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771884PMC
December 2020

The EBJIS definition of periprosthetic joint infection.

Bone Joint J 2021 Jan;103-B(1):18-25

Orthopaedic Hospital Valdoltra, Ankaran, Slovenia.

Aims: The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.

Methods: This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.

Results: This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI.

Conclusion: The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: 2021;103-B(1):18-25.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954183PMC
January 2021

Nuclear Medicine Scans in Total Joint Replacement.

J Bone Joint Surg Am 2021 02;103(4):359-372

Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts.

»: A 3-phase bone scan is a potential first-line nuclear medicine study for pain after total joint arthroplasty (TJA) when there is concern for periprosthetic joint infection or aseptic loosening.

»: In patients who have a positive bone scintigraphy result and suspected infection of the joint, but where aspiration or other studies are inconclusive, labeled leukocyte scintigraphy with bone marrow imaging may be of benefit.

»: Magnetic resonance imaging (MRI), while not a nuclear medicine study, also shows promise and has the advantage of providing information about the soft tissues around a total joint replacement.

»: Radiotracer uptake patterns in scintigraphy are affected by the prosthesis (total knee arthroplasty [TKA] versus total hip arthroplasty [THA]) and the use of cement.

»: Nuclear medicine scans may be ordered 1 year postoperatively but may have positive findings that are due to normal physiologic bone remodeling. Nuclear studies may be falsely positive for up to 2 years after TJA.

»: Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) (SPECT/CT), fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT, and MRI show promise; however, more studies are needed to better define their role in the diagnostic workup of pain after TJA.
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http://dx.doi.org/10.2106/JBJS.20.00301DOI Listing
February 2021

Activity Recommendations After Total Hip and Total Knee Arthroplasty.

J Bone Joint Surg Am 2021 Mar;103(5):446-455

Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.

»: A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).

»: In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.

»: For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.

»: Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.

»: No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.

»: Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.
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http://dx.doi.org/10.2106/JBJS.20.00983DOI Listing
March 2021

Obesity Increases Risk of Failure to Achieve the 1-Year PROMIS PF-10a Minimal Clinically Important Difference Following Total Joint Arthroplasty.

J Arthroplasty 2021 Jul 10;36(7S):S184-S191. Epub 2020 Nov 10.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA.

Introduction: The aims of this study were to determine if increasing body mass index (BMI) is a risk factor for failure to attain the 1-year Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF-10a) minimal clinically important difference (MCID) following total joint arthroplasty (TJA) and to determine a possible BMI threshold beyond which this risk increases significantly.

Methods: This retrospective study was performed using 3506 TJAs sourced from a regional-based registry. An anchor-based MCID threshold of 7.9 was chosen. PROMIS PF-10a scores were collected at the preoperative and 1-year postoperative timepoints, and the change was used to determine failure to achieve the 1-year MCID. Demographic and surgical variables were also collected. The association between BMI and failure to achieve 1-year PROMIS PF-10 MCID was then evaluated using logistic regression. A BMI threshold was determined using receiver operating characteristic (ROC) curve analysis.

Results: Increasing BMI assessed continuously was a significant risk factor for failure to achieve the MCID (P < .001). "Obese Class I" (30-35 kg/m), "Obese Class II" (35-40 kg/m), and "Obese Class III" (>40 kg/m) subgroups compared to "Normal BMI" (<25 kg/m) were significantly associated (P < .05) with this adverse outcome as well.

Conclusion: Our study showed that increasing BMI is a risk factor for failure to achieve the 1-year PROMIS PF-10a MCID following TJA. Among our patients, an increase in 1 kg/m increased the risk of failure to achieve the MCID by 2%. With these findings, surgeons will be better equipped to preoperatively advise patients with elevated BMIs considering TJA.
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http://dx.doi.org/10.1016/j.arth.2020.11.004DOI Listing
July 2021