Can Dual Mobility Cups Reduce Revision and Dislocation Risks? An Analysis of 107,528 Primary Total Hip Arthroplasties in the United States

BACKGROUND

Dual mobility acetabular cups (DMC) were designed to increase the effective femoral head size and improve stability with the goal of reducing revision risk at the potential cost of polyethylene thickness. We sought to evaluate revision risk following primary elective total hip arthroplasty with DMC compared to highly cross-linked polyethylene (XLPE).

METHODS

A cohort study was conducted using data from a Kaiser Permanente's total joint arthroplasty registry. Patients ≥18 years who underwent primary elective total hip arthroplasty using DMC, unipolar Metal-on-XLPE (MoXLPE), or unipolar Ceramic-on-XLPE (CoXLPE) were identified (2010 to 2021). The final sample comprised 2,219 DMC, 48,251 MoXLPE, and 57,058 CoXLPE. Multiple Cox proportional hazard regressions were used to evaluate aseptic revision and any dislocation regardless of revision within 6 years follow-up.

RESULTS

In adjusted analyses, no differences in aseptic revision risk were observed for MoXLPE (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 0.72 to 1.51) or CoXLPE (HR = 0.98, 95% CI = 0.69 to 1.40) compared to DMC. No differences in dislocation risk were observed for MoXLPE (HR = 1.42, 95% CI = 0.93 to 2.15) or CoXLPE (HR = 1.25, 95% CI = 0.84 to 1.87) compared to DMC.

CONCLUSIONS

In a US-based cohort, 6-year aseptic revision risk of DMC was similar to metal or ceramic femoral head unipolar constructs. Furthermore, no difference in dislocation risk was observed. Continued longer-term follow-up may reveal if there is a reduced risk of dislocation that comes at the cost of increased late revision.

LEVEL OF EVIDENCE

Level III.

Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty?

BACKGROUND

We sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint.

METHODS

We conducted a matched cohort study using data from Kaiser Permanente's arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models.

RESULTS

No difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63).

CONCLUSION

Patients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients.

LEVEL OF EVIDENCE

Level III.

Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty

BACKGROUND

As indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years.

METHODS

A Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years.

RESULTS

Patients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability.

CONCLUSION

Identified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability.

LEVEL OF EVIDENCE

III.

Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3

BACKGROUND

Although safety in same-day discharge total joint arthroplasty (TJA) has been reported, findings are limited to healthier patients, specific surgeons, and/or specific institutions. Indications for same-day discharge TJA have expanded to include patients with multiple comorbidities; however, safety in this specific patient population remains unknown. Therefore, we sought to compare the risk of 90-day adverse events in higher-risk patients undergoing same-day discharge versus inpatient TJA.

METHODS

The Kaiser Permanente Total Joint Replacement Registry was utilized to conduct a cohort study. All patients with an American Society of Anesthesiologists (ASA) classification of ≥3 who underwent primary elective TJA for osteoarthritis from 2017 through 2018 were identified. The risk of 90-day adverse events (i.e., emergency department visits, unplanned readmissions, complications, and mortality) was evaluated with use of propensity score-weighted Cox proportional hazard regression including noninferiority testing with a margin of 1.10.

RESULTS

The cohort included a total of 5,250 patients who underwent total hip arthroplasty and 9,752 patients who underwent total knee arthroplasty, of whom 1,742 (33.2%) and 3,283 (33.7%) had same-day discharge, respectively. Same-day discharge hip arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (hazard ratio [HR], 0.73; 1-sided HR 95% upper bound [UB], 0.84), readmissions (HR, 0.47; 95% UB, 0.61), and complications (HR, 0.63; 95% UB, 0.75); we did not have evidence of noninferiority for mortality (HR, 0.84; 95% UB, 1.97). Same-day discharge knee arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (HR, 0.79; 95% UB, 0.87), readmission (HR, 0.80; 95% UB, 0.95), complications (HR, 0.72; 95% UB, 0.82), and mortality (HR, 0.53; 95% UB, 1.03).

CONCLUSIONS

We found that same-day discharge TJA did not increase the risk of emergency department visits, unplanned readmissions, and complications compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge TJA in the hospital setting while maintaining safety.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement

INTRODUCTION

Although patient satisfaction with total joint arthroplasty has been a well-measured outcome, little is known about how preadmission and post-discharge care experiences affect patients' rating of satisfaction.

OBJECTIVE

This work aimed to identify actionable factors associated with better ratings of overall care and surgical results.

METHODS

A 36-item survey assessing care in the preoperative, perioperative, and post-discharge phases of care and across all phases was mailed to 7,031 patients who underwent primary unilateral elective total hip arthroplasty and total knee arthroplasty in 2018. Exploratory factor analysis identified 7 actionable domains. Stepwise logistic regression models identified domains associated with ratings of overall care and satisfaction with surgical outcome.

RESULTS

Of the 3,026 (43%) patients who returned the survey; 2,814 (93%) rated their overall experience of care as very good or excellent and satisfaction with surgical results as ≥ 7 on a 10-point scale. In exploratory factor analysis, four factors predicted higher ratings of both overall care and surgical outcome: knowing what to do with symptoms and pain during recovery (factor 1), self-reported health (factor 3), knowing what to expect before surgery (factor 4), and shared decision making (factor 6). Coordinated information among providers (factor 2), home health experience (factor 5), and patient-provider relationships (factor 7) also predicted overall care ratings.

CONCLUSION

Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patients' satisfaction with overall care and surgical results.

Assessment of Comprehensive Mutational Profiling in T-lymphoblastic leukemia/lymphoma (T-ALL/LBL): A Single Center Experience

Introduction/Objective

T-lymphoblastic leukemia/lymphoma (T-ALL/LBL) is a malignancy arising from immature precursor T cells with T-ALL involving bone marrow/blood and T-LBL occurring in the thymus and nodal/extranodal sites. Studies have now revealed &gt;100 recurrently altered genes that are not necessarily disease initiating but can provide diagnostic, prognostic, and predictive information which can then be utilized in personalized therapy.

Methods/Case Report

Next-generation sequencing was performed on DNA and/or RNA extracted from blood/marrow aspirates or tissue at an external CLIA-certified, CAP-accredited laboratory. The hematology panel sequenced DNA of 406 genes, introns of 31 gene rearrangements, and RNA of 265 genes.

This retrospective single-center study highlights salient findings noted in genomic profiles of 15 T-ALL/LBL cases out of 83 total patients with ALL from 2018-2021. While the majority were B-ALL cases, T-ALL accounted for 18%, and all but 1 case were pediatric patients (ages 9-21 years).

Results (if a Case Study enter NA)

In our pediatric cohort (14 patients; 9 males, 5 females), as in literature, NOTCH signaling was most frequently involved with NOTCH1 (50%) and FBXW7 (36%) mutations, followed by those in cell cycle process CDKN2A/2B (36%) and PTEN (28%) mutations. Other mutations: PHF6 (21%), BCOR and TAL1 (14%) each. The prognostic effect of mutations: NOTCH1 favorable, FBXW7 no effect but trend toward favorable when FBXW7 co-occurs with NOTCH1 while PTEN is unfavorable (3 patients had relapses). Some unusual or useful findings: a patient diagnosed initially as AML with aberrant CD3 was re-classified as early T-cell precursor ALL, supported by RELN mutation (occurs in 4% ETP-ALL). The adult with NOTCH1 and BCOR mutations in addition to BCR-ABL1 fusion was diagnosed as having T-ALL blasts with CML. We could not study detailed nuances in mutational profiles of T-ALL vs T-LBL with only 1 case of T-LBL showing FBXW7, PTEN, NF1, RB1, BCOR and NRAS mutations (latter is typically noted in pediatric T-LBL cases).

Conclusion

Clinical molecular testing in our pediatric T-ALL patients revealed gene alterations that provide refinement of diagnosis, prognosis, and risk stratification. It also contributes a useful data set for further analysis and potential use of clinically actionable therapeutic targets in some cases. Longer term follow-up incorporating therapy and outcomes information would be valuable.

The Role of Intraoperative Urinary Catheters on Postoperative Urinary Retention after Total Joint Arthroplasty: A Multi-Hospital Retrospective Study on 9,580 Patients

Background

Urinary catheters (UC) are used by some surgeons during total joint arthroplasty (TJA). This study investigated the impact of intraoperative urinary catheters on postoperative urinary retention (POUR) following TJA cases.

Methods

We conducted a retrospective comparative study across 11 medical centers on 9,580 TJA patients. Visits to urgent care or the emergency department within 7 and 30 postoperative days were reviewed. Medical records over a 12-month period for all patients older than 18 years old were used to gather demographic and surgical data as well as the incidence of urinary tract infection (UTI). Chi-squared tests (RStudio) were used to determine statistical significance against P-Values (P) < 0.05.

Results

13 (0.14%) patients returned within 7 days for POUR. POUR was more common in males [10 (0.3%) vs. 3 (0.1%) females, (P = 0.01)]. There was no difference in POUR when comparing total hip and knee arthroplasty procedures [0.16% vs. 0.12%, (P = 0.60)]. Of all operations, 25% had intraoperative UC use. There was no difference in POUR between the UC and no UC groups [0.21 vs. 0.11%, (P = 0.26)]. However, there was an increase in UTI in UC vs. no UC use within 7 postoperative days [0.92 vs. 0.43%, (P = 0.005)] and 30 postoperative days [2.60 vs. 1.50 %, (P < 0.001)].

Conclusion

In our study, there was no difference in POUR rates between the intraoperative UC vs. no UC groups. Therefore, the use of intraoperative UC may not decrease the rate of POUR following TJA procedures. Additionally, UTI risk was higher in the UC group which may be attributable to other factors, especially when comparing female vs. male patients.

Orthopaedic Systems Response to and Return from the COVID-19 Pandemic: Lessons for Future Crisis Management

The coronavirus disease 2019 (COVID-19) pandemic has become the dominant health-care issue of this generation and has reached every corner of the health-care delivery spectrum. Our 3 orthopaedic departments enacted a response to the COVID-19 pandemic within our organizations. We discuss our health-care systems' response to the outbreak and offer discussion for the recovery of the orthopaedic service line within large health-care systems.

Lower-extremity total joint arthroplasty in shoulder arthroplasty patients: does the order of the lower-extremity total joint arthroplasty matter?

BACKGROUND

As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures?

METHODS

Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente's shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution's total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders.

RESULTS

Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38; 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30; 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only.

CONCLUSION

In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter's success.

Highly efficient white light generation from barium fluoride

We demonstrate highly efficient white light generation by focusing 45 fs long pulses of 800 nm laser radiation with 1 mJ energy onto a 10 cm long barium fluoride crystal. The entire wavelength band from 400-1000 nm was generated with efficiency greater than 40%. We also observe multiphoton absorption induced fluorescence in the crystal. By employing line focusing geometry at low intensity, we show that white light fringes are formed with a single laser beam, indicative of the coherent property of the white light that is produced.

Fetus-in-fetu: a case report with molecular analysis

This is the report of a case of fetus-in-fetu diagnosed in a 3-month-old boy and found to be located in the upper retroperitoneum. The entity was distinguished from teratoma by the presence of vertebral axis with limb buds. It corresponded to a diamniotic, monochorionic, monozygotic twin. Complete excision of the mass was performed. Radiological, histopathologic, and DNA fingerprinting studies performed on fetus-in-fetu specimen showed that the fetus was a monozygotic twin.

Enlarging intratracheal tube cuff diameter: a quantitative roentgenographic study of its value in the early prediction of serious tracheal damage

A prospective study to radiographically document impending tracheal damage in patients on continuous mechanical ventilation was done in 135 intubated adult patients over an eighteen month period. The previously unrecognized enlarging cuff/trachea ratio over 150% was seen in 18 patients. Five of 9 patients who died with C/T ratio over 150% were autopsied; all had severe tracheal damage at the cuff site. Four of 5 patients who were decannulated/extubated developed tracheal stenosis at the cuff site, necessitating tracheal resection in 3 patients. Thus a C/T ratio over 150% is a reliable clinical indicator of tracheal damage. Some thoughts as to prevention of this iatrogenic disease are presented.