Nicholas A. Bedard

Cementless Total Hip Arthroplasty in Patients Fifty Years of Age or Younger: A Minimum Ten-Year Follow-up

BACKGROUND The durability of total hip arthroplasty in younger patients has been reported to be less than that in older patients. The purpose of this study was to evaluate the results of cementless total hip arthroplasty performed in a consecutive series of patients fifty years of age or younger who were followed for a minimum of ten years. METHODS We prospectively followed 100 consecutive patients (115 hips) who were fifty years of age or younger when they were treated with primary cementless total hip arthroplasty with use of a second-generation, extensively porous-coated femoral stem and a cementless acetabular component. The patients were followed for a minimum of ten years, and the results were compared with our patients in the same age group who had total hip arthroplasty with cement. Evaluation included the need for revision, activity questionnaires, six-minute walks, activity level monitoring with an accelerometer, and radiographic evaluation for evidence of loosening, wear, and osteolysis. RESULTS Seventy-three patients (eighty-two hips) were available for follow-up at ten years (mean, twelve years). Seventeen patients (twenty-three hips) had died, and ten patients (ten hips) were lost to follow-up. The average age at the time of surgery was 40.1 years. Three femoral stems were revised for periprosthetic fracture. No acetabular shell or femoral stem was revised for loosening, and none were loose on radiographs made at the time of a minimum ten-year follow-up. This compares favorably with the cemented cohort, which had poorer survivorship of the implant with regard to revision for aseptic loosening and radiographic loosening. Reoperation for any reason was similar between the two cohorts at ten years, primarily because of the relatively large numbers of revisions for polyethylene wear in the cementless group. CONCLUSIONS Cementless total hip arthroplasty with use of a second-generation, extensively porous-coated stem demonstrated durable fixation in an active, younger population at a minimum follow-up of ten years and had better survivorship with respect to fixation compared with our previously reported cemented cohort.

Cementless THA for the Treatment of Osteonecrosis at 10-Year Follow-Up: Have We Improved Compared to Cemented THA?

Results of cementless THA for osteonecrosis were evaluated at a minimum of 10-year follow-up and compared to our previous report of cemented THA for osteonecrosis. Eighty cementless THAs in 66 patients with osteonecrosis were followed for a minimum of 10 years. Evaluation consisted of need for revision; radiographic evidence of loosening, wear and osteolysis; activity monitoring with an accelerometer; UCLA, Tegner, WOMAC, and Harris hip scores. Results were compared to 48 cemented THAs performed for osteonecrosis with comparable follow-up. At a minimum of 10 years, 10 hips required reoperation. Loosening and revision for loosening were significantly lower in the cementless group compared to the cemented historical control. Cementless fixation in THAs for osteonecrosis demonstrated durable results with bearing surface wear being the major long-term problem.

Opioid Use After Total Knee Arthroplasty: Trends and Risk Factors for Prolonged Use

BACKGROUND The United States is in the midst of an opioid epidemic. Little is known about perioperative opioid use for total knee arthroplasty (TKA). The purpose of this study was to identify rates of preoperative opioid use, evaluate postoperative trends and identify risk factors for prolonged use after TKA. METHODS Patients who underwent primary TKA from 2007-2014 were identified within the Humana database. Postoperative opioid use was measured by monthly prescription refill rates. A preoperative opioid user (OU) was defined by history of opioid prescription within 3 months prior to TKA and a non-opioid user (NOU) was defined by no history of prior opioid use. Rates of opioid use were trended monthly for one year postoperatively for all cohorts. RESULTS 73,959 TKA patients were analyzed and 23,532 patients (31.2%) were OU. OU increased from 30.1% in 2007 to 39.3% in 2014 (P < .001). Preoperative opioid use was the strongest predictor for prolonged opioid use following TKA, with OU filling significantly more opioid prescriptions than NOU at every time point analyzed. Younger age, female sex and other intrinsic factors were found to significantly increase the rate of opioid refilling following TKA throughout the postoperative year. CONCLUSION Approximately one-third of TKA patients use opioids within 3 months prior to surgery and this percentage has increased over 9% during the years included in this study. Preoperative opioid use was most predictive of increased refills of opioids following TKA. However, other intrinsic patient characteristics were also predictive of prolonged opioid use.

Fixation and Wear With a Contemporary Acetabular Component and Cross-Linked Polyethylene at Minimum 10-Year Follow-Up

UNLABELLED Long term total hip arthroplasty follow-up has demonstrated bearing surface wear and failure of fixation as the major modes of failure. The purpose of this study was to evaluate the minimum 10year results of a third generation cementless acetabular component using moderately cross-linked polyethylene liners. 150 primary THAs were evaluated clinically for need for revision and activity evaluated using accelerometers, WOMAC, Tegner and UCLA activity-level scores. Radiographs were evaluated for wear, osteolysis and loosening. We compared this cohort to three of our previously reported cohorts. The only revision was unrelated to liner wear and all acetabular components were bone ingrown. There were no cases of acetabular osteolysis and one case of femoral osteolysis. Average steps per year were 1.59 million. Mean steady state wear rate averaged 0.04mm/year. At 10-years, excellent fixation and low wear were demonstrated using a cementless acetabular construct and moderately cross-linked polyethylene liner. LEVEL OF EVIDENCE Therapeutic study, Level III (retrospective comparative study-prospective cohort with historical control).

Can We Predict Discharge Status After Total Joint Arthroplasty? A Calculator to Predict Home Discharge

BACKGROUND Postoperative discharge to a skilled nursing facility after total joint arthroplasty (TJA) is associated with increased costs, complications, and readmission. The purpose of this study was to identify the risk factors for discharge to a location other than home to build a calculator to predict discharge disposition after TJA. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2013 to identify patients who underwent primary total hip or total knee arthroplasty. Risk factors were compared between patients discharging home vs a facility. Predictors of facility discharge were converted to discrete values to develop a simple numerical calculator. RESULTS After primary TJA, patients discharged to a facility were typically older (70.9 vs 64.3, P < .001), female (69.5% vs 55.7%, P < .001), had an elevated American Society of Anesthesiologist (ASA) class, and were more likely to be functionally dependent before surgery (3.8% vs 1.1%, P < .001). Patient age, preoperative functional status, nonelective THA for hip fracture, and ASA class were most predictive of facility discharge. After development of a predictive model, scores exceeding 40 and 80 points resulted in a facility discharge probability of 75% and 99%, respectively. CONCLUSION In patients undergoing TJA, advanced age, elevated ASA class, and functionally dependent status before surgery strongly predicted facility discharge. Given that facility discharge imposes a significant cost and morbidity burden after TJA, patients, surgeons, and hospitals may use this simple calculator to target this susceptible patient population.

Systematic Review of Literature of Cemented Femoral Components: What Is the Durability at Minimum 20 Years Followup?

BackgroundCemented femoral total hip arthroplasty may be one of the most successful surgical interventions of all time. However, although results are very encouraging over the early to mid-term followup, relatively few studies have analyzed the durability of these implants beyond 20 years followup. To evaluate the performance of contemporary implants, it is important to understand how previous implants perform at 20 or more years of followup; one way to do this is to aggregate the available data in the form of a systematic review.Questions/purposes(1) How durable is cemented femoral fixation in the long term (minimum 20-year followup) with respect to aseptic loosening? (2) Is the durability of cemented femoral fixation dependent on age of the patient? (3) Are the long-term results of the cemented femoral fixation dependent on any identifiable characteristics of the prosthesis such as surface finish?MethodsA systematic review was performed to identify long-term studies of cemented femoral components. After application of inclusion and exclusion criteria to 1228 articles found with a search in PubMed and EMBASE, 17 studies with a minimum of 20-year followup on cemented femoral components were thoroughly analyzed in an attempt to answer the questions of this review. The quality of the studies reviewed was assessed with the Methodological Index for Nonrandomized Studies (MINORS) instrument. All studies were case series and cohort sizes ranged from 110 to 2000 hips for patients older than 50 years of age and 41 to 93 hips for patients younger than 50 years at the time of surgery.ResultsAmong the six case series performed in patients older than 50 years of age, survivorship for aseptic loosening of the femoral component ranged from 86% to 98% at 20 years followup. There were no obvious differences for younger patients when analyzing the five studies in patients younger than age 50 years in which survivorship free from aseptic loosening for these studies ranged from 77% at 20 years in one study and 68% to 94% at 25 years in the other studies. Although data pooling could not be performed because of heterogeneity of the studies included here, it appeared that stems with a rougher surface finish did not perform as well as polished stems; survivorship of stems with rougher surface finishes varied between 86% and 87%, whereas those with smoother finishes ranged between 93.5% and 98% at 20 years.ConclusionsExcellent long-term fixation in both older and younger patients can be obtained with cemented, polished femoral stems. These results provide material for comparison with procedures performed with newer cementing techniques and newer designs, both cemented and cementless, at this extended duration of followup.

The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA?

BackgroundInfection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.Questions/purposesThe purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection.MethodsThe Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups.ResultsThe proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively.ConclusionsInjection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection.Level of EvidenceLevel III, therapeutic study.

Abnormally High Dislocation Rates of Total Hip Arthroplasty After Spinal Deformity Surgery.

BACKGROUND The purpose of this study was to determine the prevalence of concurrent spinopelvic fusion and THA and identify the risk of THA dislocation in patients with concurrent spinopelvic fusion. METHODS We retrospectively reviewed an institutional database of spinal deformity patients and the Humana Inc data set to identify patients with concurrent THA and spinopelvic fusion. The prevalence of concurrent THA and spinopelvic fusion was identified, as was the risk of dislocation for all cohorts. RESULTS Of 328 patients with spinopelvic fusions at our institution, 15 patients (4.6%) were found to have concurrent THA. Similarly, within the Humana database among 1049 patients with spinopelvic fusion, 4.6% had a concurrent THA. Among the 58,692 THA patients identified, only 0.1% had a concurrent spinopelvic fusion. A THA dislocation was observed in 3 of 15 patients (20.0%) and 3 of 18 THA (16.7%) within our institutional review. Within the Humana database, 8.3% of patients with THA and spinopelvic fusion went on to have a dislocation of their THA compared to 2.9% of patients with THA and no history of spinopelvic fusion (relative risk: 2.9 [1.2-7.6]). CONCLUSION Among patients with spinopelvic fusion, the prevalence of concurrent THA is 4.6%, and among primary THA patients, the prevalence of concurrent spinopelvic fusion is 0.1%. An alarmingly high THA dislocation rate has been demonstrated among THA patients with concurrent spinopelvic fusion at our institution (20%) and within a large national database (8.3%).

Fixation and Wear With Contemporary Acetabular Components and Cross-Linked Polyethylene at 10-Years in Patients Aged 50 and Under

We evaluated the mid-term performance of a moderately cross-linked polyethylene THA bearing in younger patients. One hundred consecutive THAs performed in patients 50 years of age and under using the same cementless acetabular component and moderately cross-linked polyethylene were evaluated at minimum 10 year follow-up. At final follow-up 75 patients (89 hips) were living, 7 patients (7 hips) were deceased and 4 patients (4 hips) were lost to follow-up. Average Tegner and UCLA scores were 3.7 and 5.8, respectively. Average steps per year were 1.84 million. The average linear wear rate was 0.05 mm/y and steady state wear rate was 0.033 mm/y. There was no detectable osteolysis. Minimum 10 year follow-up demonstrated durable fixation and reduced wear (P<0.001) when compared to our historical controls.

Four- to six-year follow-up of primary THA using contemporary titanium tapered stems.

Tapered cementless femoral components have been used in total hip arthroplasty constructs for more than 20 years. In the past 5 to 10 years, these stems have gained popularity in the United States. The purpose of this study was to evaluate the results of the authors’ initial experience using a contemporary tapered, proximally porous-coated, titanium femoral component at 4 to 6 years of follow-up. Eighty-eight patients underwent 100 total hip arthroplasties using the Summit stem (DePuy, Warsaw, Indiana) and a cementless acetabular component. Average age at the time of surgery was 61.6 years. Patients were prospectively followed for 4 to 6 years or until death. Patients were evaluated clinically using Harris Hip Scores and the need for revision. Radiographs were evaluated for femoral loosening and osteolysis. At final follow-up, no hips had been revised for femoral or acetabular loosening. Two hips required revision for dislocation and 1 for early femoral fracture. Bony ingrowth was seen in all but 2 femoral components. There was 1 instance of proximal femoral osteolysis and none distally on radiographs (cross-linked polyethylene was used in 73% of cases). There were 2 cases of severe stress shielding. One percent of cases had an early fracture (too tight) and 1% subsided without ingrowth (too loose). One patient reported significant thigh pain that did not limit activity. At final follow-up, the Summit femoral component demonstrated durable results at 4 to 6 years. Stability of the implant without femoral fracture is paramount.