Introduction Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective, but recovery involves pain and reduced mobility. Enhanced Recovery After Surgery (ERAS) pathways combine perioperative interventions to accelerate recovery, but evidence versus conventional care is inconsistent. Objective To evaluate ERAS pathways versus conventional perioperative care in adults undergoing elective primary THA or TKA. Methods PubMed/MEDLINE, Web of Science, and Google Scholar were searched from inception to August 2026. Randomized controlled trials and comparative cohort studies comparing a multimodal ERAS pathway (≥3 components) with conventional care were eligible. Four reviewers extracted data independently. Risk of bias was assessed using RoB 2 and ROBINS-I. Random-effects meta-analysis was performed, and certainty of evidence was rated using GRADE. Results Twenty-six studies were included (sample sizes 24 to 1,540,462). ERAS shortened length of stay (LOS) in nearly every study; the pooled mean difference was −3.61 days (95% confidence interval [CI], −5.22 to −1.99; I²=97.0%). The reduction was significant for TKA (−3.98 days; 95% CI, −7.04 to −0.92) but not for THA. Overall complications showed a non-significant trend favoring ERAS (risk ratio 0.82; 95% CI, 0.65–1.04), driven mainly by minor (Clavien-Dindo grade 1–2) events. Readmissions, transfusion, and opioid requirements did not differ significantly. Conclusion ERAS pathways are associated with a clinically important reduction in LOS, particularly for TKA. A reduction in perioperative morbidity is plausible but unconfirmed. Evidence on readmissions, opioid use, and long-term patient-reported outcomes is limited and of low certainty. Well-designed multicenter randomized trials with standardized long-term outcome reporting are needed.
Introduction Ceramic-polyethylene sandwich liners were introduced to reduce fracture, but high failure rates were reported. We report a fracture clinically recognized 21 years after revision total hip arthroplasty (THA). Case Presentation A 64-year-old man presented with two weeks of hip pain, clicking, and gait disturbance without trauma. He underwent primary THA for secondary coxarthrosis after slipped capital femoral epiphysis and revision THA for aseptic loosening three years later. Radiographs demonstrated eccentric femoral-head migration and radiopaque fragments. Computed tomography confirmed ceramic layer fracture and migration into the obturator internus muscle. Management and Outcomes Re-revision of the acetabular cup with a fourth-generation ceramic articulation was performed, with the well-fixed femoral stem retained. At 43 months, he returned to recreational hiking; the modified Harris Hip Score improved from 42.9 to 87.5. Residual fragments remained stable. Conclusion Long-term surveillance and prompt evaluation of mechanical symptoms are advised for older-generation sandwich liners.
Background Metabolic and bariatric surgery (MBS) can have lasting nutritional and skeletal effects, but outcomes after proximal humerus fracture (PHF) fixation are poorly characterized. Objective To compare unplanned readmission and complications after PHF open reduction and internal fixation in patients with prior MBS versus documented severe obesity without MBS. Methods This retrospective cohort study used the Nationwide Readmissions Database (2016-2022). Adults undergoing inpatient PHF open reduction and internal fixation were grouped by prior MBS, documented severe obesity without MBS, or neither. The primary outcome was unplanned readmission at 30, 90, and 180 days. Survey-weighted logistic regression was used. Results Among 28,035 index hospitalizations, 461 involved prior MBS and 2,528 involved documented severe obesity without MBS. Readmission was higher after prior MBS at 90 days (13.4% vs 10.8%; adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.03-2.26) and 180 days (20.3% vs 15.3%; aOR, 1.75; 95% CI, 1.15-2.64), but not at 30 days. The adjusted 180-day absolute difference was 7.1 percentage points (95% CI, 1.2-13.0). Major medical complications at 180 days were more frequent after MBS (12.7% vs 9.5%; aOR, 1.73; 95% CI, 1.04-2.88), although several sensitivity estimates included 1. A broad gastrointestinal, nutritional, or metabolic category accounted for 25.9% versus 6.8% of first 90-day readmissions and represented 13 readmissions in the prior-MBS group. Fracture-specific complications were uncommon, with no clear between-group difference. The 180-day readmission association persisted across all 13 sensitivity analyses, whereas the 90-day estimates were attenuated in the propensity-based analyses. Conclusion Prior MBS was associated with higher unplanned readmission after inpatient PHF open reduction and internal fixation, most consistently at 180 days. Bariatric history may identify patients who warrant closer attention to nutritional and metabolic concerns during perioperative care and follow-up.
Background Robot-assisted total knee arthroplasty (TKA) improves radiographic precision, but whether this translates into clinically meaningful benefit remains uncertain. Methods We conducted a systematic review and meta-analysis of randomized comparative trials evaluating robot-assisted versus conventional manual TKA with at least 12 months of follow-up. PubMed/MEDLINE, Scopus, Web of Science, and CENTRAL were searched through August 2026. Random-effects meta-analyses were performed for knee-specific patient-reported outcome measures (PROMs), knee flexion/range of motion, and mechanical-axis alignment outliers. Sensitivity analyses assessed influential studies and methodological uncertainties. Results Seven studies met eligibility criteria. Four randomized trials comprising 1,773 participants contributed to the primary PROM analysis, which showed no significant advantage of robot-assisted TKA (Hedges’ g=0.06, 95% CI -0.01 to 0.13; P=0.066; I²=0%). Robot-assisted TKA reduced mechanical-axis alignment outliers (RR=0.50, 95% CI 0.41 to 0.62), with the effect preserved after sensitivity exclusion of the study with denominator inconsistency (RR=0.51, 95% CI 0.41 to 0.63). The pooled knee-motion estimate favored conventional TKA by 3.01° (95% CI - 4.41 to -1.60), but was dominated by one large trial. Operative time was generally longer with robotic assistance, while blood-loss and safety findings were inconsistent or insufficient for pooling. Conclusion Robot-assisted TKA provides greater radiographic precision but has not demonstrated superior patient-reported outcomes beyond 12 months. Longer-term randomized evidence is needed to determine whether improved technical accuracy translates into durable clinical or survivorship benefits.
Background Postoperative pain control after total knee arthroplasty (TKA) and total hip arthroplasty (THA) commonly includes opioids, which are associated with adverse effects. Vitamin C is reported to reduce postoperative opioid requirements in several surgical settings. Objective To determine whether a single postoperative vitamin C dose added to an established pain management protocol was associated with reduced inpatient hydromorphone use following THA/TKA. Methods Charts of patients who underwent primary TKA (n=100) or THA (n=69) by a single surgeon were retrospectively reviewed. In March 2025, a single 5g intravenous vitamin C dose was incorporated into the postoperative multimodal analgesia protocol. Patients prior to March 2025 were controls (n=122); patients after vitamin C introduction were intervention cohort (n=47). Analgesics and antiemetics were recorded for postoperative day (POD) 0, 1, and 2. Results TKA patients required significantly less hydromorphone than THA patients on POD0 (control: p=0.001; vitamin C: p=0.003). TKA patients in both cohorts had similar total daily hydromorphone use on POD0 and POD2. On POD1, control TKA patients required more hydromorphone (6.1±3.2 mg) than vitamin C TKA patients (4.4±3.0 mg, p=0.036). THA patients in both cohorts had similar total daily hydromorphone use on POD0, 1, and 2. In a linear mixed-effects model, vitamin C administration was associated with reduced hydromorphone/hour of hospital stay (beta coefficient -0.0159, p=0.003). Conclusion A single postoperative 5g intravenous vitamin C dose was associated with reduced inpatient hydromorphone consumption following TKA. Prospective randomized studies are warranted to confirm this association and define the optimal perioperative vitamin C protocol. Level of Evidence III (retrospective cohort study)
