BACKGROUND:Total hip arthroplasty (THA) is a highly effective treatment for patients who have advanced arthritis. The United States Centers for Medicare & Medicaid Services (CMS) defines a successful THA as achieving a minimum 22-point improvement in the Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR). However, the accuracy of this criterion and how it correlates with patient satisfaction remains unclear. This study aimed to evaluate the validity of the CMS success criteria following primary THA. METHODS:A multicenter cohort of 6,016 patients undergoing primary THA was prospectively enrolled. Patient demographics, comorbidities, and HOOS-JR scores were collected preoperatively and at one year postoperatively. Patient satisfaction was assessed using the International Society of Arthroplasty Registries scale. Patients were categorized as successful or unsuccessful based on CMS criteria and as satisfied or not satisfied based on the International Society of Arthroplasty Registries scale. Cross-classification of outcomes was performed, and a multivariate logistic regression model was used to identify factors associated with patients satisfied after THA yet labeled as "unsuccessful" by the CMS. RESULTS:A total of 5,429 patients (90.2%) reported satisfaction; however, only 4,625 patients (76.9%) met the CMS criteria for success. Among satisfied patients, only 4,397 patients (81%) were classified as successful by CMS standards. Discordance between success and satisfaction was strongly associated with baseline HOOS-JR. Predictors of satisfied patients classified as having unsuccessful outcomes include high body mass index, prolonged narcotic use, back pain, contralateral hip pain, health literacy, and poor baseline HOOS-JR and Veterans Rand 12-Item Health Survey mental component summary. Satisfied patients who had higher baseline HOOS-JR scores by 10 points were 2.7 times more likely to be classified as having an "unsuccessful outcome" by CMS. CONCLUSIONS:A substantial discrepancy exists between patient satisfaction and the CMS definition of success following THA. A more nuanced, risk-adjusted success metric that accounts for preoperative baseline scores may better align with patient-centered outcomes and improve its accuracy in defining successful outcomes after THA.

Background:Wearable devices enabling remote monitoring by surgeons of their patients have gained prominence around total joint arthroplasty (TJA), offering continuous patient data to identify those not meeting postoperative goals, thereby facilitating timely interventions. While multiple studies highlight the utility of these devices in tracking postoperative progress, a standardized approach to their application is lacking. This review aims to synthesize existing literature on the use of wearable device-tracked activity for monitoring TJA outcomes. Objective:We examined the current literature to evaluate how wearable devices are used in monitoring and improving patient rehabilitation and outcomes following TJA. Methods:A systematic review was conducted following Cochrane methodology. A literature search of all available literature was performed in April 2024 and identified 102 studies to undergo full-text review. Systematic reviews, duplicate papers, and theoretical papers were excluded. Ultimately, 35 studies met the selection criteria. Results:The review revealed that 32 of 35 (91.4%) studies used wearable devices to monitor step counts. A total of 21 (60%) studies incorporated joint-specific patient-reported outcome measures, though the specific measures varied. Further, 9 studies used standardized performance-based outcome measures, which also differed across studies. Finally, 7 (20%) studies collected sleep data; however, the methods and outcomes for sleep measurement were inconsistent among these studies. Conclusions:Remote monitoring via wearable devices offers a novel approach to tracking outcomes in TJA patients. Although the use of these devices in perioperative care is expanding, significant variability exists in the data reported across studies. Wearable monitoring is often integrated with patient-reported outcome measures and standardized functional assessments, yet the optimal data parameters that best correlate with established outcome metrics remain undefined. Additionally, data collected by wearables has not yet been shown to predict patient recovery or satisfaction. Further research is essential to refine these data parameters and the development of postoperative protocols that leverage wearable devices to enhance patient compliance and improve clinical outcomes.

Background Previous reports have identified several potential predictors of pain and function after total knee arthroplasty (TKA). However, the results of these studies are conflicting, and most have a short follow-up after TKA. The purpose of this study was to identify factors predictive of pain and function five years after TKA. Methods A multicenter cohort of 3,688 primary unilateral TKA patients from a comparative effectiveness consortium was enrolled. Demographic data, medical, and musculoskeletal comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at five years, including the short-form health survey 36-item (SF-36) and the Knee Disability and Osteoarthritis Outcome Score (KOOS) pain and activities of daily living (ADL) function scores. Multivariate regression models with a 95% confidence interval were used to identify independent predictors of KOOS pain and function scores at five years. Results The analysis identified the factors that were independently predictive for KOOS pain score at five years as follows: age, insurance, race, Charlson comorbidity index, back pain, number of other painful hip and knee joints, contralateral knee pain, preoperative SF-36 mental component summary, and baseline KOOS pain scores. For KOOS ADL, the following predictive factors were identified: age, body mass index, insurance, race, Charlson comorbidity index, back pain, number of other painful joints, contralateral knee pain, ipsilateral hip pain, preoperative SF-36 mental component summary, and physical component summary scores, and baseline KOOS ADL scores. Conclusions We have identified the factors that each independently predict less improvement in pain and function five years after TKA. These potentially modifiable factors, such as musculoskeletal comorbidities, can be targeted with preoperative patient optimization programs to improve patient outcomes and patient satisfaction after primary TKA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making and in setting appropriate patient expectations preoperatively.

BACKGROUND:Robotic-assisted total knee arthroplasty (rTKA) offers a new method of surgical management for advanced arthritis of the knee. The objective of this review was to evaluate the current literature evidence comparing rTKA to conventional methods (cTKA) across multiple outcome measures. METHODS:PubMed was used to perform a review of articles that discussed outcomes of primary rTKA. Forty-four articles were selected. RESULTS:rTKA improves surgical precision and accuracy compared with cTKA, potentially leading to better functional outcomes and fewer complications. rTKA has longer intraoperative times and higher initial costs but leads to shorter hospital stays, lower readmission rates, reduced long-term costs and less revisions. Patient-reported outcomes for rTKA indicate less postoperative pain, reduced opioid use, and improved function. CONCLUSIONS:rTKA may provide improved outcomes compared with cTKA. More robust clinical evidence from US-based multicenter prospective propensity matched trials is needed to fully delineate the long-term benefits and limitations of rTKA.

BACKGROUND:More than 1 million total knee arthroplasties (TKAs) are performed annually in the United States to reduce knee pain, restore physical function, and enhance quality of life. However, nearly 1 in 5 patients are not satisfied after 1 year. We aimed to compare patient satisfaction with the U.S. Centers for Medicare & Medicaid Services (CMS) definition of success in TKA. METHODS:We studied a multicenter cohort of patients undergoing primary unilateral TKA, comparing patient satisfaction with CMS-defined surgery success, which is a minimum 20-point improvement in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR, scored 0 to 100) at 1 year. We cross-classified surgeries by satisfaction and success and used multivariable logistic regression to identify factors associated with satisfied patients being deemed as having undergone surgeries that failed. RESULTS:We studied 8,444 patients with a mean age of 68 years (with patients grouped by age: 30 to 64 years and 65 to 95 years). Of the patients, 67% were women and 60% were obese. With regard to the patients' race and/or ethnicity, 81% were White, 17% were Black, 1% were Asian, 0.6% were Native American or Alaskan Native, and 0.3% were native Hawaiian or other Pacific Islander. Although 84% of all patients reported satisfaction with the surgery, only 64% of surgeries were deemed successful. Among satisfied patients, only 71% underwent a surgery that was deemed to be successful, and discordance depended strongly on their baseline score. For satisfied patients with the worst baseline status (KOOS JR of <40), the CMS deemed the surgeries to be successful 91% of the time. In contrast, for satisfied patients with better baseline status (KOOS JR of ≥60), the CMS determined that only 39% of the surgeries were successful. Surgical failure in satisfied patients was also associated with younger age, back pain, contralateral knee pain, lower health literacy, diabetes, and poorer mental health. Including the baseline KOOS JR in the model significantly increased predictive accuracy (the area under the receiver operating characteristic curve rose from 0.58 to 0.79). CONCLUSIONS:We found substantial discordance between patients' satisfaction with the procedure and how the CMS currently assesses TKA success. A graded success metric, risk-adjusted for patients' baseline status, would align better with satisfaction. It is also worth exploring whether adding a few questions on joint-specific pain and function could better capture meaningful changes in patients whose high baseline status leaves little room for improvement on the KOOS JR. LEVEL OF EVIDENCE:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

BackgroundMultiple authors have sought to determine what patient characteristics influence outcomes after total knee arthroplasty (TKA). The impact of gender on outcomes after TKA remains controversial. Previous studies had less than five years of follow-up after TKA. The aim of this evaluation was to determine what differences in pain, function, and quality of life exist between female and male patients five years after primary TKA.MethodsA prospective, multi-center cohort of 11,602 unilateral primary TKA patients (7,284 females and 4,318 males) was prospectively evaluated. All patients were enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR). Demographic data, musculoskeletal and medical comorbid conditions, and patient-reported outcome measures (PROMs), including the Knee Injury and Osteoarthritis Outcome (KOOS) and Short-Form (36-item) Health Survey (SF-36) mental component score (MCS) and physical component score (PCS) scores were collected pre-operatively and at five years after TKA. Descriptive statistics were generated, and stratified by gender, and differences in pain, function, and quality of life between female and male patients were evaluated. Multivariate regression models with a 95% confidence interval (CI) were used to assess the role of patient gender as a predictive factor for KOOS pain and function in daily living (ADL) scores reported five years after primary TKA, while adjusting for other variables.ResultsPrior to surgery, female patients reported worse pain (KOOS pain 46 versus 52), function (KOOS ADL 53 versus 59), and quality of life (KOOS quality of life 26 versus 29) than male patients. The differences in pre-operative scores ranged from 2.70 (KOOS QoL) to 6.12 (KOOS ADL). At five years after TKA, female patients reported slightly worse pain (87 versus 89), function (85 versus 87), and quality of life (74 versus 75) when compared to male patients. The differences in the mean 5-year postop KOOS scores (range, 0.99 to 2.73), although statistically significant (P < 0.001), were clinically negligible. Female patients achieved greater improvement in pain (41 versus 37), function (32 versus 29), and quality of life (48 versus 46) scores in comparison to male patients. Female patients also reported lower pre-operative PCS global function (33 versus 35) scores, 5-year postoperative PCS scores (45 versus 46), and MCS global mental function scores (52 versus 54). Similarly, the differences in the 5-year postoperative SF-36 MCS and PCS scores were clinically negligible. Multivariate regression analysis showed that female gender was not independently predictive for either pain [β = -1.08; 95% CI (confidence interval) (-1.25 to 1.03) (P = 0.85)] or function [β = 0.64; 95% CI (-0.51 to 1.79) (P = 0.28)] five years after surgery.ConclusionThere are no clinically significant gender differences in pain, function, or quality of life five years after TKA. Female patients typically have worse symptoms prior to surgery, improve more than male patients and end up with pain, function, and quality of life scores clinically equal to male patients. This data can enhance the shared decision-making process between female patients and surgeons and assist in setting appropriate patient expectations prior to TKA.

BACKGROUND:Previous reports have identified a number of potential predictors of pain and function after total hip arthroplasty (THA). However, the results of these studies were conflicting, and most had a short follow-up after THA. The purpose of this study was to identify factors predictive of pain and function 5 years after THA. METHODS:A multicenter cohort of 7,934 primary unilateral THA patients was prospectively enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement consortium. Demographic data, comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at 5 years, including the Hip Disability and OSteoarthritis Outcome Score (HOOS) pain and activities of daily living (ADL) scores. Multivariate logistic regression models with 95% confidence interval were used to identify independent predictors of pain and function at 5 years. RESULTS:The patient dissatisfaction percentage was 8.2% at 5 years after THA. The multivariate regression identified the following predictive factors for the HOOS pain score at 5 years: age, educational level, insurance, smoking, race, Charlson Comorbidity Index, back pain severity, number of other lower extremity painful joints, the Knee Injury and Osteoarthritis Outcome Score pain severity of the ipsilateral knee, preoperative Short-Form Health Survey 36-item (SF-36) mental component summary score, and HOOS pain scores. The multivariate regression identified the following predictor factors for HOOS ADL score at 5 years: body mass index, insurance, smoking, race, back pain severity, number of other lower extremity painful joints, Knee Injury and Osteoarthritis Outcome Score pain severity of ipsilateral knee, preop HOOS ADL, and preoperative SF-36 mental component summary score and SF-36 physical component summary score. CONCLUSIONS:Overall, 8.2% of patients were dissatisfied 5 years after primary THA. We have identified a number of factors that predict less improvement in pain and function 5 years after THA. These potentially modifiable factors can be targeted with preoperative patient optimization programs to improve patient outcomes and satisfaction after primary THA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making, and in setting appropriate patient expectations preoperatively.

BACKGROUND:When performed well on appropriate patients, total knee arthroplasty (TKA) can dramatically improve quality of life. Patient-reported outcome measures (PROMs) are increasingly used to measure outcome following TKA. Accurate prediction of improvement in PROMs after TKA potentially plays an important role in judging the surgical quality of the health-care institutions as well as informing preoperative shared decision-making. Starting in 2027, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin mandating PROM reporting to assess the quality of TKAs. METHODS:Using data from a national cohort of patients undergoing primary unilateral TKA, we developed an original model that closely followed a CMS-proposed measure to predict success, defined as achieving substantial clinical benefit, specifically at least a 20-point improvement on the Knee injury and Osteoarthritis Outcome Score, Joint Arthroplasty (KOOS, JR) at 1 year, and an enhanced model with just 1 additional predictor: the baseline KOOS, JR. We evaluated each model's performance using the area under the receiver operator characteristic curve (AUC) and the ratio of observed to expected (model-predicted) outcomes (O:E ratio). RESULTS:We studied 5,958 patients with a mean age of 67 years; 63% were women, 93% were White, and 87% were overweight or obese. Adding the baseline KOOS, JR improved the AUC from 0.58 to 0.73. Ninety-four percent of those in the top decile of predicted probability of success under the enhanced model achieved success, compared with 34% in its bottom decile. Analogous numbers for the original model were less discriminating: 77% compared with 57%. Only the enhanced model predicted success accurately across the spectrum of baseline scores. The findings were virtually identical when we replicated these analyses on only patients ≥65 years of age. CONCLUSIONS:Adding a baseline knee-specific PROM score to a quality measurement model in a nationally representative cohort dramatically improved its predictive power, eliminating ceiling and floor effects and mispredictions for readily identifiable patient subgroups. The enhanced model neither favors nor discourages care for those with greater knee dysfunction and requires no new data collection. LEVEL OF EVIDENCE:Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: The impact of age on patient outcomes after total knee arthroplasty (TKA) remains controversial. Age has shown no effect on outcome in some studies, while others have reported better or worse outcome in younger patients. The aims of this study were to determine the differences in pain, function, and quality of life ( QoL) reported 1 year after TKA across different age groups. Methods: A prospective, multicenter cohort of 11,602 unilateral primary TKA patients was evaluated. Demographic data, comorbid conditions, and patient-reported outcome measures including the knee injury and osteoarthritis outcome score (KOOS), KOOS-12, KOOS Joint Replacement, and Short-Form health survey (12-item) were collected preoperatively and at 1-year postoperatively. Descriptive statistics were generated, stratified by age [<55 years (younger adult), 55 to 64 years (older adult), 65 to 74 years (early elder), and >= 75 years (late elder)], and differences in pain, function, and QoL among the 4 age groups were evaluated using Chi-square and Kruskal-Wallis tests. Multivariate regression models with 95% confidence interval were performed to determine if age was predictive for KOOS pain and function scores. Results: Prior to surgery, younger patients (<55 years) reported worse KOOS pain ( 39), function (50), and QoL (18) scores with poor mental health score (47) than other older patient groups. The mean preoperative score differences across the age groups in the KOOS total score (9.37), KOOS pain (11.61), KOOS-12 pain (10.14), and KOOS/KOOS-12 QoL (12.60) reached the calculated minimal clinically important difference. At 1 year after TKA, younger patients (<55 years) reported lower KOOS pain, function, and QoL scores when compared to older patients (>= 75 years). The differences in 1-year postop scores among the 4 age groups (ranging from 4.0 to 12.2) reached the minimal clinically important difference for pain (10.4) and QoL (12.2). Younger patients (<55 years) achieved higher baseline to 1-year pain (36.8 points), function (30.3 points), and QoL ( 40.7 points) score changes when compared to older patients aged >= 75 years. Although statistically significant, the differences in score changes among the age groups were clinically irrelevant. The multivariate regression analyses showed that age was a significant predictor for pain, but not for function at 1 year where KOOS pain score was predicted to be higher (less pain) (beta = 6.17; 95% confidence interval 4.12-8.22) (P < .001) in older patients (>= 75 years) when compared to younger patients (<55 years). Conclusion: A TKA provides a dramatic improvement in pain, function, and QoL in all age groups. However, there are age-related clinically significant differences in preoperative pain, QoL, and mental health and in final postoperative pain and QoL scores with younger patients (<55 years) reporting more pain, less QoL, and worse preoperative mental health. The patient-reported outcome measure data presented here can be used clinically to improve shared decision-making and patient expectations prior to TKA. (c) 2023 Elsevier Inc. All rights reserved.

Periprosthetic infections are one of the most serious complications in orthopedic surgeries, and those caused by Staphylococcus aureus (S. aureus) are particularly hard to treat due to their tendency to form biofilms on implants and their notorious ability to invade the surrounding bones. The existing prophylactic local antibiotic deliveries involve excessive drug loading doses that could risk the development of drug resistance strains. Utilizing an oligonucleotide linker sensitive to micrococcal nuclease (MN) cleavage, we previously developed an implant coating capable of releasing covalently tethered vancomycin, triggered by S. aureus-secreted MN, to prevent periprosthetic infections in the mouse intramedullary (IM) canal. To further engineer this exciting platform to meet broader clinical needs, here, we chemically modified the oligonucleotide linker by a combination of 2'-O-methylation and phosphorothioate modification to achieve additional modulation of its stability/sensitivity to MN and the kinetics of MN-triggered on-demand release. We found that when all phosphodiester bonds within the oligonucleotide linker 5'-carboxy-mCmGTTmCmG-3-acrydite, except for the one between TT, were replaced by phosphorothioate, the oligonucleotide (6PS) stability significantly increased and enabled the most sustained release of tethered vancomycin from the coating. By contrast, when only the peripheral phosphodiester bonds at the 5'- and 3'-ends were replaced by phosphorothioate, the resulting oligonucleotide (2PS) linker was cleaved by MN more rapidly than that without any PS modifications (0PS). Using a rat femoral canal periprosthetic infection model where 1000 CFU S. aureus was inoculated at the time of IM pin insertion, we showed that the prophylactic implant coating containing either 0PS- or 2PS-modified oligonucleotide linker effectively eradicated the bacteria by enabling the rapid on-demand release of vancomycin. No bacteria were detected from the explanted pins, and no signs of cortical bone changes were detected in these treatment groups throughout the 3 month follow-ups. With an antibiotic tethering dose significantly lower than conventional antibiotic-bearing bone cements, these coatings also exhibited excellent biocompatibility. These chemically modified oligonucleotides could help tailor prophylactic anti-infective coating strategies to meet a range of clinical challenges where the risks for S. aureus prosthetic infections range from transient to long-lasting.

BACKGROUND:The incidence rate of total joint replacement (TJR) continues to increase due to the aging population and the surgery that is very successful in providing pain relief to and improving function among patients with advanced knee or hip arthritis. Improving patient outcomes and patient satisfaction after TJR remain important goals. Wearable technologies provide a novel way to capture patient function and activity data and supplement clinical measures and patient-reported outcome measures in order to better understand patient outcomes after TJR.OBJECTIVE:We examined the current literature to evaluate the potential role of wearable devices and compare them with existing methods for monitoring and improving patient rehabilitation and outcomes following TJR.METHODS:We performed a literature search by using the research databases supported by the University of Massachusetts Chan Medical School's Lamar Soutter Library, including PubMed and Scopus, supplemented with the Google Scholar search engine. A specific search strategy was used to identify articles discussing the use of wearable devices in measuring and affecting postoperative outcomes of patients who have undergone TJR. Selected papers were organized into a spreadsheet and categorized for our qualitative literature review to assess how wearable data correlated with clinical measures and patient-reported outcome measures.RESULTS:A total of 9 papers were selected. The literature showed the impact of wearable devices on evaluating and improving postoperative functional outcomes. Wearable-collected data could be used to predict postoperative clinical measures, such as range of motion and Timed Up and Go times. When predicting patient-reported outcomes, specifically Hip Disability and Osteoarthritis Outcome Scores/Knee Injury and Osteoarthritis Outcome Scores and Veterans RAND 12-Item Health Survey scores, strong associations were found between changes in sensor-collected data and changes in patient-reported outcomes over time. Further, the step counts of patients who received feedback from a wearable improved over time when compared to those of patients who did not receive feedback.CONCLUSIONS:These findings suggest that wearable technology has the potential to remotely measure and improve postoperative orthopedic patient outcomes. We anticipate that this review will facilitate further investigation into whether wearable devices are viable tools for guiding the clinical management of TJR rehabilitation.

BACKGROUND:Multiple authors have sought to determine what patient characteristics influence outcome after total hip arthroplasty (THA). Age has shown no effect on outcome in some evaluations, while others have reported higher functional improvement in younger patients. The aim of this study was to determine if outcome after THA varies based on patient age. METHODS:A prospective, multicenter cohort of 7,934 unilateral primary THA patients from the FORCE-TJR comparative effectiveness consortium was evaluated. Demographic data, comorbid conditions, and Patient-Reported Outcome Measures, including (HOOS), HOOS-12, HOOS JR, and SF-36 (PCS) and (MCS), were collected preop and at 1-year postop. Descriptive statistics were generated, stratified by age (<55 years [younger adult], 55-64 years [older adult], 65-74 years [early elder], and ≥75 years [late elder]), and differences in pain, function, and quality of life among the 4 age groups were evaluated. A multivariate regression model with 95% confidence interval (CI) was used to assess the role of patient age as a predictive factor for HOOS pain and function scores reported 1 year after primary THA. RESULTS:Prior to surgery, younger patients (<55 years) reported worse pain, function, and quality of life than the other 3 patient groups. At 1 year after THA, younger patients (<55 years) reported slightly worse pain and quality of life but better function scores than the 3 older patients' groups. Younger patients (<55 years) achieved higher baseline to 1-year pain, and function score changes when compared to the older patients' groups. The quality of life score changes was not different among the 4 age groups. The differences in 1-year postop scores (ranging from 2.74 to 8.46) and the magnitude of score changes from baseline to 1 year (ranging from 1.9 to 5.85), although statistically significant (P < .001), did not reach the minimal clinically important difference (MCID). The multivariate regression analysis shows that age is a significant predictor for pain at 1 year but not for function. Although HOOS pain score is predicted to be higher by 4.38 points (less pain) 1 year after THA in older patients (≥75), when compared to younger patients (<55 years), again the difference is well below the MCID and is clinically insignificant. CONCLUSION:Although there are statistically significant differences in pain relief, functional improvement, and quality of life between younger and older patients among different patients' age groups, there is no clinically significant difference. THA provides an improvement in quality of life by decreasing pain and increasing function in all 4 age groups, with large improvements in Patient-Reported Outcome Measures scores (>2 standard deviations) without clinically significant age-related differences in THA outcome at 1 year.

BACKGROUND:Previous studies have evaluated patient dissatisfaction after total knee arthroplasty (TKA) at 1 year, but there is no data about the prevalence of dissatisfaction among TKA patients after prolonged follow-up. The purpose of this study is to determine patient dissatisfaction 5-years after TKA and to identify patient factors predictive of dissatisfaction.METHODS:Demographic and clinical data on 4402 patients undergoing primary unilateral TKA between 2012 and 2015 were collected prospectively through the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) comparative effectiveness consortium including diverse community and academic practices distributed across 23 states in the United States. Data collected at 1 year preoperatively and 5 years postoperatively included patient satisfaction (using a 5-point Likert satisfaction scale) and patient-reported outcome measures (PROMs) including the Knee injury and Osteoarthritis Outcome Score (KOOS) and Short-Form health survey (36-item). A univariate analysis of the difference between the satisfied and dissatisfied patients' groups was performed. A multivariate logistic regression model with 95% confidence interval (CI) was used to identify independent predictors of dissatisfaction at 5 years. The regression model was performed after adjusting the following variables: age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), marital status, smoking, education, and insurance type. The Receiver Operating Characteristic (ROC) analysis was performed with the measurement of area under curve (AUC). Hosmer-Lemeshow goodness of fit test was performed to evaluate the validity of the model.RESULTS:A total of 12.7% patients (559/4402) reported dissatisfaction 5-years after TKA. Increased BMI, higher CCI, higher Oswestry disability index, and increased number of other painful lower extremities (LE) joints were significantly associated with dissatisfaction. Higher rates of dissatisfaction were present in young patients, patients with less education, and non-White patients. Patient dissatisfaction was significantly associated with poor preoperative and 5-year postoperative PROMs scores and less score improvement from baseline to 5 years (P < .001). The multivariate regression analysis showed that an increased number of other painful LE joints (OR = 1.81; 95% CI (1.14-2.88) (P = .01), increased Oswestry back disability index (OR = 1.40; 95% CI (1.07-1.82) (P = .01), non-White patients (OR = 1.74; 95% CI (1.26-2.40) (P = .001), and minimal preoperative functional disability with KOOS function in daily living (ADL) score ≥70 (OR = 0.64; 95% CI (0.43-0.95) (P = .02) were independent predictive factors for dissatisfaction at 5 years.CONCLUSION:A total of 12.7% patients reported dissatisfaction 5-years after TKA. Clinical profiles of the satisfied and dissatisfied patients were captured 5-years after TKA with differences in the preoperative demographic and clinical characteristic variables identified. Risk factors for long-term patient dissatisfaction after TKA have been identified and should be considered during shared decision making while planning for TKA. Surgeons should use these identified risk factors to set realistic expectations for patients at an increased risk for dissatisfaction aiming to optimize their outcomes and increase their long-term satisfaction after TKA.

CASE:A 53-year-old male patient, subsequently diagnosed with type I Stickler syndrome, presented with severe premature osteoarthritis associated with bilateral hip dysplasia and knee epiphyseal dysplasia. Despite the presence of the typical manifestations of orofacial defects, hearing, ocular, and musculoskeletal abnormalities, the patient had never been diagnosed with the syndrome. CONCLUSION:Stickler syndrome can present with a wide spectrum of musculoskeletal abnormalities without previous diagnosis. It is often underrecognized if the manifestations of other systems are not appreciated. Stickler syndrome should be considered in the differential diagnosis of patients with unexplained musculoskeletal abnormality particularly in the presence of other system manifestations.

Implant-associated bacterial infections are difficult to treat due to the tendency of biofilm formation on implant surfaces, which protects embedded pathogens from host defense and impedes antibiotic penetration, rendering systemic antibiotic injections ineffective. Here, we test the hypothesis that implant coatings that reduce bacterial colonization would make planktonic bacteria within the periprosthetic environment more susceptible to conventional systemic antibiotic treatment. We covalently grafted zwitterionic polymer brushes poly(sulfobetaine methacryate) from Ti6Al4V surface to increase the substrate surface hydrophilicity and reduce staphylococcus aureus (S. aureus) adhesion. Using a mouse femoral intramedullary (IM) canal infection model, we showed that the anti-fouling coating applied to Ti6Al4V IM implants, when combined with a single vancomycin systemic injection, significantly suppressed both bacterial colonization on implant surfaces and the periprosthetic infections, outperforming either treatment alone. This work supports the hypothesis that grafting anti-fouling polymers to implant surfaces improves the efficacy of systemic antibiotic injections to combat periprosthetic infections.

We present the first report of bilateral knee and left ankle osteonecrosis in a 58-year-old female patient on long-term intranasal corticosteroids. Initially, our patient presented with progressive disabling knee pain with normal radiographs. The patient was presumed to have mild degenerative joint disease; therefore, she was treated conservatively. Then, the patient developed severe left ankle pain, and she was thought to have L5/S1 radiculopathy; therefore, she underwent epidural steroid injection that did not provide any benefit. However, extensive bilateral osteonecrosis of the medial tibial plateau in addition to osteonecrosis of the talus bone of left ankle were later diagnosed by MRI. The patient underwent staged bilateral total knee arthroplasty. In conclusion, the diagnosis of osteonecrosis might be challenging because of overlapping clinical presentation with other disorders particularly in the early stage of the disease with normal radiographs. Therefore, a high index of suspicion and thorough history with supplemental MRI imaging are essential for the assessment of patients presented with atypical refractory joint pain particularly in the presence of risk factors.

Graft-guided regenerative repair of critical long bone defects achieving facile surgical delivery, stable graft fixation, and timely restoration of biomechanical integrity without excessive biotherapeutics remains challenging. Here, we engineered hydration-induced swelling/stiffening and thermal-responsive shape-memory properties into scalable, three-dimensional-printed amphiphilic degradable polymer-osteoconductive mineral composites as macroporous, non-load-bearing, resorbable synthetic grafts. The distinct physical properties of the grafts enabled straightforward surgical insertion into critical-size rat femoral segmental defects. Grafts rapidly recovered their precompressed shape, stiffening and swelling upon warm saline rinse to result in 100% stable graft fixation. The osteoconductive macroporous grafts guided bone formation throughout the defect as early as 4 weeks after implantation; new bone remodeling correlated with rates of scaffold composition-dependent degradation. A single dose of 400-ng recombinant human bone morphogenetic protein-2/7 heterodimer delivered via the graft accelerated bone regeneration bridging throughout the entire defect by 4 weeks after delivery. Full restoration of torsional integrity and complete scaffold resorption were achieved by 12 to 16 weeks after surgery. This biomaterial platform enables personalized bone regeneration with improved surgical handling, in vivo efficacy and safety.

Orthopedic implant-associated bacterial infection presents a major health threat due to tendency for periprosthetic bacterial colonization/biofilm formation that protects bacteria from host immune response and conventional antibiotic treatment. Using surface-initiated atom transfer radical polymerization and copper-catalyzed azide-alkyne cycloaddition (CuAAC), alkynylated vancomycin is conjugated to azido-functionalized side chains of polymethacrylates grafted from Ti6Al4V. High-efficiency CuAAC across the substrate is confirmed by complete surface conversion of azides by X-ray photoelectron spectroscopy (XPS) and elemental mapping of changing characteristic elements. The vancomycin-modified surface (Ti-pVAN) significantly reduces in vitro adhesion and colonization of Staphylococcus aureus (S. aureus), a main bacterial pathogen responsible for periprosthetic infection and osteomyelitis, compared to untreated Ti6Al4V, supporting retained antibacterial properties of the covalently conjugated antibiotics. When the surface-modified intramedullary Ti-pVAN pins are inserted into mouse femoral canals infected by bioluminescent Xen29 S. aureus, significantly reduced local bioluminescence along with mitigated blood markers for infection are detected compared to untreated Ti6Al4V pins over 21 days. Ti-pVAN pins retrieved after 21 days are confirmed with similar to 20-fold reduction in adherent bacteria counts compared to untreated control, supporting the ability of surface-conjugated vancomycin in inhibiting periprosthetic S. aureus adhesion and colonization.