Background Self-reported cannabis use in patients undergoing total knee arthroplasty (TKA) has increased since its legalization. Despite endorsement, its efficacy has never been studied in a prospective randomized study in orthopaedic surgery. The purpose of this study was to determine whether a synthetic delta-9-tetrahydrocannabinol (sTHC), dronabinol, decreases opioid use after TKA. Methods There were 163 patients who underwent primary unilateral TKA who were prospectively randomized into receiving dronabinol (2.5 mg twice a day, n = 81) versus a placebo pill (2.5 mg twice a day, n = 82) as an adjunct to pain management. Patients, providers, our statistician, and the research team were blinded to the groups. Patients were cannabis naïve and had drug screening prior to surgery. Patients received our standard perioperative multimodal pain regimen (including opioids) regardless of randomization. The primary outcome was opioid morphine milligram equivalents (MME) at two weeks. Secondary outcomes included self-reported pain, sleep scores, nausea/vomiting, knee range of motion, and patient-reported outcomes. Patients were followed for six weeks after TKA. Statistical significance was accepted at P ≤ 0.05. Results There were no differences for in-hospital MME consumed (sTHC 40.1 ± 74.8 versus placebo 38.8 ± 76.4, P = 0.901), or in total MME noted at two weeks (sTHC 383.6 ± 309.8 versus placebo 367.6 ± 246.3, P = 0.717). Self-reported pain (P = 0.581; 0.710), hours of sleep per night (P = 0.103; 0.140), and nausea/vomiting (P = 0.689; 0.158) showed no differences between the groups at two and four weeks. No differences in patient-reported outcome measures at six weeks were noted between groups. There were no drug- or placebo-related complications were noted in either group. Conclusions Despite enthusiasm for cannabis after orthopaedic surgical procedures, this sTHC does not appear to limit opioid intake after primary TKA. Based on these data, THC may offer no benefit for patients after TKA.

BACKGROUND:Given the severe morbidity, mortality, and substantial cost of periprosthetic joint infection (PJI), substantial research has been conducted to compare perioperative and postoperative infection-prevention strategies. To our knowledge, there are no studies to date that have evaluated the 1-year efficacy of intraoperative vancomycin powder and/or dilute povidone-iodine lavage versus saline lavage in total joint arthroplasty. We previously reported no significant group differences at 3 months in a large multicenter randomized controlled trial. The present study reports 1-year outcomes of the same cohort. METHODS:In this prospective, multicenter trial, 2,053 high-risk patients undergoing primary, unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomized to one of four intraoperative protocols: vancomycin powder, dilute povidone-iodine, vancomycin povidone-iodine protocol (VPIP, combination), or saline lavage control. The primary outcome was 1-year PJI resulting in septic revision surgery. Analyses were conducted on a per-protocol basis using Chi-square tests stratified by procedure. At 1 year, complete follow-up was available for 798 THA and 1,032 TKA patients after accounting for withdrawals, loss to follow-up, and nine unrelated deaths. RESULTS:In the THA cohort, PJI occurred in 0.5% of vancomycin patients, 1.7% of iodine patients, 1.9% of VPIP patients, and 1.1% of saline patients (P = 0.62). In the TKA cohort, PJI occurred in 1.6% of vancomycin patients, none of the iodine patients, 2.0% of VPIP patients, and 0.4% of saline patients (P = 0.05). There were no significant differences between study groups at 0 to 3 months (P = 0.14 for THA, P = 0.13 for TKA), 3 to 12 months (P = 0.67 for THA, P = 0.80 for TKA), or combined 0 to 12 months (P = 0.62 for THA, P = 0.05 for TKA). CONCLUSIONS:There were no significant differences in 1-year PJI rates observed across prophylactic strategies in high-risk primary THA or TKA. These findings suggest that intraoperative antiseptic and antibiotic protocols may have limited influence on longer-term outcomes.

Background Titanium sleeves are the gold standard to protect ceramic heads placed on a previously used trunnion. However, this introduces another articulation that may lead to local soft tissue reaction. The purpose of this study is to determine the prevalence of abnormalities on metal artifact reduction sequence magnetic resonance imaging (MARS MRI) in asymptomatic patients with a titanium sleeve in revision total hip arthroplasty (rTHA). Methods Sixteen asymptomatic patients (17 hips) with a minimum of 1-year follow-up after rTHA with titanium sleeves in a ceramic head were enrolled in this study. The inclusion criteria included the absence of hip pain. All patients underwent an MARS MRI scan interpreted by a fellowship-trained musculoskeletal radiologist to determine the presence of fluid collections in asymptomatic patients with titanium sleeves. Results The average follow-up from rTHA to MRI was 5.58 ± 4.61 years (range 1-13.1). Fluid collections were observed in 13 (76%) of the 17 asymptomatic hips in this cohort. Most of these collections were extra-articular in nature over the greater trochanter, with only 3 having direct intracapsular communication. All these collections except 2 were a type 1 lesion based on the Hart classification, whereas the remaining were type 2a. The average pseudocapsule thickness was 11.2 mm in the patients with fluid collections, in comparison to 7.5 mm in those who did not. There were no signs of osteolysis at the most recent follow-up. Conclusions Fluid collections are not uncommon after r-THA with a titanium-sleeved ceramic femoral head. Unlike primary THA, synovial thickening may be present in this population. The clinical importance of these findings remains unknown, but this provides information to providers who may obtain MARS MRIs after r-THA. Level of Evidence Diagnostic level IV.

BACKGROUND:Swelling after a total knee arthroplasty (TKA) can result in pain, decreased range of motion, muscular inhibition, limitations in function, and negative perception of recovery. The objectives of this study were to determine how swelling changes after TKA and if swelling is associated with patient-reported outcomes, functional outcomes, or impairment measures. METHODS:This is a subanalysis of a two-arm, parallel, randomized controlled trial. Participants (n = 135) were recruited (mean age 64 years, 60% women, mean body mass index 28.7). The TKA participants were recruited and assessed pre-TKA and at 10 weeks, six months, and two years post-TKA. Demographic information was collected at the preoperative visit. Patient-reported outcomes (Western Ontario and McMaster Universities Arthritis Index (WOMAC) and patient satisfaction), functional outcomes (6-minute walk test [6MWT] and 30-second sit-to-stand test [30STS]), and impairment measures (quadriceps muscle strength, pain during functional measures, and knee range of motion) were collected at each clinic visit. Swelling was assessed using bioelectrical impedance analysis (BIA) and quantified post-TKA. Significance for all statistical tests was accepted at P < 0.05. RESULTS:Mean swelling pre-TKA was 2.06 ± 7.8% and then was 15.3 ± 10.6% at 10 weeks, 9.6 ± 7.3% at six months, and 5.4 ± 7.1% at two years after TKA. After TKA, 5% of patients returned to pre-TKA swelling at 10 weeks, 12% of patients returned to pre-TKA swelling at six months, and 28% of patients returned to pre-TKA swelling at two years. In comparison to pre-TKA swelling, swelling at 10 weeks, six months, and two years post-TKA was significantly higher (all P < 0.0001). The BIA ratio was significantly correlated to function as measured pre-TKA by WOMAC (0.19, P = 0.03). The BIA ratio was significantly correlated to the 6-minute walk test (6MWT) at 10 weeks post-TKA (0.24, P = 0.007). The BIA ratio was not correlated to WOMAC, patient satisfaction, 6MWT, 30STS, quadriceps muscle strength, pain during functional measures, and knee range of motion at six months post-TKA or two years post-TKA (P = 0.10 to 0.95). CONCLUSIONS:In most patients, postoperative swelling did not return to pre-TKA levels by two years after TKA. Furthermore, swelling remained elevated six months and two years post-TKA, and it is not associated with recovery of impairments and function.

Glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1 RAs) are used in diabetic patients for glycemic control. Yet, there has been a notable rise in their use for weight loss management in obese patients. This review critically appraises current evidence on perioperative implications of GLP-1 receptor agonists in TJA patients. The review discusses GLP-1 RA implications and use (physiology, pharmacology, pharmacodynamics, mechanisms of actions, and commonly used GLP-1 Ras), complications and adverse effects, considerations for the anesthesiologist, considerations for the TJA surgeon, and current clinical practice recommendations in 2025.

BACKGROUND:Few studies have evaluated postoperative opioid use after revision total knee arthroplasty (TKA). The primary objective of this study was to evaluate postoperative opioid (in-hospital and outpatient) use in revision TKA. METHODS:A retrospective review of 164 revision TKA patients that were age- and sex-matched to a primary TKA control group was conducted. The number of opioids prescribed, in-hospital morphine milligram equivalents (MME), total MME, and days between surgery and last date an opioid was dispensed were collected and calculated. Reason for revision TKA and type of revision TKA performed were determined. Medical comorbidities were collected and the Charlson Comorbidity Index (CCI) was calculated. Significance for all statistical tests was accepted at P ≤ 0.05. RESULTS:Revision TKA patients had significantly higher in-hospital MME compared to primary TKA patients (P = 0.003). Primary TKA patients had a longer duration between surgery and the last date an opioid was dispensed versus revision patients (P = 0.006). A higher percentage of revision TKA patients used anti-depressants and benzodiazepines compared to primary TKA patients (P = 0.036 and P = 0.003, respectively). Acute infection and infection stage 1 spacer implantation demonstrated the highest in-hospital MME (> 200 MME). The number of opioids sold within three months post-operation and the duration of opioid use post-surgery varied significantly depending on the revision reason (P = 0.0001 and P = 0.04). Periprosthetic femur fracture had the highest mean days and required extended opioid use. CONCLUSIONS:Revision TKA for arthrofibrosis and periprosthetic femur fractures required more intensive pain management, likely due to post-operative stiffness and increased rehabilitation demands for arthrofibrosis patients and fracture-related pain and weight-bearing restrictions for periprosthetic fracture patients, respectively. This information can help tailor postoperative pain management strategies based on the etiology of revision, to optimize patient recovery and opioid use.

Background:The impact of the spinopelvic relationship on hip instability and impingement after total hip arthroplasty (THA) has led to growing interest in functional acetabular component position. Various surgical techniques and technological advancements have been introduced to optimize acetabular component placement by accounting for individual spinopelvic mobility patterns. The purpose of this study was to evaluate the accuracy of acetabular component positioning with the use of a patient specific instrument (PSI). Methods:A consecutive series of 188 THAs performed between 2017 and 2021 was retrospectively reviewed. A preoperative analysis using a commercially available system utilizing dynamic preoperative spinopelvic imaging was utilized to determine individualized functional acetabular component position (anteversion and inclination) and generate an acetabular patient specific instrument incorporating that target orientation. The incidence of postoperative inclination and anteversion errors >5° and 10° versus the desired preoperative plan was determined using a validated ellipse fitting algorithm. Results:97.3% (183) and 96.3% (181) of acetabular components were positioned within 10° of the anteversion and inclination targets, respectively. 92.6% (174) simultaneously met both targets. 80.9% (152) and 75.0% (141) were within 5° of the anteversion and inclination targets, respectively. 59.0% (111) simultaneously met both targets. The mean absolute error (difference between plan and postoperative measurements) for inclination was 4.11° ± 3.12° (range 0.05°- 17.5°) and for anteversion was 3.38° ± 2.68° (range 0.01° - 12.3°). Conclusion:This system reliably facilitates positioning of acetabular component inclination and anteversion to within 10° of the targeted plan. Outliers increased when the error value was limited to 5° but still provided accurate placement in nearly 60% of patients for inclination and greater than 80% of patients for anteversion. Further research is warranted to assess the clinical impact and cost effectiveness of improved component placement in an individualized functional position with patient specific guides.

Abstract Introduction: Periprosthetic joint infection (PJI) may result from pathogen-to-patient transmission within the environment. High-touch surfaces (HTS) areas near the operative field from previous studies had been identified as the least likely to be thoroughly cleaned between operative cases and were utilized for this study. The purpose of this study was to assess the impact of a handheld ultraviolet-c (UV-C) light-emitting diode (LED) disinfection device on the decontamination of HTS in the operating room. Methods: This prospective study was conducted between 03/02/2021 and 04/20/2021. Tryptic soy agar contact plates were used to determine the bacterial load of the selected surfaces before the initiation of the case, after the case was complete, before manual cleaning, and after disinfection of the LED device. The plates were then incubated for 48 hours at 36º +/–1° C. Colony forming units (CFU) were recorded 48 hours after incubation. Mean, median, and range of CFU were recorded. Results: Average CFU per surface before and after the surgical case were 14.1 (range 0–200) and 13.5 (range 0–200) respectively, these were not significantly different (P = 0.9397). Manual cleaning reduced average CFU by 74% to 3.35 (range 0–200) per surface (P = 0.0162). Disinfection with the handheld LED unit further reduced the average CFU by 92% to 0.28 (range 0–4) per surface (P < 0.0001). Conclusions: A handheld UV-C LED disinfection device may decrease environmental contamination near the operative field in HTS areas. Further research is warranted with this technology to determine if this correlates with a decrease in PJI.

BACKGROUND:Periprosthetic joint infection (PJI) is a high-cost and extremely morbid complication following total joint arthroplasty; thus, developing a better understanding of perioperative infection prevention strategies is prudent. Literature is mixed regarding the efficacy of vancomycin powder and dilute povidone-iodine lavage, and limited on the combination thereof. To our knowledge, no prospective orthopedic clinical trials to date have evaluated the efficacy of local vancomycin powder, dilute povidone-iodine lavage, or a combination vancomycin-povidone-iodine protocol against normal saline irrigation. METHODS:In a large, prospective, multicenter, randomized-controlled study, four distinct infection prevention strategies were implemented in high-risk total joint arthroplasty patients. Local vancomycin powder, dilute povidone-iodine solution, combined vancomycin-povidone-iodine protocol, and saline control were used. Primary outcomes included PJI, wound complications, revisions, emergency department visits, readmissions, and serious adverse events within 3 months of index surgery. Chi-square tests were used to compare incidence rates. The criteria used for the diagnosis of PJI were the International Consensus Meeting guidelines. RESULTS:There were 821 total hip arthroplasty (THA) and 1,080 total knee arthroplasty (TKA) patients randomized into well-balanced study groups. In the THA and TKA cohorts, respectively, there were no statistically significant differences in rates of persistent wound drainage or dehiscence (P = 0.98, P = 0.95), cellulitis or abscess (P = 0.81, P = 0.51), 3-month infection rates (P = 0.14, P = 0.13), type of septic revisions performed (P = 0.51, P = 0.80), aseptic revision rates (P = 0.07, P = 0.90), emergency department visits (P = 0.61, P = 0.46), or readmissions (P = 0.78, P = 0.87) between the four treatment groups. CONCLUSIONS:There were no statistically significant differences in PJI or other surgical outcomes following THA or TKA among the study groups. Therefore, the use of such prophylactic measures, including povidone-iodine and vancomycin powder in high-risk patients, can be left up to the surgeon or hospital discretion.

IntroductionMeasuring pelvic tilt and pelvic obliquity during functional positions is important for surgical planning of total hip arthroplasty as these orientations affect optimal acetabular cup position and post-operative hip stability. The objective of this study was to compare pelvic tilt, pelvic obliquity, and pelvic mobility across 3 cohorts of age-matched patients: 1) healthy controls 2) THA patients without spinal fusion and 3) patients with instrumented spinal fusions. We hypothesized that (1) the healthy and THA cohorts would demonstrate similar pelvic mobility across the range of position demand and (2) individuals with spinal fusions would have significantly less pelvic mobility than both the healthy and THA cohorts.MethodsWe compared 10 patients in each of these cohorts using stereo radiography to quantify pelvic tilt and pelvic obliquity across a range of clinically relevant poses of varying demand on pelvic mobility.ResultsResults demonstrated that the overall pelvic mobility of the spinal fusion cohort was consistently similar in magnitude to health controls but biased anteriorly by 6.5% and 33.5% compared to the healthy and total hip cohorts, primarily due to less posterior tilting across the functional positions (Healthy: 39.6° ± 10.2°; Spinal fusion: 39.5° ± 7.3°; Total hip: 37.8° ± 7.6°). Obliquity angles varied substantially between some clinically relevant pose combinations. Low and high coronal plane mobility patients were identified in each of the three cohorts, with mobility ranging between 4.4° and 28.3°, respectively, across positions.DiscussionSubstantial intragroup variability was exhibited within each cohort across the six functional poses, highlighting the patient-specific nature of the spinopelvic relationship regardless of previous surgery at the hip or spine. The larger pelvic tilt angles demonstrated during more demanding poses in seated and standing highlights the importance of imaging patients in poses that capture the full extent of pelvic mobility.

» For patients with both lumbar spine pathology, hip and knee degenerative joint disease, it is important to consider the implications of surgically addressing each anatomic region first.» Performing total hip arthroplasty before lumbar spine fusion may decrease the risk of dislocation and revision surgery; however, if spinal fusion is performed first, it may be protective to wait 1 to 2 years to lower the risk of complications.» In all patients with concurrent hip and low back symptoms, it is recommended that an evaluation of both areas is performed before proceeding with either surgical intervention.» If arthroplasty procedures are to occur in a staged fashion, adverse events in high-risk patients may be mitigated by waiting for more than 1 year between procedures. Staged procedures performed less than 30 days apart are at increased risk of medical and surgical complications.» Simultaneous bilateral total joint arthroplasty procedures should likely be avoided in more elderly patients, those with higher body mass index and those with a greater burden of medical comorbidities due to the increased risks of postoperative complications.

Introduction: A primary objective when performing a total hip arthroplasty (THA) is to restore hip biomechanics in accordance with a chosen surgical plan. The aim of this study was to assess the accuracy of a 3D-printed patient-specific guide for delivering a planned femoral osteotomy for both a posterior and an anterior approach. Methodology: 40 patients (20 anterior and 20 posterior) scheduled for THA received a preoperative work-up allowing for patient-specific implant sizing and positioning. Following surgeon confirmation, a patient-specific guide was designed and printed, enabling the desired osteotomy to be executed. Achieved osteotomies were assessed using commercially available software platforms. Planning accuracy was also assessed using both the planning platform as well as more traditional 2D-templating techniques. Results: The mean deviation between the planned and achieved osteotomy level was −0.6 mm (range −4.1–6.4 mm). 95% of the achieved osteotomy levels were within 3 mm of the plan for both the posterior and anterior approach groups. 70% of the Optimized Positioning System (OPS) planned femoral components were the exact size as planned versus 25% of the 2D-planned components. 98% of the OPS planned femoral components were within 1 size of plan versus 58% for the 2D-planned components. No sizing accuracy difference was observed between planning approaches ( p = 0.70). Conclusions: A patient-specific osteotomy guide can be a simple and accurate method to reproduce a planned femoral neck resection through an anterior or posterior approach. Further, 3D planning appears to more accurately predict femoral sizing in THA than more conventional 2D methods.

Background:Complications following total hip arthroplasty (THA) may necessitate a revision and patients who go on to a revision THA may experience depressive symptoms. The objective of this study was to investigate the prevalence of depressive symptoms before and after revision THA for six different failure modes. Methods:Patients who underwent a THA revision with minimum 1-year follow-up at a single institution from 2008 to 2022 were retrospectively reviewed. Patients were grouped by failure modes: aseptic loosening, impingement, infection, instability, metallosis, polyethylene wear, and femoral stem pain. Preoperative and postoperative Veterans RAND 12-Item Health Scores and Harris Hip Score were compared. Results:Twenty-four percent of patients in the retrospective cohort review had a previous existing mental health diagnosis, with depression being the most common (18% of all patients). The prevalence of depressive symptoms differed significantly by failure mode both preoperatively (P = .002) and postoperatively (P = .019). Veterans RAND 12 mental component score was significant between mode of failure groups both preoperatively (P < .001) and postoperatively (P = .005). Function significantly improved in all groups from preoperatively to postoperatively. Patients with depressive symptoms had significantly lower physical component score with instability, aseptic loosening, stem pain, and metallosis preoperatively (P < .001) and with instability, aseptic loosening, stem pain, and polyethylene wear postoperatively (P = .002). Conclusions:Nearly 25% of patients with failed THA had a pre-existing mental health diagnosis and depressive symptoms were the most common. Unfortunately, depressive symptoms only improve modestly with revision surgery and can adversely affect a patient's functional outcome.

» Identifying medical comorbidities and optimizing modifiable risk factors (biological, social, and psychological) have been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care, while reducing the risk of intraoperative and postoperative complications. Modifiable biological factors include weight management to reduce obesity, optimizing diabetic control, improving malnutrition, optimizing bone health, improving anemia, managing anticoagulants and bleeding risk, controlling inflammatory conditions, reducing methicillin-sensitive Staphylococcus aureus/methicillin-resistant S. aureus colonization, and reducing frailty. Modifiable social and psychological factors include tobacco and smoking cessation, reducing alcohol use, ceasing drug use/misuse, optimizing mental health (i.e., depression, anxiety), patient TJA education and managing expectations, and evaluating discharge determination and living status. This review comprehensively evaluates and summarizes preoperative patient optimization strategies for lower extremity TJA surgery, both in the primary and revision settings.

Background Cutibacterium acnes (C acnes) is of growing concern in periprosthetic joint infections following total hip arthroplasty (THA). The dermal colonization rate of C acnes with various preoperative cleaning protocols in THA has yet to be elucidated. The purpose of the study was to investigate the effect of different preoperative skin cleansing protocols on the colonization rate of the hip in patients undergoing elective THA. Methods Patients were recruited and randomized into either: 1) standard (STD) surgical preparation (4% chlorhexidine gluconate); or 2) STD + benzoyl peroxide (BPO) gel (four applications of 5% BPO gel). On the morning of the biopsy collection, a final application of 5% BPO gel was applied. Intraoperatively, all patients had their skin prepped with STD preparation. There were six 3-mm punch skin biopsies performed per patient for both an anterior-based hypothetical incision and a more lateral/posterior incision. Samples were cultured and held for 14 days. Results Of the biopsies, 11% had a positive culture. There were 38% of the patients in the STD group and 41% of the patients in the BPO group who had a positive culture (P = 0.61). There were 17% of the patients in the STD group and 20% of the patients in the BPO group who had a positive culture for C acnes (P = 0.51). C acnes was more commonly cultured in both the STD and BPO groups as compared to Staphylococcus species and Bacillus species. There were no differences between positive culture biopsies between anterior or lateral sampling locations (P = 0.62 STD group and P = 0.71 BPO group). Conclusions There was a high rate of patients that demonstrated C acnes colonization prior to THA. There was no difference in positive culture rate with anterior or lateral sample locations. Preoperative surgical preparation was not effective at decreasing the burden of C acnes from the surgical site prior to THA, and different skin preparations should be considered.

BACKGROUND:Displacement of the native hip center of rotation (COR) following total hip arthroplasty (THA) alters biomechanical load distribution and may adversely affect outcomes. This analysis quantified alterations in the COR following THA and their relationship with postoperative axial femoral rotation. METHODS:There were 938 patients evaluated following staged bilateral THA. Each underwent a three-dimensional preoperative planning analysis. Automated registration between preoperative and postoperative computed tomography scans enabled the hip COR to be accurately compared preoperatively versus postoperatively. Changes in global anterior-posterior (AP) shift were defined by the combined difference between the anteriorization of the femoral COR and the posteriorization of the pelvic COR. Changes in global AP shift versus femoral internal rotation were assessed using linear regression. RESULTS:The mean acetabular COR was medialized by 4.6 mm and femoral COR by 5.1 mm relative to the native COR, resulting in a global medial-lateral offset increase of 0.5 mm. Similarly, the achieved acetabular and femoral CORs were shifted proximally by 0.4 and 2.8 mm, respectively, resulting in an average increase in hip length of 2.4 mm. Acetabular and femoral CORs were shifted anteriorly by -1.7 and -0.8 mm, respectively, resulting in a global AP shift decrease of 0.9 mm. Change in global AP shift was moderately correlated with change in femoral internal rotation (r = 0.5), with a regression slope indicating an average increase in femoral internal rotation of 0.6° per millimeter increase in global AP shift (P < 0.0001). Global AP shift increased by > 5 mm in 24% of cases, resulting in an average increase in femoral internal rotation of 10°. CONCLUSIONS:Acetabular COR is medialized by approximately five mm following THA with a compensatory increase in femoral offset, increasing muscle moment arms and increasing torque at the bone-stem interface. On average, global AP shift decreased by 1.0 mm, though there was significant patient-specific variability. When these changes exceed five mm, they can significantly alter axial rotational limb alignment.

BACKGROUND:Computer navigation has been used in total knee arthroplasty in an attempt to improve component alignment and clinical outcomes, although few studies directly compare computer navigation to traditional instrumentation in the same patient. METHODS:Bilateral total knee arthroplasties performed during the same surgical intervention utilizing computer navigation in one knee and traditional instrumentation in the contralateral knee were prospectively collected and followed. Reoperations and adverse events were documented. Statistical analyses were performed between the two groups to determine differences in clinical outcomes. RESULTS:There were 79 patients who had a mean follow-up of 11.8 years (range, five to 16). When comparing computer navigation to traditional instrumentation cohorts, mean postoperative femoral component coronal angle (94.9 versus 94.9°, P = 0.88), femoral component flexion (2.1 versus 1.8°, P = 0.53), tibial component coronal angle (89.7 versus 90°, P = 0.24), and posterior tibial slope (2.4 versus 2.9°, P = 0.15) showed no statistical differences. Computer navigation demonstrated a decrease in posterior tibial slope outliers (1 versus 8, P = 0.018) compared to traditional instrumentation, but no differences in the other component angles. Clinically, there were no differences in mean postoperative extension (0.2 versus 0.2°, P = 0.97), flexion (127.3 versus 127.1°, P = 0.85), functional Knee Society Scores (91.3 versus 90.5, P = 0.77), reoperation rate (6.3 versus 2.5%, P = 0.44), or closed manipulation rate (2.5 versus 3.8%, P = 0.65) at final follow-up comparing computer navigation to traditional instrumentation, respectively. Computer navigation reoperation indications included two patellar osteolysis, one infection, one patellar clunk syndrome, and one symptomatic arthrotomy nonabsorbent suture removal. Traditional instrumentation reoperation indications included one infection and one arthrotomy dehiscence. CONCLUSIONS:Computer navigation reduced posterior tibial slope outliers, although this did not translate to any appreciable difference in clinical outcome at 11 years' mean follow-up in the hands of a fellowship-trained total joint specialist.

Background: Complications following total knee arthroplasty (TKA) that necessitate revision cause considerable psychological distress and symptoms of depression, which are linked to poorer postoperative outcomes, increased complications, and increased healthcare utilization. We aimed to identify the prevalence of mental health disorders and symptoms preoperatively and postoperatively in patients undergoing aseptic revision TKA and to stratify these patients based on their mechanism of failure. Methods: All patients undergoing aseptic revision TKA from 2008 to 2019 with a minimum 1-year follow-up were retrospectively reviewed at a single institution. Patients (n = 394) were grouped based on 7 failure modes previously described. Patients were considered to have depressive symptoms if their Veterans RAND-12 mental component score was below 42. Preoperative and postoperative Veterans RAND-12 mental component scores at the latest follow-up were evaluated. Results: Overall comparative prevalence of preoperative to postoperative depressive symptoms was 23.4%-18.8%. By mode of failure are as follows: arthrofibrosis (25.8%-16.7%), aseptic loosening (25.3%-18.9%), extensor mechanism disruption (25%-50%), failed unicompartmental knee arthroplasty (8.6%-14.3%), instability (25.7%-17.1%), osteolysis or polyethylene wear (23.1%-23.1%), and patellar failure (11.8%-23.5%). There was no difference in depressive symptoms among failure modes preoperatively (P = .376) or at the latest postoperative follow-up (P = .175). Conclusions: The prevalence of depressive symptoms in revision TKA patients appears to be independent of failure mode. Surgeon awareness and screening for depressive symptoms in this patient population preoperatively with referral for potential treatment may improve early postoperative outcomes.

BACKGROUND:The impact of femoral anteversion changes on femoral rotation and anterior offset following total hip arthroplasty (THA) has not been well studied. This study therefore investigated the relationship among femoral anteversion, anterior offset, and femoral rotation before and after THA. METHODS:There were 995 patients who had staged primary bilateral THAs who received a preoperative supine computerized axial tomography (CT) scan, following a standardized protocol, for surgical planning prior to each THA. The following measurements were performed for the first operative hip preoperatively and postoperatively on the first and second CT scans, respectively: femoral anatomic anteversion, defined as the angle between the native femoral neck or stem neck axis and the posterior condylar axis; femoral rotation, defined as the angle of the posterior condylar axis relative to the coronal plane of the CT; and femoral anterior offset, defined as the shortest distance between the femoral head center and a femoral plane containing the epicondyles and the piriformis fossa. The mean time between imagings was 11 months (range, 2 to 44). Associations are described using linear regression (β = slope) and Pearson correlation (r) coefficients. A t distribution was used for testing correlation. RESULTS:Femoral anteversion correlated with femoral anterior offset preoperatively (β = 0.565, r = 0.914, P < 0.001) and postoperatively (β = 0.671, r = 0.958, P < 0.001), and with femoral rotation preoperatively (β = 0.623, r = 0.575, P < 0.001) and postoperatively (β = 0.459, r = 0.517, P < 0.001). Increasing anteversion from preoperatively to postoperatively increased anterior offset (β = 0.621, r = 0.908, P < 0.001) and femoral internal rotation (IR) (β = 0.241, r = 0.273, P < 0.001). Patients who had >20° increase in anteversion (mean increase 26°, range 20 to 40.5°, n = 71) had a mean increase in femoral IR of 9.6 ± 9.8°. CONCLUSIONS:Increasing femoral anteversion increases anterior offset and IR of the femur, with approximately a 1° increase in IR for every 4° increase in anteversion on average. Surgeons should appreciate the implications of changing anteversion during THA planning.

To perform total hip arthroplasty (THA) successfully, a surgeon must be able to place the implants in a position that will restore and duplicate the patient's baseline anatomy and soft-tissue tension. One of the critical factors is the restoration of femoral offset. It is the goal of this review to precisely define measurement of offset in THA, describe its role in hip joint biomechanics, outline alterations that can be performed intraoperatively, and explain how it can create potential pathologic states. If there is a lack of offset restoration, it can result in a host of complications, including bony impingement with pain, edge loading or prosthetic joint instability, and alterations in the muscle length-tension relationship leading to reduced motor performance. Excessive femoral offset can increase hip abductor muscle and iliotibial band tension resulting in greater trochanteric pain regardless of the surgical approach. The purpose of this review was to analyze intraoperative surgical factors, choice of prosthetic implant type and position that are required to maximize stability, and dynamic motor performance after THA.