Mabry, Tad M.

Aims Two-stage exchange arthroplasty with an antibiotic-eluting cement spacer remains the predominant strategy in the USA for managing chronic periprosthetic joint infection (PJI) following total hip arthroplasty (THA). The aim of this study was to evaluate a commercially available, partially intraoperatively fabricated articulating high-dose antibiotic cement spacer, focusing on survival, complications, and patient-reported outcomes. Methods A total of 298 patients (302 THAs) underwent two-stage exchange arthroplasty for PJI using a specific articulating antibiotic spacer between August 2005 and May 2022. Patients with a previous failed two-stage exchange were excluded, although 121 THAs (302, 40%) had undergone previous PJI-related procedures. The mean age of the patients was 65 years (SD 11), the mean BMI was 32 kg/m 2 (SD 7), and 116 (38%) were female. Most patients were classified as McPherson host B (158; 52%) and limb grade 2 (165; 55%), and 265 (88%) met the 2011 Musculoskeletal Infection Society criteria. The mean follow-up was six years (2 to 16). Results At five years after reimplantation, survival free of reinfection, aseptic rerevision, any rerevision, or any reoperation were 89% (95% CI 85.2 to 93.1), 93% (95% CI 89.3 to 96.1), 86% (95% CI 81.3 to 90.3), and 80% (95% CI 74.7 to 84.9), respectively. Dislocation accounted for most aseptic rerevisions (15/20). McPherson host C (HR 3.7 (95% CI 1.4 to 9.6); p = 0.007) and limb grade 3 (HR 3.3 (95% CI 1.0 to 11.1); p = 0.049) were significantly associated with an increased risk of reinfection. The mean Harris Hip Score at the latest follow-up was 76 (29 to 100). A total of 17 patients underwent revision or removal of a spacer for concerns about persistent infection and two for dislocation of the spacer. Eight patients underwent a non-rerevision reoperation during the spacer interval for wound drainage (n = 5), dislocation of the spacer (n = 2), and perispacer fracture (n = 1). A total of 26 spacer-related complications were treated nonoperatively (15 perispacer fractures, 11 dislocations). Dislocation of the spacer was strongly associated with dislocation after reimplantation (HR 6.2 (95% CI 2.3 to 16.9); p < 0.001). Conclusion This commercially available, partially intraoperatively fabricated articulating spacer showed excellent reinfection-free five-year survival (89%). Spacer-related fracture and dislocation each occurred in 5% of patients. Dislocation of the spacer significantly increased the risk of dislocation following reimplantation, supporting the use of higher-stability bearings in these high-risk patients. Cite this article: Bone Joint J 2026;108-B(9):1104–1112.

Background: Total joint arthroplasty (TJA) is increasingly being performed as an outpatient (i.e., same-day discharge) procedure. Postoperatively, orthostatic hypotension or pain-related tachycardia can lead to concerns regarding the hemoglobin (Hgb) level of the patient prior to discharge. The purpose of this study was to prospectively assess the reliability and accuracy of, and patient and nurse satisfaction with, postoperative noninvasive hemoglobin (nHgb) monitoring compared with an invasive serum hemoglobin (iHgb) laboratory draw in the outpatient TJA setting. Methods: We prospectively enrolled 200 patients undergoing outpatient unilateral TJA, of whom 157 were ultimately included in our analysis (94 hips, 63 knees). Postoperatively, both nHgb and iHgb values were obtained at a mean of 36 minutes apart. Surveys were completed by patients and nurses. The strength of the agreement between the 2 Hgb monitoring methods was evaluated with use of the Bland-Altman 95% limits of agreement, concordance correlation coefficient (CCC), and intraclass correlation coefficient (ICC). Receiver operating characteristic curve analyses were performed to investigate the ability of nHgb monitoring to predict an iHgb of <11.2 g/dL (the 5th-percentile iHgb value). Results: The mean preoperative iHgb was 14.2 ± 1.1 g/dL. The mean postoperative iHgb and nHgb values were 13.3 ± 1.5 and 13.3 ± 1.2 g/dL, respectively. The Bland-Altman 95% limits of agreement were −3.2 and +3.1 g/dL, indicating that 95% of patients’ iHgb values are expected to fall between these limits relative to the nHgb value of the patient. The CCC and ICC were both 0.33. An nHgb cutoff value of <12.7 g/dL had 100% sensitivity and 67% specificity for detecting an iHgb of <11.2 g/dL. Patients reported less pain with the nHgb test than with the iHgb test (mean pain score, 0.0 versus 1.8; p < 0.001), and 97% of patients preferred the nHgb test. Following the nHgb test, 73% of responding patients and 83% of responding nurses were “somewhat more reassured” to “significantly more reassured” about same-day discharge. Conclusions: Routine nHgb testing can rapidly screen patients undergoing outpatient TJA for acute anemia prior to discharge. With an nHgb of <12.7 g/dL, there was perfect sensitivity and 67% specificity for detecting an iHgb of <11.2 g/dL. Most patients and nurses felt more reassured about same-day discharge after nHgb monitoring. Level of Evidence: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Most North American surgeons predominantly use uncemented stems in primary total hip arthroplasties (THAs) and reserve cemented stems for selected older patients and those with poor bone quality. However, data on this “selective use” strategy for cemented stems in the population at risk for periprosthetic fracture and implant loosening are limited. The purpose of this study was to describe implant survivorship, complications, and radiographic results of a specific collarless, polished, tapered cemented stem (Exeter; Stryker) used selectively in a predominantly elderly population undergoing primary THA. Methods: We identified 386 patients who underwent a total of 423 primary THAs with selectively utilized Exeter stems for the treatment of osteoarthritis between 2006 and 2017. In the same time period, 11,010 primary THAs were performed with uncemented stems and 961 with non-Exeter cemented stems. The mean patient age was 77 years, 71% were female, and the mean body mass index was 29 kg/m 2 . Competing risk analysis accounting for death was utilized to determine cumulative incidences of revision and reoperation. The mean follow-up was 5 years (range, 2 to 12 years). Results: The 10-year cumulative incidence of any femoral component revision in this patient cohort was 4%, with 10 stems revised at the time of the latest follow-up. There were no intraoperative femoral fractures. The indications for revision were postoperative periprosthetic femoral fracture (n = 6), dislocation (n = 3), and infection (n = 1). There were no revisions for femoral loosening. The 10-year cumulative incidence of reoperation was 10%. The 10-year cumulative incidence of Vancouver B periprosthetic femoral fracture was 2%. Radiographically, there were no cases of aseptic loosening or osteolysis. There was a significant improvement in median Harris hip score, from 53 preoperatively to 92 at a mean follow-up of 5 years (p < 0.001). Conclusions: The strategy of selectively utilizing a collarless, polished, tapered cemented stem produced a low (4%) cumulative incidence of stem revision at 10 years postoperatively and resulted in no cases of aseptic loosening. The use of the Exeter stem did not eliminate postoperative femoral fractures in this predominantly elderly, female patient population. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Aims Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m2 (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175.

Background: Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. Methods: This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. Results: In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums. Conclusions: Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Background: Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI. Methods: This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units. Results: We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication. Conclusions: In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background: Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure. Methods: Using our institution’s total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics. Results: The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score. Conclusions: Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Postoperative infection remains a major challenge in revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA). Wound irrigation with dilute povidone-iodine (PI) solution has emerged as a simple, inexpensive, and potentially successful means of reducing postoperative infections. The aim of this study was to assess its effectiveness in reducing infection following revision THA and TKA in, to our knowledge, the largest revision cohort to date. Methods: Using our institution’s total joint registry, we identified 1,402 revision THAs and 1,482 revision TKAs performed during the study period (2013, when the PI irrigation protocol was first implemented, to 2017). The PI lavage protocol was employed in 27% of the revision THA cases and 34% of the revision TKA cases; in the remaining cases, the protocol was not used. Demographics, comorbid conditions, underlying surgical diagnoses, and whether the revision was for a septic or an aseptic etiology were compared between the groups (use or no use of PI irrigation). Any reoperation due to infection, as assessed at 3 and 12 months following revision arthroplasty, was compared between the groups and propensity scores were calculated to account for differences in baseline characteristics between the groups. Results: After adjusting for baseline differences between the groups using the propensity-score weighted models, we found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received PI lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. Conclusions: PI wound lavage demonstrated no benefit in reducing any reoperation for infection following revision THA and TKA. Moreover, the trend toward higher rates for reoperation for infection among patients who received PI irrigation merit further consideration. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: For patients undergoing 2-stage exchange for the treatment of periprosthetic joint infection (PJI) following total knee arthroplasty, the long-term risk of reinfection and mechanical failure and long-term clinical outcomes are not well known. The purpose of our study was to determine the long-term clinical results of 2-stage exchange for PJI following total knee arthroplasty. Methods: We identified 245 knees that had undergone total knee arthroplasty and were subsequently treated with 2-stage exchange due to infection during the period of 1991 to 2006; the cohort had no prior treatment for PJI. Major, or 4 of 6 minor, Musculoskeletal Infection Society (MSIS) diagnostic criteria were fulfilled by 179 (73%) of the knees. The cumulative incidence of reinfection and of aseptic revision, accounting for the competing risk of death, were calculated. Risk factors for reinfection were evaluated using Cox proportional hazards regression. Knee Society Score (KSS) values were calculated. The mean age at spacer insertion was 68 years; 50% of the patients were female. The mean follow-up was 14 years (range, 2 to 25 years) following reimplantation. Results: The cumulative incidence of reinfection was 4% at 1 year, 14% at 5 years, 16% at 10 years, and 17% at 15 years. Factors that were predictive of reinfection included a body mass index of ≥30 kg/m 2 (hazard ratio [HR], 3.1; p < 0.01), previous revision surgery (HR, 2.8; p < 0.01), and a McPherson host grade of C (HR, 2.5; p = 0.04). The cumulative incidence of aseptic revision for loosening was 2% at 5 years, 5% at 10 years, and 7% at 15 years. Femoral (HR, 5.0; p = 0.04) and tibial (HR, 6.7; p < 0.01) bone-grafting at reimplantation were predictive of aseptic failure. The most common complications were wound-healing issues, requiring reoperation in 12 (5%) of the knees. The rate of death at 2 years following reimplantation was 11%. The mean KSS improved from 45 at PJI diagnosis to 76 at 10 years following reimplantation (p < 0.01). Conclusions: Long-term reinfection rates following 2-stage exchange for PJI after total knee arthroplasty were similar to those of shorter-term reports and were maintained out to 15 years. Mechanical failure rates were low if bone loss was addressed at the time of reimplantation. Improvements in clinical outcomes were maintained at long-term follow-up. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Limited data exist that show the long-term risks of reinfection and mechanical failure with a contemporary 2-stage exchange protocol for periprosthetic joint infection following total hip arthroplasty. The purpose of this study was to determine the long-term reinfection and mechanical failure rates of 2-stage exchange for periprosthetic joint infection after total hip arthroplasty. Methods: We identified 164 hips (162 patients) with infection after total hip arthroplasty between 1991 and 2006 treated with a 2-stage exchange protocol with no prior treatment for periprosthetic joint infection. With regard to Musculoskeletal Infection Society diagnostic criteria, at least 1 major criterion or 4 of 6 minor criteria were fulfilled in 129 hips (79%). The cumulative incidence with a competing risk of death was calculated for reinfection, aseptic revisions, and all-cause revisions. The risk factors for reinfection were evaluated using Cox proportional hazards regression. Harris hip scores were calculated. The mean age at the time of spacer insertion was 68 years, and 35% of the patients were female. Excluding the patients with <2 years of follow-up, the mean follow-up was 12 years (range, 2 to 21 years). Results: The cumulative incidence of recurrence of infection was 10% at 1 year, 14% at 5 years, and 15% at 10 and 15 years. Seventeen patients (11%) used chronic antibiotic suppression (>6 months), with 7 (41%) of these having recurrent infection at the time of the latest follow-up. Use of chronic antibiotic suppression was the only predictive factor for reinfection (hazard ratio, 4.5 [95% confidence interval (CI), 1.9 to 10.9]; p = 0.001). The cumulative incidence of aseptic femoral and acetabular revisions was 2.6% at 5 years and 3.3% at 10 and 15 years. The cumulative incidence of all-cause revisions was 15% at 5 years and 16% at 10 and 15 years. Dislocation was the most common complication, with 28 dislocations occurring in 20 patients (12%). The mean Harris hip score improved from 52 points prior to spacer insertion to 70 points at 15 years after reimplantation (p < 0.01). Conclusions: The rate of recurrence of infection of 15% for up to 15 years after total hip arthroplasty was similar to previous shorter-term reports of 2-stage exchange for periprosthetic joint infection. Surgeons should anticipate mitigating instability after reimplantation. Implant survivorship free of aseptic loosening and clinical outcomes were preserved for the long term. The role of chronic antibiotic suppression in the long-term treatment of periprosthetic joint infection requires further investigation. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.