Wyles, Cody C

Abstract Deep learning is revolutionizing medical imaging analysis by enabling the classification of various pathoanatomical conditions at scale. Unfortunately, there have been a limited number of accurate and efficient machine learning (ML) algorithms that have been developed for the diagnostic workup of morphological hip pathologies, including developmental dysplasia of the hip and femoroacetabular impingement. The current study reports on the performance of a novel ML model with YOLOv5 and ConvNeXt-Tiny architecture in predicting the morphological features of these conditions, including cam deformity, ischial spine sign, dysplastic appearance, and other abnormalities. The model achieved 78.0% accuracy for detecting cam deformity, 87.2% for ischial spine sign, 76.6% for dysplasia, and 71.6% for all abnormalities combined. The model achieved an Area under the Receiver Operating Curve of 0.89 for ischial spine sign, 0.80 for cam deformity, 0.80 for dysplasia, and 0.81 for all abnormalities combined. Inter-rater agreement among surgeons, assessed using Gwet’s AC1, was substantial for dysplasia (0.83) and all abnormalities (0.88), and moderate for ischial spine sign (0.75) and cam deformity (0.61).

Abstract Periprosthetic fractures of the lesser trochanter may migrate proximally and result in anterior mechanical irritation and impingement with hip flexion refractory to comprehensive conservative management. In such cases, patients may benefit from arthroscopic resection of the displaced lesser trochanteric fragment. We present a minimally invasive, arthroscopic approach with initial access through an air bursogram. This technique can be performed percutaneously, with standard access cannulas, without the need for additional disposable instrumentation or large cannulas. In such a way, reproducible arthroscopic instrumentation can be provided for safe and efficient fragment removal while remaining cognizant of the nearby medial neurovascular bundle. Technique Video video See video under supplementary data.

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

Background: Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming 1 , leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy) 2 . Description: The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to the extent allowed by the soft-tissue attachments. The anterior longitudinal limb may be further weakened in a controlled fashion with use of serial drill holes. The anterior longitudinal limb then undergoes controlled fracture by placement of 2 to 4 broad straight osteotomes in the posterior longitudinal limb. These osteotomes are carefully levered anteriorly in unison with a gentle, steady force. After the ETO is completed, intramedullary prostheses, hardware, and cement are removed; the acetabulum is addressed as needed; and a final femoral stem is implanted, if appropriate. After completion of the osteotomy, the osteotomized fragment must be retracted gently, with care taken to avoid a fracture and maintain vascularity. To this end, debridement of the endosteum of the osteotomized fragment, including any cement removal, should be avoided until the end of the procedure, when the osteotomy is ready to be closed. Our preferred method for closure is to place 1 prophylactic cable 1 cm distal to the osteotomy, 1 to 2 cables along the diaphyseal segment of the osteotomy, and 1 Luque wire above the less trochanter. A Luque wire is our specific choice for the location above the lesser trochanter because it sits in the effective joint space; however, the use of Luque wires distal to the lesser trochanter is also acceptable. A strut allograft or locking plate can be utilized to reinforce the osteotomy in rare cases or to bridge interprosthetic stress risers. Trochanteric implants are typically avoided because of the low rate of clinically relevant trochanteric migration with this closure technique and because of the high rate of symptomatic implants with trochanteric claws or plates. Alternatives: An alternative osteotomy of similar exposure is the transfemoral osteotomy. Additionally, a variety of non-extended trochanteric osteotomies, such as trochanteric slide osteotomies, offer more limited exposure. Rationale: Femoral surgical exposure for revision THA can be aided by performing transfemoral osteotomies, but these provide less precise control of the separate proximal femoral osteotomized segment(s), and healing and fixation can be less reliable. Less invasive osteotomies such as non-extended trochanteric osteotomies typically do not provide adequate exposure in challenging cases for which ETO is being considered. Expected Outcomes: ETOs have high union rates, and notable trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. Radiographic and clinical union is achieved in 98% of patients. The mean proximal trochanteric osteotomy fragment migration prior to union is 3 mm. ETO fragment migration of >1 cm occurs in just 7% of hips. Postoperative greater trochanter fractures occur in 9% of hips. The 10-year survivorship free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason is 97%, 91%, and 82%, respectively 3 . Important Tips: Attention should be paid to patient anatomy, deformity, surgical approach, and implant type when choosing to perform a laterally based Paprosky or anteriorly based Wagner ETO. Appropriate length of the posterior longitudinal limb of the ETO is approximately 12 to 16 cm distally from the tip of the greater trochanter. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. A high-speed pencil-tip burr should be utilized to complete the corners of the osteotomy in a rounded configuration in order to avoid stress risers. The anterior longitudinal limb is completed by controlled fracture of the remaining intervening segment in order to maintain vastus lateralis attachments and vascular supply to the osteotomy fragment. The ETO is closed with use of cerclage cables and/or double-stranded Luque wires, typically utilizing a total of 3 to 4 in order to obtain secure fixation without compromising local biology. Acronyms and Abbreviations: MFT = modular fluted tapered

Aims The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation. Methods Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded. Results Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report “much better” joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all). Conclusion The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty. Cite this article: Bone Joint J 2023;105-B(5):526–533.

Background: Establishing imaging registries for large patient cohorts is challenging because manual labeling is tedious and relying solely on DICOM (digital imaging and communications in medicine) metadata can result in errors. We endeavored to establish an automated hip and pelvic radiography registry of total hip arthroplasty (THA) patients by utilizing deep-learning pipelines. The aims of the study were (1) to utilize these automated pipelines to identify all pelvic and hip radiographs with appropriate annotation of laterality and presence or absence of implants, and (2) to automatically measure acetabular component inclination and version for THA images. Methods: We retrospectively retrieved 846,988 hip and pelvic radiography DICOM files from 20,378 patients who underwent primary or revision THA performed at our institution from 2000 to 2020. Metadata for the files were screened followed by extraction of imaging data. Two deep-learning algorithms (an EfficientNetB3 classifier and a YOLOv5 object detector) were developed to automatically determine the radiographic appearance of all files. Additional deep-learning algorithms were utilized to automatically measure the acetabular angles on anteroposterior pelvic and lateral hip radiographs. Algorithm performance was compared with that of human annotators on a random test sample of 5,000 radiographs. Results: Deep-learning algorithms enabled appropriate exclusion of 209,332 DICOM files (24.7%) as misclassified non-hip/pelvic radiographs or having corrupted pixel data. The final registry was automatically curated and annotated in <8 hours and included 168,551 anteroposterior pelvic, 176,890 anteroposterior hip, 174,637 lateral hip, and 117,578 oblique hip radiographs. The algorithms achieved 99.9% accuracy, 99.6% precision, 99.5% recall, and a 99.6% F1 score in determining the radiograph appearance. Conclusions: We developed a highly accurate series of deep-learning algorithms to rapidly curate and annotate THA patient radiographs. This efficient pipeline can be utilized by other institutions or registries to construct radiography databases for patient care, longitudinal surveillance, and large-scale research. The stepwise approach for establishing a radiography registry can further be utilized as a workflow guide for other anatomic areas. Level of Evidence: Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Many risk factors have been described for dislocation following total hip arthroplasty (THA), yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to develop a high-dimensional, patient-specific risk-stratification nomogram that allows dynamic risk modification based on operative decisions. Methods: In this study, 29,349 THAs, including 21,978 primary and 7371 revision cases, performed between 1998 and 2018 were evaluated. During a mean 6-year follow-up, 1521 THAs were followed by a dislocation. Patients were characterized, through individual-chart review, according to non-modifiable factors (demographics, indication for THA, spine disease, prior spine surgery, and neurologic disease) and modifiable operative decisions (operative approach, femoral head diameter, and type of acetabular liner [standard, elevated, constrained, or dual-mobility]). Multivariable regression models and nomograms were developed with dislocation as a binary outcome at 1 year and 5 years postoperatively. Results: Dislocation risk, based on patient-specific comorbidities and operative decisions, was wide-ranging—from 0.3% to 13% at 1 year and from 0.4% to 19% at 5 years after primary THA, and from 2% to 32% at 1 year and from 3% to 42% at 5 years after revision THA. In the primary-THA group, the direct anterior approach (hazard ratio [HR] = 0.27) and lateral approach (HR = 0.58) decreased the dislocation risk compared with the posterior approach. After adjusting for the approach in that group, the combination of a ≥36-mm-diameter femoral head and an elevated liner yielded the largest decrease in dislocation risk (HR = 0.28), followed by dual-mobility constructs (HR = 0.48). In the patients who underwent revision THA, the adjusted risk of dislocation was most markedly decreased by the use of a dual-mobility construct (HR = 0.40), followed by a ≥36-mm femoral head and an elevated liner (HR = 0.88). The adjusted risk of dislocation after revision THA was decreased by acetabular revision (HR = 0.58), irrespective of whether other components were revised. Conclusions: Our patient-specific dislocation risk calculator, which was strengthened by our use of a robust multivariable model that accounted for comorbidities associated with instability, demonstrated wide-ranging patient-specific risks based on comorbidity profiles. The resultant nomograms can be used as a screening tool to identify patients at high risk for dislocation following THA and to individualize operative decisions for evidence-based risk mitigation. Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Dislocation is the most common reason for early revision following total hip arthroplasty (THA). More than 40 years ago, Lewinnek et al. proposed an acetabular “safe zone” to avoid dislocation. While novel at the time, their study was substantially limited according to modern standards. The purpose of this study was to determine optimal acetabular cup positioning during THA as well as the effect of surgical approach on the topography of the acetabular safe zone and the hazard of dislocation. Methods: Primary THAs that had been performed at a single institution from 2000 to 2017 were reviewed. Acetabular inclination and anteversion were measured using an artificial intelligence neural network; they were validated with performance testing and comparison with blinded grading by 2 orthopaedic surgeons. Patient demographics and dislocation were noted during follow-up. Multivariable Cox proportional-hazards regression, including multidimensional analysis, was performed to define the 3D topography of the acetabular safe zone and its association with surgical approach. Results: We followed 9,907 THAs in 8,081 patients (4,166 women and 3,915 men; 64 ± 13 years of age) for a mean of 5 ± 3 years (range: 2 to 16); 316 hips (3%) sustained a dislocation during follow-up. The mean acetabular inclination was 44° ± 7° and the mean anteversion was 32° ± 9°. Patients who did not sustain a dislocation had a mean anteversion of 32° ± 9° (median, 32°), with the historic ideal anteversion of 15° observed to be only in the third percentile among non-dislocating THAs (p < 0.001). Multivariable modeling demonstrated the lowest dislocation hazards at an inclination of 37° and an anteversion of 27°, with an ideal modern safe zone of 27° to 47° of inclination and 18° to 38° of anteversion. Three-dimensional analysis demonstrated a similar safe-zone location but significantly different safe-zone topography among surgical approaches (p = 0.03) and sexes (p = 0.02). Conclusions: Optimal acetabular positioning differs significantly from historic values, with increased anteversion providing decreased dislocation risk. Additionally, surgical approach and patient sex demonstrated clear effects on 3D safe-zone topography. Further study is needed to characterize the 3D interaction between acetabular positioning and spinopelvic as well as femoral-sided parameters. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.