Citations

Background: The direct anterior approach (DAA) is a popular approach for primary total hip arthroplasty (THA). However, the contemporary outcomes for DAA THA need further elucidation. Therefore, we aimed to describe implant survivorship, complications, and clinical outcomes after DAA THA. Methods: From our multi-institutional total joint registry, 3,184 patients who had undergone 3,698 primary DAA THA between 2010 and 2019 were identified. The identified patients had a mean age of 65 years and a mean body mass index (BMI) of 29 kg/m 2 , and 53% of patients were female. The indications for revision and reoperation and the incidence of complications were collected and analyzed. Potential risk factors, including age, sex, BMI, and high-volume compared with low-volume operating surgeons, were examined. Descriptive statistics and Kaplan-Meier survivorship with Cox regression analyses were performed. Results: At 10 years following primary DAA THA, the cohort had 96% (95% confidence interval [CI], 95% to 98%) survivorship free of any revision and 94% (95% CI, 92% to 96%) survivorship free of any reoperation. The leading indications for revision were periprosthetic joint infection (PJI) (n = 24; 5-year cumulative incidence, 0.93% [95% CI, 0.6% to 1.5%]), periprosthetic fracture (n = 20; 5-year cumulative incidence, 0.62% [95% CI, 0.4% to 1.0%]), and aseptic loosening (n = 14; 11 femoral, 3 acetabular; 5-year cumulative incidence, 0.84% [95% CI, 0.5% to 1.5%]). A BMI of ≥40 kg/m 2 was found to be significantly associated with PJI (hazard ratio [HR], 6.4; p < 0.001), reoperation (HR, 3.5; p < 0.001), and nonoperative complications (HR, 2.3; p = 0.018). Survivorship free of recurrent instability was 99.6% (95% CI, 99.4% to 99.8%) at 5 and 10 years, and the cumulative incidence of revision for instability was 0.14% at 5 years. Conclusions: In one of the largest published series to date, survivorship following DAA THA was satisfactory at early to intermediate follow-up. The leading indications for revision were PJI, periprosthetic fracture, and aseptic loosening. Instability after DAA THA was uncommon and infrequently led to revision. As a note of caution, a BMI of ≥40 kg/m 2 was identified as a risk factor for adverse outcome after DAA THA. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Second-generation highly cross-linked polyethylene (HXLPE) has revolutionized total hip arthroplasty. However, the long-term risks and benefits of HXLPE in primary total knee arthroplasty (TKA) remain unknown. This randomized clinical trial evaluated implant survivorship, complications, radiographic results, and clinical outcomes of HXLPE and conventional ultra-high molecular weight polyethylene (UHMWPE) inserts in primary TKAs. Methods: We enrolled 518 patients (518 knees) who underwent primary TKA in 3 centers within 1 tertiary referral network. The mean age was 67 years, the mean body mass index was 32 kg/m 2 , and 58% of the patients were women. All of the patients underwent primary TKA with a cemented posterior-stabilized tibial insert and patellar resurfacing. Randomization proceeded via stratified dynamic allocation. The patients were blinded to their study group allocation: those in the control group (254 knees) underwent TKA with an UHMWPE insert (N2Vac; Stryker); those in the treatment group (264 knees) received an HXLPE insert (X3; Stryker). Kaplan-Meier survivorship, radiographic results, and clinical outcomes were assessed. This trial was registered with ClinicalTrials.gov. The mean follow-up was 11 years. Results: The 10-year overall survivorship free from any revision and from any reoperation was 96% and 94%, respectively. There were no differences in the risk of revision or reoperation between the groups (p > 0.05). There were a total of 19 revisions. Revision indications included periprosthetic joint infection (14 knees), instability (4 knees), and open reduction and internal fixation (ORIF) for a patellar fracture due to osteolysis around a UHMWPE insert (1 knee). There were no revisions due to polyethylene wear, osteolysis, or fracture of the post in the HXLPE group. The radiographic results and clinical outcomes were otherwise similar. Conclusions: Notably, no wear-related failures were identified in the HXLPE group, but there was 1 case of osteolysis in the UHMWPE group. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Abstract Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic premalignant disorder. The current standard of care is not to screen for MGUS, so it is often incidentally diagnosed in the clinic. It is unknown whether the outcomes of screened vs clinically detected MGUS differ. We compared the progression risk between screened vs clinical MGUS cohorts and assessed whether the MGUS detection method affected risk prediction of established clinical factors (score). We included 379 screened MGUS cases from the Olmsted County population-based study and 1384 patients with MGUS diagnosed during routine clinical evaluation at Mayo Clinic. Median follow-up time for the screened vs clinical cohort was 26.6 and 40.1 years, respectively. Accounting for death as a competing risk, the cumulative incidence of progression at 25 years was similar in the screened (11.1% [95% confidence interval [CI], 8.3-14.8]) vs clinical (10.1% [95% CI, 8.6-11.8]) MGUS cohorts, even when stratified by sex, age, or the baseline MGUS risk score. Overall, 0.9 (95% CI, 0.6-1.2) of patients with screened MGUS vs 1.0 (95% CI, 0.9-1.2) of those with clinically detected MGUS experienced disease progression for every 100 person-years of follow-up. MGUS detection method did not modify the association between MGUS risk score and progression risk (pinteraction = 0.217) and did not add to known risk factors for progression (likelihood ratio test; P = .839). Here, we show that progression risk among patients with screened vs clinically detected heavy-chain MGUS was similar. Future studies are needed to assess whether tailored follow-up of patients with screened MGUS affects clinical outcomes.

Context: Epidemiological studies have shown an increased risk of musculoskeletal injury after concussion. The purpose of this study was to determine whether the reverse relationship exists, specifically whether there is an increased risk of concussion after an anterior cruciate ligament (ACL) injury in a population-based cohort. Design: Retrospective cohort. Methods: The Rochester Epidemiology Project was searched between 2000 and 2017 for International Classification of Diseases, 9th and 10th Revision codes relevant to the diagnosis and treatment of concussion and ACL tear. A total of 1294 unique patients with acute, isolated ACL tears and no previous history of concussion were identified. Medical records for cases were reviewed to confirm ACL tear diagnosis and to determine history of concussion after the ACL injury. Cases were matched by age, sex, and Rochester Epidemiology Project availability to patients without an ACL tear (1:3 match), resulting in 3882 controls. Medical records of matched control patients were reviewed to rule out history of ACL injury. The hazard ratio of concussion injury following an ACL injury was determined. Results: Nine patients with an ACL injury suffered concussion up to 3 years after the ACL injury. The rate of concussion was no different between ACL-injured cases (0.7%) compared with matched controls with no ACL injury (1.2%), which corresponded to a hazard ratio of 0.55 (95% confidence interval, 0.3–1.1; P = .10). Conclusions: Based on the current evidence, there does not appear to be a significant association between ACL injury and subsequent concussion, which suggests that a concussion uniquely affects the risk of future subsequent musculoskeletal injury.

Abstract Background New immunoglobulin free light chain (FLC) assays are available. Despite analytical differences, it seems possible to use free light chain ratios (FLCr) generated by different assays and apply similar cut-points for the diagnosis of multiple myeloma. It is still unknown if we can use different assays for risk stratification of patients with monoclonal gammopathy of undetermined significance (MGUS). Methods Patients diagnosed with MGUS (N = 923) had FLC tested using a nephelometric FreeLite (Binding Site) assay on BNII instruments (Siemens) and a Sebia FLC assay (Sebia) on a DS2 ELISA analyzer (Dynex). Patients were followed up for progression to any plasma cell dyscrasia (PCD) for several decades. The Mayo MGUS risk stratification model for progression was assessed with both assays (M-spike &gt;1.5 g/dL; non-IgG isotype and abnormal FLCr), using package insert reference intervals (RI) and a new metric called principal component 2 (PC2). Results There were 94 events of progression to PCD in the cohort during a median of 38 years of follow-up. Freelite and Sebia FLC showed similar hazard ratios in the risk models for elevated FLCr. An alternative clinical decision point lower than the package insert RI was evaluated for the Sebia assay, which improved risk stratification for patients with a low FLCr. The PC2 metric showed similar performance to the FLCr in models, without superior benefit. Conclusions The Sebia ELISA-based FLC assay can be employed in an MGUS risk stratification model with similar performance to the original 2005 risk stratification model using the FreeLite assay.

Background: Modular fluted tapered (MFT) femoral components are frequently utilized in aseptic revision total hip arthroplasties (THAs). However, long-term follow-up has been limited. The purpose of this study was to update our prior series at long-term follow-up, with specific emphasis on implant survivorship, radiographic results, and complications in a large cohort of aseptic revision THAs using MFT stems. Methods: We retrospectively identified 515 aseptic femoral revisions performed with 2 MFT stem designs in the total joint registry of a single tertiary care academic institution from 1999 to 2013. Serial radiographs were reviewed for subsidence of >5 mm. The mean follow-up (and standard deviation) was 10 ± 5 years (range, 2 to 21 years). A competing risk model accounting for death was utilized. Results: The 15-year cumulative incidence of any revision was 12%. There were 57 revisions, 27 of which involved revision of the fluted tapered component (FTC). Dislocation (n = 19), periprosthetic joint infection (n = 15), and aseptic loosening of the FTC (n = 11) were the most common reasons for revision. The 15-year cumulative incidence of any reoperation was 16%. The 15-year cumulative incidences were 6% for any FTC revision and 2% for FTC revision for aseptic loosening. Stem subsidence of >5 mm occurred in 2% of unrevised cases, and all but 1 stem was stable at the most recent follow-up. Conclusions: This large series of MFT stems used in aseptic revision THAs had a 2% incidence of subsequent revision of the FTC for aseptic loosening at 15 years. Dislocation and infection were the most common reasons for any revision. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Patients suffering post operative myocardial infarction (PMI) have higher mortality and morbidity rates than observed with non-PMI subsets. Little is known about the true incidence of PMI and how PMI differs from non-PMI with regard to clinical presentation, management and outcome. Methods: We examined the incidence and outcomes of patients with PMI in 1212 subjects (≥65 years) undergoing hip fracture surgery from 1988 – 2002 using a population-based retrospective cohort study from the Rochester Epidemiology Project in Olmstead County, Minnesota. PMI was defined on the basis of cardiac biomarker and/or electrocardiographic evidence of definitive MI within 7 days post operatively. Results: PMI occurred in 170 (14.0%) patients yet only 36 (21.2 %) patients had one or more clinical symptoms suggesting coronary ischemia. One or more classic symptoms of myocardial infarction were present in 26 (15.3%) including shortness of breath (SOB) in 18 (10.6%), chest/arm pain in 11 (6.5%), nausea/vomiting in 8 (4.7%) and diaphoresis in 1 (0.6%). Delirium was present in 15 (8.8%) patients. Median hospital length of stay was longer (10.0 vs. 8 days, p<0.01) and the in-hospital mortality rate was significantly higher (14.1% vs. 1.6%, p<0.001) among patients who had PMI within 7 days. Conclusion: The clinical presentation of PMI differs from non-PMI in the elderly undergoing hip fracture surgery. Most patients were asymptomatic or had atypical clinical presentations. We observed a significantly higher rate of hospital mortality among those experiencing a PMI. Further studies are necessary to better understand the presentation, optimal management and prevention of PMI. Table 1. Study Population Table 2. Clinical Presentation and Outcomes in Patients with and without Post Operative MI This research has received full or partial funding support from the American Heart Association, National Center.

Abstract Background Patients with Inflammatory Bowel Diseases (IBD) are at higher risk of developing dysplastic lesions and colorectal cancer (CRC). Despite the use of high-definition endoscopes, dysplasia is not always detected at colonoscopy. This study aims to determine the rate of dysplastic lesions detected only at colectomy in IBD patients and to identify the characteristics of patients with undetected dysplasia. Methods We retrospectively identified IBD patients that underwent total or sub-total colectomy at Mayo Clinic, between January 2013 and December 2022. Patients with a confirmed IBD diagnosis, with at least one colonoscopy report prior to surgery available, were included. Data collected was demographics, comorbid conditions, colonoscopy, surgery, and their pathology reports. Concordance between dysplasia found at colonoscopy and dysplasia found at surgery was evaluated, noting dysplasia sites and grade. Patients were then divided into three groups: those with at least one undetected dysplastic lesion at surgery, those with dysplasia detected at colonoscopy and no further lesions at surgery, and those without dysplasia at both. Results Seven hundred-four patients were included: 387 (55%) were male, 450 (64%) had ulcerative colitis, 197 (28%) had Crohn’s disease and 57 (8%) had indeterminate colitis. In 42 patients (6%) dysplasia was undetected at colonoscopy, 136 (19.3%) had dysplasia detected at colonoscopy, and 526 (74.7%) had no dysplasia at both. In the group with dysplasia detected, 40 patients (30%) had dysplasia only at colonoscopy while 96 (70%) had dysplasia at surgery as well. Among those with undetected dysplasia, in 17 (40%) dysplasia was identified only at surgery: 14 (82%) had low grade dysplasia and 3 (18%) had cancer. All cancers were stage 1. Three of these patients (18%) had primary sclerosing cholangitis and 4 (23%) had a family history of cancer. In the other 25 patients (60%), dysplasia was detected at colonoscopy but further dysplastic foci were identified at surgery. In 13 (52%) patients dysplasia was upgraded, in 2 (8%) was downgraded and in 10 (40%) the grade was confirmed. Compared to those with detected dysplasia, these patients more frequently had moderate-severe disease activity, and less frequently a prior history of dysplasia. There was no difference in age at surgery, but those with undetected dysplasia had less years of disease at colectomy. Further results are shown in Table 1. Conclusion The rate of dysplastic lesions found at colectomy and missed at colonoscopy is 6%. Dysplastic lesions tend to be undetected when endoscopic disease activity is more severe and regardless of the use of extensive nontargeted biopsies.

AimsKnowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs.MethodsA retrospective review of our total joint registry identified 94 patients with post-polio syndrome undergoing 116 primary TKAs between January 2000 and December 2019. The mean age was 70 years (33 to 86) with 56% males (n = 65) and a mean BMI of 31 kg/m2 (18 to 49). Rotating hinge TKAs were used in 14 of 63 affected limbs (22%), but not in any of the 53 unaffected limbs. Kaplan-Meier survivorship analyses were completed. The mean follow-up was eight years (2 to 19).ResultsThe ten-year survivorship free from revision was 91% (95% confidence interval (CI) 81 to 100) in affected and 84% (95% CI 68 to 100) in unaffected limbs. There were six revisions in affected limbs: three for periprosthetic femoral fractures and one each for periprosthetic joint infection (PJI), patellar clunk syndrome, and instability. Unaffected limbs were revised in four cases: two for instability and one each for PJI and tibial component loosening. The ten-year survivorship free from any reoperation was 86% (95% CI 75 to 97) and 80% (95% CI 64 to 99) in affected and unaffected limbs, respectively. There were three additional reoperations among affected and two in unaffected limbs. There were 12 nonoperative complications, including four periprosthetic fractures. Arthrofibrosis occurred in five affected (8%) and two unaffected limbs (4%). Postoperative range of motion decreased with 31% achieving less than 90° knee flexion by five years.ConclusionTKAs in post-polio patients are complex cases associated with instability, and one in four require constraint on the affected side. Periprosthetic fracture was the main mode of failure. Arthrofibrosis rates were high and twice as frequent in affected limbs.Cite this article: Bone Joint J 2023;105-B(6):635–640.

AimsNonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs.MethodsOur institutional total joint registry was used to identify 96 nonagenarians who underwent 97 aseptic revisions (78 hips and 19 knees) between 1997 and 2018. The most common indications were aseptic loosening and periprosthetic fracture for both revision THAs and revision TKAs. Mean age at revision was 92 years (90 to 98), mean BMI was 27 kg/m2 (16 to 47), and 67% (n = 65) were female. Mean time between primary and revision was 18 years (SD 9). Kaplan-Meier survival was used for patient mortality, and compared to age- and sex-matched control populations. Reoperation risk was assessed using cumulative incidence with death as a competing risk. Mean follow-up was five years.ResultsMortality rates were 9%, 18%, 26%, and 62% at 90 days, one year, two years, and five years, respectively, but similar to control populations. There were 43 surgical complications and five reoperations, resulting in a cumulative incidence of reoperation of 4% at five years. Medical complications were common, with a cumulative incidence of 65% at 90 days. Revisions for periprosthetic fractures were associated with higher mortality and higher 90-day risk of medical complications compared to revisions for aseptic loosening.ConclusionContemporary revision THAs and TKAs appeared to be relatively safe in selected nonagenarians managed with multidisciplinary teams. Cause of revision affected morbidity and mortality risks. While early medical and surgical complications were frequent, they seldom resulted in reoperation.Cite this article: Bone Joint J 2023;105-B(6):649–656.