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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 93 - 93
19 Aug 2024
Schaffler BC Robin JX Katzman JL Manjunath A Davidovitch R Rozell JC Schwarzkopf R
Full Access

The purpose of this study was to assess the variability in implant position between sides in patients who underwent staged, bilateral THA and whether variation from one side to the other affected patient-reported outcomes.

A retrospective review was conducted on 207 patients who underwent staged, bilateral THA by the same surgeon from 2017–2022. Leg length, acetabular height, cup version, and coronal and sagittal stem angles were assessed radiographically and compared to the contralateral THA. Surgical approach and technology utilization were further assessed for their impact on variability. Linear regression was used to model the relationship between side-to-side variability and patient-reported outcome measures (PROMS).

Between sides, mean radiographic leg length varied by 4.6mm (0.0–21.2), acetabular height varied by 3.3mm (0.0–13.7), anteversion varied by 8.2° (0.0 to 28.7), coronal stem alignment varied by 1.1° (0.0 to 6.9), and sagittal angulation varied by 2.3° (0.0 to 10.5). The anterior approach resulted in more variability in stem angle position in both the coronal (1.3° vs. 1.0°, p=0.036) and sagittal planes (2.8° vs. 2.0° p=0.012) compared to the posterior approach. The posterior approach generally led to more anteversion than the anterior approach. Use of robotics or navigation for acetabular positioning did not increase side-to-side variability in cup-related position or leg length. Despite considerable side-to-side variability, Hip dysfunction and osteoarthritis outcome scores (HOOS JR) were not affected by higher levels of position inconsistency.

Staged, bilateral THA results in considerable variability in component position between sides. The anterior approach leads to more side-to-side variability in sagittal stem angle and cup anteversion than the posterior approach. Navigation and robotics do not improve the consistency of component position in bilateral THA. Variation in implant position was not associated with differences in PROMs, suggesting that despite variability, patients can tolerate these differences between sides.


Bone & Joint Open
Vol. 5, Issue 3 | Pages 174 - 183
6 Mar 2024
Omran K Waren D Schwarzkopf R

Aims

Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories.

Methods

This retrospective cohort study analyzed THA patients at a large academic centre (NYU Langone Orthopedic Hospital, New York, USA) from January 2018 to January 2023, who completed the Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity questionnaires, collected preoperatively at one-, three-, six-, 12-, and 24-month follow-up times. Growth mixture modelling (GMM) was used to model the trajectories. Optimal model fit was determined by Bayesian information criterion (BIC), Vuong-Lo-Mendell-Rubin likelihood ratio test (VLMR-LRT), posterior probabilities, and entropy values. Association between trajectory groups and patient characteristics were measured by multinomial logistic regression using the three-step approach.


Bone & Joint Open
Vol. 4, Issue 8 | Pages 551 - 558
1 Aug 2023
Thomas J Shichman I Ohanisian L Stoops TK Lawrence KW Ashkenazi I Watson DT Schwarzkopf R

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Methods

A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_12 | Pages 77 - 77
23 Jun 2023
Thomas J Ashkenazi I Lawrence KW Rozell JC Schwarzkopf R
Full Access

Patients with a high comorbidity burden (high-risk) can achieve similar improvements in quality of life compared to low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences THA outcomes in high-risk patients has not been investigated. This study aimed to compare complication rates and implant survivorship in high-risk patients operated on by high volume (HV) and non-HV THA surgeons.

Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologist Classification of 3 or 4 undergoing primary, elective THA between 2013 and 2021 were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Ninety day readmissions and revisions were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.

Years of experience were comparable between Non-HV and HV surgeons (p=0.733). The HV group had significantly shorter surgical times (p<0.001), and shorter length of stay (p=0.009) compared to the Non-HV group. The HV group also had significantly fewer 90-day readmissions (p=0.030), all-cause revisions (p=0.023) and septic revisions (p=0.020) compared to the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p=0.023) and septic revision (p=0.020) compared to the non-HV group.

High-risk THA patients have fewer 90-day readmissions, all-cause revisions, septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a high comorbidity burden may benefit from referral to high-volume surgeons to reduce procedural risk and improve postoperative outcomes.


Bone & Joint Open
Vol. 3, Issue 6 | Pages 475 - 484
13 Jun 2022
Jang SJ Vigdorchik JM Windsor EW Schwarzkopf R Mayman DJ Sculco PK

Aims

Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error.

Methods

A total of 356 patients undergoing primary THA were prospectively enrolled from November 2016 to March 2018. Clinically relevant error using the CAS system was defined as a difference of > 5° between CAS and 3D radiological reconstruction measurements for acetabular component inclination and anteversion. Univariate and multiple logistic regression analyses were conducted to determine whether hypermobile (Δsacral slope(SS)stand-sit > 30°), or stiff (SSstand-sit < 10°) spinopelvic mobility contributed to increased error rates.


Bone & Joint Open
Vol. 3, Issue 4 | Pages 307 - 313
7 Apr 2022
Singh V Bieganowski T Huang S Karia R Davidovitch RI Schwarzkopf R

Aims

The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA.

Methods

We retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value.


Bone & Joint Research
Vol. 10, Issue 12 | Pages 780 - 789
1 Dec 2021
Eslam Pour A Lazennec JY Patel KP Anjaria MP Beaulé PE Schwarzkopf R

Aims

In computer simulations, the shape of the range of motion (ROM) of a stem with a cylindrical neck design will be a perfect cone. However, many modern stems have rectangular/oval-shaped necks. We hypothesized that the rectangular/oval stem neck will affect the shape of the ROM and the prosthetic impingement.

Methods

Total hip arthroplasty (THA) motion while standing and sitting was simulated using a MATLAB model (one stem with a cylindrical neck and one stem with a rectangular neck). The primary predictor was the geometry of the neck (cylindrical vs rectangular) and the main outcome was the shape of ROM based on the prosthetic impingement between the neck and the liner. The secondary outcome was the difference in the ROM provided by each neck geometry and the effect of the pelvic tilt on this ROM. Multiple regression was used to analyze the data.


Bone & Joint Open
Vol. 2, Issue 7 | Pages 535 - 539
15 Jul 2021
Zak SG Lygrisse K Tang A Meftah M Long WJ Schwarzkopf R

Aims

As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80.

Methods

A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_10 | Pages 58 - 58
1 Oct 2020
Tang A Lygrisse K Zak S Waren D Hutzler L Schwarzkopf R Macaulay WB
Full Access

Introduction

Venous thromboembolism (VTE), defined as either pulmonary embolism (PE) or deep venous thrombosis (DVT), is a rare, but serious complication following total hip arthroplasty (THA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81mg aspirin (ASA) twice a day (BID) and portable IPCDs were prescribed to THA patients at standard risk for VTE. The aim of this study is to determine if discontinuing the use of portable outpatient IPCDs is safe and does not increase the rate of VTE in patients undergoing THA.

Methods

A retrospective review of 1,825 consecutive THA cases was conducted identifying patients with a VTE 90-days postoperatively. Patients were divided into two separate consecutive cohorts. Cohort one consisted of THA patients who received outpatient IPCDs for a period of 14 days (control). Cohort two consisted of THA patients without outpatient IPCDs (experimental). Patients were non-randomized to 81mg ASA BID for 28 days for VTE chemoprophylaxis. An interim power analysis was performed to determine the proper sample size.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_10 | Pages 35 - 35
1 Oct 2020
Roof MA Yeroushalmi D Aggarwal VK Meftah M Schwarzkopf R
Full Access

Introduction

Previous reports have investigated the correlation between time to revision hip arthroplasty (rTHA) and reason for revision, but little is known regarding the impact of timing on outcomes following rTHA. The purpose of this study is to evaluate the effect of time to rTHA on both indication and outcomes of rTHA.

Methods

This retrospective observational study reviewed patients who underwent unilateral, aseptic rTHA at an academic orthopedic specialty hospital between January 2016 and April 2019 with at least 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary THA (pTHA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared between the groups. Post-hoc power analysis was performed (1-β=0.991).


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_10 | Pages 39 - 39
1 Oct 2020
Lygrisse K Tang A Hutzler L Schwarzkopf R Bosco J Davidovitch R Slover J
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Background

The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings.

Methods

Using our institution's data, we calculated the mean cost per episode of care. We calculated the percent reduction in target price and percent savings or losses per case for the CJR and Bundle Payment Care Initiative (BPCI) for each Medicare Severity Diagnosis Related Group (MS-DRG) using mean cost per episode and CJR and BPCI target prices. We compared the target prices, annual savings, and losses per episode of care for both CJR and BPCI. All CJR savings, projected and actual, were computed by comparing CJR savings to that of 2018 BPCI savings.


The Bone & Joint Journal
Vol. 102-B, Issue 7 Supple B | Pages 78 - 84
1 Jul 2020
Roof MA Feng JE Anoushiravani AA Schoof LH Friedlander S Lajam CM Vigdorchik J Slover JD Schwarzkopf R

Aims

Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA.

Methods

The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days.


The Bone & Joint Journal
Vol. 102-B, Issue 2 | Pages 191 - 197
1 Feb 2020
Gabor JA Padilla JA Feng JE Schnaser E Lutes WB Park KJ Incavo S Vigdorchik J Schwarzkopf R

Aims

Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications.

Methods

A multi-institutional retrospective study of all consecutive total hip arthroplasty (THA) and revision total hip arthroplasty (rTHA) patients who received the monolithic TFTS was conducted. Surgery was performed by eight fellowship-trained arthroplasty surgeons at four institutions. A total of 157 hips in 153 patients at a mean follow-up of 11.6 months (SD7.8) were included. Mean patient age at the time of surgery was 67.4 years (SD 13.3) and mean body mass index (BMI) was 28.9 kg/m2 (SD 6.5). Outcomes included intraoperative complications, one-year all-cause re-revisions, and subsidence at postoperative time intervals (two weeks, six weeks, six months, nine months, and one year).


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 17 - 17
1 Oct 2019
Roof MA Adnan M Feng JE Anoushiravani AA Schoof LH Friedlander S Vigdorchik J Slover JD Schwarzkopf R
Full Access

Introduction

Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have focused on payer type and have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry plays a role in quality outcomes and discharge disposition following THA.

Methods

The electronic medical record at our institution was retrospectively reviewed for all primary, elective, unilateral THA between January 2016 and June 2018. THA recipients were categorized as either Hospital Ambulatory Clinic Centers (HACC) with Medicaid as the primary payer or private office patients with a non-Medicaid primary payer based on a previous visit to our institution's HACC within the 6-months prior to surgery. Only patients who had been operated on by a surgeon with at least 10 HACC and 10 private office patients were included.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 73 - 73
1 Oct 2019
Sershon RA Fillingham Y Abdel MP Malkani AL Schwarzkopf R Padgett DE Vail TP Nam D Nahhas CR Culvern C Valle CJD
Full Access

Background

The purpose of this multicenter, randomized clinical trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss for revision total hip arthroplasty (THA).

Methods

Six centers prospectively randomized 155 revisions to one of four regimens: 1g of intravenous (IV) TXA prior to incision, a double dose regimen of 1g IV TXA prior to incision and 1g IV TXA during wound closure, a combination of 1g IV TXA prior to incision and 1g intraoperative topical TXA, or three doses of 1950mg oral TXA administered 2 hours preoperatively, 6 hours postoperatively, and on the morning of postoperative day one. Randomization was based upon revision subgroups to ensure equivalent group distribution, including: femur only, acetabulum only, both component, explant/spacer, and second stage reimplantation. Patients undergoing an isolated modular exchange were excluded. An a priori power analysis (alpha = 0.05; beta = 0.80) determined 40 patients per group were required to identify a 1g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher's exact tests, and two one-sided t-tests for equivalence.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 46 - 46
1 Oct 2019
Iorio R Feder O Schwarzkopf R Einhorn TA
Full Access

Introduction

Without intervention 80% of hips with osteonecrosis (ON) will progress. Core decompression has shown favorable results (60–80% survivorship) in early stage ON, and recently, bone marrow aspirate concentration (BMAC) injection into the decompressed femoral head has been proposed to stimulate healing of the necrotic lesion and improve outcomes and survivorship.

Methods

We retrospectively reviewed the clinical and radiographic outcomes of 42 hips in 26 patients who underwent core decompression with BMAC for ON with a minimum of 1 year follow up. We evaluated pre-op visual analog pain scores (VAS), Steinberg class based on radiographs, as well as Kerboul angle as measured on MRI. Clinical outcomes were reported as change in VAS at final follow up, advancement in Steinberg classification based on radiographs at final follow up, or decision to proceed with THA.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 69 - 69
1 Oct 2019
Macaulay W Feng JE Mahure S Waren D James S Long WJ Schwarzkopf R Davidovitch R
Full Access

Introduction

Total hip arthroplasty (THA) candidates have received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid administration documentation and are now implementing opioid-sparing protocols (OSP) into THA integrated care pathways (ICP). Here we evaluate the effectiveness of a novel OSP in primary THA at out institution.

Methods

Between January 2019 to April 2019, all patients undergoing primary THA were placed under a novel OSP (Table 1). Patient demographics, inpatient/surgical factors, and inpatient opiate administration events were collected. A historical 2:1 cohort was subsequently derived from patients undergoing THA between January 2018 to August 2018.

Opiate administration events collected from our EDW were converted into Morphine Milligram Equivalences (MMEs) and transformed into average MME's per patient per 24-hour interval. Nursing documented visual analog scale (VAS) pain scores were also queried and averaged per patient per 12-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) Short Forms tool was utilized.


The Bone & Joint Journal
Vol. 101-B, Issue 7 | Pages 817 - 823
1 Jul 2019
Vigdorchik J Eftekhary N Elbuluk A Abdel MP Buckland AJ Schwarzkopf RS Jerabek SA Mayman DJ

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

Patients and Methods

Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA.


The Bone & Joint Journal
Vol. 101-B, Issue 7 | Pages 808 - 816
1 Jul 2019
Eftekhary N Shimmin A Lazennec JY Buckland A Schwarzkopf R Dorr LD Mayman D Padgett D Vigdorchik J

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.


The Bone & Joint Journal
Vol. 101-B, Issue 6_Supple_B | Pages 97 - 103
1 Jun 2019
Novikov D Mercuri JJ Schwarzkopf R Long WJ Bosco III JA Vigdorchik JM

Aims

Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure.

Patients and Methods

A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded.