Michael P. Bolognesi

Introduction: Femoral neck fractures (FNFs) are a common source of morbidity and mortality in older adults, often leading to loss of independence and functional decline. Arthroplasty is the gold standard for displaced FNFs, yet the choice between hemiarthroplasty and total hip arthroplasty (THA) remains debated and case specific. We sought to evaluate training bias in treatment selection as well as evaluation of patient outcomes for arthroplasty (AR) surgeons vs non-AR surgeons. We hypothesized that AR surgeons would perform more THA and have improved patient outcomes when treating FNFs. Methods: Patients aged ≥50 years with FNFs treated with hemiarthroplasty or THA between January 2014 and May 2025 were retrospectively identified. Demographics, comorbidities, OR time, and complications were compared based on practice type (AR vs non-AR). A sub-analysis of 30 FNF cases performed by non-AR surgeons were blinded to the treatment, and AR surgeons were surveyed for hemiarthroplasty vs THA based on radiographic data and clinical presentation to evaluate treatment differences between groups. Results: 626 patients were evaluated, including 476 with hemiarthroplasty and 150 with THA. AR-trained surgeons were over 4x more likely to perform THA for FNF compared with non–AR-trained surgeons (65.7% vs 15.3%; p<0.001). For THA, operative time was significantly shorter among AR-trained surgeons (115.3 ± 31.4 vs 135.2 ± 36.4 minutes; p=0.001). 1-year mortality, readmissions, revisions, and infections were higher in Non-AR but did not reach statistical significance. In sub-analysis survey, AR-trained surgeons selected THA in 65% of cases originally treated with hemiarthroplasty by non–AR-trained surgeons (p=0.023). Conclusions: The practice of AR influenced treatment choice for FNF as well as OR time. Management of these patients may warrant larger review prior to intervention or call assignments generated for surgeons more comfortable with THA procedures. Further study of patient outcomes in the setting of treatment bias is required. Keywords: adult reconstruction, arthroplasty, femoral neck fractures, hemiarthroplasty, total hip arthroplasty

Introduction: High-impact chronic pain (HICP) is associated with impaired function, diminished quality of life, and greater healthcare utilization. Although total joint arthroplasty (TJA) is effective for osteoarthritis, up to 20% of patients report persistent pain and limitations. Objective: To examine transitions in HICP status and identify predictors of postoperative HICP following TJA. Methods: This was a retrospective longitudinal cohort study of 6631 patients who underwent total knee (46.6%), hip (31.2%), or shoulder (22.2%) arthroplasty at a large US academic medical center between January 2018 and August 2024. Transitions in HICP status were described, and multivariable logistic regression was used to evaluate predictors of postoperative HICP. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). Model performance was assessed using classification accuracy, receiver operating characteristic analysis, and the area under the curve. Results: Preoperatively, 45.3% of patients reported HICP, which declined to 15.2% after surgery. However, 4.8% developed new-onset HICP, yielding an overall postoperative prevalence of 20.0%. Preoperative HICP (OR = 2.50, 95% CI: 2.10–2.94), lower physical function (OR = 0.95, 95% CI: 0.93–0.96), higher pain intensity (OR = 1.07, 95% CI: 1.04–1.10), and postoperative opioid exposure (OR = 1.83, 95% CI: 1.59–2.11) were the strongest predictors. Additional factors included younger age, sex, alcohol use, revision surgery, and comorbidity burden. Conclusion: Although TJA substantially reduces HICP prevalence, 1 in 5 patients continues to experience significant postoperative pain. Early identification of at-risk individuals and the integration of targeted perioperative interventions are critical to optimize recovery and long-term outcomes.

Introduction: Conversion to total hip arthroplasty (THA) from prior short intramedullary nail (IMN) is an increasingly common procedure. Currently, there are no studies investigating if distal interlock screws serve as stress risers contributing to perioperative fractures, or whether primary stems can be used in previously reamed and fractured femurs. We hypothesized that conversion would be successful regardless of stem design. Methods: Nineteen patients who underwent short IMN to THA conversion were retrospectively identified from 2013 to 2022, with a mean 13 months between the procedures. Patient demographics, as well as intra- and postoperative variables, including stem design, length of stay, fractures, unplanned readmissions, and revisions, were collected. Mean follow-up was 13 months. Results: A diaphyseal-engaging revision stem was used in 13 cases, with metaphyseal press-fit stems and cemented stems each used in 3 cases. Two patients (one diaphyseal stem, one cemented stem) sustained intraoperative greater trochanteric fractures. No postoperative fractures were found. Four emergency department visits (21%) and one unplanned readmission (5%) were reported within 30 days, with 1 emergency department visit (5%) and two readmissions (11%) within 90 days. Stratified by stem type, we observed no notable difference in length of stay or procedure length. Discussion: This is the first study to investigate conversion to THA from short IMN. Overall, there were two intraoperative fractures, but no distal fractures or revisions. Although the distal interlock screw was commonly bypassed with a revision-type diaphyseal stem, this was not universal. Further research is needed to determine if primary arthroplasty stem designs can be used in this setting. Level of Evidence: Level III Treatment Study.

Aims: This study evaluated joint-specific and generic patient-reported outcome measures (PROMs) after total hip arthroplasty (THA) and total ankle arthroplasty (TAA) in matched cohorts, while evaluating implant survivorship and 90-day hospital use.Methods: Primary THA and TAA patients from 1 January 2015 to 1 January 2023 with minimum one-year follow-up were retrospectively reviewed. After applying exclusion criteria, 2,092 THAs and 478 TAAs were analyzed. Demographics, pre- and postoperative PROMs, revision surgeries, emergency department visits, and readmissions were collected. THA and TAA patients were then propensity score matched at a 2:1 ratio for age, sex, race, BMI, American Society of Anesthesiologists classification, and comorbidities, resulting in a final cohort of 844 THAs and 455 TAAs for comparison.Results: Median preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores between THA and TAA were calculated (66.0 (IQR 62.0 to 70.0) vs 65.0 (IQR 62.0 to 70.0); p = 0.276), and both showed improvement at six weeks. However, THA patients exhibited lower median PROMIS PI scores at one year (53.0 vs 54.0; p = 0.009), as well as a greater median decrease in PROMIS PI from preoperative to one year (-13.0 (IQR -20.0 to -8.0) vs -12.0 (IQR -18.0 to -7.0); p = 0.023). Median preoperative PROMIS physical function (PF) was worse in THA patients (36.0 (IQR 32.0 to 40.0) vs 37.0 (IQR 33.0 to 40.0); p = 0.031), but showed greater median improvement compared to TAA patients at both six weeks (7.0 (IQR 3.0 to 12.0) vs 3.0 (IQR -2.0 to 9.0); p < 0.001) and one year (11.0 (IQR 6.0 to 17.0) vs 8.0 (IQR 4.5 to 13.0); p < 0.001). Preoperative PROMIS depression scores were similar and improved similarly in both groups. Joint-specific PROMs improved in both cohorts.Conclusion: Patients undergoing THA or TAA experienced improvements in joint-specific PROMs postoperatively which translated to improved generic PROMs across both joints. Generic PROMs can be a useful tool to compare outcomes in THA and TAA. Results suggest that higher functional scores may be achieved sooner in THA.Cite this article: Bone Jt Open 2025;6(5 Supple A):1–13.

Purpose Studies demonstrate similar long-term Total Knee Arthroplasty (TKA) outcomes in patients with significant versus minimal preoperative coronal plane deformity. Limited short-term outcomes data, which determine costs of care, exist. Methods We retrospectively explored the impact of preoperative coronal plane deformity on operative time, length of stay (LOS), and discharge to skilled nursing facility (SNF) in TKA. A total of 3,964 patients undergoing unilateral primary TKA at our institution from 2014 to 2019 were included (1,158 > 10˚ deformity: mean age 67.2 years, 47% male; 2,806 < 10˚ deformity: mean age 67 years, 37.4% male). The degree of coronal plane deformity (mechanical axis deviation on preoperative radiographs) was recorded. Patients with no knee radiographs ≤ 3 years preoperatively were excluded. Statistical analysis included Chi-Square tests, Student’s t-tests, Mann-Whitney U tests, and uni- and multivariable linear and logistic regression analyses. Results The > 10˚ deformity cohort had a longer time from procedure start to finish (113.56 vs. 110.68 min; p = 0.020), greater deviation from surgeon mean operative time (+ 6.19 vs. + 0.69 min; p < 0.001), and higher proportion of cases requiring > 15 (26.8% vs. 22%;p = 0.001) and > 30 (12.3% vs. 7.8%;p < 0.001) additional minutes over their scheduled times. LOS was similar between cohorts (median 2 days, IQR 1–3). The deformity cohort more likely discharged to SNF (19.9% vs. 15.8%;p = 0.002). For every 1˚ increase in coronal plane deformity, operative time increased by 0.566 min (p = 0.000). The odds of SNF discharge increased with increasing coronal plane deformity (OR 1.029 [1.009,1.050]; p = 0.004). Conclusion Greater preoperative coronal deformity is associated with increased operative time and odds of discharge to SNF in TKA.

Patrick Kelly, MD, Caitlin Grant, BS, Niall Cochrane, MD, Jonathan Florance, MD, Michael Bolognesi, MD, Sean Ryan, MD. Hip Pelvis 2024;36:218-22. https://doi.org/10.5371/hp.2024.36.3.218

Aims: This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection.Methods: A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years’ clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery.Results: The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively.Conclusion: Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.Cite this article: Bone Joint J 2024;106-B(6):555–564.

Case: A 32-year-old woman with a history of hip fusion presented with significant lower back, hip, and knee pain as well as severely limited hip mobility and function. Single-stage fusion takedown and conversion to total hip arthroplasty (THA) was performed using augmented reality navigation. At 1 year, the patient was pain free with improved function. This study is the first to report the technique and outcomes of surgical fusion conversion to THA, using mixed reality navigation. Conclusion: Mixed reality navigation in complex conversion THA can be useful for identifying the patient's true acetabulum and for patient-specific acetabular component placement to maximize outcomes.

As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40–49 years), middle (50–79 years), and elderly (80–89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays (p < 0.001) but longer operative times (p < 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia (p < 0.001), acute renal failure (p < 0.001), stroke (p < 0.001), cardiac arrest (p < 0.001), and transfusions (p < 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% (p < 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.