Zhongming Chen

Image-based navigation-assisted total hip arthroplasty (THA) has been increasingly adopted to improve component positioning and reduce complications; however, its clinical benefit in patients who have morbid obesity remains unclear. The purpose of this study was to compare (1) surgical complications, (2) thromboembolic events, and (3) reoperation and revision rates between image-based navigation-assisted and manual THA in a matched cohort of patients who have morbid obesity. Using an administrative claims database, we conducted a retrospective matched cohort study of patients who had morbid obesity (BMI ≥ 40) and underwent elective primary THA between 2010 and 2023. Image-based navigation-assisted cases were matched 1:3 to manual THA controls by age, sex, year of surgery, diabetes, hypertension, tobacco use, and alcohol use. After matching, 5,835 patients who had morbid obesity undergoing THA were analyzed (1,473 navigation-assisted; 4,362 manual) with comparable baseline demographics and comorbidities. Outcomes included surgical complications (prosthetic joint infection [PJI], surgical site infection, dislocation, periprosthetic fracture, mechanical loosening, limb length discrepancy [LLD]), thromboembolic events (pulmonary embolism, deep vein thrombosis [DVT]), same-day blood transfusions, and revision surgeries (septic and aseptic) assessed at multiple postoperative timepoints including 30-days, 90-days, one-year, and two-year timepoints. Across all timepoints, image-based navigation-assisted THA was not associated with reduced rates of surgical complications, thromboembolic events, or revisions compared with manual THA (P > 0.05), with the exception of same-day blood transfusions (0.8% versus 1.9%, P = 0.005). PJI, dislocation, mechanical complications, DVT, pulmonary embolism, and septic or aseptic revision rates were statistically similar between cohorts at all time points analyzed (P > 0.05). In a large national cohort of patients who had morbid obesity and underwent primary THA, image-based navigation-assistance did not generally confer measurable clinical advantages over manual techniques outside of same-day blood transfusions. Despite increasing utilization, these findings suggest that routine use of image-based navigation in this high-risk population may not provide added clinical value within two years postoperatively, raising important considerations regarding its cost-effectiveness and role in value-based care.

Purpose Total hip arthroplasty (THA) presents unique technical challenges in patients who have morbid obesity, and benefits of imageless navigation in this population remain unclear. This study compared complications, thromboembolic events, and emergency department utilization between imageless navigation-assisted and manual THA in patients who have morbid obesity. Methods A retrospective cohort study was performed using the PearlDiver database. Patients who have morbid obesity (BMI ≥ 40) undergoing elective primary THA between 2010 and 2021 were identified. Cases performed with robotic assistance or image-based navigation were excluded. Patients were stratified by intraoperative technique into manual and imageless navigation cohorts and matched 1:3 on age, sex, year of procedure, and comorbidities. Surgical complications, thromboembolic events, revision procedures, and emergency department visits were evaluated at multiple postoperative time points and compared using univariable regression. Results After matching, 4,499 patients who have morbid obesity were included, comprising 3,367 manual (74.8%) and 1,132 imageless navigation (25.2%) cases. No significant differences were observed between cohorts in rates of surgical complications, including infection, dislocation, periprosthetic fracture, mechanical loosening, chronic pain, or leg length discrepancy at any evaluated time point (P > 0.05). Thromboembolic events were uncommon and did not differ between groups at 30 or 90 days. Emergency department visits and revision rates were also similar at all time points. Conclusions Among patients who have morbid obesity undergoing primary THA, imageless navigation was not associated with improved outcomes compared with manual techniques, suggesting postoperative risk is driven primarily by obesity-related factors. Surgeons should weigh resource utilization and patient characteristics when selecting operative technique.

Background: Effective postoperative pain management is essential in femoral limb lengthening surgery. Although regional nerve blocks reduce pain and opioid use, their benefit in antegrade femoral intramedullary limb lengthening is unclear. This study compares postoperative pain and opioid consumption in patients receiving general anesthesia (GA) alone versus GA with a preoperative femoral or fascia iliaca nerve block. Methods: A retrospective review included 192 patients who underwent femoral lengthening with intramedullary telescoping nails between January 2012 and October 2023 at a single center. Patients were categorized into Group A (GA alone, n = 131) and Group B (GA plus nerve block, n = 61). Primary outcomes were postoperative mean and maximum pain scores in the first 24 h, total opioid pills prescribed at discharge, and total morphine milligram equivalents (MMEs) used in the Post-Anesthesia Care Unit (PACU). Non-inferiority was defined by a margin of one standard deviation for pain scores and opioid usage. Results: Demographics were similar between groups. Maximum PACU pain scores were 3.8 for Group A and 3.3 for Group B (p > 0.05); mean pain scores were 2.1 and 1.9, respectively (p > 0.05). GA alone was non-inferior for pain control. However, total opioid pills prescribed at discharge were higher in Group A (23.2) than Group B (10) (p < 0.05). PACU MME usage was also higher in Group A (26 vs. 18.4 ± 15 mg, p < 0.05), though non-inferiority criteria were met. Conclusions: GA alone is non-inferior to GA with nerve block for postoperative pain management following antegrade femoral intramedullary limb lengthening. Although patients without a nerve block received more opioids at discharge, their pain control remained similarly effective. Given potential risks and the lack of clear pain reduction benefits, routine nerve block use may not be warranted. Decisions regarding nerve block application should be individualized, considering patient preferences, surgeon recommendations, and anesthesiologist input.

Background: Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year. Methods: A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128). Results: Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications. Conclusions: Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.