Sean Patrick Ryan

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.

Background: Rifampin therapy is indicated for the treatment of staphylococcal periprosthetic joint infection (PJI) in patients who have undergone debridement, antibiotics, and implant retention (DAIR) or one-stage revision as per the Infectious Diseases Society of America (IDSA) guideline. Given the well-established effectiveness of rifampin as adjunctive therapy in staphylococcal PJI, it is crucial to evaluate its utilization in practice and identify factors that contribute to its underuse or incomplete administration, as these deviations may undermine treatment efficacy and patient outcomes. Questions/purposes: Among patients who met clear indications for rifampin use having undergone DAIR or one-stage revision for staphylococcal PJI, (1) what proportion of patients did not receive it? (2) What proportion of patients started it but did not complete the planned course? (3) Where documented in the medical record, what were the common reasons for not using it or prematurely discontinuing it, and in what percentage of the patients’ charts was no reason given? (4) What proportion of patients were taking a medication that put them at risk for a drug-drug interaction (DDI)? Methods: Using an institutional database, patients who underwent DAIR or revision arthroplasty for PJI from January 2013 to April 2023 were identified (n = 935). We defined clear indications for rifampin use as a patient diagnosed with staphylococcal PJI treated via DAIR or one-stage revision, as set forth by the clinical practice guidelines of the IDSA. Based on those indications, we surveyed patients’ electronic medical records (EMRs) and calculated the proportion of patients who did not receive the drug in situations where it would have seemed appropriate that they receive it. We then determined the planned length of antibiotic management and calculated the proportion of patients whose planned courses of rifampin were not completed based on what was documented in each patient’s chart. Next, we performed a review of the EMR and recorded qualitatively the reasons why patients either did not receive rifampin or why the planned course was not completed, as well as the percentage of patients whose medical records did not indicate why the drug was not used or was discontinued before the planned course had been administered. Last, we retrospectively reviewed the medications that the patients were taking at the time of indicated adjunctive rifampin initiation and evaluated whether there were DDIs and the potential severity of those interactions. Results: A total of 9% (87 of 935) of patients who underwent DAIR or revision arthroplasty for PJI met IDSA criteria, suggesting that rifampin use would have been appropriate. Of those meeting IDSA criteria, 49% (43 of 87) started rifampin. Of those who started on rifampin for staphylococcal PJI, 19% (8 of 43) discontinued it before the planned 6-week course was complete as documented in the EMR. Among the patients who did not receive rifampin when it appeared that they ought to have based on IDSA criteria, no reason for this decision was documented in 70% (31 of 44); among those for whom a reason was documented, it was DDI in 8 of 13, concern for hepatotoxicity in 1 of 13, history of a side effect in 1 of 13, and other reasons in 3 of 13. Among the patients whose courses were terminated before the planned course was completed, it was a gastrointestinal issue in 5 of 8, acute kidney injury in 1 of 8, or other reasons in 2 of 8. Conclusion: Only about one-half of patients who met IDSA criteria for adjunctive rifampin therapy for staphylococcal PJI after DAIR or one-stage revision at a large tertiary referral academic center were started on treatment. For most patients who did not receive rifampin, there is no documentation for why not. Given the evidence of superior outcomes for patients treated with adjunctive rifampin, it is imperative that all patients meeting criteria be started on the medication unless there is a clear contraindication, which should be documented. Future studies should further evaluate the clinical benefit of rifampin when treating staphylococcal PJI and which DDIs would be considered true contraindications of treatment. This could be achieved with a prospective study that evaluates successful long-term infection-free survival after treatment with adjunctive rifampin while accounting for and stratifying the potential clinical risk of these DDIs. Level of Evidence: Level IV, therapeutic study.

Aims: Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee.Methods: Patients with C. acnes PJI between January 2005 and December 2018 were retrospectively reviewed utilizing the institutional total joint registry. Patients with monomicrobial PJI and two or more positive cultures were considered to have true C. acnes PJI. Patients with polymicrobial infection or with only one positive culture were excluded. This resulted in 35 PJIs (21 hips and 14 knees); the patients’ mean age was 63 years (35 to 84) and 15 (43%) were female. Mean follow-up was five years (1 to 14).Results: The median time to positive culture was five days (IQR 5 to 6) and median synovial fluid cell count was 22,583 cells (IQR 15,200 to 53,231). The median ESR was 25 mm/hr (IQR 7 to 37), and CRP was 15 mg/l (IQR 3 to 29). Of the 35 PJIs, 18 (51%) were treated with chronic antibiotic suppression without surgical intervention, and the remainder were treated with two-stage exchange arthroplasty. The two-year survival free of any revision was 94%. Four patients failed treatment due to symptomatic infection, with three treated with two-stage exchange and one treated with irrigation and debridement with modular component exchange for a survival rate of 89% and 83% at two and five years, respectively.Conclusion: Laboratory evidence of C. acnes PJI in this cohort was typical compared to more conventional organisms. Cultures grew more quickly than previously thought in patients with C. acnes PJI. Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up.Cite this article: Bone Joint J 2024;106-B(12):1426–1430.

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

BACKGROUND Tobacco use is a well-documented modifiable risk factor for perioperative complications. AIM To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty (TJA) procedure. METHODS A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery. Eligible patients were contacted via phone survey to understand their tobacco use pattern, and patient reported outcomes. A total of 37 TJA patients participated. RESULTS Our cohort was on average 61-years-old, 60% (n = 22) women, with an average body mass index of 30 kg/m2. The average follow-up time was 2.9 ± 1.9 years. A total of 73.0% (n = 27) of patients endorsed complete abstinence from tobacco use prior to surgery. Various cessation methods were used perioperatively including prescription therapy (13.5%), over the counter nicotine replacement (18.9%), cessation programs (5.4%). At final follow up, 43.2% (n = 16) of prior tobacco smokers reported complete abstinence. Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System (PROMIS)-10 mental health scores (49 vs 58; P = 0.01), and hip dysfunction and osteoarthritis outcome score for joint replacement (HOOS. JR) scores (63 vs 82; P = 0.02). No patients in this cohort had a prosthetic joint infection or required revision surgery. CONCLUSION We report a tobacco cessation rate of 43.2% in patients undergoing elective TJA nearly 3 years postoperatively. Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS. JR scores. The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.

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.

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days. Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days. Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection ( P < 0.01), hospital readmission ( P < 0.01), and revision surgery ( P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days. Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

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.