Nickelas Huffman

Introduction: Total joint arthroplasty (TJA) is evolving with new technologies and techniques introduced in fellowship training, but the effect on surgeons' future practices remains unclear. We assessed current practice patterns and influential factors among fellowship-trained arthroplasty surgeons. Methods: An electronic survey was sent to all currently practicing surgeons (n = 90) who had completed a high-volume adult reconstruction fellowship at a single tertiary academic center from 1986 to 2022. The survey consisted of 73 questions regarding surgeon and practice characteristics for primary and revision total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty. Data were tabulated and analyzed in REDCap software. Results: The survey was completed by 53 surgeons (59%): 46% had been in practice for 0 to 5 years, 32% for 6 to 10 years, and 21% for 11 to 20 years. Overall, 81% performed at least 100 THAs, and 77% performed at least 150 TKAs annually. Revision TJA constituted 0% to 20% of surgical practice for 70% of surgeons, whereas 30% performed revision TJA in 21% to 40% of cases. The most common approach for THA was direct anterior (28/53, 53%), followed by posterior (22/53, 42%). Fellowship experience was the most influential factor on the choice of THA approach (57%), as well as on the choice of THA (64%) and TKA (57%) implants. Among surgeons with access to robots, 52% did not perform any robotic THAs, whereas 27% performed more than 80% of their THAs robotically. By contrast, 64% of surgeons performed more than 80% of their primary TKAs robotically, and only 13% did no robotic TKAs despite having access to a robot. Conclusion: Fellowship experience was the primary factor influencing approach and implant choices in both THA and TKA, highlighting its notable effect on shaping trainees' future practices. Therefore, fellowship programs should offer exposure to diverse technologies and techniques to enable informed decision making.

Purpose This study aimed to evaluate patient-reported outcomes, functional recovery, satisfaction, and implant survivorship for cementless and cemented TKA. Methods A prospective, non-randomized, multicenter study was conducted on 453 patients. Cohort 1 (n = 373 knees) received a fully cementless construct with the Triathlon Tritanium Tibial Baseplate, Triathlon Tritanium Patella, Triathlon CR or PS Beaded Femur with Peri-Apatite, and the Triathlon Tibial Insert. Cohort 2 (n = 147 knees) received a fully cemented construct with identical implant design. Oxford Knee Score (OKS), 2011 Knee Society Score (KSS), and Short Form 12 scores were recorded preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Implant survivorship and adverse events were also recorded. Results OKS (mean difference [MD] 1.5, p = 0.0123), KSS Symptoms for pain (with level walking [MD 0.62, p = 0.0007]; with stairs or incline [MD 0.85, p = 0.0037), KSS Patient satisfaction (MD 2.31, p = 0.0004), and KSS Functional Activities (MD 0.53, p = 0.0108) were significantly greater in Cohort 1 out to 2 years postoperatively. The Kaplan–Meier estimated all-cause survivorship was 98.2% (95% CI: 95.7–99.3%) for Cohort 1 and 97.5% (95% CI: 92.6–99.2%) for Cohort 2 (p = 0.4366). Conclusion Cementless TKA exhibited similar or greater patient outcomes, satisfaction, and function up to 2 years postoperative, while both cohorts showed comparable rates of adverse events and survivorship at 5-year follow-up. This evidence underscores the clinical value and safety of cementless TKA.

Patellar tendon rupture (PTR) is a rare and severe postoperative complication of total knee arthroplasty (TKA). Even rarer is the intraoperative occurrence of PTR during TKA. PTR is a major complication as it can lead to chronic disability, functional limitations, and postoperative morbidity. Therefore, surgical repair of the intraoperative PTR is typically pursued through one of the following three methods: (i) primary repair with direct suturing; (ii) direct suturing with cerclage augmentation, and (iii) direct suturing with either autograft or synthetic graft augmentation. In the case of an incomplete tear, direct repair with suture anchors for distal tears, and end-to-end repair with/without synthetic graft augmentation for mid-substance and proximal tears, is recommended. In the case of complete tears, if adequate tissue is present, direct repair with extensor mechanism reconstruction should be performed, regardless of the location of the tear. Furthermore, for complete tears with defective tissue, extensor mechanism reconstruction should be performed using mesh or allograft augmentation, regardless of the location of the tear. This review aims to provide a comprehensive and thorough overview of the prevention, diagnosis, management, and outcomes of intraoperative extensor mechanism injuries during TKA.

Introduction There is conflicting data in the literature regarding the clinical utility of wearable devices. This study examined the association between patient reported outcome measures (PROMs) and step and stair flight counts obtained from wearable devices in postoperative total hip arthroplasty (THA) patients. Methods Data was collected from a multicenter prospective longitudinal cohort study from October 2018 to February 2022. A smartphone-based platform with smartwatch was utilized for collection of daily step and stair flight counts. Subjects (N = 1644) completed the Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and numerical rating scale (NRS) pain scores preoperatively and at 1 and 3 months postoperatively. Patients who reported living in a multi-level home (N = 931) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between step and stair flight counts with NRS pain and HOOS JR scores. Results Step counts demonstrated a weak negative correlation to NRS pain scores at preoperative (r = − 0.15, p < 0.0001), 1-month (r = − 0.15, p < 0.0001), and 3-months follow-up (r = − 0.06, p = 0.05). Step counts demonstrated a weak positive correlation with HOOS JR scores at preoperative (r = 0.16, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.13, p < 0.0001). Stair flight counts demonstrated a weak negative correlation with NRS pain preoperatively (r = − 0.19, p < 0.0001) and at 1-month (r = − 0.11, p = 0.003). Stair flight counts positively correlated with HOOS JR scores at preoperative (r = 0.24, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.09, p = 0.02). Conclusion The utilization of wearable technology can enhance the evaluation of patient outcomes after THA, primarily due to the observed correlation between data collected from wearables and PROMs. Our study highlights the importance of the use of objective data, in addition to subjective patient reported data, when analyzing postoperative patient progress, which propels forward the field of postoperative THA patient care.

Background: Unicompartmental knee arthroplasty (UKA) procedures have become much more common in the United States in recent years, with >40,000 UKAs performed annually ¹ . However, it is estimated that 10% to 40% of UKAs fail and thus require conversion to total knee arthroplasty (TKA) ^2–5 . In the field of total joint arthroplasty, robotic-assisted surgeries have demonstrated advantages such as better accuracy and precision of implant positioning and improved restoration of a neutral mechanical axis ^6–9 . These advantages may be useful in UKA to TKA conversion surgeries, as the use of robotic assistance may result in improved bone preservation. Description: Robotic-assisted TKA is performed with the patient in the supine position, under spinal anesthesia, and with use of a tourniquet. A limited incision is made approximately 1 cm medial to a standard midline incision, through the previous UKA incision. A medial parapatellar arthrotomy and partial synovectomy are performed. Array pins are placed in a standard fashion: intra-incisional in the femoral diaphysis and extra-incisional in the distal tibial diaphysis. Femoral and tibial bone registration is performed, along with functional knee balancing to adjust implant positioning. The robotic arm-assisted system is then utilized to achieve the planned bone resections. After completing all bone cuts, trial components are inserted. Trial reduction is then performed, and knee extension, stability, and range of motion are assessed. The final implant is cemented into place. We utilize a cruciate-retaining TKA implant. No augments are required. Alternatives: An alternative treatment option is manual UKA to TKA conversion. Rationale: Robotic-assisted conversion of UKA to TKA is especially useful for patients requiring bone preservation. For example, 1 case series found that the use of robotic-assisted conversion of UKA to TKA resulted in a decreased use of augments and a smaller average polyethylene insert thickness compared with manual conversion. Furthermore, mechanical bone loss may occur secondary to implant loosening. Thus, in patients with aseptic loosening, robotic-assisted conversion of UKA to TKA may be useful ¹⁰ . Expected Outcomes: Results of robotic-assisted conversion of UKA to TKA have thus far been excellent. In a study of 4 patients undergoing robotic-assisted conversion of UKA to TKA, all patients experienced uneventful recoveries without any need for subsequent re-revision ¹⁰ . In a case report of a robotic-assisted conversion of UKA to TKA, the patient was pain-free at both 6 months and 1 year postoperatively, with a range of motion of 0° to 120° at 6 months and 0° to 130° at 1 year, and excellent component alignment on radiographs at 1 year ¹¹ . In another case report, the patient had full range of motion and a normal, painless gait at 1 year postoperatively ¹² . When comparing manual versus robotic-assisted conversion, 1 study found no difference in postoperative range of motion or complications among the 28 patients assessed ¹³ . Important Tips: Ensure accurate soft-tissue balancing prior to implant removal and osseous resection. Augments can easily be cut by executing the initial cut, then moving the resection depth either 5 or 10 mm deeper. The cut is then performed only in the compartment that needs an augment. Augment cutting is usually performed in a stepwise fashion to avoid excessive resection in the other compartments in order to preserve native bone. Having revision implants with increased constraint and metaphyseal fixation available is important during these cases because, as in any revision surgery, unexpected events can lead to the need for other implant choices. Acronyms and Abbreviations: UKA = unicompartmental knee arthroplasty RA = robotic-assisted TKA = total knee arthroplasty ROM = range of motion CT = computed tomography PCL = posterior cruciate ligament DVT = deep venous thrombosis VTE = venous thromboembolism

Introduction: Birmingham Hip Resurfacing (BHR) has emerged as a compelling and innovative alternative to total hip arthroplasty (THA), especially among young, active patients. However, the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds have not yet been determined for patients undergoing BHR. Therefore, the current study aimed to (1) determine the MCID and PASS thresholds for both the Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS physical function shortform (PS), for patients who underwent BHR; and (2) identify factors influencing the achievement of MCID and PASS for HOOS-Pain and HOOS-PS. Methods: Prospectively collected data from patients undergoing BHR was analyzed. Patients with osteoarthritis and completed preoperative and 1-year postoperative PROMs were included. Distribution-based and anchored-based approaches were used to estimate MCID and PASS, respectively. The optimal cut-off point for PASS thresholds was calculated using the Youden index. Results: MCID for HOOS-Pain and PS were calculated to be 9.2 and 9.3, respectively. The PASS threshold for HOOS-Pain and PS were ≥ 77.7 and ≥ 87.3, respectively. The current study identified several factors affecting postoperative achievement of thresholds. Baseline Mental Component Summary (MCS) scores were a predictor for achieving MCID for postoperative HOOS-Pain, achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Furthermore, baseline HOOS-Pain was a significant predictor for achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Conclusions: MCID and PASS thresholds were established for HOOS-Pain and PS domains following BHR with most patients achieving these clinically meaningful benchmarks. Additionally, several factors affecting achievement of MCID and PASS were identified, including modifiable risk factors that may allow clinicians to implement optimization strategies and further improve outcomes.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = −0.14, p < 0.0001) and 1-month follow-up (r = −0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = −0.16, p < 0.0001) and 1-month follow-up (r = −0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.