James Huddleston, MD

All Publications

• Erratum to: Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study. Clinical orthopaedics and related research Connelly, J. W., Galea, V. P., Rojanasopondist, P., Nielsen, C. S., Bragdon, C. R., Kappel, A., Huddleston, J. I., Malchau, H., Troelsen, A. 2020

  View details for DOI 10.1097/CORR.0000000000001565

  View details for PubMedID 33177480

• Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine Hah, J. M., Trafton, J. A., Narasimhan, B., Krishnamurthy, P., Hilmoe, H., Sharifzadeh, Y., Huddleston, J. I., Amanatullah, D., Maloney, W. J., Goodman, S., Carroll, I., Mackey, S. C. 2020; 28: 100596

  Abstract

  Background: Postoperative opioid use can lead to chronic use and misuse. Few studies have examined effective approaches to taper postoperative opioid use while maintaining adequate analgesia.Methods: This randomized, assessor-blinded, pilot trial of postoperative motivational interviewing and guided opioid tapering support (MI-Opioid Taper) added to usual care (UC) enrolled patients undergoing total hip or knee arthroplasty at a single U.S. academic medical center. MI-Opioid Taper involved weekly (to seven weeks) and monthly (to one year) phone calls until patient-reported opioid cessation. Opioid tapering involved 25% weekly dose reductions. The primary feasibility outcome was study completion in the group to which participants were randomized. The primary efficacy outcome, time to baseline opioid use, was the first of five consecutive days of return to baseline preoperative dose. Intention-to-treat analysis with Cox proportional hazards regression was adjusted for operation. ClinicalTrials.gov registration: NCT02070003.Findings: From November 26, 2014, to April 27, 2018, 209 patients were screened, and 104 patients were assigned to receive MI-Opioid Taper (49 patients) or UC only (55 patients). Study completion after randomization was similar between groups (96.4%, 53 patients receiving UC, 91.8%, 45 patients receiving MI-Opioid Taper). Patients receiving MI-Opioid Taper had a 62% increase in the rate of return to baseline opioid use after surgery (HR 1.62; 95%CI 1.06-2.46; p=003). No trial-related adverse events occurred.Interpretation: In patients undergoing total joint arthroplasty, MI-Opioid Taper is feasible and future research is needed to establish the efficacy of MI-Opioid Taper to promote postoperative opioid cessation.Funding: National Institute on Drug Abuse.

  View details for DOI 10.1016/j.eclinm.2020.100596

  View details for PubMedID 33294812

• Do Knee Osteoarthritis Patterns Affect Patient-Reported Outcomes in Total Knee Arthroplasty? Results From an International Multicenter Prospective Study With 3-Year Follow-Up. The Journal of arthroplasty Vestergaard, V., Colon Iban, Y. E., Kappel, A., Melnic, C. M., Bedair, H., Huddleston, J. I., Bragdon, C. R., Malchau, H., Troelsen, A. 2020

  Abstract

  BACKGROUND: The aim of this multicenter study is to answer (1) Does patellofemoral osteoarthritis (OA) affect preoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) scores in total knee arthroplasty (TKA)? and (2) Do different OA patterns affect preoperative and postoperative KOOS scores in TKA?METHODS: This international, multicenter prospective study examined 384 TKA patients. Compartmental OA was divided into (1) medial, (2) medial+ patellofemoral, (3) lateral, (4) lateral+ patellofemoral, (5) medial+ lateral (bicompartmental), and (6) medial+ lateral+ patellofemoral (tricompartmental), based on preoperative anterior-posterior and lateral ± skyline radiographs with Kellgren-Lawrence grade III-IV and joint space width <2.5 mm. KOOS was collected preoperatively, 1 year postoperatively, and 3 years postoperatively. Higher KOOS score represented better clinical state, for example, higher KOOS Pain score indicated less pain.RESULTS: Patellofemoral OA had no effect on preoperative KOOS scores (P > .15). Compared to medial ± patellofemoral OA patients, bicompartmental/tricompartmental OA patients had less preoperative pain (KOOS Pain 7.4, P= .03) and higher daily function (KOOS-ADL [Activities of Daily Living] 7.1, P= .05), and higher 1-year postoperative daily function (KOOS-ADL 9.2, P= .03) and sports activity (KOOS Sports & Recreation Function 15.0, P= .04), while lateral ± patellofemoral OA patients had more symptoms (KOOS-Symptoms 7.0, P < .01), more pain (KOOS-Pain 7.5, P= .01), lower daily function (KOOS-ADL 9.3, P < .01), and lower quality of life (KOOS-QOL 9.0, P= .04), at 3 years postoperatively.CONCLUSION: Patellofemoral OA does not affect medial ± lateral OA patients' preoperative KOOS scores, challenging the importance of patellofemoral OA in TKA. Lateral ± patellofemoral OA patients have lower postoperative KOOS scores than medial/more progressed compartmental OA patients, indicating that patients with less common OA patterns present with unique surgical challenges. Further development of indications for and correct timing of TKA surgery in different patient subgroups is needed.

  View details for DOI 10.1016/j.arth.2020.08.033

  View details for PubMedID 32919849

• Reemergence of Multispecialty Inpatient Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines for a New Normal. The Journal of bone and joint surgery. American volume Anoushiravani, A. A., Barnes, C. L., Bosco, J. A., Bozic, K. J., Huddleston, J. I., Kang, J. D., Ready, J. E., Tornetta, P. 3., Iorio, R. 2020; 102 (14): e79

  View details for DOI 10.2106/JBJS.20.00829

  View details for PubMedID 32675667

• Total Knee Arthroplasty in Ambulatory Surgery Centers: The New Reality! Arthroplasty today Chambers, M., Huddleston, J. I., Halawi, M. J. 2020; 6 (2): 146–48

  Abstract

  By streamlining surgical care and eliminating postoperative hospitalization, the transition to ambulatory total knee arthroplasty (TKA) has the potential to improve efficiency and minimize the costs of care. However, practical, legal, and financial implications remain to be addressed. The Centers for Medicare and Medicaid Services has also yet to address concerns generated by the removal of TKA from the Inpatient-Only List and provide guidance on patient selection. Rolling out regulatory changes that impact high-volume procedures, such as TKA, in a short period of time and without appropriate feedback can only lead to further confusion. As surgeons, we are in a unique business model that requires us to constantly innovate to deliver high quality care, while also taking financial cuts as a result of our innovations.

  View details for DOI 10.1016/j.artd.2020.03.004

  View details for PubMedID 32346586

• American Association of Hip and Knee Surgeons Advocacy Efforts in Response to the SARS-CoV-2 Pandemic. The Journal of arthroplasty Huddleston, J. I., Iorio, R., Bosco, J. A., Kerr, J. M., Bolognesi, M. P., Barnes, C. L. 2020

  Abstract

  As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members' practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a "flattening of the curve" and discussions have begun on when, where, and how to safely start elective surgery again.

  View details for DOI 10.1016/j.arth.2020.04.050

  View details for PubMedID 32354537

• Manipulation Under Anesthesia After Total Knee: Who Still Requires a Revision Arthroplasty? The Journal of arthroplasty Bozic, K. J., Brigati, D. P., Huddleston, J. I., Lewallen, D. G., Illgen, R. L., Ziegenhorn, D. M. 2020

  Abstract

  BACKGROUND: Stiffness after total knee arthroplasty (TKA) is a multifactorial complication involving patient, implant, surgical technique, and rehabilitation, occasionally necessitating manipulation under anesthesia (MUA) or revision. Few modern databases contain sufficient longitudinal information of all factors. We characterized MUA after primary TKA and identified independent risk factors for revision TKA after MUA from the American Joint Replacement Registry.METHODS: We retrospectively reviewed primary TKAs for American Joint Replacement Registry patients ≥65 years from January 1, 2012 to 31 March, 2019. We linked these to the Centers for Medicare and Medicaid Services database to identify MUA and revision TKA procedure codes. We compared groups with chi-squared testing, identifying independent risk factors for subsequent revision with binary logistic regression presented as odds ratios with 95% confidence intervals.RESULTS: Of 664,604 primary TKAs, 3918 (0.6%) underwent MUA after a median of 2.0±1.0 months. Revision surgery occurred in 131 (3.4%) MUA patients after a median of 9.0 months. Timing of MUA was not different between revision and no revision patients (P= .09). Patients undergoing MUA compared to no MUA were older (age 71.5 vs 70.7, P < .01), predominantly female (63.9% vs 61.2%, P < .01), current/former tobacco users (24.2% vs 13.3%, P < .01), with osteoarthritis diagnoses (98.0% vs 84.3%, P < .01). Independent risk factors for revision after MUA were male gender (1.56, 1.09-2.22).CONCLUSION: The incidence of MUA after primary TKA is low (0.6%) in Medicare patients ≥65 years of age; 3.4% progress to revision after a median of 9 months. Being male was significantly associated with revision TKA after MUA.

  View details for DOI 10.1016/j.arth.2020.03.009

  View details for PubMedID 32247675

• Selective screw fixation is associated with early failure of primary acetabular components for aseptic loosening. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Henry Goodnough, L., Bonano, J. C., Finlay, A. K., Aggarwal, V., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2020

  Abstract

  Selective augmentation of the acetabular component with screws during primary total hip arthroplasty (THA) assumes that the surgeon can detect when an acetabular component needs added stability. In contrast, non-selective screw users do not alter their practice based on their interpretation of stability and either use screws all or none of the time. We aimed to determine the effect of selective screw use on aseptic acetabular component loosening. We retrospectively reviewed aseptic failures of THA acetabular components. We compared the survivorship of selective to non-selective supplementation of acetabular fixation with screws, and compared time to revision, obesity and selective screw use. Selective screw use (n=16) was associated with earlier acetabular component aseptic loosening (median 1.9 years; interquartile range (IQR) 1.1-5.0) compared to non-selective screw use (n=22; median 5.6 years; IQR 2.0- 15.3, p = 0.010). Selective screw use was independently associated with earlier revision after adjusting for patient obesity. Obesity was associated with selective screw use in 50% of the cases versus 14% of non-selective cases (OR 6.3 CI 1.2-25.2, p = 0.028), possibly reflecting the increased difficulty in achieving acetabular component stability in this and other settings with compromised bone. Surgeons should carefully assess component stability at time of primary THA. If the acetabulum is not stable, the addition of screws alone may not be sufficient for acetabular component stability. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.24649

  View details for PubMedID 32157712

• Reimbursement and Complications in Outpatient vs Inpatient Unicompartmental Arthroplasty. The Journal of arthroplasty Bosch, L. C., Bala, A., Denduluri, S. K., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Amanatullah, D. F. 2020

  Abstract

  BACKGROUND: Increasing utilization of unicompartmental knee arthroplasty (UKA) has driven a greater push for outpatient treatment and cost containment in the setting of bundled payments. The purpose of this study is to evaluate utilization trends of inpatient vs outpatient UKA, index episode and 90-day reimbursement, and any differences in medical or surgical complications.METHODS: The PearlDiver database was employed to identify all inpatient and outpatient UKAs performed between 2007 and 2016 with 2-year follow-up. Patients were matched by age, gender, and Elixhauser Comorbidity Index. We tracked index procedure and global period reimbursement, 90-day medical and surgical complications, and 2-year surgical complications.RESULTS: The reimbursement and utilization cohort included 3181 outpatient and 5490 inpatient UKAs. Outpatient UKA and overall utilization of UKA increased over the study period. Mean index reimbursement of inpatient UKA was $2486.16 higher per procedure (P < .001) while mean global period reimbursement was $2782.13 higher per inpatient procedure (P < .001). Ninety-day medical complications including postoperative anemia (P < .001), transfusion (P= .024), and arrhythmia (P= .004) were more common with inpatient UKAs, whereas surgical wound complications (P= .001) and operative debridement (P= .028) were more common among outpatient UKAs. Outpatient UKA was not associated with an increased risk of periprosthetic joint infection (P > .05), aseptic loosening (P > .05), or revision surgery (P > .05) when compared to inpatient UKA.CONCLUSION: Outpatient UKA utilization is increasing and is associated with decreased reimbursement compared to inpatient UKA without increased risk of major medical complications, although it is associated with increased risk of wound complication and need for operative debridement at 90 days.

  View details for DOI 10.1016/j.arth.2020.02.063

  View details for PubMedID 32220483

• The AAHKS Clinical Research Award: No Evidence for Superior Patient-Reported Outcome Scores After Total Hip Arthroplasty With the Direct Anterior Approach at 1.5 Months Postoperatively, and Through a 5-Year Follow-Up. The Journal of arthroplasty Sauder, N., Vestergaard, V., Siddiqui, S., Galea, V. P., Bragdon, C. R., Malchau, H., Elsharkawy, K. A., Huddleston, J. I., Emerson, R. H. 2020

  Abstract

  BACKGROUND: The direct anterior approach to total hip arthroplasty (THA) may result in superior early postoperative patient-reported outcome measures (PROMs). This study compared PROMs between THA patients treated with the direct anterior or posterolateral approach between 1.5 months and 5 years, using literature-derived patient acceptable symptom state (PASS) and minimal clinically important improvement (MCII) thresholds.METHODS: A propensity score match of 93 direct anterior patients to 93 posterolateral patients from a multicenter US collaboration (6 centers, 398 patients) was performed. The Harris Hip Score (HHS), the Short-Form 36, and a Numerical Rating Scale for Pain were collected preoperatively, postoperatively (mean days: 47), and at 1, 3, and 5 years. The proportion of patients reaching the HHS PASS, Pain MCII, and Function MCII in the direct anterior and posterolateral groups was compared using binary logistic regressions, controlling for age, gender, body mass index, and Charnley score.RESULTS: Direct anterior patients were less likely to reach the HHS PASS at the postoperative visit (P= .015; odds ratio= 0.454), but not at later visits (P > .082). Direct anterior patients had no difference from posterolateral patients in their tendency to reach the Pain MCII postoperatively or at 1 year (P > .090). The direct anterior patients were less likely to reach the Function MCII at the postoperative visit (P= .011; odds ratio= 0.422), but not at 1 year (P= .958).CONCLUSION: No evidence was found of superior early postoperative PROM scores in THA patients treated with the direct anterior approach. No PROM differences were found at or beyond 1 year, indicating that patients reach similar final symptom states, regardless of surgical approach.

  View details for DOI 10.1016/j.arth.2020.02.008

  View details for PubMedID 32169382

• Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study. Clinical orthopaedics and related research Connelly, J. W., Galea, V. P., Rojanasopondist, P., Nielsen, C. S., Bragdon, C. R., Kappel, A., Huddleston, J. I., Malchau, H., Troelsen, A. 2020

  Abstract

  BACKGROUND: Although TKA is a common and proven reliable procedure for treating end-stage knee osteoarthritis, a minority of patients still do not achieve satisfactory levels of pain relief and functional improvement. Even though several studies have attempted to identify patients at risk of having poor clinical outcomes, few have approached this issue by considering the outcome of the patient-acceptable symptom state (PASS), defined as the value on a patient-reported outcome measure scale above which the patient deems their current symptom state acceptable.QUESTIONS/PURPOSES: (1) What is the proportion of patients who do not attain the PASS in pain and function at 1 year after TKA? (2) Which preoperative patient factors are associated with not achieving the PASS in pain at 1 year after TKA? (3) Which preoperative patient factors are associated with not achieving the PASS in function at 1 year after TKA?METHODS: This retrospective study is a secondary analysis of the 1-year follow-up data from a prospective, international, multicenter study of a single TKA system. Inclusion criteria for that study were patients diagnosed with primary osteoarthritis or post-traumatic arthritis and who were able to return for follow-up for 10 years; exclusion criteria were infection, osteomyelitis, and failure of a previous joint replacement. Between 2011 and 2014, 449 patients underwent TKA at 10 centers in five countries. At 1 year, 13% (58 of 449) were lost to follow-up, 2% could not be analyzed (eight of 449; missing 1-year KOOS), leaving 85% (383 of 449) for analysis here. The primary outcomes were not surpassing evidence-derived PASS thresholds in the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and Activities in Daily Living (ADL) sub-scores. Multivariate binary logistic regressions considering preoperative demographic, radiographic, and patient-reported outcome measure data were constructed using a forward stepwise elimination algorithm to reach the simplest best-fit regression models.RESULTS: At 1 year after TKA, 32% of the patients (145 of 449) did not reach the PASS in KOOS Pain, 31% (139 of 449) did not reach the PASS in KOOS ADL, and 25% (110 of 449) did not achieve the PASS in either KOOS Pain or ADL. After controlling for potentially confounding variables such as gender, age, BMI, and comorbidity scores, we found that men (odds ratio 2.09; p = 0.01), and patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were strongly associated with not achieving the PASS in pain. After controlling for the same potentially confounding variables, we found that patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were also strongly associated with not achieving the PASS in function.CONCLUSIONS: We found that patients with less severe osteoarthritis were much less likely to attain the PASS in pain and function at 1 year after TKA, and that men were much less likely to achieve the PASS in pain at 1 year after TKA. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement. Future regional and national registry studies should assess the true proportion of patients attaining PASS in pain and function after TKA and confirm if the preoperative factors identified in this study remain significant in larger, more diverse patient populations.LEVEL OF EVIDENCE: Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000001162

  View details for PubMedID 32039954

• Total Knee Replacement: The Inpatient-Only List and the Two Midnight Rule, Patient Impact, Length of Stay, Compliance Solutions, Audits, and Economic Consequences. The Journal of arthroplasty Iorio, R., Barnes, C. L., Vitale, M. P., Huddleston, J. I., Haas, D. A. 2020

  Abstract

  BACKGROUND: In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed TKA from the Medicare inpatient-only (IPO) list. This action had significant and unexpected consequences.METHODS: We looked at 3 levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of FFS inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in admission classification of patients with TKA over time, number of QIO audits, compliance solutions for the new rule, and cost implications of those compliance solutions were evaluated.RESULTS: Hospital reimbursement averages $10,122 in an outpatient facility but does not include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in hospital reimbursement varies widely (90th percentile decrease, $6725 vs 10th percentile $2048). Physician payments are the same in both settings (avg $1403). Patients with TKA not designated for inpatient admissions are not eligible for bundle payment programs. Patients designated as outpatients are subjected to higher out-of-pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. An AAHKS survey demonstrated that 45.08% were with inpatient designation only, 17.62% were with outpatient designation only, 25.39% were designated as necessary, and 10.1% were designated by the hospital. This survey showed that 66 of 374 (17.65%) patients had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of an AMC demonstrated that since January 1, 2018, 470 of 690 (68.1%) of CMS patients with TKA left in less than 2 midnights. The institution was subjected to 2 QIO audits.CONCLUSIONS: There are many unintended consequences to the IPO rule application to TKA.

  View details for DOI 10.1016/j.arth.2020.01.007

  View details for PubMedID 32070657

• Reply to Letter to the Editor on "Mental Health Status Improves Following Total Knee Arthroplasty". The Journal of arthroplasty Horst, P. K., Barrett, A. A., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2020

  View details for DOI 10.1016/j.arth.2020.05.067

  View details for PubMedID 32571590

• Risk Adjustment in the California Joint Replacement Registry: Is Patient Complexity Accurately Assessed in Academic Versus Nonacademic Hospitals? The Journal of arthroplasty Amanatullah, D. F., Lawson, K. A., Li, Z., SooHoo, N. F., Bini, S. A., Huddleston, J. I. 2020

  Abstract

  We sought to report on the differences in observed versus expected arthroplasty outcomes between academic and nonacademic hospitals in a large joint registry. We utilized the California Joint Replacement Registry's data and risk adjustment model.Observed versus expected hip and knee arthroplasty complications were utilized to assess hospital and surgeon risk-adjusted complication rates (RACRs). Based on a hospital and surgeon RACR, each was assigned a performance rating ("worse," "expected," "better"). Associations between academic status and performance ratings, rates of individual complications, prevalence of risk factors associated with increased complication rates, and differences in complication rates were calculated.A higher percentage of academic providers had "worse" than expected ratings, whereas a higher percentage of nonacademic providers had "expected" and "better" than expected ratings (P = .011) based on the observed versus expected complication rates. There was a higher incidence of patients with congestive heart failure and an elevated American Society of Anesthesiologists classification in academic institutions (P = .0001). The complication rate was higher in academic institutions for all total knee arthroplasties (P < .0016).We identified disparities in RACRs between nonacademic and academic institutions. This may reflect the difficulty of fully adjusting for medical risk and surgical complexity in a large arthroplasty database.

  View details for DOI 10.1016/j.arth.2020.06.075

  View details for PubMedID 32739083

• The Removal of Total Hip and Total Knee Arthroplasty From the Inpatient-Only List Increases the Administrative Burden of Surgeons and Continues to Cause Confusion. The Journal of arthroplasty Krueger, C. A., Kerr, J. M., Bolognesi, M. P., Courtney, P. M., Huddleston, J. I. 2020

  Abstract

  Several studies have shown that the removal of total knee arthroplasty (TKA) from the Centers for Medicare and Medicaid Services (CMS) inpatient-only (IPO) list has caused confusion among surgeons, hospitals, and patients. The purpose of this study is to determine whether similar confusion was present after CMS recently removed total hip arthroplasty (THA) from the IPO list.We surveyed the American Association of Hip and Knee Surgeons membership via an online web-based questionnaire in February 2020. The 12-question form asked about practice type and the impact that having both THA and TKA removed from the IPO list has had on each surgeon's practice. Responses were tabulated and descriptive statistics of each question reported.Of the 2847 American Association of Hip and Knee Surgeons members surveyed, 419 responded (14.7% response rate). Three hundred forty-one surgeons (81%) stated that changes to IPO status have increased their practice's administrative burden. Fifty-four percent of surgeons reported that they have needed to obtain preauthorization or appeal a denial of preauthorization for an inpatient total joint arthroplasty at least monthly, while 257 surgeons (61%) have had patients contact their office regarding an unexpected copayment. Despite the commitment of CMS to waiving certain audits for 2 years, 43 respondents (10%) stated they had undergone an audit regarding a patient's inpatient status.The removal of THA and TKA from the IPO list continues to be an administrative burden for arthroplasty surgeons and a source of confusion among patients. CMS should provide additional guidance to address surgeons' concerns about preauthorization for inpatient stays, unexpected patient copayments, and CMS audits.

  View details for DOI 10.1016/j.arth.2020.04.079

  View details for PubMedID 32444233

• Accuracy and precision in resection alignment: Insights from 10,144 clinical cases using a contemporary computer-assisted total knee arthroplasty system. The Knee Dai, Y., Bolch, C., Jung, A., Hamad, C., Angibaud, L., Stulberg, B. N., Huddleston, J. I. 2020

  Abstract

  Studies on total knee arthroplasty (TKA) with computer-assisted orthopedic surgery (CAOS) are limited by sample size or overlooked longitudinal performance of the system. This study aimed to assess resection accuracy across the entire TKA application history of a modern CAOS system considering multiple factors.A retrospective analysis was performed based on a database that archives technical logs of all TKAs performed using a CAOS system. Coronal resection errors and percentage of outliers (<2° alignment error) in the proximal tibia and distal femur were assessed. Multilevel modeling was used to understand whether and where the resection error variability was located in the grouping categories, which included geographic region, individual established surgeon, preoperative alignment, adoption phase (learning/proficient), and version of the CAOS software application.A total of 10,144 cases were reviewed. The accuracy (mean) and precision (standard deviation) of the coronal alignment for both the tibia and femur were at the sub-degree level. High percentages of acceptable resections were observed across the pooled and each grouping category. The accountability for the amounts of total variability in tibial and femoral resection errors was negligible for all grouping categories, demonstrated by ICC values less than the common variations in observational studies.The study applied advanced analyses to assess alignment outcome in TKA bony resection alignment across the history of a specific CAOS system. The results demonstrated high resection alignment accuracy insensitive to geographic region, CAOS software application, adoption phase, preoperative alignment, and inter-surgeon differences.

  View details for DOI 10.1016/j.knee.2020.02.024

  View details for PubMedID 32223972

• Surgeons' Preoperative Work Burden Has Increased Before Total Joint Arthroplasty: A Survey of AAHKS Members. The Journal of arthroplasty Grosso, M. J., Courtney, P. M., Kerr, J. M., Della Valle, C. J., Huddleston, J. I. 2020

  Abstract

  Implementation of rapid recovery protocols and value-based programs in total joint arthroplasty (TJA) has required changes in preoperative management, such as optimization, education, and coordination. This study aimed to quantify the work burden associated with preoperative TJA care.Two web-based surveys were distributed to surgeon members of the American Association of Hip and Knee Surgeons. The first questionnaire (265 respondents) consisted of questions related to preoperative patient care in TJA and the associated work burden by orthopedic surgeons and their financially dependent health care providers. The second survey (561 respondents) consisted of questions related to relative change in preoperative patient care work burden since 2013.Greater than 98% of survey respondents reported providing some level of preoperative medical optimization to their patients. The mean amount of reported time spent by the surgeon and/or a qualified health care provider in preoperative activities not included in work captured in current procedural terminology or hospital billing codes was 153 minutes. The mean amount of reported time spent by ancillary clinical staff in preoperative activities was 177 minutes. Most surgeons reported an increase in work burden for total knee (86%) and total hip (87%) arthroplasty since 2013, with a large portion reporting a 20% or greater increase in work (knee 66%, hip 64%).To provide quality arthroplasty care with marked reductions in complication rates, lengths of stay, and readmissions, members of the American Association of Hip and Knee Surgeons report a substantial preoperative work burden that is not included in current coding metrics. Policy makers should account for this time in coding models to continue to promote pathway improvements.

  View details for DOI 10.1016/j.arth.2020.01.079

  View details for PubMedID 32057605

• Initial Presentation and Progression of Secondary Osteonecrosis of the Knee. The Journal of arthroplasty Boontanapibul, K., Steere, J. T., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2020

  Abstract

  Early detection and intervention are critical to maintaining the native articular cartilage before collapse in secondary osteonecrosis of the knee (SOK). We conducted a retrospective study documenting the initial stage of presentation and the progression of SOK.Our database was reviewed for patients younger than 65 years of age diagnosed with atraumatic SOK between 2002 and 2018. Demographic data, plain radiographs as well as MRI at initial evaluation, and initial treatment were classified and analyzed.One hundred four patients with 164 knees were identified. Mean age was 39 ± 16 years. Females (64%) with bilateral disease (58%) predominated. Seventy-five percent of patients had a history of corticosteroid use, of which 41% were diagnosed with hematologic malignancy and lupus. Fifteen percent of patients had a history of ethanol abuse. At initial presentation, 55% of patients were diagnosed with Ficat-Arlet stage I/II, while 45% were diagnosed with Ficat-Arlet stage III/IV. We found a significant difference in the mean age of patients at early stage of SOK with corticosteroid use (31 ± 12 years of age) when compared to ethanol use (43 ± 13 years of age, P = .02). Treatments included observation (57%), joint preservation surgery (20%), and total knee arthroplasty (23%).Nearly half of patients presented at late stage compromising the potential for joint preservation. The difference in age of referral by over a decade, based on etiology of SOK, suggests a strong provider-based referral or screening bias may be present. Hence, a multidisciplinary approach to earlier detection and referral may be a more effective strategy for preventing the progression of SOK.

  View details for DOI 10.1016/j.arth.2020.05.020

  View details for PubMedID 32527695

• Outcomes of Cemented Total Knee Arthroplasty for Secondary Osteonecrosis of the Knee. The Journal of arthroplasty Boontanapibul, K., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2020

  Abstract

  Secondary osteonecrosis of the knee (SOK) generally occurs in relatively young patients; at advanced stages of SOK, the only viable surgical option is total knee arthroplasty (TKA). We conducted a retrospective study to investigate implant survivorship, clinical and radiographic outcomes, and complications of contemporary cemented bicompartmental TKA with/without patellar resurfacing for SOK.Thirty-eight cemented TKAs in 27 patients with atraumatic SOK, mean age 43 years (17 to 65), were retrospectively reviewed. Seventy-four percent had a history of corticosteroid use, and 18% had a history of alcohol abuse. Patellar osteonecrosis was coincidentally found in six knees (16%), and all were asymptomatic without joint collapse. The mean followup was 7 years (2 to 12). Knee Society Score (KSS) and radiographic outcomes were evaluated at 6 weeks, 1 year, then every 2 to 3 years.Ninety-two percent had implant survivorship free from revision with significant improvement in KSS. Causes of revision included aseptic tibial loosening (one), deep infection (one), and instability with patellofemoral issues (one). Four of six cases also with patellar osteonecrosis received resurfacing, including one with periprosthetic patellar fracture after minor trauma, with satisfactory clinical results after conservative treatment. None of the unrevised knees had progressive radiolucent lines or evidence of loosening. An unresurfaced patella, use of a stem extension or a varus-valgus constrained prosthesis constituted 18%, 8% and 3%, respectively.Cemented TKAs with selective stem extension in patients with SOK had satisfactory implant survivorship and reliable outcomes. Secondary osteonecrosis of the patella should be carefully evaluated prior to operation.

  View details for DOI 10.1016/j.arth.2020.08.061

  View details for PubMedID 33011011

• Diagnosis of Osteonecrosis of the Femoral Head: Too Little, Too Late, and Independent of Etiology. The Journal of arthroplasty Boontanapibul, K., Steere, J. T., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2020

  Abstract

  Joint preservation is more effective in early-stage osteonecrosis of the femoral head (ONFH); thus, prompt diagnosis when the femoral head is still salvageable is important. We report a 20-year retrospective study that summarizes age at presentation, etiology, and Association Research Circulation Osseous stage at diagnosis.Our database was reviewed to identify patients younger than 65 years of age who were diagnosed with atraumatic ONFH between 1998 and 2018. Demographic characteristics of patients were evaluated and categorized into different subgroups.Four hundred thirteen patients were identified. At initial presentation, 23% were diagnosed with early-stage ONFH, while 77% were diagnosed with late-stage ONFH. Forty-nine percent had a history of corticosteroid use, of which 13% were diagnosed with hematologic malignancy and 8% were diagnosed with lupus. Ethanol abuse, idiopathic, sickle cell disease, and human immunodeficiency virus were present in 11%, 30%, 3%, and 3%, respectively. The mean age of patients with corticosteroid use (40 ± 14 years) was significantly younger than ethanol use (46 ± 11 years, P = .014) and idiopathic causes (48 ± 11 years, P < .001), but significantly older than sickle cell disease (32 ± 11 years, P = .031). There was no difference in the age of presentation for early-stage and late-stage ONFH by etiology.Nearly 80% of the patients presented with late-stage ONFH. Hence, we have a narrow window of opportunity for hip preservation surgery before femoral head collapse. A multidisciplinary approach to improve screening awareness for early detection by focusing on the etiologic identification and patient education might reduce the incidence of hip arthroplasty in young patients.

  View details for DOI 10.1016/j.arth.2020.04.092

  View details for PubMedID 32456965

• Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. Journal of pain research Hah, J. M., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Hernandez Boussard, T., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2020; 13: 2959–70

  Abstract

  Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use.In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18-75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively.Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87-1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68-0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40-0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39-0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80-0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89-1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06-1.77; P=0.016).Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

  View details for DOI 10.2147/JPR.S269370

  View details for PubMedID 33239904

  View details for PubMedCentralID PMC7680674

• Quantifying Surgeon Work in Total Hip and Knee Arthroplasty: Where Do We Stand Today? The Journal of arthroplasty Halawi, M. J., Mirza, M., Osman, N., Cote, M. P., Kerr, J. M., Huddleston, J. I. 2019

  Abstract

  BACKGROUND: Physician work is a critical component in determining reimbursement for total joint arthroplasty (TJA). The purpose of this study is to quantify the time spent during the different phases of TJA care relative to the benchmarks used by the Centers for Medicare and Medicaid Services.METHODS: We retrospectively reviewed all patients captured in our institutional joint database between January 1, 2014, and December 31, 2018. Four phases of care were assessed: (1) preoperative period following the decision to proceed with TJA and leading to the day before surgery, (2) immediate 24hours preceding surgery (preservice time), (3) operative time from skin incision to dressing application (intraservice time), and (4) postoperative work including day of surgery and the following 90 days.RESULTS: A total of 666 procedures were analyzed (379 total hip arthroplasties and 287 total knee arthroplasties). The mean preoperative care coordination, preservice, intraservice, immediate postservice, and 91-day global period times were 21.9 ± 10, 84.1, 114 ± 24, 35, and 150 ± 37minutes, respectively. Except for a slightly higher preoperative time associated with Medicare coverage (P= .031), there were no differences in the other phases of care by payer type. There were no temporal differences between 2014 and 2017. However, in 2018, there were significant increases in preoperative and intraservice times (6 and 20minutes, respectively, P < .001) which were accompanied with a significant decrease in postoperative service time (34minutes, P < .001).CONCLUSION: Even when performing TJA under the most optimal conditions, the overall time has remained stable over the past 5 years and consistent with current benchmarks.

  View details for DOI 10.1016/j.arth.2019.12.006

  View details for PubMedID 31883825

• Statin use is associated with less postoperative cardiac arrhythmia after total hip arthroplasty HIP INTERNATIONAL Chen, M. J., Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Aaronson, A. J., Amanatullah, D. F. 2019; 29 (6): 618–23

  View details for DOI 10.1177/1120700018816091

  View details for Web of Science ID 000487029700010

• Response to Letter to the Editor on "Total Knee Arthroplasty Has Positive Effect on Patients With Low Mental Health Scores". The Journal of arthroplasty Horst, P. K., Barrett, A. A., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2019

  View details for DOI 10.1016/j.arth.2019.10.047

  View details for PubMedID 31785963

• Total Knee Arthroplasty Has A Positive Effect on Patients With Low Mental Health Scores. The Journal of arthroplasty Horst, P. K., Barrett, A. A., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2019

  Abstract

  BACKGROUND: The purpose of this study is to determine the impact of total knee arthroplasty (TKA) on mental health.METHODS: A total of 205 patients who underwent primary TKA with baseline and 1-year postoperative Short Form-12 Mental Component Score (MCS) were included in this retrospective analysis. Eighty-five (41%) patients had a preoperative MCS less than 50 points, while 120 (59%) patients had a preoperative MCS over 50 points. Two groups were assigned to the patients based on their preoperative MCS: low MCS <50 and high MCS >50.RESULTS: A preoperative MCS less than 50 points was predictive of greater improvement in MCS at 1 year after TKA (P < .001). Patients with low MCS improved by a mean of 10.6 points from 39.1 ± 8.6 points preoperatively to mean of 49.7 ± 10.7 points 1 year after TKA (P < .001). Patients with a high MCS decreased by a mean of 3.5 points from 60.01 ± 6.0 points preoperatively to mean of 56.6 ± 6.8 points 1 year after TKA (P < .001). This remained higher than the postoperative MCS of the patients with a low MCS, 49.7 ± 10.7 (P < .001). The patients with a high MCS had greater improvement in the Short Form-12-Physical domain (14.8 points) than the patients with a low MCS (9.2 points, P < .001).CONCLUSION: Patients with lower baseline mental health had greater improvement in postoperative mental health following TKA than patients with higher baseline mental health. Low preoperative MCS was associated with less improvement in patient-reported outcome measures. Patients with lower baseline mental health scores before TKA benefit mentally and physically from the procedure.

  View details for DOI 10.1016/j.arth.2019.08.033

  View details for PubMedID 31522853

• The Use of Stems for Morbid Obesity in Total Knee Arthroplasty JOURNAL OF KNEE SURGERY Schultz, B. J., DeBaun, M. R., Huddleston, J. I. 2019; 32 (7): 607–10

  View details for DOI 10.1055/s-0039-1681078

  View details for Web of Science ID 000479167400006

• Improved Range of Motion and Patient-Reported Outcome Scores With Fixed-Bearing Revision Total Knee Arthroplasty for Suboptimal Axial Implant Rotation JOURNAL OF ARTHROPLASTY Amanatullah, D. E., Lichstein, P. M., Lundergan, W. G., Wong, W. W., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2019; 34 (6): 1174–78

  View details for DOI 10.1016/j.arth.2019.02.007

  View details for Web of Science ID 000468307600024

• Computer Navigation vs Conventional Total Hip Arthroplasty: AMedicare Database Analysis. The Journal of arthroplasty Montgomery, B. K., Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2019

  Abstract

  BACKGROUND: Computer-assisted surgery (CAS) is applied to total hip arthroplasty (THA) in an attempt to optimize implant positioning. The effect of CAS on postoperative complications after THA remains unknown. Our study aims to assess the change in complication rates when CAS is used in THA.METHODS: The Medicare database was studied from 2005 to 2012. All THAs performed with CAS were identified. A total of 64,944 THAs were identified, including 5412 CAS-THAs and 59,532 conventional THAs. Medical and surgical adverse events were collected at various time points.RESULTS: CAS-THA was not associated with a decreased rate of dislocation at 30 days (1.0% vs 1.2%; odds ratio [OR], 1.14; P= .310), 90 days (1.1% vs 1.4%; OR, 1.23; P= .090), or 2 years (2.3% vs 2.3%; OR, 1.01; P= .931). CAS-THA was associated with a significantly higher rate of periprosthetic fracture at 30 days (0.4% vs 0.6%; OR, 1.46; P= .040) as well as revision THA at 30 days (1.0% vs 1.4%; OR, 1.43; P= .003) and 90 days (1.2% vs 1.7%; OR, 1.42; P < .002) when compared to conventional THA. CAS-THA was associated with a significantly lower rate of deep vein thrombosis and pulmonary embolism when compared to conventional THA at all time points (P < .05).CONCLUSION: Administrative coding data fail to demonstrate any clinically significant reduction in short-term adverse events with CAS-THA. Further study is warranted to evaluate whether the purported benefits of CAS result in a reduction of the adverse events after THA.

  View details for DOI 10.1016/j.arth.2019.04.063

  View details for PubMedID 31176561

• Venous thromboprophylaxis after total hip arthroplasty: aspirin, warfarin, enoxaparin, or factor Xa inhibitors? Hip international : the journal of clinical and experimental research on hip pathology and therapy Bala, A., Murasko, M. J., Burk, D. R., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2019: 1120700019841600

  Abstract

  INTRODUCTION: Debate over the ideal agent for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) has led to changes in prescribing trends of commonly used agents. We investigate variation in utilisation and the differences in VTE incidence and bleeding risk in primary THA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors.METHODS: 8829 patients were age/sex matched from a large database of primary THAs performed between 2007 and 2016. Utilisation was calculated using compound annual growth rate. Incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications, postoperative anaemia, and transfusion were identified at 2weeks, 30days, 6weeks, and 90days.RESULTS: Aspirin use increased by 33%, enoxaparin by 7%, and factor Xa inhibitors by 31%. Warfarin use decreased by 1%. Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of DVT followed by enoxaparin (2.6%), and warfarin (3.7%) at 90days. Factor Xa inhibitors (12%) and aspirin (12%) had the lowest incidence of blood transfusion followed by warfarin (15%) and enoxaparin (17%) at 90 days. There was no difference in incidence of blood transfusion or bleeding-related complications nor any detectable difference in symptomatic PE incidence.CONCLUSIONS: The utilisation of aspirin and factor Xa inhibitors increased over time. Aspirin and factor Xa inhibitors provided improved DVT prophylaxis with lower rates of postoperative anaemia compared to enoxaparin and warfarin.

  View details for DOI 10.1177/1120700019841600

  View details for PubMedID 30990095

• The Use of Stems for Morbid Obesity in Total Knee Arthroplasty. The journal of knee surgery Schultz, B. J., DeBaun, M. R., Huddleston, J. I. 2019

  Abstract

  Morbidly obese patients undergoing total knee arthroplasty have worse functional outcomes and implant survival, and increased revision rates compared with nonobese patients. In addition to increased medical comorbidities and difficult exposure, increased stress on the tibial implant and altered kinematics of knee motion contribute to aseptic loosening and medial collapse. Increased implant fixation, including use of a stemmed tibial implant, may be a way to help avoid these complications. While there is limited data on tibial stems in the morbidly obese patients specifically, cemented stemmed tibial implants should be strongly considered in these patients, especially if bone quality is poor. The initial increased cost of a stemmed implant can be justified in this high-risk patient population to minimize the risk of costly revisions related to compromised tibia component fixation.

  View details for PubMedID 30861541

• Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery Secondary Analysis of a Randomized Clinical Trial JAMA NETWORK OPEN Hah, J. M., Cramer, E., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2019; 2 (3)

  View details for DOI 10.1001/jamanetworkopen.2019.0168

  View details for Web of Science ID 000465424000048

• Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery: Secondary Analysis of a Randomized Clinical Trial. JAMA network open Hah, J. M., Cramer, E., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2019; 2 (3): e190168

  Abstract

  Importance: Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable.Objective: To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes.Design, Setting, and Participants: A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018.Interventions: Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours.Main Outcomes and Measures: A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery.Results: Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P<.001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P<.001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P=.89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P=.008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P<.001), a history of alcohol or drug abuse treatment (ARR,1.90; 95% CI, 1.42-2.53; P<.001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P=.03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P<.001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P<.001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P<.001).Conclusions and Relevance: This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings.Trial Registration: ClinicalTrials.gov Identifier: NCT01067144.

  View details for PubMedID 30821824

• Improved Range of Motion and Patient-Reported Outcome Scores With Fixed-Bearing Revision Total Knee Arthroplasty for Suboptimal Axial Implant Rotation. The Journal of arthroplasty Amanatullah, D. F., Lichstein, P. M., Lundergan, W. G., Wong, W. W., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2019

  Abstract

  BACKGROUND: Suboptimal implant rotation has consequences with respect to knee kinematics and clinical outcomes. We evaluated the functional outcomes of revision total knee arthroplasty (TKA) for poor axial implant rotation.METHODS: We retrospectively reviewed 42 TKAs undergoing aseptic revision for poor axial implant rotation. We assessed improvements in Knee Society Score (KSS) and final range of motion (ROM). Subgroup analyses were performed for preoperative instability and stiffness, as well as the number of components revised and level of implant constraint used.RESULTS: Revision for poor axial rotation in isolation improved KSS from 52 ± 22 to 84 ± 25 (P < .001), and flexion increased from 105 ± 21° to 115 ± 13° (P = .001). Revision in the setting of instability significantly improved the KSS (P < .001) but did not affect ROM (P = .172). Revision in the setting of stiffness significantly improved both KSS (P < .001) and ROM (P = .002). There was no statistically significant difference between the postoperative KSS (P = .889) and final knee flexion (P = .629) with single- or both-component revision TKA for isolated poor axial rotation or between the postoperative KSS (P = .956) and final knee flexion (P = .541) with or without the use of higher constraint during revision TKA for isolated poor axial rotation.CONCLUSION: Revision TKA for poor axial alignment improves clinical outcomes scores and functional ROM.

  View details for PubMedID 30853158

• Suboptimal patellofemoral alignment is associated with poor clinical outcome scores after primary total knee arthroplasty ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY Narkbunnam, R., Electricwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2019; 139 (2): 249–54

  View details for DOI 10.1007/s00402-018-3073-z

  View details for Web of Science ID 000458199700013

• Patient Acceptable Symptom State at 1 and 3 Years After Total Knee Arthroplasty: Thresholds for the Knee Injury and Osteoarthritis Outcome Score (KOOS). The Journal of bone and joint surgery. American volume Connelly, J. W., Galea, V. P., Rojanasopondist, P., Matuszak, S. J., Ingelsrud, L. H., Nielsen, C. S., Bragdon, C. R., Huddleston, J. I., Malchau, H., Troelsen, A. 2019; 101 (11): 995–1003

  Abstract

  To facilitate the interpretation of numerical patient-reported outcome measure (PROM) scales, concepts such as the patient acceptable symptom state (PASS) have been introduced. Currently, no PASS thresholds have been established for the Knee injury and Osteoarthritis Outcome Score (KOOS) after total knee arthroplasty. The aims of the current study were to define PASS thresholds for the KOOS subscales and several other generic and knee-specific PROMs at 1 and 3 years after total knee arthroplasty using data from an international, multicenter clinical outcome study of a modern, well-performing implant system.The study cohort consisted of 499 patients undergoing total knee arthroplasty from an international, multicenter study. At 1 and 3 years after a total knee arthroplasty, patients completed the KOOS, EuroQoL 5-dimension 3-level (EQ-5D-3L), EuroQol visual analog scale (EQ-VAS), and numerical rating scales (NRS) for knee-related pain and satisfaction. PASS thresholds were calculated at each follow-up interval using 3 anchor-based approaches, using patient-reported satisfaction as the anchor.According to our satisfaction anchor, 302 (78.9%) of 383 responding patients were satisfied at 1 year, and 242 (80.4%) of 301 responding patients were satisfied at 3 years. PASS thresholds were 84.5 points at 1 year and 87.5 points at 3 years for KOOS pain, 80.5 points at 1 year and 84.0 points at 3 years for KOOS symptoms, 83.0 points at 1 year and 87.5 points at 3 years for KOOS activities of daily living, 66.0 points at 1 year and 66.0 points at 3 years for KOOS quality of life, 83.0 points at 1 year and 90.5 points at 3 years for EQ-VAS, 0.80 point at 1 year and 0.80 point at 3 years for EQ-5D, and 1.8 points at 1 year and 1.8 points at 3 years for NRS pain.The current study is the first, to our knowledge, to propose PASS thresholds for the KOOS subscales at 1 and 3 years after total knee arthroplasty and contributes to PASS literature on other common PROMs. These findings will provide a useful reference for future total knee arthroplasty outcome studies and will help to determine what patients consider to be satisfactory operations.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.18.00233

  View details for PubMedID 31169576

• Changes in Patient Satisfaction Following Total Joint Arthroplasty. The Journal of arthroplasty Galea, V. P., Rojanasopondist, P., Connelly, J. W., Bragdon, C. R., Huddleston, J. I., Ingelsrud, L. H., Malchau, H., Troelsen, A. 2019

  Abstract

  The primary aim is to identify the degree to which patient satisfaction with the outcome of total hip arthroplasty (THA) or total knee arthroplasty (TKA) changes between 1 and 3 years from the procedure. The secondary aim is to identify variables associated with satisfaction.Data were sourced from 2 prospective international, multicenter studies (919 THA and 450 TKA patients). Satisfaction was assessed by a 10-point numerical rating scale, at 1- and 3-year follow-up. Linear mixed-effects models were used to assess factors associated with satisfaction.For the THA cohort, higher preoperative joint space width (odds ratio [OR] = 0.28; P = .004), pain from other joints (OR = 0.26; P = .033), and lower preoperative health state (OR = -0.02; P < .001) were associated with consistently lower levels of satisfaction. The model also showed that patients with preoperative anxiety/depression improved in satisfaction between 1 and 3 years (OR = -0.26; P = .031). For the TKA cohort, anterior (vs neutral or posterior) tibial component slope (OR = 0.90; P = .008), greater femoral component valgus angle (OR = 0.05; P = .012), less severe osteoarthritis (OR = -0.10; P < .001), and lower preoperative health state (OR = -0.02; P = .003) were associated with lower levels of satisfaction across the study period. In addition, patients with anterior tibial component slope improved in satisfaction level over time (OR = -0.33; P = .022).Changes in satisfaction following THA and TKA are rare between 1- and 3-year follow-up. The findings of this study can be used to guide patient counseling preoperatively and to determine intervals of routine follow-up postoperatively.

  View details for DOI 10.1016/j.arth.2019.08.018

  View details for PubMedID 31492454

• The Cost of Malnutrition in Total Joint Arthroplasty. The Journal of arthroplasty Bala, A., Ivanov, D. V., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2019

  Abstract

  Malnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA), but little is known about the burden this risk factor places on the healthcare system. The purpose of this study was to evaluate the 90-day impact of malnutrition on medical and surgical complications and understand the increase in global reimbursements associated with TJA in malnourished patients.We queried a combined private-payer and Medicare database from 2007 to 2016 for TJA using International Classification of Diseases, 9th revision and Current Procedural Terminology codes. Patients with serum albumin level of <3.5 g/dL were gender, age, and mean Elixhauser Comorbidity Index matched against a cohort with a normal serum albumin level. Odds ratios and confidence intervals were calculated for complications at 90 days postoperatively. Mean index and 90-day global reimbursements were calculated for the two matched groups and compared using P-values.3053 protein malnourished patients receiving TJA were identified, and 12,202 matched protein nourished patients receiving TJA served as controls. At 90 days, the malnourished groups had increased risk for failure of multiple organ systems, periprosthetic joint infection, and reoperation. The mean 90-day increase in reimbursement was $3875 associated with performing a TJA on a protein malnourished patient (P < .001).This study demonstrates an association between malnourished patients and postoperative complications as well as significantly increased reimbursements. Understanding the reimbursement increases at 90 days for TJA in protein malnourished patients is important in the era of bundled payments.

  View details for DOI 10.1016/j.arth.2019.11.018

  View details for PubMedID 31879158

• Medical device surveillance with electronic health records. NPJ digital medicine Callahan, A., Fries, J. A., Ré, C., Huddleston, J. I., Giori, N. J., Delp, S., Shah, N. H. 2019; 2: 94

  Abstract

  Post-market medical device surveillance is a challenge facing manufacturers, regulatory agencies, and health care providers. Electronic health records are valuable sources of real-world evidence for assessing device safety and tracking device-related patient outcomes over time. However, distilling this evidence remains challenging, as information is fractured across clinical notes and structured records. Modern machine learning methods for machine reading promise to unlock increasingly complex information from text, but face barriers due to their reliance on large and expensive hand-labeled training sets. To address these challenges, we developed and validated state-of-the-art deep learning methods that identify patient outcomes from clinical notes without requiring hand-labeled training data. Using hip replacements-one of the most common implantable devices-as a test case, our methods accurately extracted implant details and reports of complications and pain from electronic health records with up to 96.3% precision, 98.5% recall, and 97.4% F1, improved classification performance by 12.8-53.9% over rule-based methods, and detected over six times as many complication events compared to using structured data alone. Using these additional events to assess complication-free survivorship of different implant systems, we found significant variation between implants, including for risk of revision surgery, which could not be detected using coded data alone. Patients with revision surgeries had more hip pain mentions in the post-hip replacement, pre-revision period compared to patients with no evidence of revision surgery (mean hip pain mentions 4.97 vs. 3.23; t = 5.14; p < 0.001). Some implant models were associated with higher or lower rates of hip pain mentions. Our methods complement existing surveillance mechanisms by requiring orders of magnitude less hand-labeled training data, offering a scalable solution for national medical device surveillance using electronic health records.

  View details for DOI 10.1038/s41746-019-0168-z

  View details for PubMedID 31583282

  View details for PubMedCentralID PMC6761113

• Statin use is associated with less postoperative cardiac arrhythmia after total hip arthroplasty. Hip international : the journal of clinical and experimental research on hip pathology and therapy Chen, M. J., Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Aaronson, A. J., Amanatullah, D. F. 2018: 1120700018816091

  Abstract

  INTRODUCTION:: While statins have been found to reduce postoperative atrial fibrillation after cardiac surgery, little is known about their use in total hip arthroplasty (THA). This study investigated if statins would similarly reduce postoperative arrhythmias in patients undergoing THA.METHODS:: We queried a large Medicare and private-payer database from 2005 to 2012 and identified 12,075 patients who were on a statin prior to THA. We then age and sex matched 34,446 non-statin users who underwent THA. Baseline comorbidities and postoperative complications were obtained and assessed via standard descriptive statistics.RESULTS:: The statin users had more preoperative comorbidities including congestive heart failure, valvular heart disease, pulmonary and renal disease, diabetes, hypertension, obesity, and anaemia (all p values < 0.001). Postoperatively, the statin users had a statistically higher 90-day incidence of transfusion, acute renal failure, heart failure, pneumonia, and sepsis/shock. All new-onset cardiac arrhythmia was significantly less frequent in the statin group at 2weeks (3.88% vs. 4.72%, p < 0.001), 30days (4.47% vs. 5.29%, p < 0.001), and 90days (5.44% vs. 6.31%, p = 0.001) postoperative. There was no difference in the frequency of venous thromboembolism, myocardial infarction, postoperative anaemia, or bleeding at 90days postoperative.DISCUSSION:: Despite being medically sicker at baseline with multiple risk factors for atrial fibrillation compared to the non-statin users, the statin users displayed a consistently lower occurrence of postoperative cardiac arrhythmia in this retrospective cohort study. Statins may therefore be beneficial in the preoperative optimisation of medically complex patients undergoing THA.

  View details for PubMedID 30526117

• Can a Conical Implant Successfully Address Complex Anatomy in Primary THA? Radiographs and Hip Scores at Early Followup (vol 474, pg 459, 2016) CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Zhang, G., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2018; 476 (12): 2458

  View details for DOI 10.1097/CORR.0000000000000540

  View details for Web of Science ID 000457619900027

• Erratum to: Can a Conical Implant Successfully Address Complex Anatomy in Primary THA? Radiographs and Hip Scores at Early Followup. Clinical orthopaedics and related research Zhang, G., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2018; 476 (12): 2458

  View details for PubMedID 30427315

• Proximal Femoral Shape Changes the Risk of a Leg Length Discrepancy After Primary Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Lim, Y., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2018; 33 (12): 3699–3703

  View details for DOI 10.1016/j.arth.2018.08.008

  View details for Web of Science ID 000450300700019

• The Unintended Impact of the Removal of Total Knee Arthroplasty From the Center for Medicare and Medicaid Services Inpatient-Only List JOURNAL OF ARTHROPLASTY Yates, A. J., Kerr, J. M., Froimson, M. I., Della Valle, C. J., Huddleston, J. I. 2018; 33 (12): 3602–6

  View details for DOI 10.1016/j.arth.2018.09.043

  View details for Web of Science ID 000450300700003

• Suboptimal patellofemoral alignment is associated with poor clinical outcome scores after primary total knee arthroplasty. Archives of orthopaedic and trauma surgery Narkbunnam, R., Electricwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2018

  Abstract

  BACKGROUND: Proper patellofemoral alignment is an important goal in total knee arthroplasty (TKA). Acceptable patellar alignment is defined as patellar tilt less than or equal to 5° and patellar displacement less than or equal to 5mm. Previous studies reported an incidence of post-operative patellar malalignment in TKA from 7 to 35%. However, correlation between patellar malalignment and clinical outcome after TKA remains unclear. The purpose of the present study was to evaluate the effect of patellar tilt and displacement on the clinical outcome of TKA.METHODS: A retrospective review of 138 primary TKAs with a minimum of 2 year follow-up is reported. Pre-operative and post-operative mechanical axis, patellar tilting angle and patellar displacement were measured. Clinical outcomes were evaluated by the knee functional scores including the Knee Society Score (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS), and Western Ontario McMaster University Osteoarthritis Index (WOMAC) at final follow-up.RESULTS: Forty-two (30%) primary TKAs had suboptimal patellofemoral alignment with a patellar tilt angle greater than 5° or lateral patellar displacement of more than 5mm. There was no statistical difference in pre-operative mechanical axis, pre-operative patellar tilt angle, or pre-operative lateral patellar displacement between the primary TKAs with proper patellofemoral alignment and those with suboptimal alignment. Patients with post-operative patellar tilt or displacement had clinically significant reductions in KSS, KOOS, and WOMAC when compared with patients without post-operative patellar tilt or displacement. The odds of having a fair or poor post-operative result, an odds ratio of 3.4 (95% CI 1.6-7.2) for KSS, 6.4 (95% CI 2.9-14.2) for KOOS, and 5.9 (95% CI 2.6-13.5) for WOMAC, were associated with suboptimal patellofemoral alignment.CONCLUSION: Establishing proper patellofemoral alignment remains an essential goal of primary TKA. There is a strong association between suboptimal post-operative patellofemoral alignment and poor clinical outcome scores after primary TKA.

  View details for PubMedID 30483917

• Effect of Computer Navigation on Complication Rates Following Unicompartmental Knee Arthroplasty JOURNAL OF ARTHROPLASTY Chona, D., Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. E. 2018; 33 (11): 3437-+

  View details for DOI 10.1016/j.arth.2018.06.030

  View details for Web of Science ID 000446993500014

• Surgery Before Subspecialty Referral for Periprosthetic Knee Infection Reduces the Likelihood of Infection Control CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Song, S., Goodman, S. B., Suh, G., Finlay, A. K., Huddleston, J. I., Maloney, W. J., Amanatullah, D. F. 2018; 476 (10): 1995–2002

  View details for DOI 10.1097/CORR.0000000000000423

  View details for Web of Science ID 000452515700021

• The Unintended Impact of the Removal of Total Knee ArthroplastyFrom the Center for Medicare and Medicaid ServicesInpatient-Only List. The Journal of arthroplasty Yates, A. J., Kerr, J. M., Froimson, M. I., Della Valle, C. J., Huddleston, J. I. 2018

  Abstract

  BACKGROUND: Total knee arthroplasty (TKA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) list starting January 1, 2018. Many hospitals responded by instructing surgeons to schedule all TKAs as outpatient procedures, and some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases. This activity and ensuing confusion has caused considerable unintended disruption for surgeons, hospitals, and patients. The purpose of this study was to gauge the impact on providers and patients.METHODS: Active members of the American Association of Hip and Knee Surgeons were sent a 9-question survey asking if the surgeon's hospital was treating all patients undergoing TKA as outpatients and if Medicare Advantage administrators and commercial payers were treating all or most the same. Questions also inquired about the impact on surgeon practices and their patients.RESULTS: Seven hundred thirty members (26%) responded; of which, 59.5% reported that their hospitals have instructed them that all Medicare TKAs should be scheduled as outpatient procedures; 40.5% have been asked to use proscribed documentation to justify that change; 30.4% reported that their patients have incurred added personal cost secondary to their surgical procedure being billed as an outpatient procedure; and 76.1% report that this issue has become an administrative burden.CONCLUSION: The CMS clearly stated its expectation in the 2018 Outpatient Prospective Payment System Final Rule that the great majority of Medicare fee-for-service TKA patients would continue to be treated as inpatients. Nonetheless, many hospitals have decided to schedule all TKA cases as outpatients due to the 2-midnight rule despite a moratorium on recovery audits. It is the position of the American Association of Hip and Knee Surgeons that the CMS needs to provide more specific expectations concerning the needed language justifying admission or exempt TKA from the 2-midnight rule to mitigate the unintended confusion demonstrated by hospitals and some payers that has resulted from the removal of TKA from the Inpatient-Only list.

  View details for PubMedID 30318252

• Surgery Before Subspecialty Referral for Periprosthetic Knee Infection Reduces the Likelihood of Infection Control. Clinical orthopaedics and related research Song, S. Y., Goodman, S. B., Suh, G., Finlay, A. K., Huddleston, J. I., Maloney, W. J., Amanatullah, D. F. 2018

  Abstract

  BACKGROUND: Failure to control a periprosthetic joint infection (PJI) often leads to referral of the patient to a tertiary care institution. However, there are no data regarding the effect of prior surgical intervention for PJI on subsequent infection control.QUESTIONS/PURPOSES: (1) Is the likelihood of 2-year infection-free survival worse if an initial surgery for PJI was performed before referral to a tertiary care center when compared with after referral for definitive treatment? (2) Is the likelihood of identifying a causal organism during PJI worse if the initial surgery for PJI was performed before referral to a tertiary care center when compared with after referral for definitive treatment? (3) We calculated how many patients are harmed by the practice of surgically attempting to treat PJI before referral to a tertiary care center when compared with treatment after referral to a tertiary care center for definitive treatment.METHODS: Among 179 patients (182 TKAs) who were referred for PJI between 2004 and 2014, we retrospectively studied 160 patients (163 TKAs) who had a minimum of 2 years of followup after surgical treatment or had failure of treatment within 2 years. Nineteen TKAs (19 patients) were excluded from the study; 13 patients (7%) had < 2-year followup, three patients had infected periprosthetic fractures, and three patients had infected extensor mechanism reconstruction. Eighty-six patients (88 TKAs, two bilateral [54%]) had no surgical treatment before referral to our institution for PJI management, and 75 patients (75 TKAs [46%]) had PJI surgery before referral. The mean followup was 2.4 ± 1.2 years for patients with PJI surgery before referral and 2.8 ± 1.3 years for patients with no surgery before referral (p = 0.065). Infection-free survival was defined as prosthesis retention without further surgical intervention or antibiotic suppression. During the period, further surgical intervention generally was performed after failure of irrigation and debridement, a one- or two-stage procedure, or between stages of a two-stage reimplantation without documentation of an eradiated infection, and antibiotic suppression generally was used when patients were not medically sound for surgical intervention or definitive implants were placed after the second of a two-stage procedure with positive cultures; these criteria were applied similarly to all patients during this time period in both study groups. Endpoints were assessed using a longitudinally maintained institutional database, and the treating surgeons were not involved in data abstraction. Relative and absolute risk reductions with 95% confidence intervals (CIs) as well as a Kaplan-Meier survival curve with a Cox proportional hazard model were used to evaluate survival adjusting for significant covariates. The number needed to harm is calculated as the number needed to treat. It is the reciprocal of the absolute risk reduction or production by an intervention.RESULTS: The cumulative infection-free survival rate of TKAs at 2 years or longer was worse when PJI surgery was performed before referral to a tertiary center (80%; 95% CI, 69%-87%) compared with when no PJI surgery was performed before referral (94%; 95% CI, 87%-98%; log-rank test p = 0.006). Additionally, PJI surgery before referral resulted in a lower likelihood of causative microorganism identification (52 of 75 [69%]) compared with patients having surgery at the tertiary center (77 of 88 [88%]; odds ratio, 2.71; 95% CI, 1.28-4.70; p = 0.006). With regard to the infection-free survival rate of TKAs, the number needed to harm was 7.0 (95% CI, 4.1-22.5), meaning the referral of less than seven patients to a tertiary care center for definitive surgical management of PJI before intervention at the referring hospital prevents one infection-related failure. With regard to the culture negativity in PJI, the number needed to harm was 5.5 (95% CI, 3.3-16.7), meaning the referral of less than six patients to a tertiary care institution for PJI before surgery at the outside hospital prevents the diagnosis of one culture-negative infection.CONCLUSIONS: Surgical treatment of a PJI before referral for subspecialty surgical management increases the risk of failure of subsequent surgical management. The prevalence of culture-negative PJI was much higher if surgery was attempted before referral to a tertiary care center when compared with referral before treatment. This suggests that surgical treatment of PJI before referral to a treating center with specialized expertise in PJI compromises the infection-free survival and impacts infecting organism isolation.LEVEL OF EVIDENCE: Level III, therapeutic study.

  View details for PubMedID 30179927

• Proximal Femoral Shape Changes the Risk of a Leg Length Discrepancy After Primary Total Hip Arthroplasty. The Journal of arthroplasty Lim, Y. W., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2018

  Abstract

  BACKGROUND: To evaluate how canal morphology affects the technical aspects of total hip arthroplasty, we investigated the effects of femoral cortical index (FCI) on the re-establishment of leg length at the conclusion of surgery.METHODS: We retrospectively reviewed age, gender, body mass index, and radiographs of 516 patients with osteoarthritis or osteonecrosis who underwent unilateral cementless primary total hip arthroplasty between 2008 and 2015. Patients were divided into level of FCI and leg length discrepancy (LLD). Each cohort was compared in terms of demographics and LLD. One-way analysis of variance and Kruskal-Wallis test were used.RESULTS: The mean FCI and LLD were 0.6 ± 0.1 and 3.5 ± 6.3 mm, respectively. Utilization of an extended offset stem was highest with Dorr type A and B hips (P= .001). High FCI increased the risk of lengthening (P= .017) and low FCI increased the risk of shortening (P= .005).CONCLUSION: A high FCI increases the probability of a leg length increase and a low FCI increases the probability of a leg length decrease. Surgeons might consider informing patients in advance of possible variation in leg length depending on the patients' proximal femoral shape and bony quality.

  View details for PubMedID 30173942

• Effect of Computer Navigation on Complication Rates Following Unicompartmental Knee Arthroplasty. The Journal of arthroplasty Chona, D., Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2018

  Abstract

  BACKGROUND: We evaluated whether the complication and revision rates of unicompartmental knee arthroplasty (UKA) performed with intraoperative computer-based navigation differ from standard UKAs performed without intraoperative computer-based navigation.METHODS: A Medicare database containing administrative claims data from 2005 to 2014 was queried. Patients who underwent a single UKA and had a minimum of 2 years of follow-up were included in the study. Data from 1025 UKAs performed with navigation were compared against 9228 age and gender-matched UKAs performed without it. Postoperative complications were identified using International Classification of Diseases, Ninth Revision, codes and evaluated at 30 days, 90 days, and 2 years.RESULTS: Orthopedic complications after UKA are rare, and the use of navigation did not affect the rate of conversion to total knee arthroplasty at 2-year follow-up (3.8% in navigated UKAs vs 4.7% in standard UKAs, P= .218). There were also no significant differences in the rates of knee arthrotomy at 2-year follow-up (1.3% in navigated UKAs vs 1.6% in standard UKAs, P= .379). The rates of deep vein thrombosis at 90-day follow-up did not significantly differ between the 2 groups (1.4% in navigated UKAs vs 2.0% in standard UKAs, P= .157).CONCLUSION: This is one of the first studies to use a large cohort to compare outcomes in computer-assisted surgery-UKA against standard UKAs without navigation. The results, particularly that there was not a difference in the rate of conversion to total knee arthroplasty, are directly relevant to clinical decision-making when surgeons are considering employing navigation during UKA.

  View details for PubMedID 30033063

• Abundant heterotopic bone formation following use of rhBMP-2 in the treatment of acetabular bone defects during revision hip arthroplasty. Arthroplasty today Arzeno, A., Wang, T., Huddleston, J. I. 2018; 4 (2): 162–68

  Abstract

  Revision hip arthroplasty in the setting of periacetabular bone loss presents a significant challenge, as options for restoring bone loss are limited. Recombinant human bone morphogenetic protein-2 may offer a solution by promoting bone growth to restore bone stock before implant reimplantation. Here we present a case of a patient with a periprosthetic acetabulum fracture, resulting in pelvic discontinuity as the result of significant periacetabular bone loss. Using a staged approach, periacetabular bone stock was nearly entirely reconstituted using recombinant BMPs and allograft, which resulted in stable fixation, but with abundant heterotopic bone formation. Recombinant BMP-2 offers a useful tool for restoring bone stock in complex hip arthroplasty revision cases with periacetabular bone loss; however, caution must be used as overabundant bone growth as heterotopic ossification may result.

  View details for PubMedID 29896546

• Protocol-Driven Revision for Stiffness After Total Knee Arthroplasty Improves Motion and Clinical Outcomes. The Journal of arthroplasty Hug, K. T., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2018

  Abstract

  BACKGROUND: Stiffness after revision total knee arthroplasty (TKA) is a difficult problem without a well-defined treatment algorithm. The purpose of this study was to evaluate the results of revision TKA for stiffness within the context of differential component replacement.METHODS: Consecutive patients who underwent revision TKA were retrospectively identified and included those who received debridement and polyethylene liner exchange alone, revision of only one of the femoral or tibial fixed components, or revision of all components. Preoperative and postoperative range of motion and Knee Society score (KSS) were collected.RESULTS: Sixty-nine knees were included in the study group with a mean follow-up of 43 months (range, 12-205 months). The mean prerevision flexion contracture of 17° improved to 5° after surgical intervention (P < .001). Similarly, mean flexion and motion arc improved from 70° to 92° and from 53° to 87°, respectively (P < .001). Mean KSS knee scores improved from 42 to 70 and KSS function scores improved from 41 to 68 (P < .001). Mean arc of motion improved by 45° in patients who underwent complete component revision, 32° with component retention, and 29° with single component revision (P= .046). KSS knee scores improved by 34, 25, and 28 points in these respective groups (P= .049). KSS function scores improved by 33, 27, and 25 points (P= .077).CONCLUSION: Revision surgery with or without component revision can improve motion and function in patients with stiffness after TKA. Complete component revision may offer the largest improvements in these outcome measures in properly selected patients.

  View details for DOI 10.1016/j.arth.2018.05.013

  View details for PubMedID 29859726

• Medial Overhang of the Tibial Component Is Associated With Higher Risk of Inferior Knee Injury and Osteoarthritis Outcome Score Pain After Knee Replacement JOURNAL OF ARTHROPLASTY Nielsen, C. S., Nebergall, A., Huddleston, J., Kallemose, T., Malchau, H., Troelsen, A. 2018; 33 (5): 1394–98

  Abstract

  The aim of this prospective multicenter study is to investigate the association among (1) tibial site-specific overhang of medial, anterior, and lateral overhang in relation to Knee Injury and Osteoarthritis Outcome Score pain 1 year after surgery (1 Y KOOS pain) and (2) the malalignment of TKA components including overall malalignment in relation to 1 Y KOOS pain.From 10 centers, across 4 continents, 323 patients were enrolled from October 2011 to February 2014. Radiographs were analyzed for tibial overhang on medial, anterior, and lateral site and for overall, tibial, femur, and combined malalignment. A 1 Y KOOS pain score <70 represented an unsatisfactory pain level.A significant association was observed between medial overhang and 1 Y KOOS pain with a cut-off of <70 (P = .04), with an odds ratio of 0.46. No significant associations were observed among the independent variables of lateral and anterior overhang or for overall, tibial, femoral, and combined component malalignment, and the dependent variable of 1 Y KOOS pain <70.This prospective multicenter study showed a significant association between medial overhang of the tibial component and a 1 Y KOOS pain <70. The related odds ratio was 0.46, which demonstrates that medial overhang may lead to a 54% reduced chance for entering an acceptable pain category 1 year after surgery when receiving a TKA.

  View details for PubMedID 29452971

• Obesity Is Independently Associated With Early Aseptic Loosening in Primary Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Goodnough, L. H., Finlay, A. K., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2018; 33 (3): 882–86

  Abstract

  Obesity affects millions of patients in the United States and is associated with several complications after total hip arthroplasty (THA). The effect of obesity on the rate and mode of primary THA failure remains poorly understood, especially given other potentially confounding patient characteristics. We hypothesized that, among patients with a failed primary THA, obesity is independently associated with aseptic loosening and a higher rate of early revision.Six hundred eighty-four consecutive cases with failed THA referred to a single academic center for revision during a 10-year period were retrospectively reviewed. Multivariate logistic regression analysis was used to test the independent association between obesity and the timing as well as cause of THA failure.The rate of primary THA failure before 5 years was 48.8% in obese and 37.1% in nonobese patients (odds ratio [OR] = 1.57, P = .010). Primary THA failure before 5 years was more likely with increasing body mass index (BMI) (BMI: 35-40 kg/m2, OR = 2.31, P = .008; BMI >40 kg/m2, OR = 2.51, P = .049). The rate of primary THA failure for aseptic loosening before 5 years was 30% in obese and 18% in nonobese patients (OR = 1.88, P = .023). Obesity was not a risk for revision for infection, whereas an American Society of Anesthesiologists class ≥3 was independently associated with primary THA failure for infection (OR = 2.33, P < .001).Among patients with a failed THA, comorbidities may account for the risk of revision due to infection in obese patients. Obesity is independently associated with early primary THA failure for aseptic loosening.

  View details for DOI 10.1016/j.arth.2017.09.069

  View details for Web of Science ID 000425893000046

  View details for PubMedID 29089226

• Outcome of 4 Surgical Treatments for Wear and Osteolysis of Cementless Acetabular Components (vol 32, pg 2799, 2017) JOURNAL OF ARTHROPLASTY Narkbunnam, R., Amanatullah, D. F., Electricwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2018; 33 (1): 308

  View details for DOI 10.1016/j.arth.2017.10.001

  View details for Web of Science ID 000418761100061

• Corrigendum to Outcome of 4 Surgical Treatments for Wear and Osteolysis of Cementless Acetabular Components [The Journal of Arthroplasty 32 (2017) 2799-2805]. The Journal of arthroplasty Narkbunnam, R., Amanatullah, D. F., Electricwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2018; 33 (1): 308

  View details for PubMedID 29107500

• Clinical Faceoff: How Does Patient Satisfaction Fit Into the Value Equation? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Delanois, R. E., Mont, M. A., Huddleston, J. I. 2018; 476 (1): 21–24

  View details for PubMedID 29389756

• Do Patient Expectations Influence Patient-Reported Outcomes and Satisfaction in Total Hip Arthroplasty? A Prospective, Multicenter Study JOURNAL OF ARTHROPLASTY Jain, D., Bendich, I., Nguyen, L. L., Nguyen, L. L., Lewis, C. G., Huddleston, J. I., Duwelius, P. J., Feeley, B. T., Bozic, K. J. 2017; 32 (11): 3322–27

  Abstract

  The relationship between patient expectations and patient-reported outcomes (PROs) in total hip arthroplasty (THA) patients is controversial. The purpose of this study was to examine the impact of preoperative patient expectations on postoperative PROs and patient satisfaction.This was a prospective multicenter observational cohort study of primary THA patients. Preoperatively, patients completed Hospital for Special Surgery (HSS) Hip Replacement Expectations Survey (expectations), 12 item Short Form Survey (SF-12), University of California, Los Angeles (UCLA) activity score, and Hip Disability and Osteoarthritis Score (HOOS). Postoperatively at 6 months and 1 year, patients completed the Hospital for Special Surgery Hip Replacement Fulfillment of Expectations Survey (fulfillment of expectations), a satisfaction survey, and the same PROs as preoperatively. Stepwise multivariate regression models were created.A total of 207 patients were enrolled. Follow-up rate was 91% at 6 months and 92% at 1 year. Being employed and lower baseline HOOS predicted higher expectations (employment status: B = -7.5, P = .002; HOOS: B = -0.27, P = .002). Higher preoperative expectations predicted greater improvements in UCLA activity, SF-12 physical component score, and HOOS at 6 months (UCLA activity: B = 0.03, P = .001; SF-12 physical component score: B = 0.15, P = .001; HOOS: B = 0.20; P = .008) and UCLA activity at 1 year (B = 0.02, P = .004). Furthermore, higher expectations predicted higher postoperative satisfaction and fulfillment of expectations at 6 months (satisfaction: B = 0.21, P < .001; fulfillment of expectations: B = 0.30, P < .001) and higher fulfillment of expectations at 1 year (B = 0.17, P = .006).In patients undergoing THA, being employed and worse preoperative hip function predict of higher preoperative expectations of surgery. Higher expectations predict greater improvement in PROs, greater patient satisfaction, and the fulfillment of expectations. These findings can be used to guide patient counseling and shared decision making preoperatively.

  View details for PubMedID 28693888

• Response to Letter to the Editor on "Weight Gain After Primary Total Knee Arthroplasty is Associated With Accelerated Time to Revision for Aseptic Loosening" JOURNAL OF ARTHROPLASTY Lim, C. T., Goodman, S. B., Huddleston, J. I., Harris, A. S., Bhowmick, S., Maloney, W. J., Amanatullah, D. F. 2017; 32 (10): 3258

  View details for PubMedID 28705544

• Continuous Femoral Nerve Catheters Decrease Opioid-Related Side Effects and Increase Home Disposition Rates Among Geriatric Hip Fracture Patients. Journal of orthopaedic trauma Arsoy, D., Gardner, M. J., Amanatullah, D. F., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Bishop, J. A. 2017; 31 (6): e186-e189

  Abstract

  To evaluate the effect of continuous femoral nerve catheter (CFNC) for postoperative pain control in geriatric proximal femur fractures compared with standard analgesia (SA) treatment.Retrospective comparative study.Academic Level 1 trauma center.We retrospectively identified 265 consecutive geriatric hip fracture patients who underwent surgical treatment.One hundred forty-nine patients were treated with standard analgesia without nerve catheter whereas 116 patients received an indwelling CFNC.Daily average preoperative and postoperative pain scores, daily morphine equivalent consumption, opioid-related side effects and discharge disposition.Patients with CFNC patients reported lower average pain scores preoperatively (1.9 ± 1.7 for CFNC vs. 4.7 ± 2 for SA; P < 0.0001), on postoperative day 1 (1.5 ± 1.6 for CFNC vs. 3 ± 1.7 for SA; P < 0.0001) and postoperative day 2 (1.2 ± 1.5 for CFNC vs. 2.6 ± 2.1 for SA; P < 0.0001). CFNC group consumed 39% less morphine equivalents on postoperative day 1 (4.4 ± 5.8 mg for CFNC vs. 7.2 ± 10.8 mg for SA; P = 0.005) and 50% less morphine equivalent on postoperative day 2 (3.4 ± 4.4 mg for CFNC vs. 6.8 ± 13 mg for SA; P = 0.105). Patients with CFNC had a lower rate of opioid-related side effects compared with patients with SA (27.5% for CFNC vs. 47% for SA; P = 0.001). More patients with CFNC were discharged to home with or without health services than patients with SA (15% for CFNC vs. 6% for SA; P = 0.023).Continuous femoral nerve catheter decreased daily average patient-reported pain scores, narcotic consumption while decreasing the rate of opioid-related side effects. Patients with CFNC were discharged to home more frequently.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000854

  View details for PubMedID 28538458

• The effect of desflurane versus propofol anesthesia on postoperative delirium in elderly obese patients undergoing total knee replacement: A randomized, controlled, double-blinded clinical trial. Journal of clinical anesthesia Tanaka, P., Goodman, S., Sommer, B. R., Maloney, W., Huddleston, J., Lemmens, H. J. 2017; 39: 17-22

  Abstract

  The goal of this study was to investigate the incidence of delirium, wake-up times and early post-operative cognitive decline in one hundred obese elderly patients undergoing total knee arthroplasty.Prospective randomized trial.Operating room, postoperative recovery area, hospital wards.100 obese patients (ASA II and III) undergoing primary total knee replacement under general anesthesia with a femoral nerve block catheter.Patients were prospectively randomized to maintenance anesthesia with either propofol or desflurane.The primary endpoint assessed by a blinded investigator was delirium as measured by the Confusion Assessment Method. Secondary endpoints were wake-up times and a battery of six different tests of cognitive function.Four of the 100 patients that gave informed consent withdrew from the study. Of the remaining 96 patients, 6 patients did not complete full CAM testing. Preoperative pain scores, durations of surgery and anesthesia, and amount of intraoperative fentanyl were not different between groups. One patient in the propofol group developed delirium compared to zero in desflurane. One patient in desflurane group developed a confused state not characterized as delirium. Fifty percent of the patients exhibited a 20% decrease in the results of at least one cognitive test on the first 2days after surgery, with no difference between groups. There were no differences in the time to emergence from anesthesia, incidence of postoperative nausea and vomiting, and length of postanesthesia care unit (PACU) stay between the two groups.In conclusion we found a low incidence of delirium but significant cognitive decline in the first 48h after surgery. In this relatively small sample size of a hundred patients there was no difference in the incidence of postoperative delirium, early cognitive outcomes, or wake up times between the desflurane or propofol group.

  View details for DOI 10.1016/j.jclinane.2017.03.015

  View details for PubMedID 28494898

• Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors? Clinical orthopaedics and related research Bala, A., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2017

  Abstract

  There is considerable debate regarding the ideal agent for venous thromboembolism (VTE) prophylaxis after TKA. Numerous studies and meta-analyses have yet to provide a clear answer and often omit one or more of the commonly used agents such as aspirin, warfarin, enoxaparin, and factor Xa inhibitors.Using a large database analysis, we asked: (1) What are the differences in VTE incidence in primary TKA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors? (2) What are the differences in bleeding risk among these four agents? (3) How has use of these agents changed with time?We queried a combined Humana and Medicare database between 2007 and Quarter 1 of 2016, and identified all primary TKAs performed using ICD-9 and Current Procedural Terminology codes. All patients who had any form of antiplatelet or anticoagulation prescribed within 1 year before TKA were excluded from our study cohort. We then identified patients who had either aspirin, warfarin, enoxaparin, or factor Xa inhibitors prescribed within 2 weeks of primary TKA. Each cohort was matched by age and sex. Elixhauser comorbidities and Charlson Comorbidity Index for each group were calculated. We identified 1016 patients with aspirin, and age- and sex-matched 6096 patients with enoxaparin, 6096 patients with warfarin, and 5080 patients with factor Xa inhibitors. Using ICD-9 codes, with the understanding that patients at greater risk may have had more-attentive surveillance, the incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications (bleeding requiring surgical intervention, hemorrhage, hematoma, hemarthrosis), postoperative anemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days postoperatively. A four-way chi-squared test was used to determine statistical significance. Utilization was calculated using compound annual growth rate.There was a difference in the incidence of DVT at 90 days (p < 0.01). Factor Xa inhibitors (2.9%) had the lowest incidence of DVT followed by aspirin (3.0%) and enoxaparin (3.5%), and warfarin (4.8%). There was a difference in the incidence of PE at 90 days (p < 0.01). Factor Xa inhibitors (0.9%) had the lowest incidence of PE followed by enoxaparin (1.1%), aspirin (1.2%), and warfarin (1.6%). There was a difference in the incidence of postoperative anemia at 90 days (p < 0.01). Aspirin (19%) had the lowest incidence of postoperative anemia followed by warfarin (22%), enoxaparin (23%), and factor Xa inhibitors (23%). There was a difference in the incidence of a blood transfusion at 90 days (p < 0.01). Aspirin (7%) had the lowest incidence of a blood transfusion followed by factor Xa inhibitors (9%), warfarin (12%), and enoxaparin (13%). There were no differences in bleeding-related complications (p = 0.81) between the groups. Aspirin use increased at a compound annual growth rate of 30%, enoxaparin at 3%, and factor Xa inhibitors at 43%, while warfarin use decreased at a compound annual growth rate of -3%.Factor Xa inhibitors had the highest growth in utilization during our study period, followed by aspirin, when compared with enoxaparin and warfarin. When selected for the right patient, factor Xa inhibitors provided improved VTE prophylaxis compared with enoxaparin and warfarin, with a lower rate of blood transfusion. Aspirin provided comparable VTE prophylaxis compared with factor Xa inhibitors with improved VTE prophylaxis compared with enoxaparin and warfarin with the lowest risk of bleeding.Level III, therapeutic study.

  View details for DOI 10.1007/s11999-017-5394-6

  View details for PubMedID 28569372

• Radiographic scoring system for the evaluation of stability of cementless acetabular components in the presence of osteolysis BONE & JOINT JOURNAL Narkbunnam, R., Amanatullah, D. F., Electricwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2017; 99-B (5): 601-606

  Abstract

  The stability of cementless acetabular components is an important factor for surgical planning in the treatment of patients with pelvic osteolysis after total hip arthroplasty (THA). However, the methods for determining the stability of the acetabular component from pre-operative radiographs remain controversial. Our aim was to develop a scoring system to help in the assessment of the stability of the acetabular component under these circumstances.The new scoring system is based on the mechanism of failure of these components and the location of the osteolytic lesion, according to the DeLee and Charnley classification. Each zone is evaluated and scored separately. The sum of the individual scores from the three zones is reported as a total score with a maximum of 10 points. The study involved 96 revision procedures which were undertaken for wear or osteolysis in 91 patients between July 2002 and December 2012. Pre-operative anteroposterior pelvic radiographs and Judet views were reviewed. The stability of the acetabular component was confirmed intra-operatively.Intra-operatively, it was found that 64 components were well-fixed and 32 were loose. Mean total scores in the well-fixed and loose components were 2.9 (0 to 7) and 7.2 (1 to 10), respectively (p < 0.001). In hips with a low score (0 to 2), the component was only loose in one of 33 hips (3%). The incidence of loosening increased with increasing scores: in those with scores of 3 and 4, two of 19 components (10.5%) were loose; in hips with scores of 5 and 6, eight of 19 components (44.5%) were loose; in hips with scores of 7 or 8, 13 of 17 components (70.6%) were loose; and for hips with scores of 9 and 10, nine of nine components (100%) were loose. Receiver-operating-characteristic curve analysis demonstrated very good accuracy (area under the curve = 0.90, p < 0.001). The optimal cutoff point was a score of ≥ 5 with a sensitivity of 0.79, and a specificity of 0.87.There was a strong correlation between the scoring system and the probability of loosening of a cementless acetabular component. This scoring system provides a clinically useful tool for pre-operative planning, and the evaluation of the outcome of revision surgery for patients with loosening of a cementless acetabular component in the presence of osteolysis. Cite this article: Bone Joint J 2017;99-B:601-6.

  View details for DOI 10.1302/0301-620X.99B5.BJJ-2016-0968.R1

  View details for PubMedID 28455468

• Cortical Strut Allograft Support of Modular Femoral Junctions During Revision Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Lim, C. T., Amanatullah, D. F., Huddleston, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2017; 32 (5): 1586-1592

  Abstract

  There is risk of junction failure when using modular femoral stems for revision total hip arthroplasty (THA), especially with loss of bone stock in the proximal femur. Using a cortical strut allograft may provide additional support of a modular femoral construct in revision THA.We reviewed prospectively gathered clinical and radiographic data for 28 revision THAs performed from 2004 to 2014 using cementless modular femoral components with cortical strut allograft applied to supplement proximal femoral bone loss: 5 (18%) were fluted taper designs and 23 (82%) were porous cylindrical designs All the patients had a Paprosky grade IIIA or greater femoral defect. The mean follow-up was 5.4 ± 3.9 years.The Harris Hip Scores improved from 26 ± 10 points preoperatively to 71 ± 10 points at final follow-up (P < .001). The Western Ontario McMaster Universities Osteoarthritis Index scores improved from 45 ± 12 points preoperatively to 76 ± 12 points at final follow-up (P < .001). Eighty-nine percent (25 hips) of all revision or conversion THAs were in place at final follow-up. Three (11%) patients underwent reoperations, 2 for infection and 1 for periprosthetic fracture. There was no statistical significant change in femoral component alignment (P = .161) at final follow-up. Mean subsidence was 1.8 ± 1.3 mm at final follow-up. Femoral diameter increased from initial postoperative imaging to final follow-up imaging by a mean of 9.1 ± 5.1 mm (P < .001) and cortical width increased by a mean of 4.5 ± 2.2 mm (P < .001). Twenty-seven hips (96%) achieved union between the cortical strut allograft and the host femur.The use of a modular femoral stem in a compromised femur with a supplementary cortical strut allgraft is safe and provides satisfactory clinical and radiological outcomes.

  View details for DOI 10.1016/j.arth.2016.12.011

  View details for Web of Science ID 000401132100033

• Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Lim, C. T., Amanatullah, D. F., Huddleston, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2017; 32 (5): 1599-1605

  Abstract

  Cortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts.We reviewed prospectively gathered data on 50 revision THAs performed from 2004-2014 using an ETO. We compared the demographic, radiological, and clinical outcome of patients with (16 hips) and without (34 hips) cortical strut allograft after an ETO.There were no significant differences in Western Ontario McMaster Universities Osteoarthritis Index or Harris Hip Score between the ETOs with and without a cortical strut allograft. Fifteen of the ETOs (94%) with a cortical strut allograft and 31 of the ETOs (91%) without a cortical strut allograft were in situ at final follow-up (P = 1.000). A higher proportion hips with cortical strut allograft (100%, 16 patients) had preoperative Paprosky grade bone loss more than IIIA compared to those without allograft (29%, 10 patients) (P < .001). There were no differences in femoral stem subsidence (P = .207), alignment (P = .934), or migration of the osteotomized fragment (P = .171). Fourteen of the ETOs (88%) in patients with cortical strut allograft united compared to 34 ETOs (100%) in patients without allograft (P = .095).Our study shows that the use of cortical strut allograft during revision THA with ETO does not reduce the rate of union, radiological or clinical outcomes.

  View details for DOI 10.1016/j.arth.2016.12.002

  View details for Web of Science ID 000401132100035

• Outcome of 4 Surgical Treatments for Wear and Osteolysis of Cementless Acetabular Components. journal of arthroplasty Narkbunnam, R., Amanatullah, D. F., Electriwala, A. J., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2017

  Abstract

  Loosening and periprosthetic osteolysis are some of the most common long-term complications after hip arthroplasty. The decision-making process and surgical treatment options are controversial.We retrospectively reviewed 96 acetabular revisions (91 patients) performed between 2002 and 2012, with a minimum of 2 years of follow-up and a mean of 5.7 years of follow-up. Clinical outcome was assessed using the Harris Hip Score. The size and location of osteolytic lesions were evaluated using the preoperative radiographs; healing of the defects was categorized using a standardized protocol.Thirty-three (34.4%) hips had isolated liner exchanges (ILEs), 10 (10.4%) hips had cemented liners into well-fixed shells (CLS), 45 (46.9%) hips had full acetabular revisions (FARs), and 8 (8.3%) hips had revision with a roof ring/antiprotrusio cage (RWC). All procedures showed significant improvement in Harris Hip Score after revision (P ≤ .001). Fifteen patients had moderate residual pain (pain score ≤20): 8 (24%) ILE, 3 (30%) CLS, and 4 (9%) FAR. Complete bone defect healing after grafting was lower with acetabular component retention procedures (ILE and CLS; 27%) compared with full acetabular component revision procedures (FAR and RWC; 57%). Fifteen patients underwent reoperation: 3 ILE, 1 CLS, 8 FAR, and 3 RWC.Acetabular component retention demonstrates a low risk of reoperation; however, residual pain and limited potential for bone graft incorporation are a concern. FAR is technically challenging and may have an elevated risk of reoperation; however, higher degrees of bone graft incorporation and satisfactory clinical outcome can be expected.

  View details for DOI 10.1016/j.arth.2017.04.028

  View details for PubMedID 28587888

• Revision Hip Arthroplasty Using a Modular, Cementless Femoral Stem: Intermediate-Term Follow-Up JOURNAL OF ARTHROPLASTY Sivananthan, S., Lim, C., Narkbunnam, R., Sox-Harris, A., Huddleston, J. I., Goodman, S. B. 2017; 32 (4): 1245-1249

  Abstract

  Modular femoral stem provides flexibility in femoral reconstruction, ensuring improved "fit and fill". However, there are risks of junction failure and corrosion, as well as cost concerns in the use of modular femoral stems.We reviewed prospectively-gathered clinical and radiographic data on revision total hip arthroplasties (THAs) performed from 2001-2007 using modular, cementless femoral component performed by the 2 senior authors. Patients with a minimum follow-up of 7 years were included in this study.Sixty-four patients (68 hips) with a median age of 68 ± 14 years (range 40-92 years) at revision THA were included. The median follow-up was 11.0 ± 1.8 years (range 7-14). Harris hip score, femoral stem subsidence, and stem osseointegration were recorded. The Harris hip score improved from an average of 38.1-80.1 (P < .01). Five hips had one or more dislocations. Seven patients underwent reoperations, 3 of which did not involve the stem. Four stems required revision because of infection, recurrent dislocation, or suboptimal implant position. Survival rates for any reasons and revision for femoral stems were 90% and 94%, respectively, at the most recent follow-up. Four stems subsided more than 5 mm, but established stable osseointegration thereafter. Seven nonloose stems (10.2%) demonstrated radiolucent lines in Gruen zones 1 and 7. No complications regarding the modular junction were encountered.Modular, cementless, extensively porous-coated femoral components have demonstrated intermediate-term clinical and radiographic success. Initial distal intramedullary fixation ensures stability, and proximal modularity further maximizes fit and fill.

  View details for DOI 10.1016/j.arth.2016.10.033

  View details for Web of Science ID 000401125600036

• The Direct Anterior Approach is Associated With Early Revision Total Hip Arthroplasty. journal of arthroplasty Eto, S., Hwang, K., Huddleston, J. I., Amanatullah, D. F., Maloney, W. J., Goodman, S. B. 2017; 32 (3): 1001-1005

  Abstract

  The direct anterior approach for total hip arthroplasty (THA) has generated increased interest recently. The purpose of this study was to compare the duration to failure and reasons for revision of primary THA performed elsewhere and subsequently revised at our institution after the direct anterior vs other nonanterior surgical approaches to the hip.All primary THAs performed elsewhere and referred to our institution for revision were divided into the direct anterior approach (30 cases) or nonanterior approach groups (100 cases, randomly selected from 453 cases) based on the original surgical approach. Because all primary direct anterior THAs were originally performed after 2004 to eliminate temporal bias, we identified a subset of the nonanterior group in which the primary THA was performed after 2004 (known as the recent nonanterior group, 100 cases, randomly selected from 169 available cases).The mean duration from primary to revision THA was 3.0 ± 2.7 years (direct anterior approach), 12.0 ± 8.8 years (nonanterior approach), and 3.6 ± 2.8 years (recent nonanterior), respectively. There was a significant difference in time to revision between the direct anterior and nonanterior approach groups (P < .001). Aseptic loosening of the stem was significantly more frequent with the direct anterior approach group (9/30, 30.0%) when compared with the nonanterior group (8/100, 8.0%, P = .007) and the recent nonanterior group (7/100, 7.0%, P = .002).Revision of the femoral component for aseptic loosening is more commonly associated with the direct anterior approach in our referral practice.

  View details for DOI 10.1016/j.arth.2016.09.012

  View details for PubMedID 27843039

• Weight Gain After Primary Total Knee Arthroplasty Is Associated With Accelerated Time to Revision for Aseptic Loosening. journal of arthroplasty Lim, C. T., Goodman, S. B., Huddleston, J. I., Harris, A. H., Bhowmick, S., Maloney, W. J., Amanatullah, D. F. 2017

  Abstract

  Obesity is a major health problem worldwide and is associated with complications after total knee arthroplasty (TKA). It remains unknown whether a change in body mass index (BMI) after primary TKA affects the reasons for revision TKA or the time to revision TKA.A total of 160 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to change in BMI from the time of their primary TKA to revision TKA. The association between change in BMI and time to revision was also analyzed according to indication for revision of TKA using Pearson's chi-square test.The mean change in BMI from primary to revision TKA was 0.82 ± 3.5 kg/m(2). Maintaining a stable weight after primary TKA was protective against late revision TKA for any reason (P = .004). Patients who failed to reduce their BMI were revised for aseptic loosening earlier, at less than 5 years (P = .020), whereas those who reduced their BMI were revised later, at over 10 years (P = .004).Maintaining weight after primary TKA is protective against later revision TKA for any reason but failure to reduce weight after primary TKA is a risk factor for early revision TKA for aseptic loosening and osteolysis. Orthopedic surgeons should recommend against weight gain after primary TKA to reduce the risk of an earlier revision TKA in the event that a revision TKA is indicated.

  View details for DOI 10.1016/j.arth.2017.02.026

  View details for PubMedID 28318864

• Response to Letter to the Editor on 'Tibiofemoral Dislocation After Total Knee Arthroplasty' JOURNAL OF ARTHROPLASTY Jethanandani, R. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Amanatullah, D. F. 2017; 32 (2): 700-700

  View details for DOI 10.1016/j.arth.2016.10.021

  View details for PubMedID 27865569

• Higher Patient Expectations Predict Higher Patient-Reported Outcomes, But Not Satisfaction, in Total Knee Arthroplasty Patients: A Prospective Multicenter Study. journal of arthroplasty Jain, D., Nguyen, L. L., Bendich, I., Nguyen, L. L., Lewis, C. G., Huddleston, J. I., Duwelius, P. J., Feeley, B. T., Bozic, K. J. 2017

  Abstract

  The relationship between patient expectations, patient-reported outcomes (PROs), and satisfaction in total knee arthroplasty (TKA) patients is not well understood.We prospectively evaluated patients who underwent primary TKA at 4 institutions. Demographics were collected. Preoperatively, patients completed the Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), SF-12, UCLA activity, and Knee Disability and Osteoarthritis Score. At 6 months and 1 year postoperatively, patients completed the Hospital for Special Surgery Knee Replacement Fulfillment of Expectations Survey (HSS-KRFES), a satisfaction survey, and PROs. Step-wise multivariate regression models were created.Eighty-three patients were enrolled. At 6 months and 1 year postoperatively, the follow-up rate was 84.3% and 92.7%, respectively. No demographics or preoperative PROs were predictive of HSS-KRES. Preoperative HSS-KRES did not predict postoperative satisfaction, but higher HSS-KRES predicted higher HSS-KRFES at 1 year, greater improvement in UCLA activity at 6 months and 1 year, and SF-12 Physical Composite Scale and Knee Disability and Osteoarthritis Score at 6 months. Higher HSS-KRFES predicted higher satisfaction at 6 months and 1 year.In TKA patients, preoperative expectations are not influenced by patient demographics or preoperative function. Higher preoperative expectations predict greater postoperative improvement in PROs and fulfillment of expectations. These findings highlight the importance of preoperative patient expectations on postoperative outcome.

  View details for DOI 10.1016/j.arth.2017.01.008

  View details for PubMedID 28258830

• Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA surgery Hah, J., Mackey, S. C., Schmidt, P., McCue, R., Humphreys, K., Trafton, J., Efron, B., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J., Curtin, C., Carroll, I. 2017

  Abstract

  Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research.clinicaltrials.gov Identifier: NCT01067144.

  View details for PubMedID 29238824

• Socioeconomic Risk Adjustment Models for Reimbursement Are Necessary in Primary Total Joint Arthroplasty JOURNAL OF ARTHROPLASTY Courtney, P., Huddleston, J. I., Iorio, R., Markel, D. C. 2017; 32 (1): 1–5

  Abstract

  Alternative payment models, such as bundled payments, aim to control rising costs for total knee arthroplasty (TKA) and total hip arthroplasty (THA). Without risk adjustment for patients who may utilize more resources, concerns exist about patient selection and access to care. The purpose of this study was to determine whether lower socioeconomic status (SES) was associated with increased resource utilization following TKA and THA.Using the Michigan Arthroplasty Registry Collaborative Quality Initiative database, we reviewed a consecutive series of 4168 primary TKA and THA patients over a 3-year period. We defined lowest SES based upon the median household income of the patient's ZIP code. Demographics, medical comorbidities, length of stay, discharge destination, and readmission rates were compared between patients of lowest SES and higher SES.Patients in the lowest SES group had a longer hospital length of stay (2.79 vs 2.22 days, P < .001), were more likely to be discharged to a rehabilitation facility (27% vs 18%, P < .001), and be readmitted to the hospital within 90 days (11% vs 8%, P = .002) than the higher SES group. Multivariate analysis revealed that lowest SES was an independent risk factor for all 3 outcome variables (all P < .001).Patients in the lowest SES group utilize more resources in the 90-day postoperative period. Therefore, risk adjustment models, including SES, may be necessary to fairly compensate hospitals and surgeons and to avoid potential problems with access to joint arthroplasty care.

  View details for PubMedID 27506724

• Smoking is associated with earlier time to revision of total knee arthroplasty. The Knee Lim, C. T., Goodman, S. B., Huddleston, J. I., Harris, A. H., Bhowmick, S., Maloney, W. J., Amanatullah, D. F. 2017

  Abstract

  Smoking is associated with early postoperative complications, increased length of hospital stay, and an increased risk of revision after total knee arthroplasty (TKA). However, the effect of smoking on time to revision TKA is unknown.A total of 619 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to the patient smoking status. Smoking status was then analyzed for associations with time to revision TKA using a Chi square test. The association was also analyzed according to the indication for revision TKA.Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to non-smokers (274/357, 77%, p=0.031). Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to ex-smokers (168/221, 76%, p=0.028). Subgroup analysis did not reveal a difference in indication for revision TKA (p>0.05).Smokers are at increased risk of earlier revision TKA when compared to non-smokers and ex-smokers. The risk for ex-smokers was similar to that of non-smokers. Smoking appears to have an all-or-none effect on earlier revision TKA as patients who smoked more did not have higher risk of early revision TKA. These results highlight the need for clinicians to urge patients not to begin smoking and encourage smokers to quit smoking prior to primary TKA.

  View details for PubMedID 28797880

• Femoral Nerve Catheters Improve Home Disposition and Pain in Hip Fracture Patients Treated With Total Hip Arthroplasty. The Journal of arthroplasty Arsoy, D., Huddleston, J. I., Amanatullah, D. F., Giori, N. J., Maloney, W. J., Goodman, S. B. 2017

  Abstract

  Opioids have been the mainstay of treatment in the physiologically young geriatric hip fracture patient undergoing total hip arthroplasty (THA). However opioid-related side effects increase morbidity. Regional anesthesia may provide better analgesia, while decreasing opioid-related side effects. The goal of this study was to examine the effect of perioperative continuous femoral nerve blockade with regards to pain scores, opioid-related side effects and posthospital disposition in hip fracture patients undergoing THA.Twenty-nine consecutive geriatric hip fracture patients (22 women/7 men) underwent THA. Average follow-up was 8.3 months (6 weeks-39 months). Fifteen patients were treated with standard analgesia (SA). Fourteen patients received an ultrasound-guided insertion of a femoral nerve catheter after radiographic confirmation of a hip fracture. All complications and readmissions that occurred within 6 weeks of surgery were noted.Continuous femoral nerve catheter (CFNC) patients were discharged home more frequently than SA patients (43% for CFNC vs 7% for SA; P = .023). CFNC patients reported lower average pain scores preoperatively (P < .0001), on postoperative day 1 (P = .005) and postoperative day 2 (P = .037). Preoperatively, CFNC patients required 61% less morphine equivalent (P = .007). CFNC patients had a lower rate of opioid-related side effects compared with SA patients (7% vs 47%; P = .035).CFNC patients were discharged to home more frequently. Use of a CFNC decreased daily average patient-reported pain scores, preoperative opioid usage, and opioid-related side effects after THA for hip fracture. Based on these data, we recommend routine use of perioperative CFNC in hip fracture patients undergoing THA.

  View details for PubMedID 28641968

• Reconstruction of Disrupted Extensor Mechanism After Total Knee Arthroplasty. The Journal of arthroplasty Lim, C. T., Amanatullah, D. F., Huddleston, J. I., Harris, A. H., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2017

  Abstract

  Disruption of the extensor mechanism after total knee arthroplasty (TKA) is a debilitating complication that results in extension lag, limited range of motion, difficulty in walking, frequent falls, and chronic pain. This study presents the clinical and radiographic results of reconstruction after extensor mechanism disruption in TKA patients.Consecutive patients with allograft reconstruction of extensor mechanism after TKA were identified retrospectively from an academic tertiary center for revision TKA.Sixteen patients with a mean age of 61 ± 14 years at extensor mechanism reconstruction with a minimum of 2-year follow-up were included. The mean follow-up was 3.3 ± 2.2 years. Knee Society score (KSS), before and at final follow-up extension lag, range of motion, and radiographic change in patellar height were reviewed. There were statistically significant improvements between preoperative and final follow-up KSS (P < .001; KSS for pain, preoperative 40 ± 14 points to final follow-up 67 ± 15 points [P < .001]; KSS for function, preoperative 26 ± 21 points to final follow-up 48 ± 25 points [P < .001]). The extension lag was also reduced from 35° ± 16° preoperatively to 14° ± 18° (P < .001) at final follow-up. There was an average proximal patellar migration of 8 ± 10 mm. Five (31%) cases had an extensor lag of >30° or revision surgery for repeat extensor mechanism reconstruction, infection, or arthrodesis.Our 10-year experience using allografts during extensor mechanism reconstruction demonstrates reasonable outcomes, but failures are to be anticipated in approximately one-third of patients.

  View details for PubMedID 28634096

• Elevated Body Mass Index Is Associated With Early Total Knee Revision for Infection JOURNAL OF ARTHROPLASTY Electricwala, A. J., Jethanandani, R. G., Narkbunnam, R., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2017; 32 (1): 252-255

  Abstract

  Obesity affects over half a billion people worldwide, including one-third of men and women in the United States. Obesity is associated with higher postoperative complication rates after total knee arthroplasty (TKA). It remains unknown whether obese patients progress to revision TKA faster than nonobese patients.A total of 666 consecutive primary TKAs referred to an academic tertiary care center for revision TKA were retrospectively stratified according to body mass index (BMI), reason for revision TKA, and time from primary to revision TKA.When examining primary TKAs referred for revision TKA, increasing BMI adversely affected the mean time to revision TKA. The percent of referred TKAs revised by 5 years was 54% for a normal BMI, 64% for an overweight patient, 71% for an obese class I patient, 68% for an obese class II patient, and 73% for a morbidly obese patient. There was a significant difference in time to revision TKA between patients with normal BMI and elevated BMI (P = .005). There was a significant increase in early revision TKA for infection in patients with an elevated BMI (54%, 74/138) when compared with the normal BMI patients (24%, 8/33, P < .003, relative risk ratio = 2.3, absolute risk = 30%, number needed to treat = 3.3). There was no significant increase in acute, early, midterm, or late revision TKA for aseptic loosening and/or osteolysis, instability, stiffness, or other causes between patients with normal BMI and elevated BMI.An elevated BMI is a risk factor for early referral to a tertiary care center for revision TKA. Specifically, orthopedic surgeons should convey to overweight and obese patients that they have at least a 130% increased relative risk and a 30% absolute risk of revision TKA for an early infection if referred for revision TKA. Patient expectations and counseling as well as reimbursement should account for the greater risks when performing a TKA on patients with an elevated BMI.

  View details for DOI 10.1016/j.arth.2016.05.071

  View details for PubMedID 27421585

• Cortical Strut Allograft Support of Modular Femoral Junctions During Revision Total Hip Arthroplasty. journal of arthroplasty Lim, C. T., Amanatullah, D. F., Huddleston, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2016

  Abstract

  There is risk of junction failure when using modular femoral stems for revision total hip arthroplasty (THA), especially with loss of bone stock in the proximal femur. Using a cortical strut allograft may provide additional support of a modular femoral construct in revision THA.We reviewed prospectively gathered clinical and radiographic data for 28 revision THAs performed from 2004 to 2014 using cementless modular femoral components with cortical strut allograft applied to supplement proximal femoral bone loss: 5 (18%) were fluted taper designs and 23 (82%) were porous cylindrical designs All the patients had a Paprosky grade IIIA or greater femoral defect. The mean follow-up was 5.4 ± 3.9 years.The Harris Hip Scores improved from 26 ± 10 points preoperatively to 71 ± 10 points at final follow-up (P < .001). The Western Ontario McMaster Universities Osteoarthritis Index scores improved from 45 ± 12 points preoperatively to 76 ± 12 points at final follow-up (P < .001). Eighty-nine percent (25 hips) of all revision or conversion THAs were in place at final follow-up. Three (11%) patients underwent reoperations, 2 for infection and 1 for periprosthetic fracture. There was no statistical significant change in femoral component alignment (P = .161) at final follow-up. Mean subsidence was 1.8 ± 1.3 mm at final follow-up. Femoral diameter increased from initial postoperative imaging to final follow-up imaging by a mean of 9.1 ± 5.1 mm (P < .001) and cortical width increased by a mean of 4.5 ± 2.2 mm (P < .001). Twenty-seven hips (96%) achieved union between the cortical strut allograft and the host femur.The use of a modular femoral stem in a compromised femur with a supplementary cortical strut allgraft is safe and provides satisfactory clinical and radiological outcomes.

  View details for DOI 10.1016/j.arth.2016.12.011

  View details for PubMedID 28130016

• Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty. journal of arthroplasty Lim, C. T., Amanatullah, D. F., Huddleston, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2016

  Abstract

  Cortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts.We reviewed prospectively gathered data on 50 revision THAs performed from 2004-2014 using an ETO. We compared the demographic, radiological, and clinical outcome of patients with (16 hips) and without (34 hips) cortical strut allograft after an ETO.There were no significant differences in Western Ontario McMaster Universities Osteoarthritis Index or Harris Hip Score between the ETOs with and without a cortical strut allograft. Fifteen of the ETOs (94%) with a cortical strut allograft and 31 of the ETOs (91%) without a cortical strut allograft were in situ at final follow-up (P = 1.000). A higher proportion hips with cortical strut allograft (100%, 16 patients) had preoperative Paprosky grade bone loss more than IIIA compared to those without allograft (29%, 10 patients) (P < .001). There were no differences in femoral stem subsidence (P = .207), alignment (P = .934), or migration of the osteotomized fragment (P = .171). Fourteen of the ETOs (88%) in patients with cortical strut allograft united compared to 34 ETOs (100%) in patients without allograft (P = .095).Our study shows that the use of cortical strut allograft during revision THA with ETO does not reduce the rate of union, radiological or clinical outcomes.

  View details for DOI 10.1016/j.arth.2016.12.002

  View details for PubMedID 28110850

• Revision Hip Arthroplasty Using a Modular, Cementless Femoral Stem: Intermediate-Term Follow-Up. journal of arthroplasty Sivananthan, S., Lim, C., Narkbunnam, R., Sox-Harris, A., Huddleston, J. I., Goodman, S. B. 2016

  Abstract

  Modular femoral stem provides flexibility in femoral reconstruction, ensuring improved "fit and fill". However, there are risks of junction failure and corrosion, as well as cost concerns in the use of modular femoral stems.We reviewed prospectively-gathered clinical and radiographic data on revision total hip arthroplasties (THAs) performed from 2001-2007 using modular, cementless femoral component performed by the 2 senior authors. Patients with a minimum follow-up of 7 years were included in this study.Sixty-four patients (68 hips) with a median age of 68 ± 14 years (range 40-92 years) at revision THA were included. The median follow-up was 11.0 ± 1.8 years (range 7-14). Harris hip score, femoral stem subsidence, and stem osseointegration were recorded. The Harris hip score improved from an average of 38.1-80.1 (P < .01). Five hips had one or more dislocations. Seven patients underwent reoperations, 3 of which did not involve the stem. Four stems required revision because of infection, recurrent dislocation, or suboptimal implant position. Survival rates for any reasons and revision for femoral stems were 90% and 94%, respectively, at the most recent follow-up. Four stems subsided more than 5 mm, but established stable osseointegration thereafter. Seven nonloose stems (10.2%) demonstrated radiolucent lines in Gruen zones 1 and 7. No complications regarding the modular junction were encountered.Modular, cementless, extensively porous-coated femoral components have demonstrated intermediate-term clinical and radiographic success. Initial distal intramedullary fixation ensures stability, and proximal modularity further maximizes fit and fill.

  View details for DOI 10.1016/j.arth.2016.10.033

  View details for PubMedID 27923596

• Reply to the Letter to the Editor: Is There a Benefit to Modularity in 'Simpler' Femoral Revisions? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I. 2016; 474 (11): 2540

  View details for PubMedID 27604585

  View details for PubMedCentralID PMC5052195

• Tibiofemoral Dislocation After Total Knee Arthroplasty. journal of arthroplasty Jethanandani, R. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Amanatullah, D. F. 2016; 31 (10): 2282-2285

  Abstract

  Tibiofemoral dislocation after total knee arthroplasty (TKA) is a rare complication. Published case reports describe fewer than 6 patients, making conclusions about the etiology, epidemiology, complications, and treatment of tibiofemoral dislocation difficult. This case series highlights common demographic features, potential causes, and difficulties during the management of tibiofemoral dislocations after TKA.Between 2005 and 2014, 14 patients presented to our institution with a tibiofemoral dislocation. Patients were excluded if they had patellofemoral dislocation or subluxation without a tibiofemoral dislocation. We retrospectively reviewed patient demographics, time to first dislocation, number of dislocations, time to surgical intervention, complications, and potential etiologies of tibiofemoral dislocation.Twelve of 14 patients were female. Their mean body mass index was 33 ± 10 kg/m(2). Thirteen of 14 patients had a mean of 2.0 ± 1.4 dislocations. Four patients dislocated due to polyethylene damage and 5 due to ligamentous incompetence. Twelve of 14 patients required open surgical intervention. Complications in this patient population were common with 3 cases of infection, 7 cases of multiple dislocation, 2 cases of popliteal artery laceration, 1 case receiving a fusion, and 1 case receiving an amputation.Patients with tibiofemoral dislocation after TKA are predominantly obese, female, and have a high risk for complications. They dislocate predominantly because of polyethylene damage or ligamentous incompetence. Re-dislocation is common if treated with closed reduction alone.

  View details for DOI 10.1016/j.arth.2016.03.010

  View details for PubMedID 27084503

• Obesity is Associated With Early Total Hip Revision for Aseptic Loosening. journal of arthroplasty Electricwala, A. J., Narkbunnam, R., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2016; 31 (9): 217-220

  Abstract

  Obesity affects more than half a billion people worldwide, including one-third of men and women in the United States. Obesity is associated with higher postoperative complication rates after total hip arthroplasty (THA). It remains unknown whether obese patients progress to revision THA faster than nonobese patients.A total of 257 consecutive primary THAs referred to an academic tertiary care center for revision THA were retrospectively stratified according to preoperative body mass index (BMI), reason for revision THA, and time from primary to revision THA.When examining primary THAs referred for revision THA, increasing BMI adversely affected the mean time to revision THA. The percentage of primary THAs revised at 5 years was 25% for a BMI of 18-25, 38% for a BMI of 25-30, 56% for a BMI of 30-35, 73% for a BMI of 35-40, and 75% for a BMI of greater than 40 (P < .001). The percentage of primary THAs revised at 15 years was 70%, 82%, 87%, 94%, and 100%, respectively (P < .001). A significant increase in early revision THA for aseptic loosening/osteolysis in obese patients (56%, 23/41) when compared with the nonobese patients (12%, 10/83, P < .001, relative risk ratio = 4.7).Preoperative BMI influences the time of failure of primary THAs referred to an academic tertiary care for revision THA as well as the mechanism of failure. Specifically, obesity increased in the relative risk of early revision THA due to aseptic loosening/osteolysis by 4.7 fold.

  View details for DOI 10.1016/j.arth.2016.02.073

  View details for PubMedID 27108056

• Obesity is Associated With Early Total Hip Revision for Aseptic Loosening JOURNAL OF ARTHROPLASTY Electricwala, A. J., Narkbunnam, R., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2016; 31 (9): S217-S220

  Abstract

  Obesity affects more than half a billion people worldwide, including one-third of men and women in the United States. Obesity is associated with higher postoperative complication rates after total hip arthroplasty (THA). It remains unknown whether obese patients progress to revision THA faster than nonobese patients.A total of 257 consecutive primary THAs referred to an academic tertiary care center for revision THA were retrospectively stratified according to preoperative body mass index (BMI), reason for revision THA, and time from primary to revision THA.When examining primary THAs referred for revision THA, increasing BMI adversely affected the mean time to revision THA. The percentage of primary THAs revised at 5 years was 25% for a BMI of 18-25, 38% for a BMI of 25-30, 56% for a BMI of 30-35, 73% for a BMI of 35-40, and 75% for a BMI of greater than 40 (P < .001). The percentage of primary THAs revised at 15 years was 70%, 82%, 87%, 94%, and 100%, respectively (P < .001). A significant increase in early revision THA for aseptic loosening/osteolysis in obese patients (56%, 23/41) when compared with the nonobese patients (12%, 10/83, P < .001, relative risk ratio = 4.7).Preoperative BMI influences the time of failure of primary THAs referred to an academic tertiary care for revision THA as well as the mechanism of failure. Specifically, obesity increased in the relative risk of early revision THA due to aseptic loosening/osteolysis by 4.7 fold.

  View details for DOI 10.1016/j.arth.2016.02.073

  View details for Web of Science ID 000382208900046

• Cytokines as a predictor of clinical response following hip arthroscopy: minimum 2-year follow-up. Journal of hip preservation surgery Shapiro, L. M., Safran, M. R., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J., Abrams, G. D. 2016; 3 (3): 229-235

  Abstract

  Hip arthroscopy in patients with osteoarthritis has been shown to have suboptimal outcomes. Elevated cytokine concentrations in hip synovial fluid have previously been shown to be associated with cartilage pathology. The purpose of this study was to determine whether a relationship exists between hip synovial fluid cytokine concentration and clinical outcomes at a minimum of 2 years following hip arthroscopy. Seventeen patients without radiographic evidence of osteoarthritis had synovial fluid aspirated at time of portal establishment during hip arthroscopy. Analytes included fibronectin-aggrecan complex as well as a multiplex cytokine array. Patients completed the modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index and the International Hip Outcomes Tool pre-operatively and at a minimum of 2 years following surgery. Pre and post-operative scores were compared with a paired t-test, and the association between cytokine values and clinical outcome scores was performed with Pearson's correlation coefficient with an alpha value of 0.05 set as significant. Sixteen of seventeen patients completed 2-year follow-up questionnaires (94%). There was a significant increase in pre-operative to post-operative score for each clinical outcome measure. No statistically significant correlation was seen between any of the intra-operative cytokine values and either the 2-year follow-up scores or the change from pre-operative to final follow-up outcome values. No statistically significant associations were seen between hip synovial fluid cytokine concentrations and 2-year follow-up clinical outcome assessment scores for those undergoing hip arthroscopy.

  View details for DOI 10.1093/jhps/hnw013

  View details for PubMedID 27583163

• Acetabular Dysplasia and Surgical Approaches Other Than Direct Anterior Increases Risk for Malpositioning of the Acetabular Component in Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Gromov, K., Greene, M. E., Huddleston, J. I., Emerson, R., Gebuhr, P., Malchau, H., Troelsen, A. 2016; 31 (4): 835-841

  Abstract

  Persistent acetabular dysplasia (AD) after periacetabular osteotomy has been hypothesized to increase the risk for malpositioning of the acetabular component. In this study, we investigate whether AD is an independent risk factor for cup malpositioning during primary total hip arthroplasty (THA).Patient demographics, surgical approach, presence of AD assessed using the lateral center-edge angle, and acetabular cup positioning determined using Martell Hip Analysis Suite were investigated in 836 primary THA patients enrolled in a prospective multicenter study.We found that presence of AD, defined as the lateral center-edge angle of <25°, is an independent risk factor for malpositioning of the acetabular component during primary THA. Surgical approach other than direct anterior was also independently associated with malpositioned cups.Surgeons should therefore take special care during placement of the acetabular component in patients with AD.

  View details for DOI 10.1016/j.arth.2015.10.045

  View details for Web of Science ID 000373625600018

  View details for PubMedID 26706838

• Removal of Well-Fixed Cementless Acetabular Components in Revision Total Hip Arthroplasty. Orthopedics Adelani, M. A., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2016; 39 (2): e280-4

  Abstract

  The Zimmer Explant Acetabular Cup Removal System (Warsaw, Indiana) has been touted as a superior method for removing well-fixed cementless acetabular components while minimizing bone loss; however, no comparative data support this. This study compares bone loss following the removal of well-fixed acetabular components with Aufranc gouges and with the Explant System. A review of 623 revision total hip arthroplasties (THAs) at the authors' institution between 2002 and 2013 identified cases involving the revision of well-fixed cementless hemispherical acetabular components for any reason except infection. Twenty-four cases using Aufranc gouges and 27 cases using the Explant System were included. The following surrogates for bone loss were used: (1) the difference between the initial acetabular component outer diameter (OD) and the final reamer OD; (2) the difference between the initial acetabular component OD and the new acetabular component OD; and (3) the use of impaction bone grafting. A 2-tailed Wilcoxon-Mann-Whitney test was used to assess the difference in bone loss between the 2 groups. The use of bone grafting was compared between the groups with the chi-square test. The median differences between the initial acetabular component and the final reamer (P=.004), as well as between the initial and new acetabular components (P=.002), were 2 mm less with the Explant System. Hips in the Aufranc group were more likely to have bone grafting (54% vs 26%; P=.04). These results suggest less bone loss when removing well-fixed acetabular components with the Zimmer Explant System compared with Aufranc gouges. [Orthopedics. 2016; 39(2):e280-e284.].

  View details for DOI 10.3928/01477447-20160129-04

  View details for PubMedID 26840697

• 3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement. Hip international Sillesen, N. H., Greene, M. E., Nebergall, A. K., Huddleston, J. I., Emerson, R., Gebuhr, P., Troelsen, A., Malchau, H. 2016; 26 (1): 97-103

  Abstract

  Preclinical studies of vitamin E diffused highly cross-linked polyethylene (E-XLPE) has shown enhanced mechanical properties with less wear. The purpose of our study was to document the early clinical outcome of E-XLPE to ensure, for the safety of patients, that there are no unforeseen early adverse events from using this new biomaterial.The enrolled patients (n = 977) have received either a porous titanium coated or porous plasma sprayed acetabular shell with either a E-XLPE liner or a medium cross-linked (AXL) liner. At each follow-up 5 patient-reported outcome measures (PROMs) were completed: Harris Hip Score, Case Mix Indicator, UCLA Activity Score, SF-36, and EQ-5D. Radiographs were measured for cup and stem position, as well as femoral head penetration into the liner (wear). Postoperative complications and revisions were collected.At 3 years follow-up, there were 13 revisions due to: 4 periprosthetic fractures; 1 sepsis; 6 instabilities; and 2 implant mismatches at surgery. Wear of the hip implant, calculated by software analysis of pelvis x-rays, from the postoperative interval to 3 years showed a liner penetration rate of 0.027 mm/year for AXL and 0.005 mm/year for E-XLPE with no significant difference between the 2 (p = 0.24). Improvement was seen in all PROMs from the preoperative interval to 3 years after surgery (p<0.0001).Early follow-up of the E-XLPE and AXL liners show low penetration. PROMs indicate improvement after total hip arthroplasty in functionality and quality of life across the centers. We have not observed any early in vivo adverse effects from diffusing the liners with vitamin E.ClinicalTrials.gov Identifier: NCT00545285.

  View details for DOI 10.5301/hipint.5000297

  View details for PubMedID 26692248

• Is There a Benefit to Modularity in 'Simpler' Femoral Revisions? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I., Tetreault, M. W., Yu, M., Bedair, H., Hansen, V. J., Choi, H., Goodman, S. B., Sporer, S. M., Della Valle, C. J. 2016; 474 (2): 415-420

  Abstract

  Modular revision femoral components allow the surgeon to make more precise intraoperative adjustments in anteversion and sizing, which may afford lower dislocation rates and improved osseointegration, but may not offer distinct advantages when compared with less expensive monoblock revision stems.We compared modular and monoblock femoral components for revision of Paprosky Type I to IIIA femoral defects to determine (1) survivorship of the stems; and (2) complications denoted as intraoperative fracture, dislocation, or failure of osseointegration.Between 2004 and 2010, participating surgeons at three centers revised 416 total hip arthroplasties (THAs) with Paprosky Type I to IIIA femoral defects. Of those with minimum 2-year followup (343 THAs, mean followup 51 ± 13 months), 150 (44%) were treated with modular stems and 193 (56%) were treated with monoblock, cylindrical, fully porous-coated stems. During this time, modular stems were generally chosen when there was remodeling of the proximal femur into retroversion and/or larger canal diameters (usually > 18 mm). A total of 27 patients died (6%) with stems intact before 2 years, 46 THAs (13%) were lost to followup before 2 years for reasons other than death, and there was no differential loss to followup between the study groups. The modular stems included 101 with a cylindrical distal geometry (67%) and 49 with a tapered geometry (33%). Mean age (64 versus 68 years), percentage of women (53% versus 47%), and body mass index (31 versus 30 kg/m(2)) were not different between the two cohorts, whereas there was trend toward a slightly greater case complexity in the modular group (55% versus 65% Type 3a femoral defects, p = 0.06). Kaplan-Meier survivorship was calculated for the endpoint of aseptic revision. Proportions of complications in each cohort (dislocation, intraoperative fracture, and failure of osseointegration) were compared.Femoral component rerevision for any reason (including infection) was greater (OR, 2.01; 95% CI, 1.63-2.57; p = 0.03) in the monoblock group (27 of 193 [14%]) compared with the modular cohort (10 of 150 [7%]). Femoral component survival free from aseptic rerevision was greater in the modular group with 91% survival (95% CI, 89%-95%) at 9 years compared with 86% survival (95% CI, 83%-88%) for the monoblock group in the same timeframe. There was no difference in the proportion of mechanically relevant aseptic complications (30 of 193 [16%] in the monoblock group versus 34 of 150 [23%] in the modular group, p = 0.10; OR, 1.47; 95% CI, 0.86-2.53). There were more intraoperative fractures in the modular group (17 of 150 [11%] versus nine of 193 [5%]; OR, 2.2; 95% CI, 1.68-2.73; p = 0.02). There were no differences in the proportions of dislocation (13 of 193 [7%] monoblock versus 14 of 150 [9%] modular; OR, 0.96; 95% CI, 0.67-1.16; p = 0.48) or failure of osseointegration (eight of 193 [4%] monoblock versus three of 150 [2%] modular; OR, 1.92; 95% CI, 0.88-2.84; p = 0.19) between the two groups with the number of hips available for study.Although rerevisions were less common in patients treated with modular stems, aseptic complications such as intraoperative fractures were more common in that group, and the sample was too small to evaluate corrosion-related or fatigue concerns associated with modularity. We cannot therefore conclude from this that one design is superior to the other. Larger studies and pooled analyses will need to be performed to answer this question, but we believe modularity should be avoided in more straightforward cases if possible.Level III, therapeutic study.

  View details for DOI 10.1007/s11999-015-4474-8

  View details for Web of Science ID 000368021900025

  View details for PubMedCentralID PMC4709297

• CORR Insights((R)): Can Radiographs Predict the Use of Modular Stems in Developmental Dysplasia of the Hip? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I. 2016; 474 (2): 430–31

  View details for PubMedID 26329793

  View details for PubMedCentralID PMC4709328

• Can a Conical Implant Successfully Address Complex Anatomy in Primary THA? Radiographs and Hip Scores at Early Followup CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Zhang, Q., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2016; 474 (2): 459-464

  Abstract

  Total hip arthroplasty (THA) in patients with small or abnormal proximal femoral anatomy is challenging as a result of complex anatomic deformities in the hip. It is unclear which stem is the most appropriate for these patients. One possible implant design that may help meet this need is the modified Wagner Cone prosthesis, whose design consists of monoblock cone with splines; however, to our knowledge, no clinical results have been published using this implant.We evaluated the hip scores and radiographic results (including signs of osseointegration and subsidence) of complex primary THA using the modified Wagner Cone cementless femoral component in patients with small or abnormal proximal femoral anatomic proportions.Between 2006 and 2011, we performed 59 THAs on patients whose femoral geometry precluded the use of standard-sized implants. Of these, 49 (83%) received the modified Wagner Cone prosthesis. During this time, our indications for use of the Wagner Cone implant in such patients included: femoral neck retroversion, excessive anteversion of the femoral neck, or small proximal femora not suitable for standard implants. Of those, 40 patients with 49 THAs were available for radiographic and clinical followup at a minimum of 3 years, and no patients were lost to followup. The diagnosis included developmental dysplasia of hip (22 patients, 28 hips), secondary trauma or posttuberculosis osteoarthritis (nine patients, 10 hips), and hip disease secondary to other disorders (eight patients, nine hips) and osteonecrosis (one patients, two hips). Two versions of the stem with 135° (28 hips) or 125° (21 hips) neck angle versions were used to reestablish normal hip biomechanics. Version angle was chosen based on preoperative templating. Cementless cups with screws were used for the acetabulum. Mean followup was 4 years (range, 3-7 years). Study endpoints were the Harris hip score and radiographic evaluations by a surgeon not involved in the clinical care of the patients (QZ); radiographic analysis included evaluating for the presence or absence of signs of osseointegration (including Engh's criteria) and subsidence.The Harris hip score improved from a mean of 41 ± 9 preoperatively to a mean of 85 ± 10 at last followup (p < 0.01). The mean vertical subsidence was 1.5 ± 1.1 mm. Radiographic evaluation demonstrated stability (no further subsidence) of all implants at last followup. Endosteal spot welds were found in 32 hips (65%). No progressive radiolucencies were observed. One patient (one hip) underwent revision surgery as a result of late infection; no other revisions were performed.The modified Wagner Cone femoral stem has provided improvements in hip scores and promising short-term radiographic results at short-term followup in complex cementless THA associated with abnormal or small femoral anatomical proportions in which standard implants are inappropriate. Longer followup will be needed to see if these results endure. Randomized trials are needed to determine the optimal stem design for these patients.Level IV, therapeutic study.

  View details for DOI 10.1007/s11999-015-4480-x

  View details for Web of Science ID 000368021900033

  View details for PubMedCentralID PMC4709298

• Treatment of Periprosthetic Knee Infection With a Two-stage Protocol Using Static Spacers CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Lichstein, P., Su, S., Hedlund, H., Suh, G., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2016; 474 (1): 120-125

  Abstract

  Two-stage exchange arthroplasty is a standard approach for treating total knee arthroplasty periprosthetic joint infection in the United States, but whether this should be performed with a static antibiotic spacer or an articulating one that allows range of motion before reimplantation remains controversial. It is unclear if the advantages of articulating spacers (easier surgical exposure during reimplantation and improved postoperative flexion) outweigh the disadvantages of increased cost and complexity in the setting of similar rates of infection eradication.The purposes of this study were (1) to determine the ultimate range of motion; and (2) to determine the proportion of patients who remained free of infection at a minimum 2 years after treatment with static antibiotic spacers as part of a two-stage revision TKA for the treatment of periprosthetic joint infection.Between 1999 and 2011, we treated 121 patients with chronically infected TKAs, of whom three had medical comorbidities precluding a two-stage exchange, four had died before 2-year followup for reasons other than the surgical intervention, and seven were lost to followup. The remaining 107 patients (109 knees; 53 men and 54 women) were treated using a two-stage approach with static spacers and are evaluated here at a mean of 3.7 years (range, 2.0-9.8 years); no patients were treated with articulating spacers during this study period. Twenty-five percent (27 of 109) of the organisms isolated the first-stage procedure were resistant to methicillin and/or vancomycin. Median age at the time of reimplantation was 67 years (range, 42-89 years). Range of motion was measured by an independent physical therapist with a standard goniometer. Knee Society knee and function scores were calculated before the first stage and at the 2-year mark. Because many of these patients were treated before consensus definitions of infection were established, we made the diagnosis of infection (and established that a patient was believed to be free of infection) using the approaches prevalent at that time, which generally included presence of a sinus tract communicating directly with the implant, two positive tissue cultures, or a combination of cultures, fluid analysis, and serology.Postoperatively, 67 knees had full extension and no patients had a flexion contracture > 10°. Median flexion was 100° (range, 60°-139°). Thirty-nine knees had postoperative flexion > 120°. Ninety-four percent of patients were clinically free of infection at last followup.Our two-stage exchange protocol with static spacers yielded comparable flexion and infection eradication when compared with other recent studies that have used articulating spacers. The large proportion of resistant organisms is alarming. Future multicenter studies should compare static with articulating spacers and should evaluate both cost and efficacy, because our study suggests that adequate range of motion can be achieved without the added cost of the articulating spacer.Level IV, therapeutic study.

  View details for DOI 10.1007/s11999-015-4443-2

  View details for Web of Science ID 000368022600023

  View details for PubMedCentralID PMC4686492

• Hip arthroplasty for treatment of advanced osteonecrosis: comprehensive review of implant options, outcomes and complications. Orthopedic research and reviews Waewsawangwong, W., Ruchiwit, P., Huddleston, J. I., Goodman, S. B. 2016; 8: 13–29

  Abstract

  Surgical treatment for late stage (post-collapse) osteonecrosis of the femoral head is controversial. In these situations, the outcome of joint preservation procedures is poor. There are several arthroplasty options for late-stage disease. The clinical outcomes of hemiarthroplasty and hemiresurfacing are unpredictable because of progressive acetabular cartilage degeneration. Total hip resurfacing may be associated with further vascular insult to the femoral head and early failure of the implant. Total hip replacement with metal-on-conventional polyethylene bearing surfaces has been the gold standard, but implant survivorship is limited in young active patients due to wear and osteolysis. Newer alternative bearing surfaces may have improved wear characteristics, but their durability must be confirmed in longer-term studies.

  View details for PubMedID 30774467

• 3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement HIP INTERNATIONAL Sillesen, N. H., Greene, M. E., Nebergall, A. K., Huddleston, J. I., Emerson, R., Gebuhr, P., Troelsen, A., Malchau, H. 2016; 26 (1): 97-103

  Abstract

  Preclinical studies of vitamin E diffused highly cross-linked polyethylene (E-XLPE) has shown enhanced mechanical properties with less wear. The purpose of our study was to document the early clinical outcome of E-XLPE to ensure, for the safety of patients, that there are no unforeseen early adverse events from using this new biomaterial.The enrolled patients (n = 977) have received either a porous titanium coated or porous plasma sprayed acetabular shell with either a E-XLPE liner or a medium cross-linked (AXL) liner. At each follow-up 5 patient-reported outcome measures (PROMs) were completed: Harris Hip Score, Case Mix Indicator, UCLA Activity Score, SF-36, and EQ-5D. Radiographs were measured for cup and stem position, as well as femoral head penetration into the liner (wear). Postoperative complications and revisions were collected.At 3 years follow-up, there were 13 revisions due to: 4 periprosthetic fractures; 1 sepsis; 6 instabilities; and 2 implant mismatches at surgery. Wear of the hip implant, calculated by software analysis of pelvis x-rays, from the postoperative interval to 3 years showed a liner penetration rate of 0.027 mm/year for AXL and 0.005 mm/year for E-XLPE with no significant difference between the 2 (p = 0.24). Improvement was seen in all PROMs from the preoperative interval to 3 years after surgery (p<0.0001).Early follow-up of the E-XLPE and AXL liners show low penetration. PROMs indicate improvement after total hip arthroplasty in functionality and quality of life across the centers. We have not observed any early in vivo adverse effects from diffusing the liners with vitamin E.ClinicalTrials.gov Identifier: NCT00545285.

  View details for DOI 10.5301/hipint.5000297

  View details for Web of Science ID 000373361600019

• Hip arthroplasty for treatment of advanced osteonecrosis: comprehensive review of implant options, outcomes and complications ORTHOPEDIC RESEARCH AND REVIEWS Waewsawangwong, W., Ruchiwit, P., Huddleston, J. I., Goodman, S. B. 2016; 8: 13–29

  View details for DOI 10.2147/ORR.S35547

  View details for Web of Science ID 000386440200001

• Is There a Benefit to Modularity in 'Simpler' Femoral Revisions? Clinical orthopaedics and related research Huddleston, J. I., Tetreault, M. W., Yu, M., Bedair, H., Hansen, V. J., Choi, H. R., Goodman, S. B., Sporer, S. M., Della Valle, C. J. 2016; 474 (2): 415–20

  Abstract

  Modular revision femoral components allow the surgeon to make more precise intraoperative adjustments in anteversion and sizing, which may afford lower dislocation rates and improved osseointegration, but may not offer distinct advantages when compared with less expensive monoblock revision stems.We compared modular and monoblock femoral components for revision of Paprosky Type I to IIIA femoral defects to determine (1) survivorship of the stems; and (2) complications denoted as intraoperative fracture, dislocation, or failure of osseointegration.Between 2004 and 2010, participating surgeons at three centers revised 416 total hip arthroplasties (THAs) with Paprosky Type I to IIIA femoral defects. Of those with minimum 2-year followup (343 THAs, mean followup 51 ± 13 months), 150 (44%) were treated with modular stems and 193 (56%) were treated with monoblock, cylindrical, fully porous-coated stems. During this time, modular stems were generally chosen when there was remodeling of the proximal femur into retroversion and/or larger canal diameters (usually > 18 mm). A total of 27 patients died (6%) with stems intact before 2 years, 46 THAs (13%) were lost to followup before 2 years for reasons other than death, and there was no differential loss to followup between the study groups. The modular stems included 101 with a cylindrical distal geometry (67%) and 49 with a tapered geometry (33%). Mean age (64 versus 68 years), percentage of women (53% versus 47%), and body mass index (31 versus 30 kg/m(2)) were not different between the two cohorts, whereas there was trend toward a slightly greater case complexity in the modular group (55% versus 65% Type 3a femoral defects, p = 0.06). Kaplan-Meier survivorship was calculated for the endpoint of aseptic revision. Proportions of complications in each cohort (dislocation, intraoperative fracture, and failure of osseointegration) were compared.Femoral component rerevision for any reason (including infection) was greater (OR, 2.01; 95% CI, 1.63-2.57; p = 0.03) in the monoblock group (27 of 193 [14%]) compared with the modular cohort (10 of 150 [7%]). Femoral component survival free from aseptic rerevision was greater in the modular group with 91% survival (95% CI, 89%-95%) at 9 years compared with 86% survival (95% CI, 83%-88%) for the monoblock group in the same timeframe. There was no difference in the proportion of mechanically relevant aseptic complications (30 of 193 [16%] in the monoblock group versus 34 of 150 [23%] in the modular group, p = 0.10; OR, 1.47; 95% CI, 0.86-2.53). There were more intraoperative fractures in the modular group (17 of 150 [11%] versus nine of 193 [5%]; OR, 2.2; 95% CI, 1.68-2.73; p = 0.02). There were no differences in the proportions of dislocation (13 of 193 [7%] monoblock versus 14 of 150 [9%] modular; OR, 0.96; 95% CI, 0.67-1.16; p = 0.48) or failure of osseointegration (eight of 193 [4%] monoblock versus three of 150 [2%] modular; OR, 1.92; 95% CI, 0.88-2.84; p = 0.19) between the two groups with the number of hips available for study.Although rerevisions were less common in patients treated with modular stems, aseptic complications such as intraoperative fractures were more common in that group, and the sample was too small to evaluate corrosion-related or fatigue concerns associated with modularity. We cannot therefore conclude from this that one design is superior to the other. Larger studies and pooled analyses will need to be performed to answer this question, but we believe modularity should be avoided in more straightforward cases if possible.Level III, therapeutic study.

  View details for PubMedID 26245164

• Can a Conical Implant Successfully Address Complex Anatomy in Primary THA? Radiographs and Hip Scores at Early Followup. Clinical orthopaedics and related research Zhang, Q., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2016; 474 (2): 459–64

  Abstract

  Total hip arthroplasty (THA) in patients with small or abnormal proximal femoral anatomy is challenging as a result of complex anatomic deformities in the hip. It is unclear which stem is the most appropriate for these patients. One possible implant design that may help meet this need is the modified Wagner Cone prosthesis, whose design consists of monoblock cone with splines; however, to our knowledge, no clinical results have been published using this implant.We evaluated the hip scores and radiographic results (including signs of osseointegration and subsidence) of complex primary THA using the modified Wagner Cone cementless femoral component in patients with small or abnormal proximal femoral anatomic proportions.Between 2006 and 2011, we performed 59 THAs on patients whose femoral geometry precluded the use of standard-sized implants. Of these, 49 (83%) received the modified Wagner Cone prosthesis. During this time, our indications for use of the Wagner Cone implant in such patients included: femoral neck retroversion, excessive anteversion of the femoral neck, or small proximal femora not suitable for standard implants. Of those, 40 patients with 49 THAs were available for radiographic and clinical followup at a minimum of 3 years, and no patients were lost to followup. The diagnosis included developmental dysplasia of hip (22 patients, 28 hips), secondary trauma or posttuberculosis osteoarthritis (nine patients, 10 hips), and hip disease secondary to other disorders (eight patients, nine hips) and osteonecrosis (one patients, two hips). Two versions of the stem with 135° (28 hips) or 125° (21 hips) neck angle versions were used to reestablish normal hip biomechanics. Version angle was chosen based on preoperative templating. Cementless cups with screws were used for the acetabulum. Mean followup was 4 years (range, 3-7 years). Study endpoints were the Harris hip score and radiographic evaluations by a surgeon not involved in the clinical care of the patients (QZ); radiographic analysis included evaluating for the presence or absence of signs of osseointegration (including Engh's criteria) and subsidence.The Harris hip score improved from a mean of 41 ± 9 preoperatively to a mean of 85 ± 10 at last followup (p < 0.01). The mean vertical subsidence was 1.5 ± 1.1 mm. Radiographic evaluation demonstrated stability (no further subsidence) of all implants at last followup. Endosteal spot welds were found in 32 hips (65%). No progressive radiolucencies were observed. One patient (one hip) underwent revision surgery as a result of late infection; no other revisions were performed.The modified Wagner Cone femoral stem has provided improvements in hip scores and promising short-term radiographic results at short-term followup in complex cementless THA associated with abnormal or small femoral anatomical proportions in which standard implants are inappropriate. Longer followup will be needed to see if these results endure. Randomized trials are needed to determine the optimal stem design for these patients.Level IV, therapeutic study.

  View details for PubMedID 26245165

• Treatment of Periprosthetic Knee Infection With a Two-stage Protocol Using Static Spacers. Clinical orthopaedics and related research Lichstein, P., Su, S., Hedlund, H., Suh, G., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2016; 474 (1): 120–25

  Abstract

  Two-stage exchange arthroplasty is a standard approach for treating total knee arthroplasty periprosthetic joint infection in the United States, but whether this should be performed with a static antibiotic spacer or an articulating one that allows range of motion before reimplantation remains controversial. It is unclear if the advantages of articulating spacers (easier surgical exposure during reimplantation and improved postoperative flexion) outweigh the disadvantages of increased cost and complexity in the setting of similar rates of infection eradication.The purposes of this study were (1) to determine the ultimate range of motion; and (2) to determine the proportion of patients who remained free of infection at a minimum 2 years after treatment with static antibiotic spacers as part of a two-stage revision TKA for the treatment of periprosthetic joint infection.Between 1999 and 2011, we treated 121 patients with chronically infected TKAs, of whom three had medical comorbidities precluding a two-stage exchange, four had died before 2-year followup for reasons other than the surgical intervention, and seven were lost to followup. The remaining 107 patients (109 knees; 53 men and 54 women) were treated using a two-stage approach with static spacers and are evaluated here at a mean of 3.7 years (range, 2.0-9.8 years); no patients were treated with articulating spacers during this study period. Twenty-five percent (27 of 109) of the organisms isolated the first-stage procedure were resistant to methicillin and/or vancomycin. Median age at the time of reimplantation was 67 years (range, 42-89 years). Range of motion was measured by an independent physical therapist with a standard goniometer. Knee Society knee and function scores were calculated before the first stage and at the 2-year mark. Because many of these patients were treated before consensus definitions of infection were established, we made the diagnosis of infection (and established that a patient was believed to be free of infection) using the approaches prevalent at that time, which generally included presence of a sinus tract communicating directly with the implant, two positive tissue cultures, or a combination of cultures, fluid analysis, and serology.Postoperatively, 67 knees had full extension and no patients had a flexion contracture > 10°. Median flexion was 100° (range, 60°-139°). Thirty-nine knees had postoperative flexion > 120°. Ninety-four percent of patients were clinically free of infection at last followup.Our two-stage exchange protocol with static spacers yielded comparable flexion and infection eradication when compared with other recent studies that have used articulating spacers. The large proportion of resistant organisms is alarming. Future multicenter studies should compare static with articulating spacers and should evaluate both cost and efficacy, because our study suggests that adequate range of motion can be achieved without the added cost of the articulating spacer.Level IV, therapeutic study.

  View details for PubMedID 26280681

• Comprehensive Operative Note Templates for Primary and Revision Total Hip and Knee Arthroplasty. The open orthopaedics journal Electricwala, A. J., Amanatullah, D. F., Narkbunnam, R. I., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2016; 10: 725-731

  Abstract

  Adequate preoperative planning is the first and most crucial step in the successful completion of a revision total joint arthroplasty. The purpose of this study was to evaluate the availability, adequacy and accuracy of operative notes of primary surgeries in patients requiring subsequent revision and to construct comprehensive templates of minimum necessary information required in the operative notes to further simplify re-operations, if they should become necessary.The operative notes of 144 patients (80 revision THA's and 64 revision TKA's) who underwent revision total joint arthroplasty at Stanford Hospital and Clinics in the year 2013 were reviewed. We assessed the availability of operative notes and implant stickers prior to revision total joint arthroplasty. The availability of implant details within the operative notes was assessed against the available surgical stickers for adequacy and accuracy. Statistical comparisons were made using the Fischer-exact test and a P-value of less than 0.05 was considered statistically significant.The primary operative note was available in 68 of 144 revisions (47%), 39 of 80 revision THAs (49%) and 29 of 66 revision TKAs (44%, p = 0.619). Primary implant stickers were available in 46 of 144 revisions (32%), 26 of 80 revision THAs (32%) and 20 of 66 revision TKAs (30%, p = 0.859). Utilizing the operative notes and implant stickers combined identified accurate primary implant details in only 40 of the 80 revision THAs (50%) and 34 of all 66 revision TKAs (52%, p = 0.870).Operative notes are often unavailable or fail to provide the necessary information required which makes planning and execution of revision hip and knee athroplasty difficult. This emphasizes the need for enhancing the quality of operative notes and records of patient information. Based on this information, we provide comprehensive operative note templates for primary and revision total hip and knee arthroplasty.

  View details for DOI 10.2174/1874325001610010725

  View details for PubMedID 28144382

• Predictors of Low Patient-Reported Outcomes Response Rates in the California Joint Replacement Registry JOURNAL OF ARTHROPLASTY Patel, J., Lee, J. H., Li, Z., SooHoo, N. F., Bozic, K., Huddleston, J. I. 2015; 30 (12): 2071-2075

  Abstract

  Total joint arthroplasty registries are increasingly collecting Patient Reported Outcome Measures (PROM) to more directly measure clinical success after surgery. Obtaining these valuable, complete pre- and post-operative surveys is challenging. We sought to identify specific patient or provider characteristics that are associated with low-reporting of PROM surveys in the California Joint Replacement Registry (CJRR). All reported total hip and knee arthroplasties (n=6861) during 2011-2014 were retrospectively reviewed. PROMs were prospectively collected to determine factors associated with non-participation. The critical factor in predicting ongoing participation post-operatively was the collection of PROM surveys pre-operatively. Specific patient demographics (race, discharge disposition, occurrence of a complication) and surgeon volume were predictive of non-response and are potential targets for increasing reporting rates.

  View details for DOI 10.1016/j.arth.2015.06.029

  View details for PubMedID 26195355

• A global reference for human genetic variation NATURE Altshuler, D. M., Durbin, R. M., Abecasis, G. R., Bentley, D. R., Chakravarti, A., Clark, A. G., Donnelly, P., Eichler, E. E., Flicek, P., Gabriel, S. B., Gibbs, R. A., Green, E. D., Hurles, M. E., Knoppers, B. M., Korbel, J. O., Lander, E. S., Lee, C., Lehrach, H., Mardis, E. R., Marth, G. T., McVean, G. A., Nickerson, D. A., Schmidt, J. P., Sherry, S. T., Wang, J., Wilson, R. K., Gibbs, R. A., Boerwinkle, E., Doddapaneni, H., Han, Y., Korchina, V., Kovar, C., Lee, S., Muzny, D., Reid, J. G., Zhu, Y., Wang, J., Chang, Y., Feng, Q., Fang, X., Guo, X., Jian, M., Jiang, H., Jin, X., Lan, T., Li, G., Li, J., Li, Y., Liu, S., Liu, X., Lu, Y., Ma, X., Tang, M., Wang, B., Wang, G., Wu, H., Wu, R., Xu, X., Yin, Y., Zhang, D., Zhang, W., Zhao, J., Zhao, M., Zheng, X., Lander, E. S., Altshuler, D. M., Gabriel, S. B., Gupta, N., Gharani, N., Toji, L. H., Gerry, N. P., Resch, A. M., Flicek, P., Barker, J., Clarke, L., Gil, L., Hunt, S. E., Kelman, G., Kulesha, E., Leinonen, R., McLaren, W. M., Radhakrishnan, R., Roa, A., Smirnov, D., Smith, R. E., Streeter, I., Thormann, A., Toneva, I., Vaughan, B., Zheng-Bradley, X., Bentley, D. R., Grocock, R., Humphray, S., James, T., Kingsbury, Z., Lehrach, H., Sudbrak, R., Albrecht, M. W., Amstislavskiy, V. S., Borodina, T. A., Lienhard, M., Mertes, F., Sultan, M., Timmermann, B., Yaspo, M., Mardis, E. R., Wilson, R. K., Fulton, L., Fulton, R., Sherry, S. T., Ananiev, V., Belaia, Z., Beloslyudtsev, D., Bouk, N., Chen, C., Church, D., Cohen, R., Cook, C., Garner, J., Hefferon, T., Kimelman, M., Liu, C., Lopez, J., Meric, P., O'Sullivan, C., Ostapchuk, Y., Phan, L., Ponomarov, S., Schneider, V., Shekhtman, E., Sirotkin, K., Slotta, D., Zhang, H., McVean, G. A., Durbin, R. M., Balasubramaniam, S., Burton, J., Danecek, P., Keane, T. M., Kolb-Kokocinski, A., McCarthy, S., Stalker, J., Quail, M., Schmidt, J. P., Davies, C. J., Gollub, J., Webster, T., Wong, B., Zhan, Y., Auton, A., Campbell, C. L., Kong, Y., Marcketta, A., Gibbs, R. A., Yu, F., Antunes, L., Bainbridge, M., Muzny, D., Sabo, A., Huang, Z., Wang, J., Coin, L. J., Fang, L., Guo, X., Jin, X., Li, G., Li, Q., Li, Y., Li, Z., Lin, H., Liu, B., Luo, R., Shao, H., Xie, Y., Ye, C., Yu, C., Zhang, F., Zheng, H., Zhu, H., Alkan, C., Dal, E., Kahveci, F., Marth, G. T., Garrison, E. P., Kural, D., Lee, W., Leong, W. F., Stromberg, M., Ward, A. N., Wu, J., Zhang, M., Daly, M. J., DePristo, M. A., Handsaker, R. E., Altshuler, D. M., Banks, E., Bhatia, G., del Angel, G., Gabriel, S. B., Genovese, G., Gupta, N., Li, H., Kashin, S., Lander, E. S., McCarroll, S. A., Nemesh, J. C., Poplin, R. E., Yoon, S. C., Lihm, J., Makarov, V., Clark, A. G., Gottipati, S., Keinan, A., Rodriguez-Flores, J. L., Korbel, J. O., Rausch, T., Fritz, M. H., Stuetz, A. M., Flicek, P., Beal, K., Clarke, L., Datta, A., Herrero, J., McLaren, W. M., Ritchie, G. R., Smith, R. E., Zerbino, D., Zheng-Bradley, X., Sabeti, P. C., Shlyakhter, I., Schaffner, S. F., Vitti, J., Cooper, D. N., Ball, E. V., Stenson, P. D., Bentley, D. R., Barnes, B., Bauer, M., Cheetham, R. K., Cox, A., Eberle, M., Humphray, S., Kahn, S., Murray, L., Peden, J., Shaw, R., Kenny, E. E., Batzer, M. A., Konkel, M. K., Walker, J. A., MacArthur, D. G., Lek, M., Sudbrak, R., Amstislavskiy, V. S., Herwig, R., Mardis, E. R., Ding, L., Koboldt, D. C., Larson, D., Ye, K., Gravel, S., Swaroop, A., Chew, E., Lappalainen, T., Erlich, Y., Gymrek, M., Willems, T. F., Simpson, J. T., Shriver, M. D., Rosenfeld, J. A., Bustamante, C. D., Montgomery, S. B., De La Vega, F. M., Byrnes, J. K., Carroll, A. W., DeGorter, M. K., Lacroute, P., Maples, B. K., Martin, A. R., Moreno-Estrada, A., Shringarpure, S. S., Zakharia, F., Halperin, E., Baran, Y., Lee, C., Cerveira, E., Hwang, J., Malhotra, A., Plewczynski, D., Radew, K., Romanovitch, M., Zhang, C., Hyland, F. C., Craig, D. W., Christoforides, A., Homer, N., Izatt, T., Kurdoglu, A. A., Sinari, S. A., Squire, K., Sherry, S. T., Xiao, C., Sebat, J., Antaki, D., Gujral, M., Noor, A., Ye, K., Burchard, E. G., Hernandez, R. D., Gignoux, C. R., Haussler, D., Katzman, S. J., Kent, W. J., Howie, B., Ruiz-Linares, A., Dermitzakis, E. T., Devine, S. E., Goncalo, R. A., Kang, H. M., Kidd, J. M., Blackwell, T., Caron, S., Chen, W., Emery, S., Fritsche, L., Fuchsberger, C., Jun, G., Li, B., Lyons, R., Scheller, C., Sidore, C., Song, S., Sliwerska, E., Taliun, D., Tan, A., Welch, R., Wing, M. K., Zhan, X., Awadalla, P., Hodgkinson, A., Li, Y., Shi, X., Quitadamo, A., Lunter, G., McVean, G. A., Marchini, J. L., Myers, S., Churchhouse, C., Delaneau, O., Gupta-Hinch, A., Kretzschmar, W., Iqbal, Z., Mathieson, I., Menelaou, A., Rimmer, A., Xifara, D. K., Oleksyk, T. K., Fu, Y., Liu, X., Xiong, M., Jorde, L., Witherspoon, D., Xing, J., Eichler, E. E., Browning, B. L., Browning, S. R., Hormozdiari, F., Sudmant, P. H., Khurana, E., Durbin, R. M., Hurles, M. E., Tyler-Smith, C., Albers, C. A., Ayub, Q., Balasubramaniam, S., Chen, Y., Colonna, V., Danecek, P., Jostins, L., Keane, T. M., McCarthy, S., Walter, K., Xue, Y., Gerstein, M. B., Abyzov, A., Balasubramanian, S., Chen, J., Clarke, D., Fu, Y., Harmanci, A. O., Jin, M., Lee, D., Liu, J., Mu, X. J., Zhang, J., Zhang, Y., Li, Y., Luo, R., Zhu, H., Alkan, C., Dal, E., Kahveci, F., Marth, G. T., Garrison, E. P., Kural, D., Lee, W., Ward, A. N., Wu, J., Zhang, M., McCarroll, S. A., Handsaker, R. E., Altshuler, D. M., Banks, E., del Angel, G., Genovese, G., Hartl, C., Li, H., Kashin, S., Nemesh, J. C., Shakir, K., Yoon, S. C., Lihm, J., Makarov, V., Degenhardt, J., Korbel, J. O., Fritz, M. H., Meiers, S., Raeder, B., Rausch, T., Stuetz, A. M., Flicek, P., Casale, F. P., Clarke, L., Smith, R. E., Stegle, O., Zheng-Bradley, X., Bentley, D. R., Barnes, B., Cheetham, R. K., Eberle, M., Humphray, S., Kahn, S., Murray, L., Shaw, R., Lameijer, E., Batzer, M. A., Konkel, M. K., Walker, J. A., Ding, L., Hall, I., Ye, K., Lacroute, P., Lee, C., Cerveira, E., Malhotra, A., Hwang, J., Plewczynski, D., Radew, K., Romanovitch, M., Zhang, C., Craig, D. W., Homer, N., Church, D., Xiao, C., Sebat, J., Antaki, D., Bafna, V., Michaelson, J., Ye, K., Devine, S. E., Gardner, E. J., Abecasis, G. R., Kidd, J. M., Mills, R. E., Dayama, G., Emery, S., Jun, G., Shi, X., Quitadamo, A., Lunter, G., McVean, G. A., Chen, K., Fan, X., Chong, Z., Chen, T., Witherspoon, D., Xing, J., Eichler, E. E., Chaisson, M. J., Hormozdiari, F., Huddleston, J., Malig, M., Nelson, B. J., Sudmant, P. H., Parrish, N. F., Khurana, E., Hurles, M. E., Blackburne, B., Lindsay, S. J., Ning, Z., Walter, K., Zhang, Y., Gerstein, M. B., Abyzov, A., Chen, J., Clarke, D., Lam, H., Mu, X. J., Sisu, C., Zhang, J., Zhang, Y., Gibbs, R. A., Yu, F., Bainbridge, M., Challis, D., Evani, U. S., Kovar, C., Lu, J., Muzny, D., Nagaswamy, U., Reid, J. G., Sabo, A., Yu, J., Guo, X., Li, W., Li, Y., Wu, R., Marth, G. T., Garrison, E. P., Leong, W. F., Ward, A. N., del Angel, G., DePristo, M. A., Gabriel, S. B., Gupta, N., Hartl, C., Poplin, R. E., Clark, A. G., Rodriguez-Flores, J. L., Flicek, P., Clarke, L., Smith, R. E., Zheng-Bradley, X., MacArthur, D. G., Mardis, E. R., Fulton, R., Koboldt, D. C., Gravel, S., Bustamante, C. D., Craig, D. W., Christoforides, A., Homer, N., Izatt, T., Sherry, S. T., Xiao, C., Dermitzakis, E. T., Abecasis, G. R., Kang, H. M., McVean, G. A., Gerstein, M. B., Balasubramanian, S., Habegger, L., Yu, H., Flicek, P., Clarke, L., Cunningham, F., Dunham, I., Zerbino, D., Zheng-Bradley, X., Lage, K., Jespersen, J. B., Horn, H., Montgomery, S. B., DeGorter, M. K., Khurana, E., Tyler-Smith, C., Chen, Y., Colonna, V., Xue, Y., Gerstein, M. B., Balasubramanian, S., Fu, Y., Kim, D., Auton, A., Marcketta, A., DeSalle, R., Narechania, A., Sayres, M. A., Garrison, E. P., Handsaker, R. E., Kashin, S., McCarroll, S. A., Rodriguez-Flores, J. L., Flicek, P., Clarke, L., Zheng-Bradley, X., Erlich, Y., Gymrek, M., Willems, T. F., Bustamante, C. D., Mendez, F. L., Poznik, G. D., Underhill, P. A., Lee, C., Cerveira, E., Malhotra, A., Romanovitch, M., Zhang, C., Abecasis, G. R., Coin, L., Shao, H., Mittelman, D., Tyler-Smith, C., Ayub, Q., Banerjee, R., Cerezo, M., Chen, Y., Fitzgerald, T., Louzada, S., Massaia, A., McCarthy, S., Ritchie, G. R., Xue, Y., Yang, F., Gibbs, R. A., Kovar, C., Kalra, D., Hale, W., Muzny, D., Reid, J. G., Wang, J., Dan, X., Guo, X., Li, G., Li, Y., Ye, C., Zheng, X., Altshuler, D. M., Flicek, P., Clarke, L., Zheng-Bradley, X., Bentley, D. R., Cox, A., Humphray, S., Kahn, S., Sudbrak, R., Albrecht, M. W., Lienhard, M., Larson, D., Craig, D. W., Izatt, T., Kurdoglu, A. A., Sherry, S. T., Xiao, C., Haussler, D., Abecasis, G. R., McVean, G. A., Durbin, R. M., Balasubramaniam, S., Keane, T. M., McCarthy, S., Stalker, J., Chakravarti, A., Knoppers, B. M., Abecasis, G. R., Barnes, K. C., Beiswanger, C., Burchard, E. G., Bustamante, C. D., Cai, H., Cao, H., Durbin, R. M., Gerry, N. P., Gharani, N., Gibbs, R. A., Gignoux, C. R., Gravel, S., Henn, B., Jones, D., Jorde, L., Kaye, J. S., Keinan, A., Kent, A., Kerasidou, A., Li, Y., Mathias, R., McVean, G. A., Moreno-Estrada, A., Ossorio, P. N., Parker, M., Resch, A. M., Rotimi, C. N., Royal, C. D., Sandoval, K., Su, Y., Sudbrak, R., Tian, Z., Tishkoff, S., Toji, L. H., Tyler-Smith, C., Via, M., Wang, Y., Yang, H., Yang, L., Zhu, J., Bodmer, W., Bedoya, G., Ruiz-Linares, A., Cai, Z., Gao, Y., Chu, J., Peltonen, L., Garcia-Montero, A., Orfao, A., Dutil, J., Martinez-Cruzado, J. C., Oleksyk, T. K., Barnes, K. C., Mathias, R. A., Hennis, A., Watson, H., McKenzie, C., Qadri, F., LaRocque, R., Sabeti, P. C., Zhu, J., Deng, X., Sabeti, P. C., Asogun, D., Folarin, O., Happi, C., Omoniwa, O., Stremlau, M., Tariyal, R., Jallow, M., Joof, F. S., Corrah, T., Rockett, K., Kwiatkowski, D., Kooner, J., Tran Tinh Hien, T. T., Dunstan, S. J., Nguyen Thuy Hang, N. T., Fonnie, R., Garry, R., Kanneh, L., Moses, L., Sabeti, P. C., Schieffelin, J., Grant, D. S., Gallo, C., Poletti, G., Saleheen, D., Rasheed, A., Brook, L. D., Felsenfeld, A., McEwen, J. E., Vaydylevich, Y., Green, E. D., Duncanson, A., Dunn, M., Schloss, J. A., Wang, J., Yang, H., Auton, A., Brooks, L. D., Durbin, R. M., Garrison, E. P., Kang, H. M., Korbel, J. O., Marchini, J. L., McCarthy, S., McVean, G. A., Abecasis, G. R. 2015; 526 (7571): 68-?

  Abstract

  The 1000 Genomes Project set out to provide a comprehensive description of common human genetic variation by applying whole-genome sequencing to a diverse set of individuals from multiple populations. Here we report completion of the project, having reconstructed the genomes of 2,504 individuals from 26 populations using a combination of low-coverage whole-genome sequencing, deep exome sequencing, and dense microarray genotyping. We characterized a broad spectrum of genetic variation, in total over 88 million variants (84.7 million single nucleotide polymorphisms (SNPs), 3.6 million short insertions/deletions (indels), and 60,000 structural variants), all phased onto high-quality haplotypes. This resource includes >99% of SNP variants with a frequency of >1% for a variety of ancestries. We describe the distribution of genetic variation across the global sample, and discuss the implications for common disease studies.

  View details for DOI 10.1038/nature15393

  View details for Web of Science ID 000362095100036

• Does Intraoperative Fluoroscopy Optimize Limb Length and the Precision of Acetabular Positioning in Primary THA? ORTHOPEDICS Leucht, P., Huddleston, H. G., Bellino, M. J., Huddleston, J. I. 2015; 38 (5): E380-E386

  Abstract

  Reduced limb length discrepancy and more accurate cup positioning are purported benefits of using fluoroscopy for total hip arthroplasty (THA). The authors compared limb length discrepancy and cup position in 200 patients (group I, posterior approach without fluoroscopy; group II, anterior supine approach with fluoroscopy) who underwent primary THA. Mean limb length discrepancy was 2.7 mm (SD, 5.2 mm; range, -9.8 to 20.9 mm) and 0.7 mm (SD, 3.7 mm; range, -11.8 to 10.5 mm) for groups I and II, respectively (P=.002). In group I, 7% of hips had limb length discrepancy greater than 1 cm compared with 3% in group II. Mean cup inclination measured 40.8° (SD, 5.0°; range, 26.1°-53.7°) in group I and 43.4° (SD, 5.6°; range, 31.3°-55.9°) in group II (P=.008). In group I, 96% of cups had inclination within 10° of the mean compared with 92% in group II (P=.24). Mean anteversion measured 35.3° (SD, 7.1°; range, 17.8°-60.7°) in group I and 25.9° (SD, 8.2°; range, 1.5°-44.8°) in group II (P=.0001). In group I, 87% of hips exhibited anteversion within 10° of the mean compared with 76% in group II (P=.045). Although the anterior approach with intraoperative fluoroscopy reduced mean limb length discrepancy, the clinical significance of this reduction is unclear. Fluoroscopy reduced the incidence of limb length discrepancy greater than 1 cm. However, the use of fluoroscopy did not help to improve the precision of cup positioning.

  View details for DOI 10.3928/01477447-20150504-54

  View details for Web of Science ID 000356148900005

  View details for PubMedID 25970364

• Collecting Patient-Reported Outcomes: Lessons from the California Joint Replacement Registry. EGEMS (Washington, DC) Chenok, K., Teleki, S., SooHoo, N. F., Huddleston, J., Bozic, K. J. 2015; 3 (1): 1196-?

  Abstract

  While patient-reported outcomes (PROs) have long been used for research, recent technology advancements make it easier to collect patient feedback and use it for patient care. Despite the promise and appeal of PROs, substantial barriers to widespread adoption remain-including challenges in interpreting privacy regulations, educating patients and physicians about the power that PRO collection can provide to patient-centered care.This article describes lessons learned from the California Joint Replacement Registry's (CJRR) five-year effort to collect PROs from patients undergoing total hip and total knee replacement surgeries. CJRR is a voluntary, multi-institutional registry in California that collects clinical and device information, as well as PROs from patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries.The CJRR encountered and developed solutions to overcome several key issues: (1) limitations of electronic PRO collection, (2) challenges in patient recruitment and tracking, (3) challenges in encouraging patients to complete PRO surveys, (4) real and perceived administrative burden to clinic and hospital staff, (5) surgeon engagement, and (6) survey costs.The CJRR's field experience can inform growing numbers of providers and researchers who seek to more fully understand the impact of care from the patient's perspective. In addition, the authors believe that these challenges can best be addressed through a combination of policy changes and increased incentives.

  View details for DOI 10.13063/2327-9214.1196

  View details for PubMedID 26793737

  View details for PubMedCentralID PMC4708091

• Total knee arthroplasty in patients with ipsilateral fused hip: a technical note. Clinics in orthopedic surgery Goodman, S. B., Huddleston, J. I., Hur, D., Song, S. J. 2014; 6 (4): 476-479

  Abstract

  We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient's medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

  View details for DOI 10.4055/cios.2014.6.4.476

  View details for PubMedID 25436074

• Regional Differences Between US and Europe in Radiological Osteoarthritis and Self Assessed Quality of Life in Patients Undergoing Total Hip Arthroplasty Surgery JOURNAL OF ARTHROPLASTY Gromov, K., Greene, M. E., Sillesen, N. H., Troelsen, A., Malchau, H., Huddleston, J. I., Emerson, R., Garcia-Cimbrelo, E., Gebuhr, P. 2014; 29 (11): 2078-2083

  Abstract

  Precise indications for THA remain unclear and regional differences might exist in selecting patients for surgery. In this study we investigate radiological OA grade and self-reported quality of life in 909 patients undergoing THA in 16 centers across US and Europe. Patients in US were younger and had higher BMI. More patients with mild Tönnis OA grade underwent surgery in the US compared to Europe. Patients in the US had significantly higher pain VAS and significantly lower SF-36 Physical, while having significantly higher EQ-VAS scores preoperatively. Patient demographics and disease severity according to radiological OA grade and self-reported survey scores vary between the United States and Europe. This knowledge can be used in the interpretation of US and European based studies on outcome following THA.

  View details for DOI 10.1016/j.arth.2014.07.006

  View details for Web of Science ID 000344228000005

• Clinical recovery from surgery correlates with single-cell immune signatures SCIENCE TRANSLATIONAL MEDICINE Gaudilliere, B., Fragiadakis, G. K., Bruggner, R. V., Nicolau, M., Finck, R., Tingle, M., Silva, J., Ganio, E. A., Yeh, C. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Davis, M. M., Bendall, S. C., Fantl, W. J., Angst, M. S., Nolan, G. P. 2014; 6 (255)

  Abstract

  Delayed recovery from surgery causes personal suffering and substantial societal and economic costs. Whether immune mechanisms determine recovery after surgical trauma remains ill-defined. Single-cell mass cytometry was applied to serial whole-blood samples from 32 patients undergoing hip replacement to comprehensively characterize the phenotypic and functional immune response to surgical trauma. The simultaneous analysis of 14,000 phosphorylation events in precisely phenotyped immune cell subsets revealed uniform signaling responses among patients, demarcating a surgical immune signature. When regressed against clinical parameters of surgical recovery, including functional impairment and pain, strong correlations were found with STAT3 (signal transducer and activator of transcription), CREB (adenosine 3',5'-monophosphate response element-binding protein), and NF-κB (nuclear factor κB) signaling responses in subsets of CD14(+) monocytes (R = 0.7 to 0.8, false discovery rate <0.01). These sentinel results demonstrate the capacity of mass cytometry to survey the human immune system in a relevant clinical context. The mechanistically derived immune correlates point to diagnostic signatures, and potential therapeutic targets, that could postoperatively improve patient recovery.

  View details for DOI 10.1126/scitranslmed.3009701

  View details for Web of Science ID 000343316800006

• Clinical recovery from surgery correlates with single-cell immune signatures. Science translational medicine Gaudillière, B., Fragiadakis, G. K., Bruggner, R. V., Nicolau, M., Finck, R., Tingle, M., Silva, J., Ganio, E. A., Yeh, C. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Davis, M. M., Bendall, S. C., Fantl, W. J., Angst, M. S., Nolan, G. P. 2014; 6 (255): 255ra131-?

  Abstract

  Delayed recovery from surgery causes personal suffering and substantial societal and economic costs. Whether immune mechanisms determine recovery after surgical trauma remains ill-defined. Single-cell mass cytometry was applied to serial whole-blood samples from 32 patients undergoing hip replacement to comprehensively characterize the phenotypic and functional immune response to surgical trauma. The simultaneous analysis of 14,000 phosphorylation events in precisely phenotyped immune cell subsets revealed uniform signaling responses among patients, demarcating a surgical immune signature. When regressed against clinical parameters of surgical recovery, including functional impairment and pain, strong correlations were found with STAT3 (signal transducer and activator of transcription), CREB (adenosine 3',5'-monophosphate response element-binding protein), and NF-κB (nuclear factor κB) signaling responses in subsets of CD14(+) monocytes (R = 0.7 to 0.8, false discovery rate <0.01). These sentinel results demonstrate the capacity of mass cytometry to survey the human immune system in a relevant clinical context. The mechanistically derived immune correlates point to diagnostic signatures, and potential therapeutic targets, that could postoperatively improve patient recovery.

  View details for DOI 10.1126/scitranslmed.3009701

  View details for PubMedID 25253674

• Registries collecting level-I through IV Data: institutional and multicenter use: AAOS exhibit selection. journal of bone and joint surgery. American volume Hansen, V. J., Greene, M. E., Bragdon, M. A., Nebergall, A. K., Barr, C. J., Huddleston, J. I., Bragdon, C. R., Malchau, H. 2014; 96 (18)

  View details for DOI 10.2106/JBJS.M.01458

  View details for PubMedID 25232090

• Patient, surgeon, and healthcare purchaser views on the use of decision and communication aids in orthopaedic surgery: a mixed methods study BMC HEALTH SERVICES RESEARCH Bozic, K. J., Chenok, K. E., Schindel, J., Chan, V., Huddleston, J. I., Braddock, C., Belkora, J. 2014; 14

  Abstract

  Despite evidence that decision and communication aids are effective for enhancing the quality of preference-sensitive decisions, their adoption in the field of orthopaedic surgery has been limited. The purpose of this mixed-methods study was to evaluate the perceived value of decision and communication aids among different healthcare stakeholders.Patients with hip or knee arthritis, orthopaedic surgeons who perform hip and knee replacement procedures, and a group of large, self-insured employers (healthcare purchasers) were surveyed regarding their views on the value of decision and communication aids in orthopaedics. Patients with hip or knee arthritis who participated in a randomized controlled trial involving decision and communication aids were asked to complete an online survey about what was most and least beneficial about each of the tools they used, the ideal mode of administration of these tools and services, and their interest in receiving comparable materials and services in the future. A subset of these patients were invited to participate in a telephone interview, where there were asked to rank and attribute a monetary value to the interventions. These interviews were analyzed using a qualitative and mixed methods analysis software. Members of the American Hip and Knee Surgeons (AAHKS) were surveyed on their perceptions and usage of decision and communication aids in orthopaedic practice. Healthcare purchasers were interviewed about their perspectives on patient-oriented decision support.All stakeholders saw value in decision and communication aids, with the major barrier to implementation being cost. Both patients and surgeons would be willing to bear at least part of the cost of implementing these tools, while employers felt health plans should be responsible for shouldering the costs.Decision and communication aids can be effective tools for incorporating patients preferences and values into preference-sensitive decisions in orthopaedics. Future efforts should be aimed at assessing strategies for efficient implementation of these tools into widespread orthopaedic practice.

  View details for DOI 10.1186/1472-6963-14-366

  View details for Web of Science ID 000341387100001

  View details for PubMedCentralID PMC4162971

• Current Modes of Failure in TKA: Infection, Instability, and Stiffness Predominate. Clinical orthopaedics and related research Le, D. H., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2014; 472 (7): 2197-2200

  Abstract

  Historically, polyethylene wear and its sequelae (osteolysis, late instability, aseptic loosening) were common causes for revision total knee arthroplasty (TKA). Recently, polyethylene manufacturing has become more consistent; furthermore, a clearer understanding of the importance of oxidation on polyethylene performance led to packaging of the polyethylene bearings in an inert environment. This improved the quality and consistency of polyethylene used in TKA, raising the question of whether different failure modes now predominate after TKA.The purpose of this study was to determine the current reasons for (1) early and (2) late failures after TKA at one high-volume arthroplasty center.We reviewed all first-time revision TKAs performed between 2001 and 2011 at one institution, yielding a group of 253 revision TKAs in 251 patients. Mean age at the time of revision was 64 years (SD 10 years). Mean time to revision was 35 months (SD 23 months). Preoperative evaluations, laboratory data, radiographs, and intraoperative findings were used to determine causes for revision. Early failure was defined as revision within 2 years of the index procedure. The primary failure mechanism was determined by the operating surgeon.Early failure accounted for 46% (116 of 253) of all revisions with infection (28 of 116 [24%]), instability (30 of 116 [26%]), and stiffness (21 of 116 [18%]) being the leading causes. Late failure accounted for 54% (137 of 253) of all revisions with the most common causes including infection (34 of 137 [25%]), instability (24 of 137 [18%]), and stiffness (19 of 253 [14%]). Polyethylene wear was implicated as the failure mechanism in 2% of early cases (two of 116) and 9% of late cases (13 of 137).In contrast to previous studies, wear-related implant failure in TKA was relatively uncommon in this series. Changes in polyethylene manufacturing, sterilization, and storage may have accounted for some of this difference; however, longer-term followup will be required to verify this finding. Infection, instability, and stiffness represent the most common causes of early and late failure. Strategies to improve outcomes in TKA should be aimed at infection prophylaxis and treatment, surgical technique, and patient selection.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1007/s11999-014-3540-y

  View details for PubMedID 24615421

• Polyethylene wear and osteolysis is associated with high revision rate of a small sized porous coated THA in patients with hip dysplasia. journal of arthroplasty Murray, P. J., Hwang, K. L., Imrie, S. N., Huddleston, J. I., Goodman, S. B. 2014; 29 (7): 1373-1377

  Abstract

  The outcome of 25 primary THAs in patients with hip dysplasia using the AML Bantam femoral stem (DePuy) is reported. Age at operation averaged 43 ± 10 years. Twenty-two of 25 stems were cementless. All cementless acetabular components had conventional or cross-linked polyethylene and screws. Follow-up averaged 11 ± 5 years (range 4-18). Four cementless stems were revised after 3, 4, 8, and 9 years; 2/3 cemented stems were revised at 8 and 18 years. Femoral revisions demonstrated extensive conventional polyethylene wear, periprosthetic osteolysis and loosening. Five entire cups were revised for wear and loosening; four liners were replaced. Harris Hip Scores for patients with retained stems went from 43 ± 12 to 85 ± 13. High revision rates with the proximally porous coated Bantam stem are due to loss of fixation, often associated with polyethylene wear and osteolysis.

  View details for DOI 10.1016/j.arth.2014.02.027

  View details for PubMedID 24698818

• Outcome of Porous Tantalum Acetabular Components for Paprosky Type 3 and 4 Acetabular Defects JOURNAL OF ARTHROPLASTY Batuyong, E. D., Brock, H. S., Thiruvengadam, N., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2014; 29 (6): 1318-1322

  Abstract

  Porous tantalum acetabular implants provide a potential solution for dealing with significant acetabular bone loss. This study reviews 24 acetabular revisions using tantalum implants for Paprosky type 3 and 4 defects. The mean Harris Hip Score improved from 35±19 (range, 4-71) to 88±14 (range, 41-100), p<0.0001. Postoperative radiographs showed radiolucent lines in 14 hips with a mean width of 1.3±1.0mm (range, 0.27-4.37mm). No gaps enlarged and 71% of them disappeared at a mean of 13±10months (range, 3-29months). At a mean follow-up of 37±14months (range, 24-66months), 22 reconstructions showed radiograpic evidence of osseointegration (92%). The two failures were secondary to septic loosening. When dealing with severe acetabular bone loss, porous tantalum acetabular components show promising short-term results.

  View details for DOI 10.1016/j.arth.2013.12.002

  View details for Web of Science ID 000338115400048

• Fibronectin-aggrecan complex as a marker for cartilage degradation in non-arthritic hips. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Abrams, G. D., Safran, M. R., Shapiro, L. M., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J. 2014; 22 (4): 768-773

  Abstract

  To report hip synovial fluid cytokine concentrations in hips with and without radiographic arthritis.Patients with no arthritis (Tonnis grade 0) and patients with Tonnis grade 2 or greater hip osteoarthritis (OA) were identified from patients undergoing either hip arthroscopy or arthroplasty. Synovial fluid was collected at the time of portal establishment for those undergoing hip arthroscopy and prior to arthrotomy for the arthroplasty group. Analytes included fibronectin-aggrecan complex (FAC) as well as a standard 12 cytokine array. Variables recorded were Tonnis grade, centre-edge angle of Wiberg, as well as labrum and cartilage pathology for the hip arthroscopy cohort. A priori power analysis was conducted, and a Mann-Whitney U test and regression analyses were used with an alpha value of 0.05 set as significant.Thirty-four patients were included (17 arthroplasty, 17 arthroscopy). FAC was the only analyte to show a significant difference between those with and without OA (p < 0.001). FAC had significantly higher concentration in those without radiographic evidence of OA undergoing microfracture versus those not receiving microfracture (p < 0.05).There was a significantly higher FAC concentration in patients without radiographic OA. Additionally, those undergoing microfracture had increased levels of FAC. As FAC is a cartilage breakdown product, no significant amounts may be present in those with OA. In contrast, those undergoing microfracture have focal area(s) of cartilage breakdown. These data suggest that FAC may be useful in predicting cartilage pathology in those patients with hip pain but without radiographic evidence of arthritis.Diagnostic, Level III.

  View details for DOI 10.1007/s00167-014-2863-2

  View details for PubMedID 24477496

• Causes of instability after total knee arthroplasty. journal of arthroplasty Song, S. J., Detch, R. C., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2014; 29 (2): 360-364

  Abstract

  The purpose of the present study was to characterize the underlying causes that lead to instability after total knee arthroplasty (TKA). We reviewed 83 revision TKAs (79 patients) performed for instability. After detailed analysis of patient's history, physical examination, operative report and radiographs, we identified six categories: flexion/extension gap mismatch, component malposition, isolated ligament insufficiency, extensor mechanism insufficiency, component loosening, and global instability. Twenty-five knees presented with multi-factorial instability. When these knees were classified according to the most fundamental category, each category above included 24, 12, 11, 10, 10 and 16 knees respectively. The unstable TKA may result from a variety of distinct etiologies which must be identified and treated at the time of revision. The revision TKA could be tailored to the specific causes.

  View details for DOI 10.1016/j.arth.2013.06.023

  View details for PubMedID 23896358

• Outcome of porous tantalum acetabular components for paprosky type 3 and 4 acetabular defects. The Journal of arthroplasty Batuyong, E. D., Brock, H. S., Thiruvengadam, N., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2014; 29 (6): 1318–22

  Abstract

  Porous tantalum acetabular implants provide a potential solution for dealing with significant acetabular bone loss. This study reviews 24 acetabular revisions using tantalum implants for Paprosky type 3 and 4 defects. The mean Harris Hip Score improved from 35±19 (range, 4-71) to 88±14 (range, 41-100), p<0.0001. Postoperative radiographs showed radiolucent lines in 14 hips with a mean width of 1.3±1.0mm (range, 0.27-4.37mm). No gaps enlarged and 71% of them disappeared at a mean of 13±10months (range, 3-29months). At a mean follow-up of 37±14months (range, 24-66months), 22 reconstructions showed radiograpic evidence of osseointegration (92%). The two failures were secondary to septic loosening. When dealing with severe acetabular bone loss, porous tantalum acetabular components show promising short-term results.

  View details for PubMedID 24405625

• DESIGNING FOR CROSSLINKED UHMWPE IMPLANTS: CLINICAL CONSEQUENCES OF STRESS CONCENTRATIONS Ansari, F., Patten, E., Chang, J., Chou, S., Mehdizadeh, A., Kury, M., Huddleston, J., Jewett, B., Mickelson, D., Kim, H., Ries, M., Pruitt, L., ASME AMER SOC MECHANICAL ENGINEERS. 2014

  View details for Web of Science ID 000359389300091

• Fractography and oxidative analysis of gamma inert sterilized posterior-stabilized tibial insert post fractures: Report of two cases KNEE Ansari, F., Chang, J., Huddleston, J., Van Citters, D., Ries, M., Pruitt, L. 2013; 20 (6): 609-613

  Abstract

  Highly crosslinked ultra-high molecular weight polyethylene (UHMWPE) has shown success in reducing wear in hip arthroplasty but there remains skepticism about its use in Total Knee Replacement (TKR) inserts that are known to experience fatigue loading and higher local cyclic contact stresses.Two Legacy Posterior-Stabilized (LPS) Zimmer NexGen tibial implants sterilized by gamma irradiation in an inert environment with posts that fractured in vivo were analyzed. Failure mechanisms were determined using optical and scanning electron microscopy along with oxidative analysis via Fourier Transform Infra-Red (FTIR) spectroscopy.Micrographs of one retrieval revealed fatigue crack initiation on opposite sides of the post and quasi-brittle micromechanisms of crack propagation. FTIR of this retrieval revealed no oxidation. The fracture surface image of the second retrieval indicated a brittle fracture process and FTIR revealed oxidation in the explant.These two cases suggest that crosslinking of UHMWPE as a manufacturing process or sterilization method in conjunction with designs that incorporate high stress concentrations, such as the tibial post, may reduce material strength. Moreover, free radicals generated from ionizing radiation can render the polymer susceptible to oxidative embrittlement.Our findings suggest that tibial post fractures may be the results of in vivo oxidation and low level crosslinking. These and previous reports of fractured crosslinked UHMWPE devices implores caution when used with high stress concentrations, particularly when considering the potential for in vivo oxidation in TKR.

  View details for DOI 10.1016/j.knee.2013.04.004

  View details for Web of Science ID 000330824200046

  View details for PubMedID 24220187

• Shared Decision Making in Patients with Osteoarthritis of the Hip and Knee Results of a Randomized Controlled Trial JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Bozic, K. J., Belkora, J., Chan, V., Youm, J., Zhou, T., Dupaix, J., Bye, A. N., Braddock, C. H., Chenok, K. E., Huddleston, J. I. 2013; 95A (18): 1633-1639

  Abstract

  Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement, they are not commonly employed in orthopaedic practice. The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge, efficiency of decision making, treatment choice, and patient and surgeon experience in patients with osteoarthritis of the hip or knee.One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were randomized to either a shared decision-making intervention or usual care. Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach. Patients in the control group received information about the surgeon's practice. Both groups reported their knowledge and stage in decision making and their treatment choice, satisfaction, and communication with their surgeon. Surgeons reported the appropriateness of patient questions and their satisfaction with the visit. The primary outcome measure tracked whether patients reached an informed decision during their first visit. Statistical analyses were performed to evaluate differences between groups.Significantly more patients in the intervention group (58%) reached an informed decision during the first visit compared with the control group (33%) (p = 0.005). The intervention group reported higher confidence in knowing what questions to ask their doctor (p = 0.0034). After the appointment, there was no significant difference between groups in the percentage of patients choosing surgery (p = 0.48). Surgeons rated the number and appropriateness of patient questions higher in the intervention group (p < 0.0001), reported higher satisfaction with the efficiency of the intervention group visits (p < 0.0001), and were more satisfied overall with the intervention group visits (p < 0.0001).Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice.

  View details for DOI 10.2106/JBJS.M.00004

  View details for Web of Science ID 000326250400001

• Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. journal of bone and joint surgery. American volume Bozic, K. J., Belkora, J., Chan, V., Youm, J., Zhou, T., Dupaix, J., Bye, A. N., Braddock, C. H., Chenok, K. E., Huddleston, J. I. 2013; 95 (18): 1633-1639

  Abstract

  Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement, they are not commonly employed in orthopaedic practice. The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge, efficiency of decision making, treatment choice, and patient and surgeon experience in patients with osteoarthritis of the hip or knee.One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were randomized to either a shared decision-making intervention or usual care. Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach. Patients in the control group received information about the surgeon's practice. Both groups reported their knowledge and stage in decision making and their treatment choice, satisfaction, and communication with their surgeon. Surgeons reported the appropriateness of patient questions and their satisfaction with the visit. The primary outcome measure tracked whether patients reached an informed decision during their first visit. Statistical analyses were performed to evaluate differences between groups.Significantly more patients in the intervention group (58%) reached an informed decision during the first visit compared with the control group (33%) (p = 0.005). The intervention group reported higher confidence in knowing what questions to ask their doctor (p = 0.0034). After the appointment, there was no significant difference between groups in the percentage of patients choosing surgery (p = 0.48). Surgeons rated the number and appropriateness of patient questions higher in the intervention group (p < 0.0001), reported higher satisfaction with the efficiency of the intervention group visits (p < 0.0001), and were more satisfied overall with the intervention group visits (p < 0.0001).Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice.

  View details for DOI 10.2106/JBJS.M.00004

  View details for PubMedID 24048550

• Should Draining Wounds and Sinuses Associated With Hip and Knee Arthroplasties Be Cultured? JOURNAL OF ARTHROPLASTY Tetreault, M. W., Wetters, N. G., Aggarwal, V. K., Moric, M., Segreti, J., Huddleston, J. I., Parvizi, J., Della Valle, C. J. 2013; 28 (8): 133-136

  Abstract

  We assessed the utility of culturing draining wounds or sinuses in evaluating periprosthetic joint infection (PJI). Fifty-five patients with a draining wound or sinus after total joint arthroplasty (28 knees, 27 hips) who had not received antibiotics for at least two weeks were prospectively studied. Superficial wound cultures were compared to intra-articular cultures to determine accuracy in isolating infecting organism(s). The superficial cultures were concordant with deep cultures in 26 of 55 cases (47.3%) and were more likely to generate polymicrobial results (27.3% vs. 10.9%; P=0.023). In 23 cases (41.8%), the superficial cultures would have led to a change in antibiotic regimen. Superficial cultures yielded bacterial growth in 8 of the 10 cases (80%) when deep cultures and further work-up suggested the absence of deep infection. Given the potential to misguide diagnosis and treatment, we recommend against obtainment of superficial cultures in patients with a draining wound or sinus following hip or knee arthroplasty.

  View details for DOI 10.1016/j.arth.2013.04.057

  View details for Web of Science ID 000209487600032

• Combined turnover vastus lateralis and lateral gastrocnemius flaps as a salvage option for soft tissue reconstruction of the knee EUROPEAN JOURNAL OF PLASTIC SURGERY Momeni, A., Lee, T., Huddleston, J., Lee, G. K. 2013; 36 (9): 595–602

  View details for DOI 10.1007/s00238-012-0806-z

  View details for Web of Science ID 000217694000010

• Should draining wounds and sinuses associated with hip and knee arthroplasties be cultured? journal of arthroplasty Tetreault, M. W., Wetters, N. G., Aggarwal, V. K., Moric, M., Segreti, J., Huddleston, J. I., Parvizi, J., Della Valle, C. J. 2013; 28 (8): 133-136

  Abstract

  We assessed the utility of culturing draining wounds or sinuses in evaluating periprosthetic joint infection (PJI). Fifty-five patients with a draining wound or sinus after total joint arthroplasty (28 knees, 27 hips) who had not received antibiotics for at least two weeks were prospectively studied. Superficial wound cultures were compared to intra-articular cultures to determine accuracy in isolating infecting organism(s). The superficial cultures were concordant with deep cultures in 26 of 55 cases (47.3%) and were more likely to generate polymicrobial results (27.3% vs. 10.9%; P=0.023). In 23 cases (41.8%), the superficial cultures would have led to a change in antibiotic regimen. Superficial cultures yielded bacterial growth in 8 of the 10 cases (80%) when deep cultures and further work-up suggested the absence of deep infection. Given the potential to misguide diagnosis and treatment, we recommend against obtainment of superficial cultures in patients with a draining wound or sinus following hip or knee arthroplasty.

  View details for DOI 10.1016/j.arth.2013.04.057

  View details for PubMedID 23906868

• Determinants of time to opioid cessation post-surgery Ruchelli, G., Clay, D., Schmidt, P., Humphreys, K., Trafton, J., Dirbas, F., Giori, N., Goodman, S., Hoang, C., Huddleston, J., Maloney, W., Merritt, R., Miller, M., Shrager, J., Whyte, R., Mackey, S., Carroll, I. CHURCHILL LIVINGSTONE. 2013: S18–S18

  View details for Web of Science ID 000317639400072

• MI TKA: a risk factor for early revision surgery. The journal of knee surgery Mayle, R. E., Graw, B. P., Huddleston, H. G., Woolson, S. T., Goodman, S. B., Huddleston, J. I. 2012; 25 (5): 423-427

  Abstract

  Minimal incision total knee arthroplasty (MI TKA) was developed with the potential to decrease surgical trauma, pain, and recovery time. While this procedure has increased in popularity, some surgeons have questioned its safety and long-term efficacy. In this study 58 consecutive revision total knee arthroplasties (TKAs) (57 patients) performed at one academic medical center from 2006 to 2008 are reviewed. Prospectively collected clinical and radiographic data included: incision length, gender, age, time to revision surgery, and primary diagnosis at time of revision. Of these, 34 knees involving infection and rerevision were excluded. Of the remaining 24 knees, 11 knees that met inclusion criteria had undergone MI TKA. There were no differences between the groups with regard to age, diagnosis, body mass index, and gender. Average time to revision was shorter for the MI TKA patients (29 vs. 65 months, p < 0.032, odds ratio 14.7). Reasons for revision were aseptic loosening (55%), pain/stiffness (27%), malrotation (9%), and instability (9%) in the MI TKA group and aseptic loosening (53%), instability (15%), pain/stiffness (8%), malrotation (8%), combined malrotation and instability (8%), and polyethylene wear/osteolysis (8%) in the traditional TKA group. These data suggest that MI TKA may be a risk factor for early revision.

  View details for DOI 10.1055/s-0032-1313757

  View details for PubMedID 23150354

• MI TKA: A Risk Factor for Early Revision Surgery JOURNAL OF KNEE SURGERY Mayle, R. E., Graw, B. P., Huddleston, H. G., Woolson, S. T., Goodman, S. B., Huddleston, J. I. 2012; 25 (5): 423-427

  Abstract

  Minimal incision total knee arthroplasty (MI TKA) was developed with the potential to decrease surgical trauma, pain, and recovery time. While this procedure has increased in popularity, some surgeons have questioned its safety and long-term efficacy. In this study 58 consecutive revision total knee arthroplasties (TKAs) (57 patients) performed at one academic medical center from 2006 to 2008 are reviewed. Prospectively collected clinical and radiographic data included: incision length, gender, age, time to revision surgery, and primary diagnosis at time of revision. Of these, 34 knees involving infection and rerevision were excluded. Of the remaining 24 knees, 11 knees that met inclusion criteria had undergone MI TKA. There were no differences between the groups with regard to age, diagnosis, body mass index, and gender. Average time to revision was shorter for the MI TKA patients (29 vs. 65 months, p < 0.032, odds ratio 14.7). Reasons for revision were aseptic loosening (55%), pain/stiffness (27%), malrotation (9%), and instability (9%) in the MI TKA group and aseptic loosening (53%), instability (15%), pain/stiffness (8%), malrotation (8%), combined malrotation and instability (8%), and polyethylene wear/osteolysis (8%) in the traditional TKA group. These data suggest that MI TKA may be a risk factor for early revision.

  View details for DOI 10.1055/s-0032-1313757

  View details for Web of Science ID 000209168300012

• Heparin-induced thrombocytopenia after total knee arthroplasty, with subsequent adrenal hemorrhage. journal of arthroplasty Chow, V. W., Abnousi, F., Huddleston, J. I., Lin, L. H. 2012; 27 (7): 1413 e15-8

  Abstract

  Heparin-induced thrombocytopenia (HIT) is a life-threatening immune-mediated adverse effect of chemoprophylaxis for venous thromboembolic events. We present the case of a 44-year-old man who developed bilateral adrenal hemorrhage (BAH) as a sequela of HIT after bilateral total knee arthroplasty. In our review of clinical management of HIT-induced BAH, we discuss the 21 published cases of this phenomenon, 14 of which occurred after orthopedic surgery. Given the potentially fatal consequences and the importance of early intervention, physicians should be on the alert for recognizing HIT-induced BAH in patients experiencing shock unresponsive to fluid resuscitation. In addition, chemoprophylaxis with alternative agents such as a synthetic pentasaccharide factor Xa inhibitor and oral direct thrombin inhibitors that are associated with lower risks of HIT in orthopedic patients merits exploration.

  View details for DOI 10.1016/j.arth.2012.01.012

  View details for PubMedID 22397862

• Advanced Age and Comorbidity Increase the Risk for Adverse Events After Revision Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Koenig, K., Huddleston, J. I., Huddleston, H., Maloney, W. J., Goodman, S. B. 2012; 27 (7): 1402-1407

  Abstract

  With the institution of quality-assurance parameters in health care, physicians must accurately measure and report the true baseline rates of adverse events (AEs) after complex surgical interventions. To better quantify the risk of AEs for revision total hip arthroplasty (THA), we divided a cohort of 306 patients (322 procedures) into age groups: group I (<65 years, n = 138), group II (65-79 years, n = 119), and group III (≥80 years, n = 65). Ninety-day rates of major AE were 9%, 19%, and 34% in the groups, respectively. Group III had an increased chance of experiencing major AE compared with groups I and II. Age and Charlson Comorbidity Index independently predicted major complications, whereas body mass index, sex, and type of revision did not.

  View details for DOI 10.1016/j.arth.2011.11.013

  View details for PubMedID 22245123

• Commentary: Is the hip bone connected to the spine bone? SPINE JOURNAL Huddleston, J. I., Maloney, W. J. 2012; 12 (5): 370-371

  Abstract

  COMMENTARY ON: Prather H, Van Dillen LR, Kymes SM, et al. Impact of coexistent lumbar spine disorders on clinical outcomes and physician charges associated with total hip arthroplasty. Spine J 2012;12:363-9 (in this issue).

  View details for DOI 10.1016/j.spinee.2012.05.002

  View details for Web of Science ID 000305298300002

  View details for PubMedID 22698149

• Age and Obesity Are Risk Factors for Adverse Events After Total Hip Arthroplasty Scientific Meeting of the Hip-Society / Annual Meeting of the American-Academy-of-Orthopaedic-Surgeons Huddleston, J. I., Wang, Y., Uquillas, C., Herndon, J. H., Maloney, W. J. SPRINGER. 2012: 490–96

  Abstract

  Defining the epidemiology of adverse events after THA will aid in the development of strategies to enhance perioperative care.We identified (1) risk factors for adverse events in Medicare beneficiaries while hospitalized after THA and (2) trends in the rates of adverse events.Data were abstracted from medical records of 1809 Medicare beneficiaries who underwent THA from 2002 to 2007. We used the hierarchical generalized linear modeling approach to assess the odds of change in adverse events over time, the association of adverse events with outcomes, and the relationship of adverse events with patient characteristics by modeling the log-odds of adverse events as a function of demographic and clinical variables adjusted for year variable.The overall rate of adverse events was 5.8%; the 30-day mortality rate was 1.00%. Increased age, obesity, and year of procedure were risk factors for experiencing any adverse event. Annual rates of adverse events from 2002 to 2007 were 9.1%, 8.2%, 4.9%, 4.1%, 3.5%, and 3.0%, respectively. Experiencing any adverse event was associated with an increased length of stay and an increased chance of readmission but not with an increased chance of mortality. The annual rate of all adverse events decreased from 2002-2004 to 2005-2007 (odds ratio = 0.83; 95% confidence interval, 0.74-0.92).Older and obese patients should be counseled regarding their increased risk for the development of adverse events after THA. The cause of the decline in the rate of adverse events between two time periods is unclear and warrants further investigation to confirm and identify the cause.

  View details for DOI 10.1007/s11999-011-1967-y

  View details for Web of Science ID 000299056000022

  View details for PubMedID 21796477

  View details for PubMedCentralID PMC3254770

• Decreased Length of Stay After TKA Is Not Associated With Increased Readmission Rates in a National Medicare Sample CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Vorhies, J. S., Wang, Y., Herndon, J. H., Maloney, W. J., Huddleston, J. I. 2012; 470 (1): 166-171

  Abstract

  There is a trend toward decreasing length of hospital stay (LOS) after TKA although it is unclear whether this trend is detrimental to the overall postoperative course. Such information is important for future decisions related to cost containment.We determined whether decreases in LOS after TKA are associated with increases in readmission rates.We retrospectively reviewed the rates and reasons for readmission and LOS for 4057 Medicare TKA patients from 2002 to 2007. We abstracted data from the Medicare Patient Safety Monitoring System. Hierarchical generalized linear modeling was used to assess the odds of changing readmission rates and LOS over time, controlling for changes in patient demographic and clinical variables.The overall readmission rate in the 30 days after discharge was 228/4057 (5.6%). The 10 most common reasons for readmission were congestive heart failure (20.4%), chronic ischemic heart disease (13.9%), cardiac dysrhythmias (12.5%), pneumonia (10.8%), osteoarthrosis (9.4%), general symptoms (7.4%), acute myocardial infarction (7.0%), care involving other specified rehabilitation procedure (6.3%), diabetes mellitus (6.3%), and disorders of fluid, electrolyte, and acid-base balance (5.9%); the top 10 causes did not include venous thromboembolism syndromes. We found no difference in the readmission rate between the periods 2002-2004 (5.5%) and 2005-2007 (5.8%) but a reduction in LOS between the periods 2002-2004 (4.1 ± 2.0 days) and 2005-2007 (3.8 ± 1.7 days).The most common causes for readmission were cardiac-related. A reduction in LOS was not associated with an increase in the readmission rate in this sample. Optimization of cardiac status before discharge and routine primary care physician followup may lead to lower readmission rates.

  View details for DOI 10.1007/s11999-011-1957-0

  View details for Web of Science ID 000298103100021

  View details for PubMedID 21720934

  View details for PubMedCentralID PMC3237965

• Long-Term Comparison of Mobile-Bearing vs Fixed-Bearing Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Woolson, S. T., Epstein, N. J., Huddleston, J. I. 2011; 26 (8): 1219-1223

  Abstract

  Few published reports have been published regarding a comparison of the long-term outcomes between mobile- (MB) and fixed-bearing component designs for knee arthroplasty. The minimum 10-year clinical and radiologic follow-up of an unselected consecutive series of 89 patients (107 knees) who were randomized to have one of these different designs for primary arthroplasty was done. Twenty-six patients (30 knees) who had a fixed-bearing design and 24 patients (33 knees) who had an MB prosthesis were available for follow-up. Two MB knees were revised for aseptic loosening of a tibial component in one and femoral component fracture in the other. In patients who did not have revision surgery, there were no differences between the groups with respect to mean Knee Society scores, knee flexion, or pain scores.

  View details for DOI 10.1016/j.arth.2011.01.014

  View details for Web of Science ID 000297389100017

  View details for PubMedID 21397453

• Readmission and Length of Stay After Total Hip Arthroplasty in a National Medicare Sample JOURNAL OF ARTHROPLASTY Vorhies, J. S., Wang, Y., Herndon, J., Maloney, W., Huddleston, J. I. 2011; 26 (6): 119-123

  Abstract

  Evaluation of hospital readmissions after total hip arthroplasty may help improve patient safety and cost reduction. This study investigates the rates and reasons for readmission as well as length of hospital stay (LOS) for 1802 total hip arthroplasty patients from 2002 to 2007. Data were abstracted from the Medicare Patient Safety Monitoring System. The overall 30-day rate of readmission was 6.8%. There was no difference in readmission rate from 2002 to 2004 (7.1%) to 2005 to 2007 (6.3%) (odds ratio, 0.90; 95% confidence interval, 0.63-1.30; P = .58). The overall mean LOS was 4.2 ± 2.2 days. There was a significant reduction in LOS from 2002 to 2004 (4.4 ± 2.5 days) to 2005 to 2007 (3.8 ± 1.7 days) (odds ratio, 1.28; 95% confidence interval, 1.25-1.31; P < .0001). The most common causes for readmission were cardiac related. A reduction in LOS was not associated with an increase in the rate of readmission in this sample. Efforts to optimize cardiac status before discharge may lead to lower rates of readmission in the future.

  View details for DOI 10.1016/j.arth.2011.04.036

  View details for Web of Science ID 000294393000023

  View details for PubMedID 21723700

• Synovial Tissue-Infiltrating Natural Killer Cells in Osteoarthritis and Periprosthetic Inflammation ARTHRITIS AND RHEUMATISM Huss, R. S., Huddleston, J. I., Goodman, S. B., Butcher, E. C., Zabel, B. A. 2010; 62 (12): 3799-3805

  Abstract

  Infiltrating immune cells play a central role in degenerative joint disease associated with osteoarthritis (OA) and particle-mediated periprosthetic osteolysis. The goal of this study was to characterize a newly identified population of synovial tissue-infiltrating natural killer (NK) cells obtained from patients with OA or patients with periprosthetic joint inflammation.Synovial and interfacial tissue samples were collected from patients with OA who were undergoing primary or revision total joint replacement (TJR) surgery. The histologic features of OA synovium obtained from patients undergoing primary surgery and interfacial tissue obtained from patients undergoing revision surgery were determined by immunohistochemistry and immunofluorescence. Synovial tissue-infiltrating NK cells were evaluated for the expression of surface receptors, using flow cytometry. Chemoattractant and cytokine protein and RNA levels in synovial and interfacial tissue and fluid were assessed by Luminex assay and real-time quantitative polymerase chain reaction. Cytokine production and degranulation by stimulated synovial tissue versus normal blood NK cells were evaluated by intracellular cytokine staining.NK cells comprised nearly 30% of the CD45+ mononuclear cell infiltrate in synovial tissue obtained from patients undergoing primary TJR and from patients undergoing revision TJR. NK cells from both groups expressed CXCR3, CCR5, L-selectin, α4 integrins, and cutaneous lymphocyte antigen. Synovial fluid from patients undergoing revision surgery contained elevated concentrations of the NK cell attractants CCL4, CCL5, CXCL9, and CXCL10; all levels in synovial fluid obtained from patients undergoing revision surgery were higher than those in synovial fluid from patients undergoing primary surgery. Cytokine-stimulated interferon-γ production was significantly impaired in NK cells derived from primary and revision TJRs compared with blood NK cells.NK cells are a principal tissue-infiltrating lymphocyte subset in patients with OA and patients with periprosthetic inflammation and display a quiescent phenotype that is consistent with postactivation exhaustion.

  View details for DOI 10.1002/art.27751

  View details for PubMedID 20848566

• Use and Cost-Effectiveness of Intraoperative Acid-Fast Bacilli and Fungal Cultures in Assessing Infection of Joint Arthroplasties JOURNAL OF ARTHROPLASTY Wadey, V. M., Huddleston, J. I., Goodman, S. B., Schurman, D. J., Maloney, W. J., Baron, E. J. 2010; 25 (8): 1231-1234

  Abstract

  The objective of this study is to determine a protocol for collecting acid-fast bacilli (AFB) and fungal intraoperative cultures during orthopedic procedures. An observational study was undertaken. Four hundred forty-six AFB cultures and 486 fungal cultures were processed over a 2-year period. The number of positive cultures was determined. A protocol specific to handling these types of specimens was developed. Cost analysis was completed to determine both the time and money saved if the new protocol was implemented. The infrequency of positive AFB and fungal cultures in this study suggests that it is only necessary to routinely request AFB and fungal cultures on 1 of 5 samples. Implementation of this protocol has potential to lead to substantial cost reduction and resource savings without diminishing patient outcomes.

  View details for DOI 10.1016/j.arth.2009.08.018

  View details for Web of Science ID 000284749500009

  View details for PubMedID 19879728

• Repair of a Deficient Abductor Mechanism with Achilles Tendon Allograft After Total Hip Replacement JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Fehm, M. N., Huddleston, J. I., Burke, D. W., Geller, J. A., Malchau, H. 2010; 92A (13): 2305-2311

  View details for DOI 10.2106/JBJS.I.01011

  View details for Web of Science ID 000283832300007

• Repair of a deficient abductor mechanism with Achilles tendon allograft after total hip replacement. journal of bone and joint surgery. American volume Fehm, M. N., Huddleston, J. I., Burke, D. W., Geller, J. A., Malchau, H. 2010; 92 (13): 2305-2311

  Abstract

  Abductor mechanism insufficiency after total hip arthroplasty is a rare but debilitating problem. The diagnosis is difficult, and when the condition is recognized there are few successful treatment options. The purpose of this study was to review our experience with a surgical technique involving use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to reconstruct a deficient abductor mechanism after total hip arthroplasty.From 2003 to 2006, we performed seven abductor reconstructions with an Achilles tendon allograft in patients with abductor deficiency after total hip arthroplasty. At a mean of twenty-nine months after the total hip arthroplasty, all seven patients had symptoms of lateral hip pain and abductor muscle weakness as demonstrated by a Trendelenburg test. The abductor tendon rupture was diagnosed on the basis of an arthrogram and was confirmed at surgery.Before the reconstruction, the average Harris hip score was 34.7 points and the average pain score was 11.4 points. After a minimum duration of follow-up of twenty-four months, the average Harris hip score was 85.9 points and the average pain score was 38.9 points.Abductor reconstruction with an Achilles tendon allograft with a calcaneal bone block attached to the greater trochanter can produce substantial relief of pain, increased abductor muscle strength, decreased limp, and improvements in the Trendelenburg sign and in function at the time of early follow-up.

  View details for DOI 10.2106/JBJS.I.01011

  View details for PubMedID 20926725

• Candida infection in total knee arthroplasty with successful reimplantation. The journal of knee surgery Graw, B., Woolson, S., Huddleston, J. I. 2010; 23 (3): 169-174

  Abstract

  Fungal infections associated with prosthetic joints are uncommon. The first case report describes a woman with insidious onset of a candidal infection of a revision total knee arthroplasty. After multiple joint debridements and prolonged antibacterial and antifungal therapy, she had a successful reimplantation of a knee prosthesis. The second case report concerns a man who had a primary cemented total knee arthroplasty that became infected with Candida albicans. He underwent resection arthroplasty with eventual replant without recurrence at 20 years. Although resection arthroplasty should be maintained as the gold standard in the surgical treatment of this problem, the first case shows a successful short-term outcome ofreimplantation of a patient with fungal infection of long-stemmed, revision total knee replacement. It also shows a treatment failure with fluconazole that was cured by voriconazole and caspofungin, two more recently developed antifungal agents.

  View details for PubMedID 21329258

• Minimal Incision Surgery as a Risk Factor for Early Failure of Total Hip Arthroplasty CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Graw, B. P., Woolson, S. T., Huddleston, H. G., Goodman, S. B., Huddleston, J. I. 2010; 468 (9): 2372-2376

  Abstract

  Minimal incision total hip arthroplasty (MI THA) techniques were developed to decrease postoperative pain and recovery time. Although these techniques have increased in popularity, the long-term survivorship of these procedures is unknown.We therefore investigated whether the time to revision in our referral practice was shorter for patients who underwent primary MI THA compared to primary traditional THA.We retrospectively reviewed 46 revision THAs performed during a 3-year period. We excluded revisions performed for infection and rerevisions. Patients with incisions less than or equal to 10 cm were defined as having had MI THA. Fifteen of the 46 patients (33%) had undergone primary MI THA. At the time of primary index THA, the mean ages of the MI and non-MI patients were 65 years and 55 years, respectively.The mean time to revision was 1.4 years for the MI patients compared with 14.7 years for the non-MI patients. Twelve of the 15 patients having MI THA required revision within 2 years of primary THA compared to 4 of the 31 patients without MI surgery (OR = 26.5, 95% CI 4.4-160.0). There were no differences between the groups with regard to age, gender, or body mass index. The most common reasons for revision in the MI THA group were intraoperative fracture and failure of femoral component osseointegration.Our data suggest MI THA may be a risk factor for early revision surgery and the long-term survival therefore may be lower than that for non-MI surgery.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

  View details for DOI 10.1007/s11999-010-1300-1

  View details for PubMedID 20352391

• Patellar Management in Revision Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 25 (4): 589-593

  Abstract

  The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.

  View details for DOI 10.1016/j.arth.2009.04.009

  View details for PubMedID 19493648

• Aseptic versus septic revision total knee arthroplasty: Patient satisfaction, outcome and quality of life improvement KNEE Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 17 (3): 200-203

  Abstract

  We prospectively compared the clinical outcomes and patient satisfaction rates of aseptic (n=30) versus septic revision TKA (n=15) at a mean follow-up of 40 months. We hypothesized that the clinical results of septic revision TKA would be inferior to aseptic revision TKA. The indication for revision in aseptic group was stiffness in 11 patients, aseptic loosening in 13, patellar loosening or maltracking in 6 patients. Patients operated for infection had better post-operative Knee Society Scores (KSS), Function Scores and SF-36 Mental Scores than aseptic group but there were no significant differences in the satisfaction rates. Patients operated for infection had more improvement in their KSS (p=0.004) and Function Scores (p=0.02) than patients revised for stiffness. Moreover, patients operated on for patellar problems had higher satisfaction rates than patients revised for stiffness (p=0.01) or aseptic loosening (p=0.01). Thus, patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. However, in the aseptic group, revision TKA for stiffness was associated with the poorest outcomes. The indication for aseptic revision is an important variable when discussing treatment and outcome with patients.

  View details for DOI 10.1016/j.knee.2009.09.001

  View details for PubMedID 19875297

• Hylamer vs Conventional Polyethylene in Primary Total Hip Arthroplasty: A Long-Term Case-Control Study of Wear Rates and Osteolysis JOURNAL OF ARTHROPLASTY Huddleston, J. I., Harris, A. H., Atienza, C. A., Woolson, S. T. 2010; 25 (2): 203-207

  Abstract

  The long-term results of Hylamer implants have not been reported previously. Clinical and radiographic results of a consecutive series of 43 patients (45 hips) who had primary total hip arthroplasty using Hylamer liners were compared with those of 37 patients (43 hips) who had conventional liners after 10-year follow-up. The linear wear rates for Hylamer and conventional polyethylene acetabular liners were 0.21 and 0.20 mm/y, respectively. The number of pelvic osteolytic lesions and their size detected on plain radiographs were significantly greater for Hylamer liners. Seven Hylamer hips were revised or are pending revision for osteolysis (16%) compared with 1 control hip. Close radiographic surveillance of patients who have Hylamer liners and evidence of osteolysis found on plain radiographs is warranted.

  View details for DOI 10.1016/j.arth.2009.02.006

  View details for Web of Science ID 000277580900006

  View details for PubMedID 19264443

• Early Catastrophic Failure of a Porous-Coated Acetabular Cup due to Bead Shedding. A Case Report HIP INTERNATIONAL Hsu, A. R., Vaughn, Z., Huddleston, J. I. 2009; 19 (4): 392-395

  Abstract

  We present a patient in whom an uncemented porous-coated acetabular cup underwent early catastrophic failure due to debonding and was successfully managed with a revision total hip arthroplasty. Early bead shedding of an acetabular cup leading to a sudden component failure requiring revision surgery is a rare event.

  View details for Web of Science ID 000275580700016

  View details for PubMedID 20041389

• Primary Total Hip Arthroplasty Using an Anterior Approach and a Fracture Table Short-term Results From a Community Hospital JOURNAL OF ARTHROPLASTY Woolson, S. T., Pouliot, M. A., Huddleston, J. I. 2009; 24 (7): 999-1005

  Abstract

  There are no data regarding the efficacy and safety of minimally invasive hip arthroplasty technique performed by community practice orthopedists. The early clinical and radiographic results of primary total hip arthroplasty using a minimally invasive anterior approach to the hip performed on a fracture table were studied. Two hundred thirty-one consecutive patients (247 hips) of 5 community practice surgeons were studied. The average surgical time (164 minutes) and estimated blood loss (858 mL) were more than double, and the major complication rate (9%) was 6 times that reported by an innovator of the procedure. However, no postoperative dislocations occurred. Adequate training is critical to reduce the risk of complications during the learning experience of minimally invasive hip arthroplasty procedures by community practice surgeons.

  View details for DOI 10.1016/j.arth.2009.04.001

  View details for Web of Science ID 000270764600001

  View details for PubMedID 19493651

• Adverse Events After Total Knee Arthroplasty A National Medicare Study JOURNAL OF ARTHROPLASTY Huddleston, J. I., Maloney, W. J., Wang, Y., Verzier, N., Hunt, D. R., Herndon, J. H. 2009; 24 (6): 95-100

  Abstract

  Adverse events from 2033 total knee arthroplasty patients were documented by nonphysician abstractors. The annual rate of adverse events from 2002 to 2004 was 9.2%, 6.4%, and 5.8%, respectively. Congestive heart failure (odds ratio, 2.1; 95% confidence interval, 1.2-3.5; P < .01) and chronic obstructive pulmonary disease (odds ratio, 1.8; 95% confidence interval, 1.2-2.7; P < .01) were associated with a significantly increased risk of experiencing any adverse event during the index hospitalization. The 30-day postprocedure rate of readmission for all causes was 5.5%. Experiencing an adverse event during the index hospitalization increased the length of stay (P < .001). The rate of symptomatic venous thromboembolism 30 days postprocedure was 1.7%. The 30-day postprocedure mortality rate was 0.3%. Experiencing any adverse event was associated with an increased 30-day postprocedure mortality (P < .001). Compared with previous studies of Medicare claims, these data reveal a substantial decrease in the mortality rate, an increased readmission rate, and no substantial change in the rate of venous thromboembolism.

  View details for DOI 10.1016/j.arth.2009.05.001

  View details for Web of Science ID 000269607800020

  View details for PubMedID 19577884

• How Often Do Patients with High-Flex Total Knee Arthroplasty Use High Flexion? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I., Scarborough, D. M., Goldvasser, D., Freiberg, A. A., Malchau, H. 2009; 467 (7): 1898-1906

  Abstract

  Although high-flexion TKA designs aim to safely accommodate deep flexion, it is unknown how often patients use deep flexion outside the laboratory. We used a validated smart-activity monitor to document the prevalence of knee flexion greater than 90 degrees in 20 consecutive patients (21 knees) who had high-flexion TKAs, at a minimum of 2 years' followup. Patients wore the device continuously for a mean of 35.7 +/- 0.5 hours. The 21 knees flexed more than 90 degrees for an average of 10 +/- 3.8 minutes (0.5%). Activities performed with flexion greater than 90 degrees were, on average, 70% in single-limb stance, 12% moving from sitting to standing, 8% walking, 7% moving from standing to reclining, 2% stepping, 0.9% moving from lying to standing, and 0.1% running. Eight knees flexed greater than 120 degrees for an average of 2.2 minutes (range, 0.2-15 minutes), or 0.1% of the testing time. Activities performed with flexion greater than 120 degrees were, on average, 90% in single-limb stance, 6% moving from sitting to standing, 3% walking, 0.6% moving from standing to reclining, 0.3% stepping, and 0.1% moving from lying to standing. Peak flexion used at any time during testing was, on average, 84% +/- 11% of maximum postoperative flexion (125 degrees +/- 12 degrees). These patients rarely used deep flexion.Level IV, therapeutic study.

  View details for DOI 10.1007/s11999-009-0874-y

  View details for Web of Science ID 000266652000041

  View details for PubMedCentralID PMC2690769

• 2009 Marshall Urist Young Investigator Award: how often do patients with high-flex total knee arthroplasty use high flexion? Clinical orthopaedics and related research Huddleston, J. I., Scarborough, D. M., Goldvasser, D., Freiberg, A. A., Malchau, H. 2009; 467 (7): 1898-1906

  Abstract

  Although high-flexion TKA designs aim to safely accommodate deep flexion, it is unknown how often patients use deep flexion outside the laboratory. We used a validated smart-activity monitor to document the prevalence of knee flexion greater than 90 degrees in 20 consecutive patients (21 knees) who had high-flexion TKAs, at a minimum of 2 years' followup. Patients wore the device continuously for a mean of 35.7 +/- 0.5 hours. The 21 knees flexed more than 90 degrees for an average of 10 +/- 3.8 minutes (0.5%). Activities performed with flexion greater than 90 degrees were, on average, 70% in single-limb stance, 12% moving from sitting to standing, 8% walking, 7% moving from standing to reclining, 2% stepping, 0.9% moving from lying to standing, and 0.1% running. Eight knees flexed greater than 120 degrees for an average of 2.2 minutes (range, 0.2-15 minutes), or 0.1% of the testing time. Activities performed with flexion greater than 120 degrees were, on average, 90% in single-limb stance, 6% moving from sitting to standing, 3% walking, 0.6% moving from standing to reclining, 0.3% stepping, and 0.1% moving from lying to standing. Peak flexion used at any time during testing was, on average, 84% +/- 11% of maximum postoperative flexion (125 degrees +/- 12 degrees). These patients rarely used deep flexion.Level IV, therapeutic study.

  View details for DOI 10.1007/s11999-009-0874-y

  View details for PubMedID 19421828

  View details for PubMedCentralID PMC2690769

• Early outcome of a modular femoral component in revision total hip arthroplasty JOURNAL OF ARTHROPLASTY Kang, M. N., Huddleston, J. I., Hwang, K., Imrie, S., Goodman, S. B. 2008; 23 (2): 220-225

  Abstract

  Forty-six hips in 42 patients underwent revision surgery with a modular femoral component (ZMR; Zimmer, Warsaw, Ind). Thirty-nine hips with 2 to 5 years' follow-up were evaluated radiographically and clinically by the Harris hip score and WOMAC pain/stiffness/function scores. The Harris hip score improved from 47.4 to 72.3 (P<.001), with significant improvements in the WOMAC pain/stiffness/function scores. The mean subsidence was 4.4 mm, with 5 hips demonstrating significant subsidence of more than 5 mm. Four hips required reoperation, 1 due to failure of the femoral component. No early complications were encountered regarding the modular junction. Modular, cementless, extensively porous, coated femoral components have demonstrated early clinical and radiographic success. Distal intramedullary fit helps ensure initial stability; proximal modularity further maximizes fit while optimizing hip offset and length.

  View details for DOI 10.1016/j.arth.2007.03.006

  View details for PubMedID 18280416

• How have alternative bearings (such as metal-on-metal, highly cross-linked polyethylene, and ceramic-on-ceramic) affected the prevention and treatment of osteolysis? AAOS/NIH Osteolysis and Implant Wear: Biological, Biomedical Engineering, and Surgical Principles Callaghan, J. J., Cuckler, J. M., Huddleston, J. I., Galante, J. O. AMER ACAD ORTHOPAEDIC SURGEONS. 2008: S33–S38

  Abstract

  Osteolysis is a multifactorial process dependent on surgical technique, implant design, patient factors, and material composition. Alternative bearing surfaces, such as highly cross-linked polyethylene, ceramic-on-ceramic, and metal-on-metal articular surfaces, have been introduced in an attempt to reduce wear and osteolysis following total hip arthroplasty. Intermediate-term follow-up data available suggest that the prevalence and severity of osteolysis may be reduced with these materials compared with conventional metal-on-polyethylene bearing surface couples. However, long-term data are presently unavailable; the future performance of these bearings awaits clinical validation.

  View details for Web of Science ID 000257474600008

  View details for PubMedID 18612011

• What is the outcome of treatment for osteolysis? AAOS/NIH Osteolysis and Implant Wear: Biological, Biomedical Engineering, and Surgical Principles Maloney, W., Rosenberg, A. AMER ACAD ORTHOPAEDIC SURGEONS. 2008: S26–S32

  Abstract

  Periprosthetic osteolysis secondary to wear-induced particle generation is a common long-term complication of hip and knee replacement and frequently results in the need for revision surgery. Management of significant bone defects remains a surgical challenge. Surgical intervention must address the wear particle generator (usually, but not always, the bearing surface), the osteolytic defects, and implant-related issues, primarily fixation and alignment. Indications for surgical intervention in the absence of loosening and pain are not well established. In general, patient age and activity level, the location and size of the osteolytic defect, and the clinical record of the implant system will dictate treatment choices.

  View details for PubMedID 18612010

• Modulation of allograft incorporation by growth factors over a prolonged continuous infusion of duration in vivo BONE Ma, T., Gutnick, J., Salazar, B., Larsen, M. D., Suenaga, E., Zilber, S., Huang, Z., Huddleston, J., Smith, R. L., Goodman, S. 2007; 41 (3): 386-392

  Abstract

  Morselized cancellous allograft bone is frequently used in the reconstruction of bone defects in cases of revision total joint replacement, trauma, spine fusion and treated infection. However, the initial lack of viable bone cells in morselized allograft bone significantly slows the process of graft incorporation compared to autograft bone. This study examined the effects of prolonged local infusion of the growth factors bone morphogenic protein-7 (BMP-7 or OP-1) and fibroblast growth factor-2 (FGF-2 or basic FGF) in the process of allograft incorporation using a rabbit tibial chamber model. New bone formation was evaluated by two indices, the activity of alkaline phosphatase and the level of birefringence. The markers of osteoclast-like cells were also measured. Without the infusion of the growth factors, lower levels of new bone formation were observed in the allograft group, compared to the autograft group. Infusion of growth factors FGF-2 and OP-1, singly or in combination, for 4 weeks, diminished this difference. The numbers of osteoclast-like cells were much higher in the allograft group before the growth factors were delivered. The infusion of FGF, singly, diminished this difference. However, the infusion of OP-1 or the combination of FGF and OP-1 did not decrease the number of osteoclast-like cells to a level comparable to autograft only. Local infusion of growth factors appears to be a useful adjunct to promote the incorporation of allograft bone in vivo.

  View details for DOI 10.1016/j.bone.2007.05.015

  View details for PubMedID 17613298

• Ambulatory measurement of knee motion and physical activity: preliminary evaluation of a smart activity monitor JOURNAL OF NEUROENGINEERING AND REHABILITATION Huddleston, J., Alaiti, A., Goldvasser, D., Scarborough, D., Freiberg, A., Rubash, H., Malchau, H., Harris, W., Krebs, D. 2006; 3

  Abstract

  There is currently a paucity of devices available for continuous, long-term monitoring of human joint motion. Non-invasive, inexpensive devices capable of recording human activity and joint motion have many applications for medical research. Such a device could be used to quantify range of motion outside the gait laboratory. The purpose of this study was to test the accuracy of the modified Intelligent Device for Energy Expenditure and Activity (IDEEA) in measuring knee flexion angles, to detect different physical activities, and to quantify how often healthy subjects use deep knee flexion in the ambulatory setting.We compared Biomotion Laboratory (BML) "gold standard" data to simultaneous IDEEA measures of knee motion and gait, step up/down, and stair descent in 5 healthy subjects. In addition, we used a series of choreographed physical activities outside the BML to confirm the IDEEA's ability to accurately measure 7 commonly-performed physical activities. Subjects then continued data collection during ordinary activities outside the gait laboratory.Pooled correlations between the BML and IDEEA knee flexion angles were .97 +/- .03 for step up/down, .98 +/- .02 for stair descent, and .98 +/- .01 for gait. In the BML protocol, the IDEEA accurately identified gait, but was less accurate in identifying step up/down and stair descent. During sampling outside the BML, the IDEEA accurately detected walking, running, stair ascent, stair descent, standing, lying, and sitting. On average, subjects flexed their knees >120 degrees for 0.17% of their data collection periods outside the BML.The modified IDEEA system is a useful clinical tool for evaluating knee motion and multiple physical activities in the ambulatory setting. These five healthy subjects rarely flexed their knees >120 degrees.

  View details for Web of Science ID 000251258600001

  View details for PubMedID 16970818

  View details for PubMedCentralID PMC1592500

• Biomotion community-wearable human activity monitor: Total knee replacement and healthy control subjects BSN 2006: INTERNATIONAL WORKSHOP ON WEARABLE AND IMPLANTABLE BODY SENSOR NETWORKS, PROCEEDINGS Krebs, D. E., Huddleston, J. I., Goldvasser, D., Scarborough, D. M., Harris, W. H., Malchau, H. 2006: 109-112

  View details for Web of Science ID 000236909800027

• Femoral Alignment Revision Total Knee Arthroplasty Huddleston JI, Gobezie R, Rubash HE 2005
• Zone 4 femoral radiolucent lines in hybrid versus cemented total knee arthroplasties: are they clinically significant? Clinical Orthopaedics and Related Research Huddleston JI, Wiley J, Scott RD 2005; 441: 334-339
• Determination of neutral tibial rotational alignment in rotating platform TKA Clinical Orthopaedics and Related research Huddleston JI, Scott RD, Wimberley DW 2005; 440: 101-106
• A comparison of subjective, psychomotor and physiologic effects of a novel muscarinic analgesic, LY 297802 tartrate, and oral morphine in occasional drug users Drug and Alcohol Dependence Petry NM, Bickel WK, Huddleston J, Tzanis E, Badger GJ 1998; 50: 29-36