Derek F. Amanatullah, M.D., Ph.D.

All Publications

• Host and Microbial Characteristics Associated with Recurrent Prosthetic Joint Infections. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Hampton, J. P., Zhou, J. Y., Kameni, F. N., Espiritu, J. R., Manasherob, R., Cheung, E., Miller, M. D., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2023

  Abstract

  Approximately 20% of patients after resection arthroplasty and antibiotic spacer placement for prosthetic joint infection develop repeat infections, requiring an additional antibiotic spacer before definitive reimplantation. The host and bacterial characteristics associated with the development of recurrent infection is poorly understood. A case-control study was conducted for 106 patients with intention to treat by two-stage revision arthroplasty for prosthetic joint infection at a single institution between 2009-2020. Infection was defined according to the 2018 Musculoskeletal Infection Society criteria. Thirty-nine cases ("recurrent-PJI") received at least two antibiotic spacers before clinical resolution of their infection, and 67 controls ("single-PJI") received a single antibiotic cement spacer prior to infection-free prosthesis reimplantation. Patient demographics, McPherson host grade, and culture results including antibiotic susceptibilities were compared. Fifty-two (78%) single-PJI and 32 (82%) recurrent-PJI patients had positive intraoperative cultures at the time of their initial spacer procedure. The odds of polymicrobial infections were 11-fold higher among recurrent-PJI patients, and the odds of significant systemic compromise (McPherson host-grade C) were more than double. Recurrent-PJI patients were significantly more likely to harbor Staphylococcus aureus. We found no differences between cases and controls in pathogen resistance to the six most tested antibiotics. Among recurrent-PJI patients, erythromycin-resistant infections were more prevalent at the final than initial spacer, despite no erythromycin exposure. Our findings suggest that McPherson host grade, polymicrobial infection, and S. aureus infection are key indicators of secondary or persistent joint infection following resection arthroplasty and antibiotic spacer placement, while bacterial resistance does not predict infection-related arthroplasty failure. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.25768

  View details for PubMedID 38093490

• Is Operative Time Associated With Obesity-related Outcomes in TKA? Clinical orthopaedics and related research Abella, M. K., Angeles, J. P., Finlay, A. K., Amanatullah, D. F. 2023

  Abstract

  Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA.We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes?In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m2, < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m2, 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m2, 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m2, 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m2, 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m2, 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted.After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration.We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000002888

  View details for PubMedID 37820225

• Selecting a High-dose Antibiotic-laden Cement Knee Spacer. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Hollyer, I., Ivanov, D., Kappagoda, S., Lowenberg, D. W., Goodman, S. B., Amanatullah, D. F. 2023

  Abstract

  Periprosthetic infection (PJI) after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics and the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer has yet to be demonstrated as superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.25570

  View details for PubMedID 37127938

• Does Operative Time Modify Obesity-related Outcomes in THA? Clinical orthopaedics and related research Abella, M. K., Angeles, J. P., Finlay, A. K., Amanatullah, D. F. 2023

  Abstract

  Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA.We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes?This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted.A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation.Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000002659

  View details for PubMedID 37083564

• Immune checkpoint upregulation in periprosthetic joint infection. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Warren, S. I., Charville, G. W., Manasherob, R., Amanatullah, D. F. 2022

  Abstract

  Periprosthetic joint infections (PJI) induce an immunosuppressive cytokine profile through an unknown mechanism. Immune checkpoints, like programmed cell death 1 (PD-1) and its ligand (PD-L1), initiate innate immunosuppressive pathways essential for self-tolerance. Several malignancies and chronic infections co-opt these pathways to derive a survival advantage. This study evaluates PD-1/PD-L1 expression in periprosthetic tissue from patients undergoing revision hip or knee arthroplasty for a PJI versus an aseptic failure. PD-1/PD-L1 in the global tissue sample and the high-power microscopic field of maximum expression was analyzed prospectively using immunohistochemistry. Fifteen patients with a PJI (45%) and 16 patients with an aseptic failure (52%) were included. PD-1 expression was uniformly low. Maximum PD-L1 expression was upregulated in patients with a PJI (25%, interquartile range [IQR]: 5%-75%) versus an aseptic failure, (8%, IQR: 1%-48%, p = 0.039). In the PJI cohort, maximum PD-L1 expression was higher among patients who developed a recurrent PJI (68%, IQR: 53%-86% vs. 15%, IQR: 5%-70%, p = 0.039). Patients with global PD-L1 over 5% trended toward a near 22-fold increase in the odds of reinfection (odds ratio [OR]: 21.9, 95% confidence interval [CI]: 0.9-523.5, p = 0.057) and patients with maximum PD-L1 over 20% trended toward a 15-fold increase in the odds of reinfection (OR: 15.0, 95% CI: 0.6-348.9, p = 0.092). These results support immune checkpoint upregulation as a mechanism of PJI-induced local immune dysfunction. Future studies should confirm PD-L1 as a risk factor for reinfection in larger cohorts.

  View details for DOI 10.1002/jor.25276

  View details for PubMedID 35124851

• Migration Patterns for Revision Total Knee Arthroplasty in the United States as Reported in the American Joint Replacement Registry. The Journal of arthroplasty Lawson, K. A., Chen, A. F., Springer, B. D., Illgen, R. L., Lewallen, D. G., Huddleston, J. I., Amanatullah, D. F. 2021

  Abstract

  BACKGROUND: Revision total knee arthroplasty (TKA) is associated with a higher complication rate and a greater cost when compared to primary TKA. Based on patient choice, referral, or patient transfers, revision TKAs are often performed in different institutions by different surgeons than the primary TKA. The aim of this study is to evaluate the effect of hospital size, teaching status, and revision indication on the migration patterns of failed primary TKA in patients 65 years of age and older.METHODS: All primary and revision TKAs reported to the American Joint Replacement Registry from January 2012 through March 2020 were included and merged with the Centers for Medicare and Medicaid Services database. Migration was defined as a patient having a primary TKA and revision TKA performed at separate institutions by different surgeons.RESULTS: In total, 9167 linked primary and revision TKAs were included in the analysis. Overall migration rates were significantly higher from small (<100 beds; P= .019), non-teaching institutions (P= .002) driven primarily by patients diagnosed with infection. Infection patients had significantly higher migration rates from small (46.8%, P < .001), non-teaching (43.5%, P < .001) institutions, while migration rates for other causes of revision were statistically similar. Most patients migrated to medium or large institutions (84.7%) for revision TKA rather than small institutions (15.3%, P < .001) and to teaching (78.3%) rather than non-teaching institutions (21.7%, P < .001).CONCLUSION: There is a diagnosis-dependent referral bias that affects the migration rates of infected primary TKA from small non-teaching institutions leading to a flow of more medically complex patients to medium and large teaching institutions for infected revision TKA.

  View details for DOI 10.1016/j.arth.2021.06.005

  View details for PubMedID 34238622

• Tolerant Small-colony Variants Form Prior to Resistance Within a Staphylococcus aureus Biofilm Based on Antibiotic Selective Pressure. Clinical orthopaedics and related research Manasherob, R. n., Mooney, J. A., Lowenberg, D. W., Bollyky, P. L., Amanatullah, D. F. 2021

  Abstract

  The treatment of periprosthetic joint infection (PJI) is focused on the surgical or chemical removal of biofilm. Antibiotics in isolation are typically ineffective against PJI. Bacteria survive after antibiotic administration because of antibiotic tolerance, resistance, and persistence that arise in the resident bacteria of a biofilm. Small-colony variants are typically slow-growing bacterial subpopulations that arise after antibiotic exposure and are associated with persistent and chronic infections such as PJI. The role of biofilm-mediated antibiotic tolerance in the emergence of antibiotic resistance remains poorly defined experimentally.We asked: (1) Does prior antibiotic exposure affect how Staphylococcus aureus survives within a developing biofilm when exposed to an antibiotic that penetrates biofilm, like rifampicin? (2) Does exposure to an antibiotic with poor biofilm penetration, such as vancomycin, affect how S. aureus survives within a developing biofilm? (3) Do small-colony variants emerge from antibiotic-tolerant or-resistant bacteria in a S. aureus biofilm?We used a porous membrane as an in vitro implant model to grow luminescent S. aureus biofilms and simultaneously track microcolony expansion. We evaluated the impact of tolerance on the development of resistance by comparing rifampicin (an antibiotic that penetrates S. aureus biofilm) with vancomycin (an antibiotic that penetrates biofilm poorly). We performed viability counting after membrane dissociation to discriminate among tolerant, resistant, and persistent bacteria. Biofilm quantification and small-colony morphologies were confirmed using scanning electron microscopy. Because of experimental variability induced by the starting bacterial inoculum, relative changes were compared since absolute values may not have been statistically comparable.Antibiotic-naïve S. aureus placed under the selective pressure of rifampicin initially survived within an emerging biofilm by using tolerance given that biofilm resident cell viability revealed 1.0 x 108 CFU , of which 7.5 x 106 CFU were attributed to the emergence of resistance and 9.3 x 107 CFU of which were attributed to the development of tolerance. Previous exposure of S. aureus to rifampicin obviated tolerance-mediate survival when rifampicin resistance was present, since the number of viable biofilm resident cells (9.5 x 109 CFU) nearly equaled the number of rifampicin-resistant bacteria (1.1 x 1010 CFU). Bacteria exposed to an antibiotic with poor biofilm penetration, like vancomycin, survive within an emerging biofilm by using tolerance as well because the biofilm resident cell viability for vancomycin-naïve (1.6 x 1010 CFU) and vancomycin-resistant (1.0 x 1010 CFU) S. aureus could not be accounted for by emergence of resistance. Adding rifampicin to vancomycin resulted in a nearly 500-fold reduction in vancomycin-tolerant bacteria from 1.5 x 1010 CFU to 3.3 x 107 CFU. Small-colony variant S. aureus emerged within the tolerant bacterial population within 24 hours of biofilm-penetrating antibiotic administration. Scanning electron microscopy before membrane dissociation confirmed the presence of small, uniform cells with biofilm-related microstructures when unexposed to rifampicin as well as large, misshapen, lysed cells with a small-colony variant morphology [29, 41, 42, 63] and a lack of biofilm-related microstructures when exposed to rifampicin. This visually confirmed the rapid emergence of small-colony variants within the sessile niche of a developing biofilm when exposed to an antibiotic that exerted selective pressure.Tolerance explains why surgical and nonsurgical modalities that rely on antibiotics to "treat" residual microscopic biofilm may fail over time. The differential emergence of resistance based on biofilm penetration may explain why some suppressive antibiotic therapies that do not penetrate biofilm well may rely on bacterial control while limiting the emergence of resistance. However, this strategy fails to address the tolerant bacterial niche that harbors persistent bacteria with a small-colony variant morphology.Our work establishes biofilm-mediated antibiotic tolerance as a neglected feature of bacterial communities that prevents the effective treatment of PJI.

  View details for DOI 10.1097/CORR.0000000000001740

  View details for PubMedID 33835090

• The routine use of synovial alpha-defensin is not necessary. The bone & joint journal Amanatullah, D. F., Cheng, R. Z., Huddleston Iii, J. I., Maloney, W. J., Finlay, A. K., Kappagoda, S. n., Suh, G. A., Goodman, S. B. 2020; 102-B (5): 593–99

  Abstract

  To establish the utility of adding the laboratory-based synovial alpha-defensin immunoassay to the traditional diagnostic work-up of a prosthetic joint infection (PJI).A group of four physicians evaluated 158 consecutive patients who were worked up for PJI, of which 94 underwent revision arthroplasty. Each physician reviewed the diagnostic data and decided on the presence of PJI according to the 2014 Musculoskeletal Infection Society (MSIS) criteria (yes, no, or undetermined). Their initial randomized review of the available data before or after surgery was blinded to each alpha-defensin result and a subsequent randomized review was conducted with each result. Multilevel logistic regression analysis assessed the effect of having the alpha-defensin result on the ability to diagnose PJI. Alpha-defensin was correlated to the number of synovial white blood cells (WBCs) and percentage of polymorphonuclear cells (%PMN).Intraobserver reliability and interobserver agreement did not change when the alpha-defensin result was available. Positive alpha-defensin results had greater synovial WBCs (mean 31,854 cells/μL, SD 32,594) and %PMN (mean 93.0%, SD 5.5%) than negative alpha-defensin results (mean 974 cells/μL, SD 3,988; p < 0.001 and mean 39.4% SD 28.6%; p < 0.001). Adding the alpha-defensin result did not alter the diagnosis of a PJI using preoperative (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.14 to 1.88; p = 0.315) or operative (OR 0.52, CI 0.18 to 1.55; p = 0.242) data when clinicians already decided that PJI was present or absent with traditionally available testing. However, when undetermined with traditional preoperative testing, alpha-defensin helped diagnose (OR 0.44, CI 0.30 to 0.64; p < 0.001) or rule out (OR 0.41, CI 0.17 to 0.98; p = 0.044) PJI. Of the 27 undecided cases with traditional testing, 24 (89%) benefited from the addition of alpha-defensin testing.The laboratory-based synovial alpha-defensin immunoassay did not help diagnose or rule out a PJI when added to routine serologies and synovial fluid analyses except in cases where the diagnosis of PJI was unclear. We recommend against the routine use of alpha-defensin and suggest using it only when traditional testing is indeterminate. Cite this article: Bone Joint J 2020;102-B(5):593-599.

  View details for DOI 10.1302/0301-620X.102B5.BJJ-2019-0473.R3

  View details for PubMedID 32349594

• 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

• 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

• The contribution of neutrophils to bacteriophage clearance and pharmacokinetics in vivo. JCI insight Echterhof, A., Dharmaraj, T., Khosravi, A., McBride, R., Miesel, L., Chia, J., Blankenberg, P. M., Lin, K., Shen, C., Lee, Y., Yeh, Y., Liao, W. T., Blankenberg, F. G., Dabrowska, K., Amanatullah, D. F., Frymoyer, A. R., Bollyky, P. L. 2024; 9 (20)

  Abstract

  With the increasing prevalence of antimicrobial-resistant bacterial infections, there is interest in using bacteriophages (phages) to treat such infections. However, the factors that govern bacteriophage pharmacokinetics in vivo remain poorly understood. Here, we have examined the contribution of neutrophils, the most abundant phagocytes in the body, to the pharmacokinetics of i.v. administered bacteriophage in uninfected mice. A single dose of LPS-5, a bacteriophage recently used in human clinical trials to treat drug-resistant Pseudomonas aeruginosa, was administered i.v. to both immunocompetent BALB/c and neutropenic CD1 mice. Phage concentrations were assessed in peripheral blood and spleen at 0.25, 1, 2, 4, 8, 12, and 24 hours after administration by plaque assay and qPCR. We observed that the phage clearance was only minimally affected by neutropenia. Indeed, the half-lives of phages in blood in BALB/c and CD1 mice were 3.45 and 3.66 hours, respectively. These data suggest that neutrophil-mediated phagocytosis is not a major determinant of phage clearance. Conversely, we observed a substantial discrepancy in circulating phage levels over time when measured by qPCR versus plaque assay, suggesting that significant inactivation of circulating phages occurs over time. These data indicate that alternative factors, but not neutrophils, inactivate i.v. administered phages.

  View details for DOI 10.1172/jci.insight.181309

  View details for PubMedID 39435664

• Current Use of Patient-Reported Outcome Measures Ignores Functional Demand. The Journal of the American Academy of Orthopaedic Surgeons Kamal, R. N., Gomez, G., Chakraborty, A., Leversedge, C., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S. S., Safran, M., Zhuang, T., Shapiro, L. M. 2024

  Abstract

  Patient-reported outcome measures (PROMs) are used in orthopaedic surgery to measure aspects of musculoskeletal function that are important to patients, such as disability and pain. However, current assessments of function using PROMs do not necessarily consider a patient's functional demands in detail. A patient's functional demands could serve as a confounder to their perception of their functional ability. Hence, functional demands may need to be adjusted for when PROMs are used to measure musculoskeletal function.We conducted a cross-sectional study in which new orthopaedic patients completed a questionnaire regarding demographics, function [Patient-Reported Outcomes Measurement Information System], functional demand (Tegner Activity Level Scale), pain self-efficacy, and symptoms of depression. 169 eligible patients with diverse orthopaedic conditions were enrolled in the study from an orthopaedic clinic, and 19 were excluded for incomplete questionnaires.The mean Patient-Reported Outcomes Measurement Information System score was 36.5 ± 9.1, and the mean Tegner score was 2.6 ± 2.0. In the multivariable regression model, patient-reported function was significantly associated with functional demand (β = 0.17, P < 0.001). Significant associations were observed for pain self-efficacy (β = 0.15, P < 0.001), acuity (β = -0.10, P = 0.004), and age 80 years or older (β = -0.16, P = 0.004). No notable association was observed with depression or age 65 to 79 years.Higher patient-reported physical function is associated with higher levels of functional demand when controlling for psychosocial factors, acuity, and age. Because of its confounding effect on measuring physical function, functional demand should be assessed and included in models using PROMs before and after surgery. For example, payment models using improvements in PROMs, such as the short form of the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score after joint arthroplasty, should include functional demand in the model when assessing quality of care.Level II.

  View details for DOI 10.5435/JAAOS-D-24-00069

  View details for PubMedID 39186610

• The Influence of an Unexpected Symbolic Gift on Postoperative Arthroplasty Patients' Press Ganey Scores. The Journal of arthroplasty Lee, J. J., Mitchell, A. R., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2024

  Abstract

  INTRODUCTION: Hospitals use Press Ganey surveys to evaluate patient satisfaction. The goal of our study was to evaluate whether surgeon-driven gifting to patients post-operatively affects Press Ganey Survey responses.METHODS: There were 1,468 patients undergoing arthroplasty at our institution who were randomized to receive a thank you gift, a small bouquet of flowers, and a note from their provider after surgery, or nothing for completing their pre-operative arthroplasty registry questionnaire. Press Ganey surveys were sent to patients who received and did not receive flowers immediately after their hospital stay and after the patients' first post-operative visit. Scores were reported as the mean score and the fraction of responses with a top-box rating. One-sided student t-tests and Fischer Exact tests were used to assess statistical significance.RESULTS: Hospital Discharge Patients who received flowers had higher Press Ganey survey scores than patients who did not receive flowers. For example, for "Physician's concerns for questions," they had higher scores (mean difference: 3.7 ± 1.6 points, P = 0.012) and a 9% higher top-box rating (P = 0.032). For "Staff attitude towards visitors," they also had higher scores (mean difference: 2.8 ± 1.3 points, P = 0.019) and a 7% higher top-box rating (P = 0.049). First Follow-up Patients who received flowers had a higher top-box rating for "Concern provider showed for questions" and "Amount of time provider spent with you" by 6% (P = 0.046) and 11% (P = 0.009), respectively. They also had higher scores for "Information provider gave about medications" (mean difference: 4.0 ± 1.6 points, P = 0.009) and 11% higher top-box rating (P = 0.006).DISCUSSION: Press Ganey Surveys were higher in orthopaedic patients who received bouquets of flowers from their arthroplasty surgeons compared to patients who did not. At follow-up, improved Press Ganey scores persisted if the patient received flowers. The gift of flowers generates patient loyalty to their surgeon.

  View details for DOI 10.1016/j.arth.2024.07.018

  View details for PubMedID 39025277

• Remote Summer Research Program to Improve Opportunity and Mentorship for Underrepresented Students With Interest in Orthopaedic Surgery: 3-Year Experiences. The Journal of the American Academy of Orthopaedic Surgeons Klemt, C., Amanatullah, D. F., Gardner, M. J., Frick, S., Jobanputra, A., Shea, K. 2024

  Abstract

  INTRODUCTION: Medical students are challenged with a limited number of research opportunities to help prepare for an exceptionally competitive process for matching in an orthopaedic residency. The aim of this study was to assess the 3-year experience of our 8 to 10-week remote summer research program in support of underrepresented students with an interest in orthopaedic surgery.METHODS: We received over 500 applications, and a total of 37 students (7.4%) participated in the program over the past 3 years. A total of 14 faculty mentors were matched with 1 or 2 students each. The research program delivered a curriculum including (1) research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic conditions, diversity in orthopaedics, leadership, and work-life balance; and (3) a minimum of 8 weeks of mentorship experience with an assigned faculty and a peer mentor. Students and faculty were surveyed to measure skill progression, research productivity, and program satisfaction.RESULTS: Program participants represented a range of race/ethnic backgrounds and research experience levels. The cohort included a high rate of female (51%) and Black (35%) participants relative to representation of these groups in orthopaedic surgery. Postprogram surveys indicated that all participants improved their research skills, orthopaedic interest, and mentorship/networking skills. Most students (89%) stated that they were adequately matched to their faculty mentor. Most students (79%) indicated that they contributed to either manuscript or conference abstract as coauthors.DISCUSSION: The study findings suggest improved research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. Our long-term vision is to improve the accessibility and quality of mentorship for underrepresented students to foster an equitable pathway into the field of orthopaedic surgery.

  View details for DOI 10.5435/JAAOS-D-24-00134

  View details for PubMedID 39018663

• Performing region-specific tasks does not improve lower extremity patient-reported outcome scores. Arthroplasty (London, England) Korth, M. J., Banta, W. A., Arora, P., Kamal, R. N., Amanatullah, D. F. 2024; 6 (1): 42

  Abstract

  BACKGROUND: Patient-reported outcome measures quantify outcomes from patients' perspective with validated instruments. QuickDASH (Quick Disability of Arm, Shoulder and Hand, an upper extremity PROM) scores improve after completing instrument tasks, suggesting patient-reported outcome results can be modified. We hypothesized that performing lower extremity tasks on the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS-JR) and hip disability and osteoarthritis outcome score for joint reconstruction (HOOS-JR) instruments would similarly improve the scores.METHODS: Forty seven hip and 62 knee osteoarthritis patients presenting to a suburban academic center outpatient osteoarthritis and joint replacement clinic were enrolled and randomized to an intervention or a control group. Inclusion criteria were age over 18years and English competency. Patients completed a HOOS-JR or KOOS-JR instrument, completed tasks similar to those of the instrument (intervention) or the QuickDASH (control), and then repeated instruments again. Paired and unpaired t-tests were used to compare the intervention and control group scores before and after tasks.RESULTS: There was no significant difference in total or individual scores after task completion compared to baseline in either the HOOS-JR or the KOOS-JR groups. There was no significant difference in the scores between the intervention or control groups.CONCLUSIONS: Disability may be less modifiable in the lower extremity than in the upper extremity, perhaps because upper extremity activities are more easily compensated by the contralateral limb, or because lower extremity activities are more frequent. Thorough evaluation of factors influencing patient-reported outcome measures is necessary before their extensive application to quality control and reimbursement models.

  View details for DOI 10.1186/s42836-024-00261-3

  View details for PubMedID 38971795

• Pain Self-Efficacy Can Improve During a Visit With an Orthopedic Surgeon ORTHOPEDICS Lemos, J. L., Gomez, G. I., Tewari, P., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S., Safran, M., Kamal, R. N. 2024; 47 (4): e197-e203

  Abstract

  Greater pain self-efficacy (PSE) is associated with reduced pain, fewer limitations, and increased quality of life after treatment for orthopedic conditions. The aims of this study were to (1) assess if PSE improves during a visit with an orthopedic surgeon and (2) identify modifiable visit factors that are associated with an increase in PSE.We performed a prospective observational study of orthopedic clinic visits at a multispecialty clinic from February to May 2022. New patients who presented to one of six orthopedic surgeons were approached for the study. Patients who provided consent completed a pre-visit questionnaire including the Pain Self-Efficacy Questionnaire (PSEQ) and demographic questions. A trained research member recorded the five-item Observing Patient Involvement in Decision Making Instrument (OPTION-5) score, number of questions asked, and visit duration. Immediately after the visit, patients completed a post-visit questionnaire consisting of the PSEQ and Perceived Involvement in Care Scale (PICS).Of 132 patients enrolled, 61 (46%) had improved PSE after the orthopedic visit, with 38 (29%) having improvement above a clinically significant threshold. There were no significant differences between patients with increased PSE and those without increased PSE when comparing the PICS, OPTION-5, questions asked, or visit duration.Almost half of the patients had improvement in PSE during an orthopedic visit. The causal pathway to how to improve PSE and the durability of the improved PSE have implications in strategies to improve patient outcomes in orthopedic surgery, such as communication methods and shared decision-making. Future research can focus on studying different interventions that facilitate improving PSE. [Orthopedics. 2024;47(4):e197-e203.].

  View details for DOI 10.3928/01477447-20240605-01

  View details for Web of Science ID 001274494200007

  View details for PubMedID 38864646

• A balance focused biometric does not predict rehabilitation needs and outcomes following total knee arthroplasty. BMC musculoskeletal disorders Lee, J. J., Arora, P., Finlay, A. K., Amanatullah, D. F. 2024; 25 (1): 473

  Abstract

  Both length of hospital stay and discharge to a skilled nursing facility are key drivers of total knee arthroplasty (TKA)-associated spending. Identifying patients who require increased postoperative care may improve expectation setting, discharge planning, and cost reduction. Balance deficits affect patients undergoing TKA and are critical to recovery. We aimed to assess whether a device that measures preoperative balance predicts patients' rehabilitation needs and outcomes after TKA.40 patients indicated for primary TKA were prospectively enrolled and followed for 12 months. Demographics, KOOS-JR, and PROMIS data were collected at baseline, 3-months, and 12-months. Single-leg balance and sway velocity were assessed preoperatively with a force plate (Sparta Science, Menlo Park, CA). The primary outcome was patients' discharge facility (home versus skilled nursing facility). Secondary outcomes included length of hospital stay, KOOS-JR scores, and PROMIS scores.The mean preoperative sway velocity for the operative leg was 5.7 ± 2.7 cm/s, which did not differ from that of the non-operative leg (5.7 ± 2.6 cm/s, p = 1.00). Five patients (13%) were discharged to a skilled nursing facility and the mean length of hospital stay was 2.8 ± 1.5 days. Sway velocity was not associated with discharge to a skilled nursing facility (odds ratio, OR = 0.82, 95% CI = 0.27-2.11, p = 0.690) or longer length of hospital stay (b = -0.03, SE = 0.10, p = 0.738). An increased sway velocity was associated with change in PROMIS items from baseline to 3 months for global07 ("How would you rate your pain on average?" b = 1.17, SE = 0.46, p = 0.015) and pain21 ("What is your level of pain right now?" b = 0.39, SE = 0.17, p = 0.025) at 3-months.Preoperative balance deficits were associated with postoperative improvements in pain and function after TKA, but a balance focused biometric that measured single-leg sway preoperatively did not predict discharge to a skilled nursing facility or length of hospital stay after TKA making their routine measurement cost-ineffective.

  View details for DOI 10.1186/s12891-024-07580-1

  View details for PubMedID 38880892

  View details for PubMedCentralID 4169369

• No differences in outcomes with stopping or continuing antibiotic suppression in periprosthetic joint infections JOURNAL OF BONE AND JOINT INFECTION Furukawa, D., Dunning, M., Shen, S., Chang, A., Aronson, J., Amanatullah, D. F., Suh, G. A., Kappagoda, S. 2024; 9 (3): 143-148

  View details for DOI 10.5194/jbji-9-143-2024

  View details for Web of Science ID 001221610500001

• No differences in outcomes with stopping or continuing antibiotic suppression in periprosthetic joint infections. Journal of bone and joint infection Furukawa, D., Dunning, M., Shen, S., Chang, A., Aronson, J., Amanatullah, D. F., Suh, G. A., Kappagoda, S. 2024; 9 (3): 143-148

  Abstract

  The data on long-term antibiotic use following debridement, antibiotics, and implant retention (DAIR) for treatment of periprosthetic joint infections are limited. In this single-center retrospective study, we show that patients with eventual cessation of antibiotic suppression after DAIR had similar outcomes to those who remained on chronic antibiotic suppression.

  View details for DOI 10.5194/jbji-9-143-2024

  View details for PubMedID 38899055

  View details for PubMedCentralID PMC11184613

• Hydrogels for Local and Sustained Delivery of Bacteriophages to Treat Multidrug-Resistant Wound Infections. bioRxiv : the preprint server for biology Lin, Y. H., Dharmaraj, T., Chen, Q., Echterhof, A., Manasherob, R., Zheng, L. J., de Leeuw, C., Peterson, N. A., Stannard, W., Li, Z., Hajfathalian, M., Hargil, A., Martinez, H. A., Chang, T. H., Blankenberg, F. B., Amanatullah, D., Chaudhuri, O., Bollyky, P. 2024

  Abstract

  Bacteriophages (phages), viruses that specifically target and kill bacteria, represent a promising strategy to combat multidrug-resistant (MDR) pathogens such as Pseudomonas aeruginosa (Pa). However, delivering sufficient concentrations of active phages directly to the infection site remains challenging, with current methods having variable success. Here we present "HydroPhage", an innovative hydrogel system for the sustained release of high-titer phages to effectively treat infections caused by MDR pathogens. Our injectable hydrogels, featuring dual-crosslinking of hyaluronic acid and PEG-based hydrogels through static covalent thioether bonds and dynamic covalent hemithioacetal crosslinks (DCC), encapsulate phages at concentration up to 1011 PFU/mL, and achieves controlled release of 109 PFU daily over a week, surpassing levels of current clinical dosages, with more than 60% total phage recovery. In a preclinical mouse model of extended wound infection, compared to intravenous treatment, we demonstrate enhanced bacterial clearance by localized, high-dose, and repeated phage dosing despite the emergence of bacterial resistance to phages. This work advances the development of clinically practical wound dressings tailored for resistant infections.

  View details for DOI 10.1101/2024.05.07.593005

  View details for PubMedID 38766200

  View details for PubMedCentralID PMC11100690

• The outcome of revision total hip arthroplasty for instability. The bone & joint journal Apinyankul, R., Hong, C., Hwang, K. L., Burket Koltsov, J. C., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2024; 106-B (5 Supple B): 105-111

  Abstract

  Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability.Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR).The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m2 (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term.Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors.

  View details for DOI 10.1302/0301-620X.106B5.BJJ-2023-0726.R1

  View details for PubMedID 38688516

• An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes ORTHOPEDICS Abella, M. L., Thorne, T., Hayashi, J., Finlay, A. K., Frick, S., Amanatullah, D. F. 2024; 47 (3): e131-e138

  Abstract

  Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

  View details for DOI 10.3928/01477447-20240122-01

  View details for Web of Science ID 001229126100008

  View details for PubMedID 38285555

• Detecting Contamination Events during Robotic Total Joint Arthroplasty. American journal of infection control Lee, J. J., Oladeji, K., Finlay, A. K., Manasherob, R., Amanatullah, D. F. 2024

  Abstract

  BACKGROUND: Robot-assisted total joint arthroplasty (robotic-TJA) has become more widespread over the last 20 years due to higher patient satisfaction and reduced complications. However, robotic-TJA may have longer operative times and increased operating room traffic, which are known risk factors for contamination events. Contamination of surgical instruments may be contact- or airborne-related with documented scalpel blade contamination rates up to 9%. The robot arm is a novel instrument that comes in and out of the surgical field, so our objective was to assess whether the robot-arm is a source of contamination when used in robotic-TJA compared to other surgical instruments.METHODS: This was a prospective, single-institution, single-surgeon pilot study involving 103 robotic TJAs. The robot-arm was swabbed prior to incision and after closure. Pre- and postoperative control swabs were also collected from the suction tip and scalpel blade. Swabs were incubated for 24 hours on tryptic soy agar followed by inspection for growth of any contaminating bacteria.RESULTS: A contamination event was detected in 10 cases (10%). The scalpel blade was the most common site of contamination (8%) followed by the robot-arm (2%) and suction tip (0%).DISCUSSION: Contamination of the robot-arm during robotic-TJA is minimal when compared to contamination of the scalpel blade.

  View details for DOI 10.1016/j.ajic.2024.04.008

  View details for PubMedID 38663453

• The PJI-TNM classification for periprosthetic joint infections. Bone & joint research Baertl, S., Rupp, M., Kerschbaum, M., Morgenstern, M., Baumann, F., Pfeifer, C., Worlicek, M., Popp, D., Amanatullah, D. F., Alt, V. 2024; 13 (1): 19-27

  Abstract

  This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated.A total of ten orthopaedic surgeons classified 20 cases of PJI based on the PJI-TNM classification. Subsequently, the classification was re-evaluated using the PJI-TNM app. Classification accuracy was calculated separately for each subcategory (reinfection, tissue and implant condition, non-human cells, and morbidity of the patient). Fleiss' kappa and Cohen's kappa were calculated for interobserver and intraobserver reliability, respectively.Overall, interobserver and intraobserver agreements were substantial across the 20 classified cases. Analyses for the variable 'reinfection' revealed an almost perfect interobserver and intraobserver agreement with a classification accuracy of 94.8%. The category 'tissue and implant conditions' showed moderate interobserver and substantial intraobserver reliability, while the classification accuracy was 70.8%. For 'non-human cells,' accuracy was 81.0% and interobserver agreement was moderate with an almost perfect intraobserver reliability. The classification accuracy of the variable 'morbidity of the patient' reached 73.5% with a moderate interobserver agreement, whereas the intraobserver agreement was substantial. The application of the app yielded comparable results across all subgroups.The PJI-TNM classification system captures the heterogeneity of PJI and can be applied with substantial inter- and intraobserver reliability. The PJI-TNM educational app aims to facilitate application in clinical practice. A major limitation was the correct assessment of the implant situation. To eliminate this, a re-evaluation according to intraoperative findings is strongly recommended.

  View details for DOI 10.1302/2046-3758.131.BJR-2023-0012.R2

  View details for PubMedID 38176440

• An External Acetabular Alignment Guide Decreases Positional Variance. Surgical technology international Wadhwa, H., Warren, S. I., Oladeji, K., Finlay, A. K., Huddleston, J. I., Amanatullah, D. F. 2023; 43

  Abstract

  Certain patient and operative factors limit accurate estimation of acetabular component positioning during total hip arthroplasty (THA). This study aimed to determine whether an intraoperative external alignment guide decreases variance in acetabular component positioning.Adult patients who underwent primary THA from 2014-2018 were reviewed. Exclusion criteria were navigation, robot-assisted surgery, and inflammatory, post-traumatic, or avascular arthritis. One surgeon used an external guide while the second surgeon resected osteophytes and utilized available anatomical landmarks for positioning. Anteversion and inclination, variance, "safe zone" positioning, operative time, and hip instability were assessed. Multivariable regression models were used to examine effects on primary and secondary outcomes.409 patients were included, of which 182 underwent component placement with landmarks only. Patients undergoing component placement with landmarks only were younger (p=0.002) and more often smokers (p=0.016). After multivariable risk adjustment, use of the external alignment guide was independently associated with 2.7° higher anteversion (CI: 1.6° to 3.8°) and smaller anteversion variance (-0.3, CI: -0.6 to 0.1) compared to landmarks only. It was independently associated with 3.2° higher inclination (CI: 2.0° to 4.4°), but there was no difference in inclination variance (-0.1, CI: -0.3 to 0.2). The external alignment guide was independently associated with a 14-minute shorter operative time (CI: 9.6 to 18.7) and smaller operative time variance (-0.9, CI: -1.2 to 0.6).Use of anatomical landmarks alone was associated with increased likelihood of safe zone positioning but lower precision and longer operative time. While this study was limited by lack of randomization and its retrospective nature, an acetabular positioner may be preferable to palpable or visible anatomy alone for acetabular component placement.

  View details for PubMedID 38038174

• Costs and Outcomes of Total Joint Arthroplasty in Medicare Beneficiaries Are Not Meaningfully Associated with Industry Payments. The Journal of bone and joint surgery. American volume Wadhwa, H., Leung, C., Sklar, M., Malacon, K., Rangwalla, T., Williamson, T., Castillo, T. N., Amanatullah, D. F., Zygourakis, C. C. 2023

  Abstract

  BACKGROUND: Prior studies have demonstrated that industry payments affect physician prescribing patterns, but their effect on orthopaedic surgical costs is unknown. This study examines the relationship between industry payments and the total costs of primary total joint arthroplasty, as well as operating room cost, length of stay, 30-day mortality, and 30-day readmission.METHODS: Open Payments data were matched across a 20% sample of Medicare-insured patients undergoing primary elective total hip arthroplasty (THA) (n = 130,872) performed by 7,539 surgeons or primary elective total knee arthroplasty (TKA) (n = 230,856) performed by 8,977 surgeons from 2013 to 2015. Patient, hospital, and surgeon-specific factors were gathered. Total and operating room costs, length of stay, mortality, and readmissions were recorded. Multivariable linear and logistic regression models were used to identify the risk-adjusted relationships between industry payments and the primary and secondary outcomes.RESULTS: In this study, 96.7% of THA surgeons and 97.4% of TKA surgeons received industry payments. After multivariable risk adjustment, for each $1,000 increase in industry payments, the total costs of THA increased by $0.50 (0.003% of total costs) and the operating room costs of THA increased by $0.20 (0.003% of total costs). Industry payments were not associated with TKA cost. Industry payments were not associated with 30-day mortality after either THA or TKA. Higher industry payments were independently associated with a marginal decrease in the length of stay for patients undergoing THA (0.0045 days per $1,000) or TKA (0.0035 days per $1,000) and a <0.1% increase in the odds of 30-day readmission after THA for every $1,000 in industry payments. The median total THA costs were $300 higher (p < 0.001), whereas the median TKA costs were $150 lower (p < 0.001), for surgeons receiving the highest 5% of industry payments. These surgical procedures were more often performed in large urban areas, in hospitals with a higher number of beds, with a higher wage index, and by more experienced surgeons and were associated with a 0.4 to 1-day shorter length of stay (p < 0.001).CONCLUSIONS: Although most arthroplasty surgeons received industry payments, a minority of surgeons received the majority of payments. Overall, arthroplasty costs and outcomes were not meaningfully impacted by industry relationships.LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.23.00768

  View details for PubMedID 37992189

• Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance? The Journal of arthroplasty Chakraborty, A., Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Kamal, R. N. 2023

  Abstract

  Disparities in access to care based on insurance type exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus non-operative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 vs. 10.9 or 12.0%, respectively; P<0.0001) and had longer times to surgery (297 vs. 215 or 261 days, respectively; P<0.0001) compared to Medicare Advantage and commercially insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (Odds Ratio (OR) = 0.62 [95% Confidence Intervals (CI): 0.60-0.64] vs. Medicare Advantage, OR = 0.63 [95% CI: 0.61-0.64] vs. commercial) or NOI (OR = 0.92 [95% CI: 0.91-0.94] vs. Medicare Advantage, OR = 0.81 [95% CI: 0.79-0.82] vs. commercial).Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially insured patients. Further investigation into the causes of these disparities, such as patient costs or access barriers, is necessary to ensure equitable care.

  View details for DOI 10.1016/j.arth.2023.09.029

  View details for PubMedID 37778640

• Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study. Pain and therapy Hah, J. M., Vialard, J. D., Efron, B., Mackey, S. C., Carroll, I. R., Amanatullah, D. F., Narasimhan, B., Hernandez-Boussard, T. 2023

  Abstract

  The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes.A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3 months, weekly thereafter up to 6 months, and monthly thereafter up to 1 year. Emotional distress and pain catastrophizing were assessed weekly to 6 months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation.The median time to opioid and pain cessation was 54 and 152 days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model.These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.

  View details for DOI 10.1007/s40122-023-00543-9

  View details for PubMedID 37556071

  View details for PubMedCentralID 7317603

• Lack of alignment between orthopaedic surgeon priorities and patient expectations in total joint arthroplasty. Patient safety in surgery Shah, H. N., Barrett, A. A., Le, P. H., Arora, P., Kamal, R. N., Amanatullah, D. F. 2023; 17 (1): 17

  Abstract

  Healthcare systems are shifting toward "patient-centered" care often without assessing the values important to patients. Analogously, the interests of the patient may be disparate with physician interests, as pay-for-performance models become common. The purpose of the study was to determine which medical preferences are essential for patients during their surgical care.This prospective, observational study surveyed 102 patients who had undergone a primary knee replacement and/or hip replacement surgery about hypothetical scenarios regarding their surgical experience. Data analysis included categorical variables presented as a number and percent, while continuous variables presented as mean and standard deviation. Statistical analysis for anticoagulation data included the Pearson chi-square test and one-way ANOVA test.A large majority, 73 patients (72%), would not pay to have a four-centimeter or smaller incision. The remaining 29 patients (28%) would prefer to have a four-centimeter or smaller incision and would pay a mean of $1,328 ± 1,629 for that day. A significant number of patients preferred not to use anticoagulation (p = 0.019); however, the value attributed to avoiding a specific method of anticoagulation was found not to be significant (p = 0.507).The study determined the metrics prioritized by hospitals and surgeons are not important to the majority of patients when they evaluate their own care. These disconnects in the entitlements patients expect and receive can be solved by including patients in discussions with physicians and hospital systems.

  View details for DOI 10.1186/s13037-023-00365-w

  View details for PubMedID 37386583

  View details for PubMedCentralID PMC10308647

• Practice Changes Induced by a Traveling Fellowship. The journal of knee surgery Hollyer, I., Cabell, A. C., Duncan, S., Rossi, S. M., Sculco, P. K., Barnes, L., Amanatullah, D. F. 2023

  Abstract

  The John N. Insall Knee Society Traveling Fellowship selects four international arthroplasty or sports fellowship-trained orthopaedic surgeons to spend one month traveling to various Knee Society members' joint replacement and knee surgery centers in North America. The fellowship aims to foster research and education and share ideas among fellows and Knee Society members. The role of such traveling fellowships on surgeon preferences has yet to be investigated.A 59-question survey encompassing patient selection, preoperative planning, intraoperative techniques, and postoperative protocols was completed by the four 2018 Insall Traveling Fellows before and immediately after traveling fellowship completion to assess anticipated practice changes (e.g., initial excitement) related to their participation in a traveling fellowship. The same survey was completed four years after traveling fellowship completion to assess the implementation of the anticipated practice changes.Survey questions were divided into two groups based on levels of evidence in the literature. Immediately after fellowship, there was a median of 6.5 (range: 3-12) anticipated changes in consensus topics and a median of 14.5 (range: 5-17) anticipated changes in controversial topics. There was no statistical difference in the excitement to change consensus or controversial topics (p = 0.921). Four years after completing a traveling fellowship, a median of 2.5 (range: 0-3) consensus topics and 4 (range: 2-6) controversial topics were implemented. There was no statistical difference in the implementation of consensus or controversial topics (p = 0.709). There was a statistically significant decline in the implementation of changes in consensus and controversial preferences compared to the initial level of excitement (p = 0.038 and 0.031, respectively).After the John N. Insall Knee Society Traveling Fellowship, there is excitement for practice change in consensus and controversial topics related to total knee arthroplasty. However, few practice changes that had initial excitement were implemented after 4-year follow-up. Ultimately the effects of time, practice inertia, and institutional friction overcome most of the anticipated changes induced by a traveling fellowship.

  View details for DOI 10.1055/a-2094-5443

  View details for PubMedID 37192657

• AOA Critical Issues Symposium: Shaping the Impact of Artificial Intelligence within Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Patel, A. A., Schwab, J. H., Amanatullah, D. F., Divi, S. N. 2023

  Abstract

  Artificial intelligence (AI) is a broad term that is widely used but inconsistently understood. It refers to the ability of any machine to exhibit human-like intelligence by making decisions, solving problems, or learning from experience. With its ability to rapidly process large amounts of information, AI has already transformed many industries such as entertainment, transportation, and communications through consumer-facing products and business-to-business applications. Given its potential, AI is also anticipated to impact the practice of medicine and the delivery of health care. Interest in AI-based techniques has grown rapidly within the orthopaedic community, resulting in an increasing number of publications on this topic. Topics of interest have ranged from the use of AI for imaging interpretation to AI-based techniques for predicting postoperative outcomes.The highly technical and data-driven nature of orthopaedic surgery creates the potential for AI, and its subdisciplines machine learning (ML) and deep learning (DL), to fundamentally transform our understanding of musculoskeletal care. However, AI-based techniques are not well known to most orthopaedic surgeons, nor are they taught with the same level of insight and critical thinking as traditional statistical methodology. With a clear understanding of the science behind AI-based techniques, orthopaedic surgeons will be able to identify the potential pitfalls of the application of AI to musculoskeletal health. Additionally, with increased understanding of AI, surgeons and their patients may have more trust in the results of AI-based analytics, thereby expanding the potential use of AI in clinical care and amplifying the impact it could have in improving quality and value. The purpose of this American Orthopaedic Association (AOA) symposium was to facilitate understanding and development of AI and AI-based techniques within orthopaedic surgery by defining common terminology related to AI, demonstrating the existing clinical utility of AI, and presenting future applications of AI in surgical care.

  View details for DOI 10.2106/JBJS.22.01330

  View details for PubMedID 37172106

• Arthroplasty for femoral neck fractures is at risk for under restoration of lateral femoral offset. Hip international : the journal of clinical and experimental research on hip pathology and therapy Shah, H. N., Barrett, A. A., Finlay, A. K., Arora, P., Bellino, M. J., Bishop, J. A., Gardner, M. J., Miller, M. D., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2023: 11207000231169914

  Abstract

  PURPOSE: The aim of the study was to determine the restoration of hip biomechanics through lateral offset, leg length, and acetabular component position when comparing non-arthroplasty surgeons (NAS) to elective arthroplasty surgeons (EAS).METHODS: 131 patients, with a femoral neck fracture treated with a THA by 7 EAS and 20 NAS, were retrospectively reviewed. 2 blinded observers measured leg-length discrepancy, femoral offset, and acetabular component position. Multivariate logistic regression models examined the association between the surgeon groups and restoration of lateral femoral, acetabular offset, leg length discrepancy, acetabular anteversion, acetabular position, and component size, while adjusting for surgical approach and spinal pathology.RESULTS: NAS under-restored 4.8mm of lateral femoral offset (43.9±8.7mm) after THA when compared to the uninjured side (48.7±7.1mm, p=0.044). NAS were at risk for under-restoring lateral femoral offset when compared to EAS (p=0.040). There was no association between lateral acetabular offset, leg length, acetabular position, or component size and surgeon type.CONCLUSIONS: Lateral femoral offset is at risk for under-restoration after THA for femoral neck fractures, when performed by surgeons that do not regularly perform elective THA. This indicates that lateral femoral offset is an under-appreciated contributor to hip instability when performing THA for a femoral neck fracture. Lateral femoral offset deserves as much attention and awareness as acetabular component position since a secondary analysis of our data reveal that preoperative templating and intraoperative imaging did not prevent under-restoration.

  View details for DOI 10.1177/11207000231169914

  View details for PubMedID 37128124

• Assessment of Team Dynamics and Operative Efficiency in Hip and Knee Arthroplasty. JAMA surgery Cousins, H. C., Cahan, E. M., Steere, J. T., Maloney, W. J., Goodman, S. B., Miller, M. D., Huddleston, J. I., Amanatullah, D. F. 2023

  Abstract

  Surgical team communication is a critical component of operative efficiency. The factors underlying optimal communication, including team turnover, role composition, and mutual familiarity, remain underinvestigated in the operating room.To assess staff turnover, trainee involvement, and surgeon staff preferences in terms of intraoperative efficiency.Retrospective analysis of staff characteristics and operating times for all total joint arthroplasties was performed at a tertiary academic medical center by 5 surgeons from January 1 to December 31, 2018. Data were analyzed from May 1, 2021, to February 18, 2022. The study included cases with primary total hip arthroplasties (THAs) and primary total knee arthroplasties (TKAs) comprising all primary total joint arthroplasties performed over the 1-year study interval.Intraoperative turnover among nonsurgical staff, presence of trainees, and presence of surgeon-preferred staff.Incision time, procedure time, and room time for each surgery. Multivariable regression analyses between operative duration, presence of surgeon-preferred staff, and turnover among nonsurgical personnel were conducted.A total of 641 cases, including 279 THAs (51% female; median age, 64 [IQR, 56.3-71.5] years) and 362 TKAs (66% [238] female; median age, 68 [IQR, 61.1-74.1] years) were considered. Turnover among circulating nurses was associated with a significant increase in operative duration in both THAs and TKAs, with estimated differences of 19.6 minutes (SE, 3.5; P < .001) of room time in THAs and 14.0 minutes (SE, 3.1; P < .001) of room time in TKAs. The presence of a preferred anesthesiologist or surgical technician was associated with significant decreases of 26.5 minutes (SE, 8.8; P = .003) of procedure time and 12.6 minutes (SE, 4.0; P = .002) of room time, respectively, in TKAs. The presence of a surgeon-preferred vendor was associated with a significant increase in operative duration in both THAs (26.3 minutes; SE, 7.3; P < .001) and TKAs (29.6 minutes; SE, 9.6; P = .002).This study found that turnover among operative staff is associated with procedural inefficiency. In contrast, the presence of surgeon-preferred staff may facilitate intraoperative efficiency. Administrative or technologic support of perioperative communication and team continuity may help improve operative efficiency.

  View details for DOI 10.1001/jamasurg.2023.0168

  View details for PubMedID 36947044

  View details for PubMedCentralID PMC10034665

• Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients who have Multiple Hip and Knee Arthroplasties. The Journal of arthroplasty Lee, J. J., Oladeji, K., Sweeney, B., Chakoma, T., Arora, P., Finlay, A. K., Amanatullah, D. F. 2023

  Abstract

  The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require additional arthroplasties, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factor profiles.We identified 337 patients who had multiple arthroplasties and at least one PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (i.e., presenting at the same time as the initial infection) or metachronous (i.e., presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria.There were 39 (12%) patients who experienced recurrent PJI, while 31 (9%) patients developed PJI in a second joint. Positive blood cultures were more likely in second joint PJI (48%) compared to recurrent PJI (23%) or single PJI (15%, P<0.001). Synchronous PJI represented 42% of second joint PJI cases (n=13), while metachronous PJI represented 58% (n=18). Tobacco users had 75% higher odds of metachronous PJI (Odds Ratio 1.75, 95% Confidence Interval: 1.1-2.9, P=0.041).Over 20% of the patients who have multiple arthroplasties and a PJI will develop a subsequent PJI in another arthroplasty - 12% will occur in the initial arthroplasty and nearly 10% will occur in another arthroplasty. Particular caution should be taken in patients who use tobacco and had bacteremia or Staphylococcus aureus isolation at time of initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI.

  View details for DOI 10.1016/j.arth.2023.03.014

  View details for PubMedID 36924855

• Comparing Unicompartmental Knee Arthroplasty and High Tibial Osteotomy for Isolated Medial Compartment Knee Osteoarthritis. JBJS reviews Goodell, P. B., Johansen, P. M., Bartels, D. W., Sherman, S. L., Amanatullah, D. F. 2023; 11 (3)

  Abstract

  Both unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) allow for compartment-specific intervention on an arthritic knee joint that preserves bone stock and native soft tissue compared to a total knee arthroplasty (TKA). Both operations give a more natural feeling with native proprioception compared with a TKA.HTO is better suited in patients who are younger (<55 years-of-age), have a body mass index (BMI) <30 kg/m2, high activity requirements, mechanical malalignment, asymmetric varus, isolated anterior cruciate ligament insufficiency, need for multiplanar correction, and a preference for joint preserving interventions. Recent data suggest that age (>55 years-of-age) should not solely contraindicate a HTO.UKA may be chosen in patients who are older (>55 years-of-age), low activity requirements, have a BMI <40 kg/m2, severe osteoarthritis with significant joint space narrowing, acceptable coronal alignment, symmetric varus, and patient preference for arthroplasty.

  View details for DOI 10.2106/JBJS.RVW.22.00127

  View details for PubMedID 36930742

• Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty with Prior Hardware. The Journal of arthroplasty Apinyankul, R., Hui, A. Y., Hwang, K., Segovia, N. A., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2023

  Abstract

  End-stage knee osteoarthritis with retained peri-articular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention vs. removal of hardware during TKA is controversial.Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. Mean follow-up was 60 months (range, 24 to 223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (Odds ratio (OR) 20.7, p < 0.05), implant failures (OR 13.9, p < 0.05), and lower Veteran Rand 12 Mental Score (VR-12 MS) (-14.8, p < 0.05). Hardware removal vs. retention and use of single vs. multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, p < 0.05) VR-12 MS compared to retention of all hardware.TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure, rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

  View details for DOI 10.1016/j.arth.2023.01.049

  View details for PubMedID 36758842

• Pes Planovalgus Is Associated with Increased Comorbidities and Poor Outcomes After Total Knee Arthroplasty. Journal of surgical orthopaedic advances Mitchell, A. R., Oladeji, K. A., Bonano, J. C., Bala, A., Amanatullah, D. F. 2023; 32 (3): 202-206

  Abstract

  Pes planovalgus affects knee biomechanics but there are no studies describing its impact on total knee arthroplasty (TKA). We aim to characterize the demographics, medical, and surgical complications of patients with pes planovalgus undergoing TKA. A Medicare database was queried using ICD-9 codes to identify 5,750 patients with and 23,000 patients without pes planovalgus who underwent TKA from 2005 to 2014. Standard descriptive statistics were used to compare medical and surgical complications at 90 days and 2 years, with alpha < 0.003 after a Bonferroni Correction. Patients with pes planovalgus had an elevated incidence of hypertension (80%, p < 0.001), pulmonary disease (31%, p < 0.001), hypothyroidism (28%, p < 0.001), diabetes (30%, p < 0.001), vascular disease (20%, p < 0.001), obesity (26%, p < 0.001), and depression (23%, p < 0.001). They also had increased odds of deep vein thrombosis (DVT) (odds ratio [OR] 1.3, p < 0.001), stiffness (OR 1.3, p < 0.003) and revision (OR 1.59, p < 0.003) at 90 days. At 2 years, odds of stiffness had increased (OR 1.34, p < 0.001) with similar rates of revision and medical complications. Pes planovaglus is associated with increased medical comorbidities and this patient population may be at an increased risk for postoperative stiffness, early revisions, and DVT after TKA. Arthroplasty surgeons should be conscious of these risks when considering TKA in a patient with pes planovalgus and counsel them appropriately. (Journal of Surgical Orthopaedic Advances 32(3):202-206, 2023).

  View details for PubMedID 38252610

• Identifying Risk Factors for Complication and Readmission for Same-day Discharge Arthroplasty. The Journal of arthroplasty Abella, M. K., Ezeanyika, C. N., Finlay, A. K., Amanatullah, D. F. 2022

  Abstract

  BACKGROUND: The COVID-19 pandemic caused a surge of Same Day Discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary, as well as risk stratification for improved patient outcomes.METHODS: This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated.RESULTS: SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complication (AOR: 0.998, CI: 0.997-1.000). Patients who have pre-operative dyspnea (AOR: 1.03, CI: 1.02-1.04, p < 0.001), chronic obstructive pulmonary disease (COPD, AOR: 1.02, CI: 1.01-1.03, p = 0.002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, p < 0.001) had higher odds of postoperative complication. Patients who had pre-operative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, p = 0.003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, p < 0.001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, p < 0.001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, p = 0.038) had higher odds of readmission.CONCLUSIONS: SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (e.g., dyspnea, hypertension, and COPD), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

  View details for DOI 10.1016/j.arth.2022.12.036

  View details for PubMedID 36572233

• Revision hip arthroplasty using a modular, cementless femoral stem: long-term follow-up. The Journal of arthroplasty Valtanen, R. S., Hwang, K. L., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2022

  Abstract

  BACKGROUND: As the number of primary total hip arthroplasty (THA) cases increase, so does the demand for revision operations. However, long-term follow-up data for revision THA is lacking.METHODS: A retrospective review was completed of patients who underwent revision THA at a single institution between January 2002 and October 2007 using a cementless modular stem. Patient demographic, clinical, and radiographic data was collected. Preoperative and postoperative patient reported outcome (PRO) scores were compared at a minimum of fourteen-year follow-up.RESULTS: Eighty-four patients (89 hips) with a median age of 69 years (range, 28 to 88) at operation were included. Indications for revision included aseptic loosening (84.2%), infection (12.4%), and periprosthetic fracture (3.4%). Twenty-two hips sustained at least one complication: intraoperative fracture (7.9%), dislocation (6.7%), prosthetic joint infection (4.5%), deep venous thrombosis (3.4%), late periprosthetic fracture (2.2%). There were no modular junction complications. Eight patients underwent reoperations; only three involved the stem. Thirty-eight patients (45%) were deceased prior to final follow-up without known reoperations. Twenty-seven patients (32%) were lost to follow-up. Twenty-one patients (23%) were alive at minimum fourteen-year follow-up. Complete PROs were available for nineteen patients (range, 14 to 18.5 years follow-up). Significant improvement was seen in UCLA Activity, VR-12 physical, HOOS, JR., and HHS pain and function scores.CONCLUSION: Challenges of long-term follow-up include patient migration, an unwillingness to travel for re-examination, medical comorbidities, advanced age, and death. The cementless modular revision stem demonstrated long-term clinical success and remains a safe and reliable option for complex revision operations.

  View details for DOI 10.1016/j.arth.2022.12.018

  View details for PubMedID 36535440

• Outcome of the Wagner Cone femoral component for difficult anatomical conditions during total hip arthroplasty. International orthopaedics Lawson, K., Hwang, K. L., Montgomery, S., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2022

  Abstract

  PURPOSE: Total hip arthroplasty (THA) in patients with small or unusual proximal femoral anatomy is challenging due to sizing issues, control of version, and implant fixation. The Wagner Cone is a monoblock, fluted, tapered stem with successful outcomes for these patients; however, there is limited information on subsidence, a common finding with cementless stems.METHODS: We retrospectively reviewed our cases using the modified Wagner Cone (Zimmer, Warsaw, IN) implanted over a 13-year period (2006-2019) in patients with small or abnormal proximal femoral anatomy. We performed 144 primary THAs in 114 patients using this prosthesis. Mean follow-up was 4.5±3.4years (range, 1-13years). Common reasons for implantation were hip dysplasia (52%) and osteoarthritis in patients with small femoral proportions (22%). Analysis of outcomes included assessment of stem subsidence and stability.RESULTS: Survival was 98.6% in aseptic cases; revision-free survival was 97.9%. Femoral subsidence occurred in 84 cases (58%). No subsidence progressed after 3months. Of those that subsided, the mean distance was 2.8±2.0mm. There was less subsidence in stems that stabilized prior to sixweeks (2.2±1.4mm) compared to those that continued until 12weeks (3.9±1.6, p=0.02). Harris Hip, UCLA, and WOMAC scores significantly improved from pre-operative evaluation (p<0.001*, p<0.003*, p≪0.001*); there was no difference in outcome between patients with and without subsidence (p=0.430, p=0.228, p=0.147).CONCLUSION: The modified Wagner Cone demonstrates excellent clinical outcomes in patients with challenging proximal femoral anatomy. Subsidence is minor, stops by 3months, and does not compromise clinical outcome.

  View details for DOI 10.1007/s00264-022-05608-6

  View details for PubMedID 36224431

• A Pilot Program: Remote Summer Program to Improve Opportunity and Mentorship Among Underrepresented Students Pursuing Orthopaedic Surgery. JB & JS open access Hastings, K. G., Freiman, H. D., Amanatullah, D. F., Gardner, M. J., Frick, S., Shea, K. G. 2022; 7 (4)

  Abstract

  The purpose of this study was to evaluate the impact of an 8-week remote summer program in supporting underrepresented students interested in orthopaedic surgery.Methods: We received 115 applications, and a total of 17 students participated in the program (14.8%). Nine faculty mentors were matched with 1 or 2 students each. The program delivered a curriculum from June-August 2021 consisting of (1) weekly instructional courses on research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic topics, diversity in medicine, leadership, and work-life balance; and (3) a research experience paired with a faculty mentor and peer mentor. We surveyed students to measure skill progression, satisfaction, and overall program evaluation. Preprogram/postprogram evaluation, midprogram check-in, and student feedback surveys were collected.Results: Program participants represented a range of race and ethnic backgrounds, research experience levels, and various geographic locations across the United States. The cohort included a high rate of female (42%) and Black (35%) participants. On average, postprogram survey scores indicated that participants believed that the summer program improved their research skills (9.6 of 10), improved their orthopaedic interest (8.9 of 10), and improved mentorship and networking (9.1 of 10). For feedback surveys, 14 respondents of 15 total responses (93%) felt they were adequately matched to their faculty mentor. Twelve (80%) felt they had realistic deliverables for research projects within the 8-week program. Thirteen (87%) indicated they contributed to an abstract or manuscript as a coauthor.Conclusion: Our findings indicate that students improved their research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. The long-term goal is to improve the accessibility and quality of mentorship for underrepresented students in order to foster an equitable pathway into the field of orthopaedic surgery.

  View details for DOI 10.2106/JBJS.OA.22.00059

  View details for PubMedID 36338797

• Isolated Versus Full Component Revision In Total Knee Arthroplasty For Aseptic Loosening. The Journal of arthroplasty Apinyankul, R., Hwang, K., Segovia, N. A., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2022

  Abstract

  Revision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost, however, implant survivorship and clinical outcomes of these different operations are unclear.Between January 2009 and December 2019, a consecutive cohort of revision TKA were reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles (UCLA), Knee Society (KS) functional, Knee osteoarthritis and outcome score for joint replacement (KOOS JR), Veterans RAND 12 (VR-12) physical, and VR-12 mental).A total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, p = 0.343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [HR 10.11, p < 0.001] and iliotibial band release was associated with more complications (Odds ratio (OR) 9.87, p = 0.027). Preoperative symptoms of instability were associated with the worst improvement in UCLA score. Higher American Society of Anesthesiologists (ASA) and higher Charlson Comorbidity Index (CCI) were related with worse VR-12 physical (-30.5, p = 0.008) and KOOS JR (-4.2, p = 0.050) scores, respectively.Isolated and full component revision TKA for aseptic loosening do not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor ASA status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.

  View details for DOI 10.1016/j.arth.2022.09.006

  View details for PubMedID 36099937

• The Impact of Extended Trochanteric Osteotomy with Cerclage Fixation in Revision Total Hip Arthroplasty for Prosthetic Joint Infection. The Journal of arthroplasty Whittaker, M. J., Arora, P., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Amanatullah, D. F. 2022

  Abstract

  BACKGROUND: An extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a prosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection.METHODS: The institutional database included 76 ETOs for revision arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated.RESULTS: Forty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (p = 0.082), postoperative complications (p = 0.258), or rate of repeat revision surgery (p = 0.322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (p = 0.758), blood loss (p = 0.498), rate of repeat revision surgery (p = 0.302), or postoperative complications (p = 0.253) including infection (p = 0.639).CONCLUSION: An ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.

  View details for DOI 10.1016/j.arth.2022.08.041

  View details for PubMedID 36067886

• Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis CURRENT ORTHOPAEDIC PRACTICE Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Maloney, W. J., Kamal, R. N. 2022; 33 (4): 338-346

  View details for Web of Science ID 000816578100006

• Health Literacy and Patient Participation in Shared Decision-Making in Orthopedic Surgery ORTHOPEDICS Mertz, K., Eppler, S., Shah, R., Yao, J., Steffner, R., Safran, M., Hu, S., Chou, L., Amanatullah, D. F., Kamal, R. N. 2022; 45 (4): 227-232

  Abstract

  The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score <6). Forty-eight percent of patients preferred to share decision-making with their physician equally (CPS score=3), whereas 38% preferred to have a more active role in decision-making (CPS score≤2). There was no statistically significant correlation between health literacy and patient preference for involvement in decision-making (r=0.130; P=.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [Orthopedics. 2022;45(4):227-232.].

  View details for DOI 10.3928/01477447-20220401-04

  View details for Web of Science ID 000831125900015

  View details for PubMedID 35394383

• Supine Knee Positioning Does Not Interfere with Mobile-Bearing Unicompartmental Knee Arthroplasty Performance. The journal of knee surgery Bonano, J. C., Barrett, A. A., Aggarwal, V. K., Chen, F., Schirmers, J., Finlay, A. K., Arora, P., Amanatullah, D. F. 2022

  Abstract

  The Food and Drug Administration has only approved mobile-bearing unicompartmental knee arthroplasty (MB-UKA) to be performed with a hanging leg holder. The purpose of this study is to evaluate the impact of a supine knee position on MB-UKA performance.In total, 16 cadavers were randomized so that either the right or left knee was placed in the flexed or supine positions. One board-certified orthopaedic surgeon and three adult reconstruction fellows that attended the required Oxford partial knee instructional course performed four operations in each position. The primary outcome was final knee balance. Secondary outcomes included procedure duration, timing of individual surgical steps, implant sizes, range of motion, implant alignment, and fracture. A Students t-test was used to examine differences between positions with significance set at p<0.05. Secondary analyses using two one-sided tests were conducted to explore equivalence between the two positions.There was no significant difference in mean final balance between supine (1.7mm±standard deviation [SD]=1.5mm) and flexed (1.3±1.3mm) positions (p=0.390). There were also no significant differences between positions for procedure time (p=0.497), tibia coronal alignment (p=0.614), tibial slope (p=0.194), femoral component sagittal alignment (p=0.091), and fractures (n=0). Exploratory equivalence analyses indicated that the positions were equivalent for final balance (p=0.002).MB-UKA performed in the supine position is not significantly different from the flexed position in terms of ligament balance, overall procedure time, and radiographic appearance. These initial safety data warrant further clinical investigations and support the expansion of the surgical technique to include performing MB-UKAs in the supine position.

  View details for DOI 10.1055/s-0042-1748822

  View details for PubMedID 35688441

• Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis. Current orthopaedic practice Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Maloney, W. J., Kamal, R. N. 2022; 33 (4): 338-346

  Abstract

  Poorly controlled diabetes mellitus (DM) increases the risk for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). While institutional protocols include hemoglobin A1c (HbA1c) screening in TJA patients, the costs and benefits of routine preoperative screening have not been described.The authors created a decision tree model to evaluate short-term costs and risk reduction for PJIs with routine screening of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. Probabilities and costs were obtained from published sources. They calculated net costs and absolute risk reduction in PJI for routine screening versus no screening. The authors also performed sensitivity analyses of model inputs including probabilistic sensitivity analyses (PSAs) consisting of 10,000 Monte Carlo simulations.In patients with DM, routine screening before THA resulted in net cost savings of $81 per patient with 286 patients needing to be screened to prevent 1 PJI, while screening before TKA incurred net additional costs of $25,810 per PJI prevented. Routine screening in patients with DM undergoing THA or TKA was cost-saving across 75.5% or 21.8% of PSA simulations, respectively. In patients with no history of DM, routine screening before THA or TKA incurred net additional costs of $24,583 or $87,873 per PJI prevented, respectively.Routine HbA1c screening in patients with DM prior to THA with referral of patients with elevated HbA1c for glycemic optimization may prevent PJI and reduce healthcare costs. In contrast, routine screening in patients with DM prior to TKA or in patients with no history of DM is not cost-saving.Economic Level IV.

  View details for DOI 10.1097/bco.0000000000001131

  View details for PubMedID 36340586

  View details for PubMedCentralID PMC9632610

• Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care ORTHOPEDICS MURASKO, M. J., V. IVANOV, D. D., ROE, A. K., KAMAL, R. N., AMANATULLAH, D. F. 2022; 45 (3): E127-+

  Abstract

  Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

  View details for DOI 10.3928/01477447-20220217-06

  View details for Web of Science ID 000800016300002

  View details for PubMedID 35201936

• Staging Bilateral Total Knee Arthroplasties Reduces Alignment Outliers. The Journal of arthroplasty Follett, M. A., Arora, P., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Amanatullah, D. F. 1800

  Abstract

  PURPOSE: Patients frequently present with bilateral symptomatic knee osteoarthritis and request simultaneous total knee arthroplasties (TKAs). Technical differences between simultaneous and staged TKAs could affect clinical and radiographic outcomes. We hypothesized staged TKAs would have fewer mechanical alignment outliers than simultaneous TKAs.METHODS: We reviewed 87 simultaneous and 72 staged TKAs with at least 2 years of follow-up. Radiographic assessment was done using standing long leg and lateral radiographs of the knee. Coronal and sagittal measurements were performed by four blinded observers on two separate occasions with an intra-observer agreement of 0.95 and inter-observer of 0.92.RESULTS: The first simultaneous knee had no difference in the probability of establishing the mechanical axis outside 3° of neutral (45%) compared to the first staged knee (54%, p = 0.337). However, the second simultaneous knee (49%) was more likely to establish the axis outside mechanical neutral compared to the second staged knee (28%; Odds Ratio (OR): 2.54, Confidence Interval (CI): 1.31 - 4.94, p = 0.006). There was an increased risk of deep venous thrombosis with staged TKA (OR: 2.96, CI: 1.28 - 6.84, p = 0.011), but other perioperative complication rates were not significantly different. There were no clinically significant differences in range of motion or Knee Society Score.CONCLUSION: There is a significantly increased risk of establishing the second knee outside mechanical neutral during a simultaneous TKA compared to staged bilateral TKAs, possibly related to a number of surgeon- and system-related factors. The impact on clinical outcomes and radiographic loosening may become significant in long-term follow up.

  View details for DOI 10.1016/j.arth.2022.01.003

  View details for PubMedID 35017050

• Response; MD-PhD graduates remain underrepresented in orthopedic surgery: National MD-PhD Program Outcome Survey update JOURNAL OF ORTHOPAEDIC RESEARCH von Kaeppler, E. P., Amanatullah, D. F. 2021

  View details for DOI 10.1002/jor.25231

  View details for Web of Science ID 000729182600001

  View details for PubMedID 34897791

• Notching of the Neck After Acetabular Constraint Necessitating Femoral Component Revision. Arthroplasty today Bonano, J. C., Bala, A., Chen, F., Amanatullah, D. F., Goodman, S. B. 2021; 12: 32-35

  Abstract

  A 75-year-old woman who had previously undergone a left revision total hip arthroplasty with the use of a constrained acetabular liner presented with recurrent dislocation of the hip. Intraoperatively, there was metallic staining of the hip capsule and significant notching of the femoral neck, consistent with impingement of the intact locking ring, necessitating stem revision. Constrained acetabular liners have high failure rates due to intraprosthetic impingement, but to our knowledge, failure due to notching of the femoral component and metallosis from repeated impingement has not been described. Surgeons should be aware of this potential mode of failure.

  View details for DOI 10.1016/j.artd.2021.09.007

  View details for PubMedID 34761091

• Knee Implant Identification by Fine-Tuning Deep Learning Models. Indian journal of orthopaedics Sharma, S., Batta, V., Chidambaranathan, M., Mathialagan, P., Mani, G., Kiruthika, M., Datta, B., Kamineni, S., Reddy, G., Masilamani, S., Vijayan, S., Amanatullah, D. F. 2021; 55 (5): 1295-1305

  Abstract

  Identification of implant model from primary knee arthroplasty in pre-op planning of revision surgery is a challenging task with added delay. The direct impact of this inability to identify the implants in time leads to the increase in complexity in surgery. Deep learning in the medical field for diagnosis has shown promising results in getting better with every iteration. This study aims to find an optimal solution for the problem of identification of make and model of knee arthroplasty prosthesis using automated deep learning models.Deep learning algorithms were used to classify knee arthroplasty implant models. The training, validation and test comprised of 1078 radiographs with a total of 6 knee arthroplasty implant models with anterior-posterior (AP) and lateral views. The performance of the model was calculated using accuracy, sensitivity, and area under the receiver-operating characteristic curve (AUC), which were compared against multiple models trained for comparative in-depth analysis with saliency maps for visualization.After training for a total of 30 epochs on all 6 models, the model performing the best obtained an accuracy of 96.38%, the sensitivity of 97.2% and AUC of 0.985 on an external testing dataset consisting of 162 radiographs. The best performing model correctly and uniquely identified the implants which could be visualized using saliency maps.Deep learning models can be used to differentiate between 6 knee arthroplasty implant models. Saliency maps give us a better understanding of which regions the model is focusing on while predicting the results.

  View details for DOI 10.1007/s43465-021-00529-9

  View details for PubMedID 34824729

  View details for PubMedCentralID PMC8586384

• Knee Implant Identification by Fine-Tuning Deep Learning Models INDIAN JOURNAL OF ORTHOPAEDICS Sharma, S., Batta, V., Chidambaranathan, M., Mathialagan, P., Mani, G., Kiruthika, M., Datta, B., Kamineni, S., Reddy, G., Masilamani, S., Vijayan, S., Amanatullah, D. F. 2021

  View details for DOI 10.1007/s43465-021-00529-9

  View details for Web of Science ID 000701591300001

• A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Lai, C. H., Shapiro, L. M., Amanatullah, D. F., Chou, L. B., Gardner, M. J., Hu, S. S., Safran, M. R., Kamal, R. N. 2021

  Abstract

  PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians.METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted.RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and(3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care.CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

  View details for DOI 10.1007/s11136-021-02972-5

  View details for PubMedID 34510335

• To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons. The Journal of the American Academy of Orthopaedic Surgeons Van Rysselberghe, N. L., Campbell, S. T., Goodnough, L. H., Amanatullah, D. F., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  INTRODUCTION: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.METHODS: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.RESULTS: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).DISCUSSION: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.

  View details for DOI 10.5435/JAAOS-D-20-00968

  View details for PubMedID 34288890

• Google Trends Analysis Shows Increasing Public Interest in Platelet-Rich Plasma Injections for Hip and Knee Osteoarthritis. The Journal of arthroplasty Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Amanatullah, D. F., Kamal, R. N. 2021

  Abstract

  BACKGROUND: Osteoarthritis is a chronic musculoskeletal condition that frequently affects the hip and knee joints. Given the burden associated with surgical intervention for hip and knee osteoarthritis, patients continue to search for potential nonoperative treatments. One biologic therapy with mixed clinical and basic science evidence for treating osteoarthritis is platelet-rich plasma injections into the affected joint. We used the Google Trends tool to provide a quantitative analysis of national interest in platelet-rich plasma injections for hip and knee osteoarthritis.METHODS: Google Trends parameters were selected to obtain search data from January 2009 to December 2019. Various combinations of "arthritis," "osteoarthritis," "PRP," "platelet-rich plasma," "knee," and "hip" were entered into the Google Trends tool and trend analyses were performed.RESULTS: Three linear models were generated to display search volume trends in the United States for platelet-rich plasma and osteoarthritis, hip osteoarthritis, and knee osteoarthritis, respectively. All models showed increased Google queries as time progressed (P < .001), with R2 ranging from 0.837 to 0.940. Seasonal, income-related, and geographic variations in public interest in platelet-rich plasma for osteoarthritis were noted.CONCLUSION: Our results demonstrate a significant rise in Google queries related to platelet-rich plasma injections for osteoarthritis of the hip and knee since 2009. Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data. Trends in public interest may inform patient counseling, shared decision-making, and directions for future clinical research.

  View details for DOI 10.1016/j.arth.2021.05.040

  View details for PubMedID 34172346

• Excellent Clinical and Radiographic Outcomes with Direct Superior Total Hip Arthroplasty with a Minimum of Two-Year Follow Up SURGICAL TECHNOLOGY INTERNATIONAL-INTERNATIONAL DEVELOPMENTS IN SURGERY AND SURGICAL RESEARCH Korth, M., Ezzibdeh, R., Arora, P., Amanatullah, D. F. 2021; 38

  View details for Web of Science ID 000661729000041

• Case-Controlled Analysis of the Direct Superior and Mini-Posterior Approach for Total Hip Arthroplasty at a Minimum of Two Years of Follow Up SURGICAL TECHNOLOGY INTERNATIONAL-INTERNATIONAL DEVELOPMENTS IN SURGERY AND SURGICAL RESEARCH Ezzibdeh, R., Korth, M., Arora, P., Amanatullah, D. F. 2021; 38

  View details for Web of Science ID 000661729000043

• Perioperative Statin Use May Reduce Postoperative Arrhythmia Rates After Total Joint Arthroplasty. The Journal of arthroplasty Bonano, J. C., Aratani, A. K., Sambare, T. D., Goodman, S. B., Huddleston, J. I., Maloney, W. J., Burk, D. R., Aaronson, A. J., Finlay, A. K., Amanatullah, D. F. 2021

  Abstract

  BACKGROUND: Postoperative arrhythmias are associated with increased morbidity and mortality in total joint arthroplasty (TJA) patients. HMG-CoA (3-hydroxy-3-methyl-glutaryl-CoA) reductase inhibitors (statins) decrease atrial fibrillation rates after cardiac surgery, but it is unknown if this cardioprotective effect is maintained after joint reconstruction surgery. We aim to determine if perioperative statin use decreases the incidence of 90-day postoperative arrhythmias in patients undergoing primary TJA.METHODS: We performed a single-center retrospective cohort study in which 231 primary TJA patients (109 hips, 122 knees) received simvastatin 80 mg daily during their hospitalization as part of a single surgeon's standard postoperative protocol. This cohort was matched to 966 primary TJA patients (387 hips and 579 knees) that did not receive simvastatin. New-onset arrhythmias (bradycardia, atrial fibrillation/tachycardia/flutter, paroxysmal supraventricular tachycardia, and ventricular tachycardia) and complications (readmissions, thromboembolism, infection, and dislocation) within 90 days of the procedure were documented. Categorical variables were analyzed using Fisher's exact tests. Our study was powered to detect a 3% difference in arrhythmia rates.RESULTS: Within 90 days postoperatively, arrhythmias occurred in 1 patient (0.4%) who received a perioperative statin, 39 patients (4.0%) who did not receive statins (P= .003), and 24 patients (4.2%) who were on outpatient statins (P= .005). This is 10-fold reduction in the relative risk of developing a postoperative arrhythmia within 90 days of arthroplasty and an absolute risk reduction of 3.6%.CONCLUSION: Treating as few as 28 patients with perioperative simvastatin prevents one new cardiac arrhythmia within 90 days in statin-naive patients undergoing TJA.

  View details for DOI 10.1016/j.arth.2021.05.022

  View details for PubMedID 34127349

• Articulating vs Static Spacers for Native Knee Infection in the Setting of Degenerative Joint Disease. Arthroplasty today Hooper, J., Arora, P., Kappagoda, S., Huddleston, J. I., Goodman, S. B., Amanatullah, D. F. 2021; 8: 138–44

  Abstract

  Background: Patients with advanced knee arthritis who develop a septic joint are not adequately treated with irrigation and debridement and intravenous antibiotics because of antecedent cartilage damage. The gold standard treatment has been a 2-stage approach. The periprosthetic joint infection literature has demonstrated the superiority of articulating spacers, and metal-on-poly (MOP) spacers are being used with increasing frequency. The purpose of this study was to compare the postoperative outcomes of patients with infected, arthritic knees treated by a 2-stage approach to those of patients who received single-stage treatment with a MOP spacer.Methods: Sixteen patients with native knee septic arthritis treated with an antibiotic spacer between 1998 and 2019 were reviewed. Demographic data, clinical data, knee motion, Knee Society score, Timed-Up-and-Go, and pain scores were collected. Survivorship of final implants was compared.Results: Six of 16 knees (38%) received single-stage treatment, and 10 received 2-stage treatment (62%). Five of 6 MOP spacers (83%) were retained at a mean follow-up of 3 ± 1.2 years. Nine of 10 (90%) receiving static spacers had subsequent reconstruction, with 9 (100%) surviving at mean follow-up of 7 ± 3.2 years. The patients who received MOP spacers trended toward greater terminal flexion, higher Knee Society score, and faster Timed-Up-and-Go at final follow-up.Conclusion: Infection in a native, arthritic knee may be effectively treated using single-stage MOP spacer. Postoperative outcomes of single-stage MOP spacers compare favorably to staged static spacers and with those undergoing revision surgery for other indications. Longer follow-up is needed to evaluate durability of MOP spacers.

  View details for DOI 10.1016/j.artd.2021.01.009

  View details for PubMedID 33748374

• Next generation sequencing for pathogen detection in periprosthetic joint infections. EFORT open reviews Indelli, P. F., Ghirardelli, S., Violante, B., Amanatullah, D. F. 2021; 6 (4): 236-244

  Abstract

  Periprosthetic joint infections (PJI) represent one of the most catastrophic complications following total joint arthroplasty (TJA). The lack of standardized diagnostic tests and protocols for PJI is a challenge for arthroplasty surgeons.Next generation sequencing (NGS) is an innovative diagnostic tool that can sequence microbial deoxyribonucleic acids (DNA) from a synovial fluid sample: all DNA present in a specimen is sequenced in parallel, generating millions of reads. It has been shown to be extremely useful in a culture-negative PJI setting.Metagenomic NGS (mNGS) allows for universal pathogen detection, regardless of microbe type, in a 24-48-hour timeframe: in its nanopore-base variation, mNGS also allows for antimicrobial resistance characterization.Cell-free DNA (cfDNA) NGS, characterized by lack of the cell lysis step, has a fast run-time (hours) and, together with a high sensitivity and specificity in microorganism isolation, may provide information on the presence of antimicrobial resistance genes.Metagenomics and cfDNA testing have reduced the time needed to detect infecting bacteria and represent very promising technologies for fast PJI diagnosis.NGS technologies are revolutionary methods that could disrupt the diagnostic paradigm of PJI, but a comprehensive collection of clinical evidence is still needed before they become widely used diagnostic tools. Cite this article: EFORT Open Rev 2021;6:236-244. DOI: 10.1302/2058-5241.6.200099.

  View details for DOI 10.1302/2058-5241.6.200099

  View details for PubMedID 34040801

  View details for PubMedCentralID PMC8142595

• Medial Unicompartmental Knee Arthroplasty with a Mobile-Bearing Implant. JBJS essential surgical techniques Bonano, J. C., Barrett, A. A., Amanatullah, D. F. 2021; 11 (2)

  Abstract

  Background: For patients with isolated medial knee arthritis, unicompartmental knee arthroplasty (UKA) is an appealing surgical option. Compared with total knee arthroplasty (TKA), UKA is less invasive, preserves more native bone stock, has lower perioperative morbidity and mortality1,2, allows for quicker recovery1,2, and has higher patient satisfaction2,3. It also allows for more dynamic proprioception and postural control, allowing for function more similar to a native knee4. Proper surgical technique and patient selection are critical to the growing success of UKA.Description: The general principles of UKA are to remove and replace the diseased femoral and tibial joint surfaces while restoring limb alignment. The key steps of this procedure are demonstrated in the video article: (1) patient evaluation, (2) patient positioning, (3) surgical exposure, (4) tibial guide placement and resection, (5) femoral guide placement and resection, (6) knee balancing and implant trialing, (7) preventing impingement, (8) final tibial preparation, (9) final component placement, and (10) closure and postoperative course.Alternatives: Patients should first exhaust all nonoperative treatments before considering UKA. For those patients who do not meet the appropriate indications for UKA, TKA is the most acceptable alternative treatment. In active patients <55 years old without bone-on-bone osteoarthritis, a high tibial osteotomy may be considered. When considering UKA, options include both mobile-bearing and fixed-bearing designs.Rationale: The potential advantages of UKA over TKA make it an attractive option for the appropriate patient. Recently, indications for UKA have expanded to include (1) isolated noninflammatory bone-on-bone arthritis in the medial compartment; (2) retained full-thickness cartilage in the lateral compartment, best visualized on valgus-stress radiographs; (3) a functionally normal medial collateral ligament; and (4) a functionally normal anterior cruciate ligament5. Mobile-bearing UKA designs consist of a dual articulation between the concave polyethylene insert and the metallic tibial and spherical femoral components, which allows for distribution of contact forces over a large surface area6. In contrast, fixed-bearing designs have a flat polyethylene insert that does not conform to the femur. Current data do not demonstrate a clear difference in clinical performance between the 2 bearings. However, a recent systematic review has shown lower polyethylene wear rates in mobile-bearing implants7.Expected Outcomes: The survivorship of mobile-bearing UKA ranges from 85% to 98% at 10 years8-12 and from 79% to 94% at 15 years8,13,14. The most common indications for revision include aseptic loosening (36%), progression of osteoarthritis (20%), and unexplained pain (11%)7. Bearing dislocation is a unique complication for mobile-bearing UKAs, with reported rates between 0.3% to 4.2%6,10,12.Important Tips: Always inspect all compartments of the knee for evidence of substantial degenerative changes prior to proceeding with UKA. If there is advanced arthritis in other compartments, the decision should be made to proceed with TKA instead. Therefore, preoperatively, all patients indicated for UKA should also sign a consent form for TKA, and TKA implants should be available in case they are needed.When assessing bearing size, it is important that there is no axial loading through the heel to properly assess the flexion gap. Intraoperatively, this can be done by elevating the thigh so that the foot hangs freely. The trial spoon should fit into the joint without substantial resistance or effort.Spigots do not reference the end of the bone. Rather, they reference the end of the spigot hole that was drilled using the initial 0 spigot.Spigot number represents the total thickness of additional bone that will be removed from the first mill cut.Confirm the amount of bone that was resected by inspecting the small rim of bone that remains around the spigot hole after milling.

  View details for DOI 10.2106/JBJS.ST.20.00002

  View details for PubMedID 34277135

• Next generation sequencing for pathogen detection in periprosthetic joint infections EFORT OPEN REVIEWS Indelli, P. F., Ghirardelli, S., Violante, B., Amanatullah, D. F. 2021; 6 (4): 236–44

  View details for DOI 10.1302/2058-5241.6.200099

  View details for Web of Science ID 000636744800003

• A Qualitative Study of Patient Themes for the Quality of the Total Joint Arthroplasty Experience ORTHOPEDICS Amanatullah, D. F., Eppler, S. L., Shah, R. F., Mertz, K., Roe, A. K., Murasko, M., Kamal, R. N. 2021; 44 (2): 117–22

  View details for DOI 10.3928/01477447-20210217-01

  View details for Web of Science ID 000634508300034

• Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy. The Journal of arthroplasty Boontanapibul, K., Huddleston, J. I., Amanatullah, D. F., Maloney, W. J., Goodman, S. B. 2021

  Abstract

  BACKGROUND: Core decompression is the most common procedure for early-stage osteonecrosis of the femoral head (ONFH). This study investigated outcomes of core decompression with/without bone marrow aspirate concentrate (BMAC), based on the Kerboul combined necrotic angles using magnetic resonance imaging.METHODS: We reviewed 66 patients (83 hips) with early ONFH, Association Research Circulation Osseous stages I-IIIa, who underwent core decompression alone (26 patients, 33 hips) or in combination with BMAC (40 patients, 50 hips). Survival rate and progressive collapse were analyzed using the Kaplan-Meier method, and conversion to total hip arthroplasty (THA) was evaluated. Subgroup analyses based on the modified Kerboul angle were performed: grade I (<200°), grade II (200°-249°), grade III (250°-299°), and grade IV (≥300°).RESULTS: Mean follow-up was 36±23 months. Femoral head collapse with BMAC (16 hips, 32%) was significantly lower than without BMAC (19 hips, 58%, P= .019). Conversion THA was significantly lower with BMAC (28%) than without (58%, P= .007). Survival rates among groups showed significant differences (P= .017). In grade I, 0/12 hips with BMAC collapsed while 3/9 (33%) without BMAC collapsed (P= .063); in grade II, 2/16 hips (12%) with BMAC collapsed while 7/13 (54%) without BMAC collapsed (P= .023). There was no significant difference in collapse with (64%) or without (82%) BMAC in grade III-IV hips (P= .256).CONCLUSION: Core decompression with/without BMAC had a high failure rate, by increasing disease progression and the necessity for THA, for combined necrotic angles >250°. In our study, addition of BMAC had more reliable outcomes than isolated core decompression for precollapse ONFH if the combined necrotic angles were <250°.

  View details for DOI 10.1016/j.arth.2021.01.075

  View details for PubMedID 33618954

• Influence of team composition on turnover and efficiency of total hip and knee arthroplasty. The bone & joint journal Cahan, E. M., Cousins, H. C., Steere, J. T., Segovia, N. A., Miller, M. D., Amanatullah, D. F. 2021; 103-B (2): 347–52

  Abstract

  AIMS: Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty.METHODS: We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score.RESULTS: Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon's 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043).CONCLUSION: Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347-352.

  View details for DOI 10.1302/0301-620X.103B2.BJJ-2020-0170.R2

  View details for PubMedID 33517742

• The CARDE-B Scoring System Predicts 30-Day Mortality After Revision Total Joint Arthroplasty. The Journal of bone and joint surgery. American volume Raad, M., Amin, R., Musharbash, F., Rao, S., Best, M., Amanatullah, D. F. 2021

  Abstract

  BACKGROUND: There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA.METHODS: A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017.RESULTS: Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample.CONCLUSIONS: The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool.LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.20.00969

  View details for PubMedID 33475307

• Case-Controlled Analysis of the Direct Superior and Mini-Posterior Approach for Total Hip Arthroplasty at a Minimum of Two Years of Follow Up. Surgical technology international Ezzibdeh, R., Korth, M. J., Arora, P., Amanatullah, D. F. 2021; 37

  Abstract

  INTRODUCTION: The direct superior approach to total hip arthroplasty (THA) is a recently developed technique aimed at sparing the iliotibial band, obturator externus tendon, and quadratus femoris muscle while working within the familiar anatomical landscape of the posterior approach. While the direct superior approach has been used for more than a decade, there is a lack of midterm outcomes and safety data. This study elaborates on promising short-term results and aims to investigate the midterm outcomes of the direct superior approach.MATERIALS AND METHODS: We present a unicentric, retrospective case-controlled analysis of a minimum two-year follow up of the direct superior approach in comparison to those of the more conventional and established mini-posterior approach.RESULTS: The results indicate that patient recovery, as measured by Harris Hip Score and timed-up-and-go at three months and two years, are virtually identical. There was no difference in gait aid utilization or frequency of narcotic use. However, there was a statistically significant reduction in length of stay by over one day associated with the direct superior approach (p=0.003). There was no compromise in acetabular component position or observed lucencies over time.CONCLUSION: Overall, the direct superior approach appears to be safe and warrants longer-term study to evaluate its effect on hospital-related cost, same-day discharge, and hip stability.

  View details for PubMedID 33463694

• Excellent Clinical and Radiographic Outcomes with Direct Superior Total Hip Arthroplasty with a Minimum of Two-Year Follow Up. Surgical technology international Korth, M. J., Ezzibdeh, R., Arora, P., Amanatullah, D. F. 2021; 37

  Abstract

  This study aims to establish the midterm safety and performance for the direct superior approach to minimally invasive surgery total hip arthroplasty (MIS-THA). We used a unicentric, single-surgeon, retrospective, consecutive case series analysis of the first 40 patients who received primary unilateral direct superior MIS-THA. Special attention was given to functional recovery by measuring Harris Hip Score (HHS) and timed-up-and-go (TUG) with a mean follow up of 2.2 ± 0.4 years. A radiologic evaluation was performed. HHS and TUG improved significantly at three months and one year (p < 0.001). All components were placed within the Lewinnek safe zone with no change position or signs of loosening at two years. With a minimum of two years of follow up, the direct superior approach appears to be safe without any obvious or consistent postoperative complications-clinically or radiographically-with excellent functional recovery. Additionally, our subgroup analysis supported no late learning curve effect.

  View details for PubMedID 33463695

• Objective Activity Parameters Track Patient-Specific Physical Recovery Trajectories After Surgery and Link With Individual Preoperative Immune States. Annals of surgery Fallahzadeh, R., Verdonk, F., Ganio, E., Culos, A., Stanley, N., Marić, I., Chang, A. L., Becker, M., Phongpreecha, T., Xenochristou, M., De Francesco, D., Espinosa, C., Gao, X., Tsai, A., Sultan, P., Tingle, M., Amanatullah, D. F., Huddleston, J. I., Goodman, S. B., Gaudilliere, B., Angst, M. S., Aghaeepour, N. 2021

  Abstract

  The longitudinal assessment of physical function with high temporal resolution at a scalable and objective level in patients recovering from surgery is highly desirable to understand the biological and clinical factors that drive the clinical outcome. However, physical recovery from surgery itself remains poorly defined and the utility of wearable technologies to study recovery after surgery has not been established.Prolonged postoperative recovery is often associated with long-lasting impairment of physical, mental, and social functions. While phenotypical and clinical patient characteristics account for some variation of individual recovery trajectories, biological differences likely play a major role. Specifically, patient-specific immune states have been linked to prolonged physical impairment after surgery. However, current methods of quantifying physical recovery lack patient specificity and objectivity.Here, a combined high-fidelity accelerometry and state-of-the-art deep immune profiling approach was studied in patients undergoing major joint replacement surgery. The aim was to determine whether objective physical parameters derived from accelerometry data can accurately track patient-specific physical recovery profiles (suggestive of a 'clock of postoperative recovery'), compare the performance of derived parameters with benchmark metrics including step count, and link individual recovery profiles with patients' preoperative immune state.The results of our models indicate that patient-specific temporal patterns of physical function can be derived with a precision superior to benchmark metrics. Notably, six distinct domains of physical function and sleep are identified to represent the objective temporal patterns: "activity capacity" and "moderate and overall activity" (declined immediately after surgery); "sleep disruption and sedentary activity" (increased after surgery); "overall sleep", "sleep onset", and "light activity" (no clear changes were observed after surgery). These patterns can be linked to individual patients' preoperative immune state using cross-validated canonical-correlation analysis. Importantly, the pSTAT3 signal activity in M-MDSCs predicted a slower recovery.Accelerometry-based recovery trajectories are scalable and objective outcomes to study patient-specific factors that drive physical recovery.

  View details for DOI 10.1097/SLA.0000000000005250

  View details for PubMedID 35129529

• Return to work and productivity loss after surgery: A health economic evaluation. International journal of surgery (London, England) M Hah, J., Lee, E., Shrestha, R., Pirrotta, L., Huddleston, J., Goodman, S., Amanatullah, D. F., Dirbas, F. M., Carroll, I. R., Schofield, D. 2021: 106100

  Abstract

  We aimed to identify preoperative psychosocial factors associated with return-to-work (RTW) and the associated cost of productivity loss due to work absenteeism following surgery. Research demonstrates a high economic burden from productivity loss after surgery, but the comparative cost of productivity loss relative to income across different operations has not been examined.A mixed surgical cohort recruited for a randomized controlled trial were prospectively followed for up to two years following surgery with daily phone assessments to three months, weekly assessments thereafter to six months, then monthly assessments thereafter to determine RTW status, opioid use and pain.183 of 207 (88.3%) patients in paid employment prior to surgery, who provided at least one day of follow-up, were included in this analysis. The average cost of productivity loss due to work absenteeism was $13 761 (median $9064). Patients who underwent total knee replacement incurred the highest income loss. Medical claims filed before surgery were significantly associated with relative income loss (AOR 5.09; 95% CI 1.73-14.96; p < 0.01) and delayed postoperative RTW. Elevated preoperative PTSD symptoms were associated with delayed RTW (HR 0.78; 95%CI 0.63-0.96; p-value = 0.02) while male gender (HR 1.63; 95%CI 1.11-2.38; p-value = 0.01) was associated with faster postoperative RTW.Surgery places a high economic burden on individuals due to postoperative productivity loss. Multidisciplinary approaches, such as pathways, that facilitate the operation and recovery may mitigate the economic consequences for patients, employers, and the healthcare system.

  View details for DOI 10.1016/j.ijsu.2021.106100

  View details for PubMedID 34600123

• Effect of Comorbidity Burden on the Risk of Venous Thromboembolic Events After Total Knee Arthroplasty. Geriatric orthopaedic surgery & rehabilitation Bala, A., Oladeji, K., Amanatullah, D. F. 2021; 12: 21514593211043998

  Abstract

  Background: Venous thromboembolic events (VTEs) are common after total knee arthroplasty (TKA). The rate of VTEs has improved with early mobilization, mechanical prophylaxis, and appropriate chemoprophylaxis. The aim of this study was to analyze the contribution of medical comorbidities to the risk of VTE after TKA.Method: Medicare claims from 2005 to 2014 were queried. International Classification of Diseases, Ninth revision (ICD-9), and Current Procedural Terminology codes were used to identify the diagnoses, procedures, and complications. 157,200 primary TKAs were age, sex, and Elixhauser Comorbidity Index (ECI) matched with 157,200 osteoarthritis controls. First instances of deep venous thrombosis (DVT) and pulmonary embolism were tracked at 90 days and 2 years. Odds ratios (ORs), confidence intervals, and P-values (p) were calculated and used to investigate the contribution of comorbidities.Results: 90 days after TKA or OA diagnosis, comorbidities were associated with 45% of the DVT risk, 38% of the PE risk. 1 in 92 patients would be expected to be diagnosed with VTE after TKA and 1 in 136 patients after only the diagnosis of osteoarthritis. After 90 days, medical comorbidities were associated with 70% of the DVT risk, 68% of the PE risk.Conclusion: Nearly 50% of DVTs and 40% of PEs within 90 days of TKA may be related to the baseline health of OA patients. Venous thromboembolic events after TKA are a "never" event according to Center of Medicare and services that appropriate VTE prophylaxis likely cannot be neutralized.

  View details for DOI 10.1177/21514593211043998

  View details for PubMedID 34595047

• The Safety and Toxicity of Phage Therapy: A Review of Animal and Clinical Studies. Viruses Liu, D., Van Belleghem, J. D., de Vries, C. R., Burgener, E., Chen, Q., Manasherob, R., Aronson, J. R., Amanatullah, D. F., Tamma, P. D., Suh, G. A. 2021; 13 (7)

  Abstract

  Increasing rates of infection by antibiotic resistant bacteria have led to a resurgence of interest in bacteriophage (phage) therapy. Several phage therapy studies in animals and humans have been completed over the last two decades. We conducted a systematic review of safety and toxicity data associated with phage therapy in both animals and humans reported in English language publications from 2008-2021. Overall, 69 publications met our eligibility criteria including 20 animal studies, 35 clinical case reports or case series, and 14 clinical trials. After summarizing safety and toxicity data from these publications, we discuss potential approaches to optimize safety and toxicity monitoring with the therapeutic use of phage moving forward. In our systematic review of the literature, we found some adverse events associated with phage therapy, but serious events were extremely rare. Comprehensive and standardized reporting of potential toxicities associated with phage therapy has generally been lacking in the published literature. Structured safety and tolerability endpoints are necessary when phages are administered as anti-infective therapeutics.

  View details for DOI 10.3390/v13071268

  View details for PubMedID 34209836

• Provider Personal and Demographic Characteristics and Patient Satisfaction in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Lu, L. Y., Sharabianlou Korth, M. J., Cheng, R. Z., Finlay, A. K., Kamal, R. N., Goodman, S. B., Maloney, W. J., Huddleston, J. I., Amanatullah, D. F. 2021; 5 (4)

  Abstract

  INTRODUCTION: Patient satisfaction has increasingly been used to assess physician performance and quality of care. Although there is evidence that patient satisfaction is associated with patient-reported health outcomes and communication-related measures, there is debate over the use of patient satisfaction in reimbursement policy. Patient characteristics that influence satisfaction have been studied, but the effects of personal and demographic characteristics of physicians on patient satisfaction have yet to be explored.METHODS: Outpatient satisfaction scores from 11,059 patients who rated 25 orthopaedic surgeons from a single institution were studied. In this study, we sought to explore the relationship between nonmodifiable physician characteristics, such as sex and race, and patient satisfaction with outpatient orthopaedic surgery care, as expressed in the Press Ganey Satisfaction Scores. Univariate logistic regression models were used to test the associations between each provider characteristic and patient satisfaction on the Press Ganey patient satisfaction questionnaire.RESULTS: Three nonmodifiable physician personal and demographic characteristics were markedly associated with lower patient satisfaction scores across overall satisfaction, communication, and empathy domains: (1) female gender, (2) Asian ethnicity, and (3) being unmarried. Asian ethnicity reduced the odds of receiving a 5-star rating for likelihood to recommend the provider by nearly 40%, but none of these nonmodifiable physician personal and demographic characteristics affected the likelihood to recommend the practice.DISCUSSION: Sex, ethnicity, and marital status are nonmodifiable provider characteristics, each associated with markedly lower odds of receiving a 5-star rating on Press Ganey patient satisfaction survey. These data reveal inherent patient biases that negatively affect physician-patient interactions and may exacerbate the lack of diversity in orthopaedic surgery. More research is necessary before using patient satisfaction ratings to evaluate surgeons or as quality measures that affect reimbursement policies.

  View details for DOI 10.5435/JAAOSGlobal-D-20-00198

  View details for PubMedID 33835991

• Use of Navigation-Enhanced Instrumentation to Mitigate Surgical Outliers During Total Knee Arthroplasty ORTHOPEDICS Mooney, J. A., Bala, A., Denduluri, S. K., Lichstein, P. M., Kleimeyer, J. P., Lundergan, W. G., Snyder, B. M., Huddleston, J. I., Amanatullah, D. F. 2021; 44 (1): 54–57

  Abstract

  Computer-assisted orthopedic surgery improves mechanical alignment and the accuracy of surgical cuts in the context of total knee arthroplasty (TKA). A simplified, navigation-enhanced instrumentation system was assessed to determine whether the same effects could be achieved with a less intrusive system. Two cohorts of surgeons (experienced and trainees) performed a series of TKA cuts using models with and without navigation-enhanced instrumentation. The accuracy of each system was determined via the rate of outliers, measured as any cut that deviated from the planned cut by more than 2° or 2 mm. The effect of experience level was limited, with only the outlier rate for tibial varus or valgus measurement showing a significant difference between user groups with conventional instrumentation (P=.004). The use of navigation-enhanced instrumentation significantly reduced the total outlier rate compared with conventional instrumentation from 35% to 4% for experienced users (P<.001) and from 34% to 10% for trainees (P<.001). These results suggest that navigation-enhanced instrumentation is a viable alternative to conventional instrumentation to reduce outlier rates and improve cut accuracy. This trial also showed that additional experience may not correlate with improved surgical accuracy. Outliers may not reflect individual surgical ability as much as limitations of the instrumentation or other unidentified factors. [Orthopedics. 2021;44(1):54-57.].

  View details for DOI 10.3928/01477447-20201012-01

  View details for Web of Science ID 000623233600036

  View details for PubMedID 33089338

• Encapsulated Mesenchymal Stromal Cell Microbeads Promote Endogenous Regeneration of Osteoarthritic Cartilage Ex Vivo. Advanced healthcare materials Sahu, N. n., Agarwal, P. n., Grandi, F. n., Bruschi, M. n., Goodman, S. n., Amanatullah, D. n., Bhutani, N. n. 2021: e2002118

  Abstract

  The anti-inflammatory secretome of mesenchymal stromal cells (MSCs) is lucrative for the treatment of osteoarthritis (OA), a disease characterized by low-grade inflammation. However, the precise effects of the MSC secretome on patient-derived OA tissue is lacking. To investigate these effects, alginate encapsulated MSCs are co-cultured with patient-derived OA cartilage explants for 8 days. Proteoglycan distribution in OA cartilage explants examined by Safranin O staining is markedly improved when cultured with MSC microbeads as compared to control OA explants cultured alone. Total sulfated glycosaminoglycan (sGAG) content in OA explants is significantly increased upon co-culture with MSC microbeads on day 8. The sGAG released into the culture media is unchanged by the presence of MSC microbeads, suggesting de novo sGAG synthesis in OA explants. Co-culture with MSC microbeads increased the DNA content and Ki67+ cells in OA explants, indicating proliferation. An increase in secreted cytokines IL-10, HGF, and sFAS assessed by multiplex cytokine assay, increased TIMP1 levels, and reduction in percent apoptotic cells in OA explants is noted. Together, data demonstrates that paracrine factors secreted by alginate encapsulated MSCs microbeads in response to OA cartilage, create an anabolic, proliferative, and anti-apoptotic microenvironment inducing endogenous regeneration in clinically relevant, patient-derived OA cartilage.

  View details for DOI 10.1002/adhm.202002118

  View details for PubMedID 33434393

• Response to Letter to the Editor on "Diagnosis of Osteonecrosis of the Femoral Head: Too Little, Too Late, and Independent of Etiology". The Journal of arthroplasty Boontanapibul, K. n., Steere, J. T., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2021; 36 (2): e12–e13

  View details for DOI 10.1016/j.arth.2020.09.037

  View details for PubMedID 33446355

• Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial. Clinical orthopaedics and related research Mariano, D. J., Liu, A., Eppler, S. L., Gardner, M. J., Hu, S., Safran, M., Chou, L., Amanatullah, D. F., Kamal, R. N. 2020

  Abstract

  BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs.QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions?METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement.RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71.CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000001582

  View details for PubMedID 33239521

• 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

• Analysis of Computer Vision Methods for Counting Surgical Instruments. Surgical innovation Chavez, G., Zhao, D., Haque, A., Nazerali, R., Amanatullah, D. F. 2020: 1553350620956425

  View details for DOI 10.1177/1553350620956425

  View details for PubMedID 32877306

• The Importance of Concordance Between Patients and Their Subspecialists ORTHOPEDICS Shah, R. F., Mertz, K., Gil, J. A., Eppler, S. L., Amanatullah, D., Yao, J., Chou, L., Steffner, R., Safran, M., Hu, S. S., Kamal, R. N. 2020; 43 (5): 315-+

  Abstract

  Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient-physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient-physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315-319.].

  View details for DOI 10.3928/01477447-20200818-01

  View details for Web of Science ID 000608158400032

  View details for PubMedID 32931591

• Preoperative Exercise Participation Reflects Patient Engagement and Predicts Earlier Patient Discharge and Less Gait Aid Dependence After Total Joint Arthroplasty ORTHOPEDICS Denduluri, S. K., Huddleston, J. I., Amanatullah, D. F. 2020; 43 (5): E364–E368

  Abstract

  Whether preoperative physical therapy actually leads to improved clinical outcomes after total joint arthroplasty (TJA) remains unclear. The authors sought to use participation in a preoperative online exercise and education program as a marker for patient engagement. They hypothesized that increased preoperative participation with the program would predict shorter length of stay (LOS) and gait independence. Forty consecutive patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) by a single surgeon were given access to the PrimePrehab Prehabilitation Exercise Program (NextPT, Boulder, Colorado). Patients were guided through questionnaires, and the program generated educational readings and exercise modules directed toward initial ability. Preoperative completion of readings, completion of exercise modules, and improvement in exercise difficulty were tracked. Patients received a standardized postoperative protocol, including physical therapy on the day of surgery and subsequent hospital days. Length of stay and gait aid use at 90 days postoperatively were recorded. Analyses were simple or multiple regression with a significance of P≤.05. Patients completed a mean of 7 exercise modules with 30% improvement in difficulty. Controlling for demographic variables, the frequency of program completion correlated with shorter LOS (P=.037). This finding was not different between THA and TKA (P=.387). No association was found between the frequency of program completion and gait aid use at 90 days (P=.213), although there was a decrease in gait aid use at 90 days with improvement in exercise difficulty (P=.034). A preoperative education and exercise program can predict patient engagement, which correlates with a shorter LOS and suggests that increasing exercise difficulty is associated with gait independence after TJA. [Orthopedics. 2020;43(5):e364-e368.].

  View details for DOI 10.3928/01477447-20200619-04

  View details for Web of Science ID 000608158400004

  View details for PubMedID 32602926

• A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial. Medical decision making : an international journal of the Society for Medical Decision Making Mertz, K., Shah, R. F., Eppler, S. L., Yao, J., Safran, M., Palanca, A., Hu, S. S., Gardner, M., Amanatullah, D. F., Kamal, R. N. 2020: 272989X20943520

  Abstract

  Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

  View details for DOI 10.1177/0272989X20943520

  View details for PubMedID 32744134

• A Small Amount of Retraction Force Results in Inadvertent Piriformis Muscle Damage During a Piriformis-Sparing Approach to the Hip. The Journal of bone and joint surgery. American volume Amanatullah, D. F., Shah, H. N., Barrett, A. A., Storaci, H. W. 2020

  Abstract

  BACKGROUND: Piriformis-sparing approaches to the hip allow surgeons to avoid releasing the piriformis tendon during total hip arthroplasty; however, the consequences of retracting an intact piriformis tendon during such an approach remain ill-defined. The present study aimed to determine the upper limit of force that can be applied during retraction of the piriformis tendon to expose the hip, and to quantify the resultant damage to the piriformis musculotendinous complex.METHODS: A patent-pending instrumented retractor was designed to record the applied force, duration, and angle of retraction during a piriformis-sparing posterior approach to the hip. In addition to the data collected with use of the instrumented retractor, damage to the piriformis muscle and tendon was quantified by a blinded observer.RESULTS: There was no damage to the piriformis tendon in 22 (96%) of 23 hips during piriformis retraction for visualization of the hip capsule; however, there was complete or partial damage to the piriformis muscle at the sacral origin, belly, or musculotendinous junction (i.e., outside the surgical field) noted in 21 (91%) of 23 hips. The mean peak force to failure of the piriformis muscle was exceedingly small (29.0 ± 9.4 N; range, 10.1 to 44.9 N).CONCLUSIONS: The mean peak force applied to the piriformis retractor is much less than the force required for several common daily activities, such as opening a door or crushing an empty aluminum can. Soft-tissue damage that occurs outside the surgical field during the retraction of unreleased muscles, like the piriformis muscle, is common and remains an uncontrolled surgical variable. This inadvertent soft-tissue damage is not routinely accounted for when accessing the invasiveness of a procedure. Hence, it is no longer adequate to define a minimally invasive surgical procedure simply as an approach that involves the limited release of anatomical structures.CLINICAL RELEVANCE: The use of instrumented retractors may redefine surgical invasiveness by providing data that could alter our understanding of the soft-tissue damage caused by retraction and open the possibility of robot-assisted or damage-limiting retractor systems.

  View details for DOI 10.2106/JBJS.20.00036

  View details for PubMedID 32657951

• Learning Curve for the Direct Superior Approach to Total Hip Arthroplasty ORTHOPEDICS Ezzibdeh, R. M., Barrett, A. A., Arora, P., Amanatullah, D. F. 2020; 43 (4): E237–E243

  Abstract

  Surgical learning curves are a representation of the number of cases required for a surgeon to reach a stable rate of outcomes and complications. In this study, the authors present the learning curve for the direct superior (DS) approach to total hip arthroplasty, which is a muscle-sparing modification to the mini-posterior technique. This was a retrospective analysis of the first 40 primary DS cases done by a single surgeon. These cases were divided into 2 groups of 20 and compared for intra- and postoperative complications, acetabular component positioning, and Harris Hip Score at 90 days after surgery. As a control, the first 20 primary mini-posterior cases were analyzed as the baseline performance of the surgeon and the DS approach. There was no statistically significant difference between the first and second sets of DS patients regarding Harris Hip Score, intraoperative complications, dislocations, estimated blood loss, length of hospital stay, and components positioned within the Lewinnek safe zone. The only statistically significant difference between the first and second sets of DS cases was a decrease in operating time (P<.001). This suggests that the learning curve is less than 20 patients. The results also indicate that the first 20 DS cases ambulated farther (P=.007) and had a shorter length of stay (P=.007), outperforming the mini-posterior approach. This study suggests that the DS learning curve is short for surgeons trained in the posterior approach. The data could be especially pertinent as 90-day results and safety are becoming increasingly important in evaluating performance for bundled-payment models. [Orthopedics. 2020;43(4):e237-e243.].

  View details for DOI 10.3928/01477447-20200404-05

  View details for Web of Science ID 000565459300008

  View details for PubMedID 32271934

• Medications Available for Weight Reduction in Elective Total Joint Arthroplasty JBJS REVIEWS Amanatullah, D. F., Ohanisian, L., Bailony, R. 2020; 8 (6)

  View details for DOI 10.2106/JBJS.RVW.19.00123

  View details for Web of Science ID 000561737500006

• Short-Term Safety of the Direct Superior Approach for Total Hip Arthroplasty SURGICAL TECHNOLOGY INTERNATIONAL-INTERNATIONAL DEVELOPMENTS IN SURGERY AND SURGICAL RESEARCH Ezzibdeh, R. M., Barrett, A., Arora, P., Kaplan, L., Roger, D., Ward, D., Mas Martinez, J. J., Amanatullah, D. F. 2020; 36

  View details for Web of Science ID 000587503100014

• MD-PhD Graduates Remain Underrepresented in Orthopaedic Surgery: National MD-PhD Program Outcome Survey Update. Journal of orthopaedic research : official publication of the Orthopaedic Research Society von Kaeppler, E. P., Akabas, M. H., Brass, L. F., Amanatullah, D. F. 2020

  Abstract

  With dramatic expansion of the biomedical knowledge base and increasing demands for evidence-based medicine, the role of the clinician-scientist is becoming increasingly important. In orthopaedic surgery, clinician-scientists are at the forefront of translational efforts to address the growing burden of musculoskeletal disease, yet MD-PhD trained investigators have historically been underrepresented in this field. Here, we examine the trend, over time, of MD-PhD graduates pursuing orthopaedic surgery, compared to other specialties. Survey data from the 2018 Association of American Medical Colleges (AAMC) National MD-PhD Program Outcomes Study, including data on 4,647 individuals who had completed residency training and 2,124 who were still in training, were re-analyzed. Numbers, proportions, workplace choice, and percent research effort of MD-PhD graduates completing orthopaedic surgery were compared with other surgical and non-surgical specialties. Trends over time were analyzed by linear regression. While a decreasing proportion of MD-PhD graduates completed internal medicine training, just 1.1% of MD-PhD graduates completed orthopaedic surgery training, lower than that of all other surgical specialties. The proportion of MD-PhD graduates completing orthopaedic surgery has not increased over time and was mirrored in MD-PhD residents still in training. Though MD-PhDs are increasingly choosing to pursue "non-traditional" specialties, they remain underrepresented in orthopaedic surgery, compared to other clinical disciplines. Thus, there exists an opportunity to encourage MD-PhD graduates to pursue careers in orthopaedic surgery, to supplement the existing intellectual capital in the orthopaedic science workforce. This, along with other strategies to support all orthopaedic surgeon-scientists, will ultimately advance the care of musculoskeletal diseases. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.24669

  View details for PubMedID 32198793

• Mechanical Compression Augments Venous Flow Equal to Intermittent Pneumatic Compression. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Amanatullah, D. F., Shah, H. N., Johnson, B., Wall, J. 2020

  Abstract

  Intermittent pneumatic compression is part of the current standard of care model for preventing venous thromboembolic events (VTE) after total joint arthroplasty. Pneumatic motors limit the rate of inflation resulting in bulky devices with uncomfortable sleeves that inhibited patient compliance and mobility. Non-pneumatic mechanical; devices are an alternative for providing mobile, graded, intermittent, sequential, rapid, and monitorable compression post-hospitalization. Fifteen healthy volunteers underwent mechanical compression using the Cirvo (Radial Medical, Mountain View, CA) as well as pneumatic compression with four commercially available systems (VenaFlow Elite, Kendall SCD Compression System, ActiveCare DVT, Vasculaire Compression System,) and manual calf compression. Peak flow velocity (PFV) was measured by ultrasound of the femoral vein during compression and at baseline. Mechanical compression for 1 second resulted in a significant increase in femoral venous PFV to 107.8 ± 38.2 cm/s from 17.1 ± 4.7 cm/s at baseline (p < 0.001, Figure 2). The change in femoral venous PFV with mechanical compression for 1 second (90.7 ± 34.9 cm/s) was not statistically different from pneumatic compression from VenaFlow system (106.0 ± 35.6 cm/s, p = 0.124) and statistically lower than manual calf compression (115.5 ± 26.8 cm/s, p = 0.015). Pneumatic compression from VenaFlow system produced the largest change in femoral venous PFV of all commercial pneumatic systems tested. Mechanical compression replicates or exceeds femoral venous PFV available from currently available intermittent pneumatic compression. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.24664

  View details for PubMedID 32175638

• 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

• Outcomes of Cemented Total Knee Arthroplasty for Secondary Osteonecrosis of the Knee. The Journal of arthroplasty Boontanapibul, K. n., 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

• 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. n., 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

• Initial Presentation and Progression of Secondary Osteonecrosis of the Knee. The Journal of arthroplasty Boontanapibul, K. n., 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

• The Rationale for Using Bacteriophage to Treat and Prevent Periprosthetic Joint Infections. Frontiers in microbiology Van Belleghem, J. D., Manasherob, R., Miȩdzybrodzki, R., Rogoz, P., Gorski, A., Suh, G. A., Bollyky, P. L., Amanatullah, D. F. 2020; 11: 591021

  Abstract

  Prosthetic joint infection (PJI) is a devastating complication after a joint replacement. PJI and its treatment have a high monetary cost, morbidity, and mortality. The lack of success treating PJI with conventional antibiotics alone is related to the presence of bacterial biofilm on medical implants. Consequently, surgical removal of the implant and prolonged intravenous antibiotics to eradicate the infection are necessary prior to re-implanting a new prosthetic joint. Growing clinical data shows that bacterial predators, called bacteriophages (phages), could be an alternative treatment strategy or prophylactic approach for PJI. Phages could further be exploited to degrade biofilms, making bacteria more susceptible to antibiotics and enabling potential combinatorial therapies. Emerging research suggests that phages may also directly interact with the innate immune response. Phage therapy may play an important, and currently understudied, role in the clearance of PJI, and has the potential to treat thousands of patients who would either have to undergo revision surgery to attempt to clear an infections, take antibiotics for a prolonged period to try and suppress the re-emerging infection, or potentially risk losing a limb.

  View details for DOI 10.3389/fmicb.2020.591021

  View details for PubMedID 33408703

• 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

• Single-cell mass cytometry reveals cross-talk between inflammation-dampening and inflammation-amplifying cells in osteoarthritic cartilage Science Advances Grandi, F. ., Baskar, R., Smeriglio, P., Murkherjee, S., Indelli, P., F. Amanatullah, D., Goodman, S., Chu, C., Bendall , S., Bhutani, N. 2020; 6 (11)

  View details for DOI 10.1126/sciadv.aay5352

• Diagnosis of Osteonecrosis of the Femoral Head: Too Little, Too Late, and Independent of Etiology. The Journal of arthroplasty Boontanapibul, K. n., 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

• Short-Term Safety of the Direct Superior Approach for Total Hip Arthroplasty. Surgical technology international Ezzibdeh, R. M., Barrett, A., Arora, P., Kaplan, L., Roger, D., Ward, D., Mas Martinez, J. J., Amanatullah, D. F. 2019; 36

  Abstract

  INTRODUCTION: Minimally invasive surgery total hip arthroplasty (MIS-THA) is becoming increasingly popular. There are several approaches to MIS-THA that vary according to anatomical access to the hip joint. The direct superior (DS) approach is a recent modification of an MIS posterior approach that spares the iliotibial band and most of the short external rotators of the hip, particularly the quadratus femoris. While FDA approved, there is a lack of data in the current literature on DS outcomes and the safety of this approach is yet to be systematically evaluated.MATERIALS AND METHODS: The goal of this study is to provide a quantitative analysis of the safety and complications of primary DS-total hip arthroplasty at 90 days post-surgery through a retrospective multicenter case series of 301 patients. Special attention was given to intra- and postoperative complications, readmissions, mean operative time, hospital-stay length, and postoperative ambulation distance.RESULTS: Surgical complications included three (1%) intraoperative calcar fractures and four (1%) postoperative peri-prosthetic fractures. The postoperative medical complication rate was 3% with four (1%) patients requiring readmission. The mean operative time was 70 ± 19 minutes, hospital-stay length 41 ± 19 hours, and the estimated blood loss (EBL) was 213 ± 129 ml. There were no acute episodes of instability at 90-day follow up. The intra- and postoperative results are similar with those reported in the literature for both the anterior and posterior approaches.CONCLUSION: This study indicates that the DS approach appears to be safe with a low complication rate at 90 days that is comparable to more conventional approaches, such as the direct anterior and posterior techniques. This information is also valuable for the evaluation of reimbursements for DS-THA as current bundled-payment models heavily emphasize 90-day outcomes and complications. Long-term direct comparative studies with the anterior and posterior approaches is required to fully evaluate DS-THAs.

  View details for PubMedID 31821527

• 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

• Timing of Lumbar Spinal Fusion Affects Total Hip Arthroplasty Outcomes. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Bala, A., Chona, D. V., Amanatullah, D. F., Hu, S. S., Wood, K. B., Alamin, T. F., Cheng, I. 2019; 3 (11): e00133

  Abstract

  Many patients are affected by concurrent disease of the hip and spine, undergoing both total hip arthroplasty (THA) and lumbar spinal fusion (LSF). Recent literature demonstrates increased prosthetic dislocation rates in patients with THA done after LSF. Evidence is lacking on which surgery to do first to minimize complications. The purpose of this study was to evaluate the effect of timing between the two procedures on postoperative outcomes.Methods: We queried the Medicare standard analytics files between 2005 and 2014. Four groups were identified and matched by age and sex: THA with previous LSF, LSF with previous THA, THA with spine pathology without fusion, and THA without spine pathology. Revision THA or LSF and bilateral THA were excluded. Comorbidities and Charlson Comorbidity Index were identified. Postoperative complications at 90 days and 2 years were calculated after the most recent surgery. Four-way chi-squared and standard descriptive statistics were calculated.Results: Thirteen thousand one hundred two patients had THA after LSF, 10,482 patients had LSF after THA, 104,820 had THA with spine pathology, and 492,654 had THA without spine pathology. There was no difference in the Charlson Comorbidity Index score between the THA after LSF and LSF after THA groups. There was a statistically significant difference in THA dislocation rate, with LSF after THA at 1.7%, THA without spine pathology at 2.3%, THA with spine pathology at 3.3%, and THA after LSF at 4.6%. There was a statistically significant difference in THA revision rate, with THA without spine pathology at 3.3%, LSF after THA at 3.7%, THA with spine pathology at 4.2%, and THA after LSF at 5.7%.Conclusion: LSF after THA is associated with a reduced dislocation rate compared with THA after LSF. Reasons may include decreasing pelvic mobility in a stable, well-healed THA or early postoperative spine precautions after LSF restricting positions of dislocation.

  View details for DOI 10.5435/JAAOSGlobal-D-19-00133

  View details for PubMedID 31875203

• 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

• Intraoperative Practice Variability in Total Knee Arthroplasty. The Journal of arthroplasty Bosch, L. C., Beger, S. B., Duncan, S. T., Rossi, S. M., Sculco, P. K., Barnes, C. L., Amanatullah, D. F. 2019

  Abstract

  BACKGROUND: Considerable practice variability exists among orthopedic surgeons performing total knee arthroplasty (TKA). The purpose of this study is to understand what TKA surgical and perioperative techniques are standard among high-volume academic knee arthroplasty surgeons.METHODS: A written survey with 59 questions regarding management preferences in TKA was distributed by the 2018 John N. Insall Traveling Fellows to all arthroplasty-trained attending physicians at 13 medical centers, with 45 responses recorded.RESULTS: Surveyed surgeons performed unicompartmental knee arthroplasty (88%) and bilateral TKA (87%). Most surveyed surgeons rarely or never performed outpatient primary TKA (71%). Conventional alignment guides and cemented implants were used by 80% of respondents. Most surgeons used posterior-stabilized implants (67%), followed by cruciate-retaining (20%), ultracongruent (20%), and medial congruent or medial pivot designs (17.8%). Surveyed surgeons frequently or always resurfaced the patella (73%), used a tourniquet for the entire case (73%), and used tranexamic acid for all TKAs (91%). The most common locations for intra-articular anesthetic injection were the arthrotomy (91%), the periosteum (84%), and the medial posterior capsule (82%). Saline (62%) and dilute iodine (47%) were the most common irrigation fluids. The arthrotomy was most commonly closed with running barbed suture (60%) followed by interrupted vicryl (40%). Skin closure was predominantly with running monocryl (60%) followed by staples (29%). Anticoagulation for TKA was primarily aspirin 81 mg BID (60%).CONCLUSION: There was considerable variability among surgeons polled although a strong preference for more conventional and less developmental techniques prevailed.

  View details for DOI 10.1016/j.arth.2019.10.014

  View details for PubMedID 31759798

• Utilization of a pneumatic exoskeleton after total knee arthroplasty. Arthroplasty today Ezzibdeh, R., Arora, P., Amanatullah, D. F. 2019; 5 (3): 314–15

  Abstract

  Exoskeletons are wearable, powered devices intended to support and augment limb function. With the aging population and increasing demand for total knee arthroplasty, exoskeletons could prove a valuable tool for regaining function and minimizing the number of patients discharged to skilled nursing facilities. However, the safety of these devices in postoperative populations remains unexplored. A lightweight pneumatic device was piloted on three patients after primary total knee arthroplasty. The patients were asked to perform simple locomotive tasks followed by a questionnaire to assess their experience and safety using the exoskeleton. All patients indicated the exoskeleton did not interfere with their wound and made them feel stable on their feet, and two of the three patients stated it was manageable and safe to operate. This report pilots the general safety of a pneumatic exoskeleton, laying the groundwork for larger and more comprehensive studies.

  View details for DOI 10.1016/j.artd.2019.02.008

  View details for PubMedID 31516973

• 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

• Calcium phosphate cement and locked plate augmentation of distal femoral defects: A biomechanical analysis. The Knee DeBaun, M. R., Williams, J. C., Bennett, C. G., Pridgen, E. M., Tamurian, R. M., Amanatullah, D. F. 2019

  Abstract

  PURPOSE: Bone tumors are common in the distal femur and often treated with intralesional curettage. The optimal method of stabilization of large distal femoral defects after curettage remains unclear. The goal of this study is to compare stabilization techniques for large distal femoral defects.METHODS: Large defects (60 cm3) were milled in the distal lateral metaphysis of 45 adult composite sawbone femurs. The defect was either (1) left untreated or reconstructed with (2) locked plate fixation, (3) calcium phosphate cement packing, or (4) locked plate fixation with calcium phosphate cement packing, or (5) polymethylmethacrylate packing. Each specimen then underwent axial and torsional stiffness testing followed by torsional loading to failure. The data were analyzed using ANOVA with Tukey-Kramer post-hoc analysis.RESULTS: The calcium phosphate cement filled defect with a locked plate was the stiffest construct in axial and torsional loading as well as the strongest in torque to failure. However, this difference only reached significance with respect to all other groups in torque to failure testing. The calcium phosphate cement filled defect with a locked plate was significantly stiffer than three of the four other groups in both axial and torsional stiffness testing.CONCLUSIONS: These results indicate that calcium phosphate cement, with or without the addition of locked plate fixation, may provide improved construct stability under time zero testing conditions. This result warrants further testing under cyclic loading condition and consideration for fixation of large femoral metaphyseal defects in future clincal trails.

  View details for DOI 10.1016/j.knee.2019.07.006

  View details for PubMedID 31405629

• The Association of Financial Distress With Disability in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Mertz, K., Eppler, S. L., Thomas, K., Alokozai, A., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. N. 2019; 27 (11): e522–e528

  Abstract

  INTRODUCTION: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?METHODS: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.RESULTS: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.CONCLUSIONS: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.LEVEL OF EVIDENCE: Level III prospective cohort.

  View details for DOI 10.5435/JAAOS-D-18-00252

  View details for PubMedID 31125323

• 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

• 4 Effect of trabecular metal on the elution of gentamicin from Palacos cement JOURNAL OF ORTHOPAEDIC RESEARCH Mooney, J. A., Manasherob, R., Smeriglio, P., Bhutani, N., Amanatullah, D. F. 2019; 37 (5): 1018–24

  View details for DOI 10.1002/jor.24274

  View details for Web of Science ID 000467453100003

• Distal Femur Locking Plates Fit Poorly Before and After Total Knee Arthroplasty JOURNAL OF ORTHOPAEDIC TRAUMA Campbell, S. T., Bosch, L. C., Swinford, S., Amanatullah, D. F., Bishop, J. A., Gardner, M. J. 2019; 33 (5): 239–43

  View details for DOI 10.1097/BOT.0000000000001431

  View details for Web of Science ID 000467807900015

• 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

• DIRECT SUPERIOR APPROACH TO THE HIP FOR TOTAL HIP ARTHROPLASTY JBJS ESSENTIAL SURGICAL TECHNIQUES Barrett, A. A., Ezzibdeh, R. M., Horst, P. K., Roger, D. J., Amanatullah, D. F. 2019; 9 (2)

  View details for DOI 10.2106/JBJS.ST.18.00078

  View details for Web of Science ID 000480692200006

• Effect of Trabecular Metal on the Elution of Gentamicin from Palacos Cement. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Mooney, J. A., Manasherob, R., Smeriglio, P., Bhutani, N., Amanatullah, D. F. 2019

  Abstract

  Periprosthetic joint infections continues to be a common complication in total joint arthroplasty, resulting in significant morbidity, mortality and additional costs. Antibiotic loaded bone cement has profoundly reduced the incidence of infection and revision. Trabecular metal implants with an internal cemented interface may be customizable drug delivery devices with an ingrowth interface. Thirty-six acetabular implants were assembled in vitro, half with a trabecular metal shell and half without. The antibiotic loaded bone cement was prepared via three different mixing techniques and at two mixing times. Mixing time had a significant effect on the total amount of gentamicin eluted. The long mix protocol eluted up to 126% (p=0.001) more gentamicin than the short mix at four hours and 192% (p<0.001) more at seven days. The use of a trabecular metal shell had no significant effect at four hours (p>0.05) but significantly reduced total elution under certain mixing protocols at seven days. Mixing technique had no significant effect on elution at four hours. At seven days, the mechanical mixing system under vacuum eluted over 50% (p=0.031) more antibiotic than without a vacuum and nearly 60% (p=0.040) more antibiotic than hand mixing. The use of trabecular metal implants does not significantly inhibit the initial bulk elution of gentamicin. A possible optimization strategy to improve elution kinetics would be to use a long mixing time with a mechanical mixing system under vacuum. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30839118

• 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

• Distal Femur Locking Plates Fit Poorly Before and After Total Knee Arthroplasty. Journal of orthopaedic trauma Campbell, S. T., Bosch, L. C., Swinford, S., Amanatullah, D. F., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVE: To evaluate the fit of distal femur locking plates. Secondarily, we sought to compare plate fit among patients with and without a total knee arthroplasty (TKA).DESIGN: We retrospectively reviewed full-length femur radiographs of patients who underwent primary TKA.SETTING: All patients underwent TKA at a large university hospital.INTERVENTION: Standard length pre-contoured distal femur locking plates from four manufacturers were digitally templated onto each patient's pre- and post-TKA radiographs.MAIN OUTCOME MEASUREMENTS: The maximum distance from the plate to the lateral femoral cortex (plate-bone distance) was measured in the metaphyseal region. Mean plate-bone distances were compared between manufacturers and between pre and post-TKA radiographs.RESULTS: All implants tested were undercontoured in all patients. Plate-bone distances ranged from 6.6 ± 0.4 mm to 8.0 ± 0.4 mm (mean ± standard error) pre-TKA and 8.2 ± 0.3 mm to 8.6 ± 0.3 mm after TKA, indicating worse fit after arthroplasty (p < 0.001). There were also inter-manufacturer differences, with Synthes and Smith & Nephew implants demonstrating the lowest plate-bone distances in the pre- and post-TKA groups, respectively. Proportionally, plate-bone increase was greater in the female cohort (16%) compared to the male cohort (8%).CONCLUSIONS: There was a plate-bone mismatch for the distal femur locking plates tested in this study, due to undercontouring of the implants. After patients underwent TKA, poor implant fit was exacerbated. Surgeons must be aware of the potential for deformity if the proximal segment is brought into contact with the implant. These finding may help optimize implant design for the treatment of periprosthetic distal femur fractures.LEVEL OF EVIDENCE: V.

  View details for PubMedID 30614915

• EMTALA (Emergency Medical Treatment and Active Labor Act) Obligations: A Case Report and Review of the Literature. The Journal of bone and joint surgery. American volume Zhou, J. Y., Amanatullah, D. F., Frick, S. L. 2019; 101 (12): e55

  Abstract

  The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 in the United States to address "patient dumping," or refusing to provide emergency care to patients and instead transferring them to other hospitals. Under EMTALA, the "reverse-dumping" provision prevents hospitals from refusing patients who require specialized capabilities or facilities if the hospital has the capacity to treat them. Despite this provision, patients continue to be transferred to distant tertiary care centers.We reviewed the literature on EMTALA in the context of a critically ill woman with an infection associated with an orthopaedic implant who was rejected from 2 geographically closer tertiary care centers and was ultimately transferred by helicopter ambulance to an academic teaching hospital that was 169 miles away from her home.After transfer to our tertiary care, level-I trauma center, the patient spent 61 days in the intensive care unit; she required 9 operative procedures, which totaled 1,520 minutes of operative time. Eighteen medical specialties and 8 ancillary medical consulting teams were involved in her care. She underwent 1,436 laboratory and 83 radiographic studies. The total reimbursement from Medi-Cal (California's Medicaid program) for her care in our tertiary care center was $463,753; the hospital charges were more than tenfold higher.Dumping and reverse dumping continue despite compromise of patient care and the high financial burden of the accepting institutions. This may be due to ineffective monitoring and enforcement, lack of uniformity among the courts, and lack of incentive to receive uninsured or poorly funded patients. Under EMTALA, it is difficult for tertiary care centers to argue lack of specialized capabilities or capacity to accept patients, and neither hospitals nor physicians are compensated for the charges of providing care to uninsured or underinsured patients. Moving forward, efforts to better align financial incentives through cost-sharing between community hospitals and tertiary care centers, increased clinician literacy regarding the provisions of EMTALA, and increased transparency with hospital transfers may help improve EMTALA compliance and patient care.

  View details for DOI 10.2106/JBJS.18.01166

  View details for PubMedID 31220031

• The Cost of Malnutrition in Total Joint Arthroplasty. The Journal of arthroplasty Bala, A. n., 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

• Agreement and Reliability of Lateral Patellar Tilt and Displacement following Total Knee Arthroplasty with Patellar Resurfacing. The journal of knee surgery Kleimeyer, J. P., McQuillan, T. J., Arsoy, D. n., Aggarwal, V. K., Amanatullah, D. F. 2019

  Abstract

  Patellar position and alignment may be measured on routine axial radiographs by various techniques; however, the agreement and reliability of such measurements with a resurfaced patella remain unknown. This study evaluated the range and reliability of lateral patellar tilt and lateral patellar displacement following total knee arthroplasty (TKA) with a resurfaced patella among three observers on 45° Merchant view in 139 TKAs. Intraclass correlation coefficient (ICCs) were used to evaluate intraobserver agreement (IOA) and inter-rater reliability (IRR). IRR was high between each of the observers for lateral patellar tilt (ICC = 0.8) and lateral patellar displacement (ICC = 0.87). IOA was also high upon repeat measurement for the same observer for lateral patellar tilt (ICC ≥ 0.90) and lateral patellar displacement (ICC ≥ 0.86). Therefore, lateral patellar tilt and lateral patellar displacement are reproducible measurements of patellar position on a Merchant axial radiograph following a well-functioning TKA with a resurfaced patella.

  View details for DOI 10.1055/s-0039-1700843

  View details for PubMedID 31698498

• Phage Therapy in Orthopaedic Implant-Associated Infections PHAGE THERAPY: A PRACTICAL APPROACH Rogoz, P., Amanatullah, D. F., Miedzybrodzki, R., Manasherob, R., Tikunova, N. V., Weber-Dabrowska, B., Fortuna, W., Letkiewicz, S., Gorski, A., Gorski, A., Miedzybrodzki, R., Borysowski, J. 2019: 189–211

  View details for DOI 10.1007/978-3-030-26736-0_8

  View details for Web of Science ID 000569408300009

• Quantitative Multiplex Immunoassay for Profiling Bone Turnover Biomarkers in Human Bone Tissue Culture Supernatants. Methods in molecular biology (Clifton, N.J.) Lie, W., Amanatullah, D. F., King, B. L. 2019; 1862: 251–62

  Abstract

  Bone is a metabolically dynamic tissue that is continuously built up and broken down through anabolic and catabolic processes regulated by a variety of systemic and local signaling molecules. Here, we describe quantitative multiplex immunoassay analysis of supernatants collected from cultured human bone tissue fragments to profile local factors associated with the bone turnover process.

  View details for PubMedID 30315473

• 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

• 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

• Strategies for Weight Reduction Prior to Total Joint Arthroplasty. The Journal of bone and joint surgery. American volume Chen, M. J., Bhowmick, S., Beseler, L., Schneider, K. L., Kahan, S. I., Morton, J. M., Goodman, S. B., Amanatullah, D. F. 2018; 100 (21): 1888–96

  View details for PubMedID 30399084

• Deep-learning-assisted diagnosis for knee magnetic resonance imaging: Development and retrospective validation of MRNet. PLoS medicine Bien, N., Rajpurkar, P., Ball, R. L., Irvin, J., Park, A., Jones, E., Bereket, M., Patel, B. N., Yeom, K. W., Shpanskaya, K., Halabi, S., Zucker, E., Fanton, G., Amanatullah, D. F., Beaulieu, C. F., Riley, G. M., Stewart, R. J., Blankenberg, F. G., Larson, D. B., Jones, R. H., Langlotz, C. P., Ng, A. Y., Lungren, M. P. 2018; 15 (11): e1002699

  Abstract

  BACKGROUND: Magnetic resonance imaging (MRI) of the knee is the preferred method for diagnosing knee injuries. However, interpretation of knee MRI is time-intensive and subject to diagnostic error and variability. An automated system for interpreting knee MRI could prioritize high-risk patients and assist clinicians in making diagnoses. Deep learning methods, in being able to automatically learn layers of features, are well suited for modeling the complex relationships between medical images and their interpretations. In this study we developed a deep learning model for detecting general abnormalities and specific diagnoses (anterior cruciate ligament [ACL] tears and meniscal tears) on knee MRI exams. We then measured the effect of providing the model's predictions to clinical experts during interpretation.METHODS AND FINDINGS: Our dataset consisted of 1,370 knee MRI exams performed at Stanford University Medical Center between January 1, 2001, and December 31, 2012 (mean age 38.0 years; 569 [41.5%] female patients). The majority vote of 3 musculoskeletal radiologists established reference standard labels on an internal validation set of 120 exams. We developed MRNet, a convolutional neural network for classifying MRI series and combined predictions from 3 series per exam using logistic regression. In detecting abnormalities, ACL tears, and meniscal tears, this model achieved area under the receiver operating characteristic curve (AUC) values of 0.937 (95% CI 0.895, 0.980), 0.965 (95% CI 0.938, 0.993), and 0.847 (95% CI 0.780, 0.914), respectively, on the internal validation set. We also obtained a public dataset of 917 exams with sagittal T1-weighted series and labels for ACL injury from Clinical Hospital Centre Rijeka, Croatia. On the external validation set of 183 exams, the MRNet trained on Stanford sagittal T2-weighted series achieved an AUC of 0.824 (95% CI 0.757, 0.892) in the detection of ACL injuries with no additional training, while an MRNet trained on the rest of the external data achieved an AUC of 0.911 (95% CI 0.864, 0.958). We additionally measured the specificity, sensitivity, and accuracy of 9 clinical experts (7 board-certified general radiologists and 2 orthopedic surgeons) on the internal validation set both with and without model assistance. Using a 2-sided Pearson's chi-squared test with adjustment for multiple comparisons, we found no significant differences between the performance of the model and that of unassisted general radiologists in detecting abnormalities. General radiologists achieved significantly higher sensitivity in detecting ACL tears (p-value = 0.002; q-value = 0.019) and significantly higher specificity in detecting meniscal tears (p-value = 0.003; q-value = 0.019). Using a 1-tailed t test on the change in performance metrics, we found that providing model predictions significantly increased clinical experts' specificity in identifying ACL tears (p-value < 0.001; q-value = 0.006). The primary limitations of our study include lack of surgical ground truth and the small size of the panel of clinical experts.CONCLUSIONS: Our deep learning model can rapidly generate accurate clinical pathology classifications of knee MRI exams from both internal and external datasets. Moreover, our results support the assertion that deep learning models can improve the performance of clinical experts during medical imaging interpretation. Further research is needed to validate the model prospectively and to determine its utility in the clinical setting.

  View details for PubMedID 30481176

• Quality Measures in Total Hip and Total Knee Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons Amanatullah, D. F., McQuillan, T., Kamal, R. N. 2018

  Abstract

  INTRODUCTION: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures.METHODS: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search.RESULTS: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%).CONCLUSION: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement.LEVEL OF EVIDENCE: Level I, systematic review of level I evidence.

  View details for PubMedID 30303844

• Periprosthetic Bacterial Biofilm and Quorum Sensing JOURNAL OF ORTHOPAEDIC RESEARCH Mooney, J. A., Pridgen, E. M., Manasherob, R., Suh, G., Blackwell, H. E., Barron, A. E., Bollyky, P. L., Goodman, S. B., Amanatullah, D. F. 2018; 36 (9): 2331–39

  View details for DOI 10.1002/jor.24019

  View details for Web of Science ID 000443808900002

• 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

• Headless Compression Screw Fixation of Vertical Medial Malleolus Fractures is Superior to Unicortical Screw Fixation. American journal of orthopedics (Belle Mead, N.J.) Wegner, A. M., Wolinsky, P. R., Robbins, M. A., Garcia, T. C., Maitra, S., Amanatullah, D. F. 2018; 47 (8)

  Abstract

  This study is the first biomechanical research of headless compression screws for fixation of vertical shear fractures of the medial malleolus, a promising alternative that potentially offers several advantages for fixation. Vertical shear fractures were simulated by osteotomies in 20 synthetic distal tibiae. Models were randomly assigned to fixation with either 2 parallel cancellous screws or 2 parallel Acutrak 2 headless compression screws (Acumed). Specimens were subjected to offset axial loading to simulate supination-adduction loading and tracked using high-resolution video. The headless compression screw construct was significantly stiffer (P < .0001) (360 ± 131 N/mm) than the partially threaded cancellous screws (180 ± 48 N/mm) and demonstrated a significantly increased (P < .0001) mean load to clinical failure (719 ± 91 N vs 343 ± 83 N). When specimens were displaced to 6 mm and allowed to relax, the headless compression screw constructs demonstrated an elastic recoil and were reduced to the pretesting fragment alignment, whereas the parallel cancellous screw constructs remained displaced. Along with the headless design that may decrease soft tissue irritation, the increased stiffness and elastic recoil of the headless compression screw construct offers improved fixation of medial malleolus vertical shear fractures over the traditional methods.

  View details for DOI 10.12788/ajo.2018.0066

  View details for PubMedID 30180221

• Financial Distress and Discussing the Cost of Total Joint Arthroplasty. The Journal of arthroplasty Amanatullah, D. F., Murasko, M. J., Chona, D. V., Crijns, T. J., Ring, D., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.METHODS: One hundred forty-one patients undergoing elective total hip and knee arthroplasty at a suburban academic medical center were enrolled and completed questionnaires about cost prior to surgery. Questions regarding if and when doctors should discuss the cost of healthcare with patients, evaluating if patients were affected by the cost of healthcare and to what extent, and financial security scores to assess current financial situation were included. The primary outcome was the answer to the question of whether a doctor should discuss cost with patients.RESULTS: Financial stress was found to be associated with patient experience of hardship due to cost of care [P= .004], likelihood to turn down a test or treatment due to copayment [P= .029], to decline a test or treatment due to other costs [P= .003], to experience difficulty affording basic necessities [P= .008], and to have used up all or most of their savings to pay for surgery [P= .011]. In total, 84% of patients reported that they wanted to discuss surgical costs with their doctors, but 90% did not want to do so at every visit.CONCLUSION: Total joint arthroplasty creates considerable out-of-pocket costs that may affect patient decisions. These findings help elucidate important patient concerns that orthopedic surgeons should account for when discussing elective arthroplasty with patients.

  View details for PubMedID 30057266

• 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

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for PubMedID 29965894

• Headless compression screw for horizontal medial malleolus fractures. Clinical biomechanics (Bristol, Avon) Cheng, R. Z., Wegner, A. M., Behn, A. W., Amanatullah, D. F. 2018; 55: 1–6

  Abstract

  BACKGROUND: Horizontal medial malleolus fractures are caused by the application of rotational force through the ankle joint in several orientations. Multiple techniques are available for the fixation of medial malleolar fractures.METHODS: Horizontal medial malleolus osteotomies were performed in eighteen synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) two Acutrak 2 headless compression screws. Specimens were subjected to offset axial tension loading. Frontal plane interfragmentary motion was monitored.FINDINGS: The headless compression group (1699 (SD 947) N/mm) had significantly greater proximal-distal stiffness than the unicortical group (668 (SD 298) N/mm), (P = 0.012). Similarly, the headless compression group (604 (SD 148) N/mm) had significantly greater medial-lateral stiffness than the unicortical group (281 (SD 152) N/mm), (P < 0.001). The force at 2 mm of lateral displacement was significantly greater in the headless compression group (955 (SD 79) N) compared to the unicortical group (679 (SD 198) N), (P = 0.003). At 2 mm of distal displacement, the mean force was higher in the headless compression group (1037 (SD 122) N) compared to the unicortical group (729 (SD 229) N), but the difference was not significant (P = 0.131).INTERPRETATION: A headless compression screw construct was significantly stiffer in both the proximal-distal and medial-lateral directions, indicating greater resistance to both axial and shear loading. Additionally, they had significantly greater load at clinical failure based on lateral displacement. The low-profile design of the headless compression screw minimizes soft tissue irritation and reduces need for implant removal.

  View details for PubMedID 29604557

• 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

• Mini-Fragment Fixation Is Equivalent to Bicortical Screw Fixation for Horizontal Medial Malleolus Fractures ORTHOPEDICS Wegner, A. M., Wolinsky, P. R., Robbins, M. A., Garcia, T. C., Amanatullah, D. F. 2018; 41 (3): E395–E399

  Abstract

  Horizontal fractures of the medial malleolus occur through application of valgus or abduction force through the ankle that creates a tension failure of the medial malleolus. The authors hypothesize that mini-fragment T-plates may offer improved fixation, but the optimal fixation construct for these fractures remains unclear. Forty synthetic distal tibiae with identical osteotomies were randomized into 4 fixation constructs: (1) two parallel unicortical cancellous screws; (2) two parallel bicortical cortical screws; (3) a contoured mini-fragment T-plate with 2 unicortical screws in the fragment and 2 bicortical screws in the shaft; and (4) a contoured mini-fragment T-plate with 2 bicortical screws in the fragment and 2 unicortical screws in the shaft. Specimens were subjected to offset axial tension loading on a servohydraulic testing system and tracked using high-resolution video. Failure was defined as 2 mm of articular displacement. Analysis of variance followed by a Tukey-Kramer post hoc test was used to assess for differences between groups, with significance defined as P<.05. The mean stiffness (±SD) values of both mini-fragment T-plate constructs (239±83 N/mm and 190±37 N/mm) and the bicortical screw construct (240±17 N/mm) were not statistically different. The mean stiffness values of both mini-fragment T-plate constructs and the bicortical screw construct were higher than that of a parallel unicortical screw construct (102±20 N/mm). Contoured T-plate constructs provide stiffer initial fixation than a unicortical cancellous screw construct. The T-plate is biomechanically equivalent to a bicortical screw construct, but may be superior in capturing small fragments of bone. [Orthopedics. 2018; 41(3):e395-e399.].

  View details for DOI 10.3928/01477447-20180409-03

  View details for Web of Science ID 000432834800016

  View details for PubMedID 29658979

• Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Giori, N. J., Amanatullah, D. F., Gupta, S., Bowe, T., Harris, A. 2018; 100 (7): 539–45

  Abstract

  Morbidly obese patients with severe osteoarthritis benefit from successful total joint arthroplasty. However, morbid obesity increases the risk of complications. Because of this, some surgeons enforce a body mass index (BMI) eligibility criterion above which total joint arthroplasty is denied. In this study, we investigate the trade-off between avoiding complications and restricting access to care when enforcing BMI-based eligibility criteria for total joint arthroplasty.In this retrospective cohort study, the Veterans Health Administration (VHA) Corporate Data Warehouse (CDW) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) databases were reviewed for patients undergoing total joint arthroplasty from October 2011 through September 2014. We determined, if various BMI eligibility criteria had been enforced over that period of time, how many short-term complications would have been avoided, how many complication-free surgical procedures would have been denied, and the positive predictive value of BMI eligibility criteria as tests for major complications. To provide a frame of reference, we also determined what would have happened if eligibility for total joint arthroplasty were arbitrarily determined by flipping a coin.In this study, 27,671 total joint arthroplasties were reviewed. With a BMI criterion of ≥40 kg/m, 1,148 patients would have been denied a surgical procedure free of major complications, and 83 patients would have avoided a major complication. The positive predictive value of a complication using a BMI of ≥40 kg/m as a test for major complications was 6.74% (95% confidence interval [CI], 5.44% to 8.33%). The positive predictive value of a complication using a BMI criterion of 30 kg/m was 5.33% (95% CI, 4.99% to 5.71%). Flipping a coin had a positive predictive value of 5.05%.A 30 kg/m criterion for total joint arthroplasty eligibility is marginally better than flipping a coin and should not determine surgical eligibility. With a BMI criterion of ≥40 kg/m, the number of patients denied a complication-free surgical procedure is about 14 times larger than those spared a complication. Although the acceptable balance between avoiding complications and providing access to care can be debated, such a quantitative assessment helps to inform decisions regarding the advisability of enforcing a BMI criterion for total joint arthroplasty.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for PubMedID 29613922

  View details for PubMedCentralID PMC5895162

• 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 DOI 10.1016/j.arth.2017.10.001

  View details for PubMedID 29107500

• Implant-Associated Bacterial Biofilm and Quorum Sensing in Periprosthetic Joint Infections. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Mooney, J. A., Pridgen, E. M., Manasherob, R. n., Suh, G. n., Blackwell, H. E., Barron, A. E., Bollyky, P. L., Goodman, S. B., Amanatullah, D. F. 2018

  Abstract

  Periprosthetic joint infection (PJI) continues to be a common complication after total knee arthroplasty and total hip arthroplasty leading to severe morbidity and mortality. With an aging population and increasing prevalence of total joint replacement procedures, the burden of PJI will be felt not only by individual patients, but in increased healthcare costs. Current treatment of PJI is inadequate resulting in incredibly high failure rates. This is believed to be largely mediated by the presence of bacterial biofilms. These polymicrobial bacterial colonies form within secreted extracellular matrices, adhering to the implant surface and local tissue. The biofilm architecture is believed to play a complex and critical role in a variety of bacterial processes including nutrient supplementation, metabolism, waste management, and antibiotic and immune resistance. The establishment of these biofilms relies heavily on the quorum sensing communication systems utilized by bacteria. Early stage research into disrupting bacterial communication by targeting quorum sensing show promise for future clinical applications. However, prevention of the biofilm formation via early forced induction of the biofilm forming process remains yet unexplored. This article is protected by copyright. All rights reserved.

  View details for PubMedID 29663554

• 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

• 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

• 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

• Revision Total Hip Arthroplasty Using the Cement-in-Cement Technique ORTHOPEDICS Amanatullah, D. F., Pallante, G. D., Floccari, L. V., Vasileiadis, G. I., Trousdadale, R. T. 2017; 40 (2): E348-E351

  View details for DOI 10.3928/01477447-20161213-05

  View details for Web of Science ID 000397587200023

• 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

• Reproducibility and Precision of CT Scans to Evaluate Tibial Component Rotation. journal of arthroplasty Amanatullah, D. F., Ollivier, M. P., Pallante, G. D., Abdel, M. P., Clarke, H. D., Mabry, T. M., Taunton, M. J. 2017

  Abstract

  Component rotation likely plays a greater role on the survivorship and outcomes of total knee arthroplasties than is currently known. Our goal was to evaluate the precision, interobserver reliability, and intrarater reliability of tibial component rotation as measured by computed tomography (CT) scan, regardless of measurement technique.Three fellowship-trained, academic arthroplasty surgeons independently measured tibial component rotation on CT scans of 62 total knee arthroplasties using their methods of choice. Measurements were repeated at least 2 weeks after the initial measurement. The precision of the measurements was assessed using a formal 8-step protocol as the gold standard. Intraclass correlation coefficients (ICCs) were calculated to evaluate precision, interobserver agreement, and intrarater reliability RESULTS: The interobserver agreement between the 3 surgeons for tibial component rotation was also moderate (ICC = 0.52). The intrarater reliability of tibial rotation was excellent (ICC = 0.81). Comparison of surgeons' measurement to a validated gold standard revealed only moderate precision for tibial component rotation (ICC = 0.64).Practicing surgeons measuring tibial rotation were internally consistent, but failed to demonstrate satisfactory precision and interobserver agreement. We support the adoption of standardized criteria for the measurement of tibial component rotation on CT scans.

  View details for DOI 10.1016/j.arth.2017.01.040

  View details for PubMedID 28434699

• Sled fixation for horizontal medial malleolus fractures. Clinical biomechanics Wegner, A. M., Wolinsky, P. R., Cheng, R. Z., Robbins, M. A., Garcia, T. C., Amanatullah, D. F. 2017; 42: 92-96

  Abstract

  Horizontal fractures of the medial malleolus occur through exertion of various rotational forces on the ankle, including supination--external rotation, pronation--external rotation, and pronation-abduction. Many methods of fixation are employed for these fractures, but the optimal fixation construct remains unclear.Horizontal medial malleolus osteotomies were performed in synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) medial malleolar sled fixation. Specimens were subjected to offset axial tension loading and tracked using high-resolution video. Clinical failure was defined as 2mm of articular displacement.There were statistically significant increases in mean stiffness (127% higher, P=0.0007) and mean force to clinical failure (52% higher, P=0.0002) with the medial malleolar sled. The mean stiffness in offset tension loading was 232 (SD 83) N/mm for medial malleolar sled and 102 (SD 20) N/mm for parallel unicortical cancellous screws. The mean force to clinical failure was 595 (SD 112) N for medial malleolar sled and 392 (SD 34) N for unicortical screws. In addition, the medial malleolar sled demonstrated elastic recoil to pre-testing alignment while the unicortical screws did not.Medial malleolar sled fixation was significantly stiffer and required more force to clinical failure than parallel unicortical cancellous screws. A medial malleolar sled requires more dissection to apply surgically, but provides significantly more initial fixation strength. Additionally, a medial malleolar sled acts like a tension band in its ability to capture comminuted fragments while being low profile enough to minimize soft tissue irritation.

  View details for DOI 10.1016/j.clinbiomech.2017.01.011

  View details for PubMedID 28119205

• 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

• Local estrogen axis in the human bone microenvironment regulates estrogen receptor-positive breast cancer cells. Breast cancer research : BCR Amanatullah, D. F., Tamaresis, J. S., Chu, P. n., Bachmann, M. H., Hoang, N. M., Collyar, D. n., Mayer, A. T., West, R. B., Maloney, W. J., Contag, C. H., King, B. L. 2017; 19 (1): 121

  Abstract

  Approximately 70% of all breast cancers express the estrogen receptor, and are regulated by estrogen. While the ovaries are the primary source of estrogen in premenopausal women, most breast cancer is diagnosed following menopause, when systemic levels of this hormone decline. Estrogen production from androgen precursors is catalyzed by the aromatase enzyme. Although aromatase expression and local estrogen production in breast adipose tissue have been implicated in the development of primary breast cancer, the source of estrogen involved in the regulation of estrogen receptor-positive (ER+) metastatic breast cancer progression is less clear.Bone is the most common distant site of breast cancer metastasis, particularly for ER+ breast cancers. We employed a co-culture model using trabecular  bone tissues obtained from total hip replacement (THR) surgery specimens to study ER+ and estrogen receptor-negative (ER-) breast cancer cells within the human bone microenvironment. Luciferase-expressing ER+ (MCF-7, T-47D, ZR-75) and ER- (SK-BR-3, MDA-MB-231, MCF-10A) breast cancer cells were cultured directly on bone tissue fragments or in bone tissue-conditioned media, and monitored over time with bioluminescence imaging (BLI). Bone tissue-conditioned media were generated in the presence vs. absence of aromatase inhibitors, and testosterone. Bone tissue fragments were analyzed for aromatase expression by immunohistochemistry.ER+ breast cancer cells were preferentially sustained in co-cultures with bone tissues and bone tissue-conditioned media relative to ER- cells. Bone fragments analyzed by immunohistochemistry revealed expression of the aromatase enzyme. Bone tissue-conditioned media generated in the presence of testosterone had increased estrogen levels and heightened capacity to stimulate ER+ breast cancer cell proliferation. Pretreatment of cultured bone tissues with aromatase inhibitors, which inhibited estrogen production, reduced the capacity of conditioned media to stimulate ER+ cell proliferation.These results suggest that a local estrogen signaling axis regulates ER+ breast cancer cell viability and proliferation within the bone metastatic niche, and that aromatase inhibitors modulate this axis. Although endocrine therapies are highly effective in the treatment of ER+ breast cancer, resistance to these treatments reduces their efficacy. Characterization of estrogen signaling networks within the bone microenvironment will identify new strategies for combating metastatic progression and endocrine resistance.

  View details for PubMedID 29141657

  View details for PubMedCentralID PMC5688761

• Headless Compression Screw Fixation of Vertical Medial Malleolus Fractures is Superior to Unicortical Screw Fixation American Journal of Orthopedics Wegner, A. M., Robbins, M. A., Garcia, T. C., Wolinsky, P. R., Amanatullah, D. F. 2017; accepted
• Modularity in Total Hip Arthroplasty: Benefits, Risks, Mechanisms, Diagnosis, and Management. Orthopedics Vierra, B. M., Blumenthal, S. R., Amanatullah, D. F. 2017: 1–12

  Abstract

  Modular implants are currently widely used in total hip arthroplasty because they give surgeons versatility during the operation, allow for easier revision surgery, and can be adjusted to better fit the anatomy of the specific patient. However, modular implants, specifically those that have metal-on-metal junctions, are susceptible to crevice and fretting corrosion. This can ultimately cause implant failure, inflammation, and adverse local tissue reaction, among other possible side effects. Surgeons should be aware of the possibility of implant corrosion and should follow a set of recommended guidelines to systematically diagnose and treat patients with corroded implants. Ultimately, surgeons will continue to use modular implants because of their widespread benefits. However, more research is needed to determine how to minimize corrosion and the negative side effects that have been associated with modular junctions in total hip arthroplasty. [Orthopedics. 201x; xx(x):xx-xx.].

  View details for DOI 10.3928/01477447-20170606-01

  View details for PubMedID 28598491

• Use of Cortical Strut Allograft after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty Journal of Arthroplasty, Lim, C. T., Amanatullah, D. F., Huddleston III, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2017 ; 32(5): 1599-1605.
• Taper Corrosion after Total Hip Arthroplasty: Evaluation and Management Advanced Reconstruction of the Hip, 2nd Edition. Amanatullah, D. F., Taunton, M. J. edited by Lieberman, J. A., Berry, D. J. American Academy of Orthopaedic Surgeons, Rosemont, IL. Chapter 45. 2017: 437–448
• 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. n., 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. n., 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

• Intraobserver Reliability and Interobserver Agreement in Radiographic Classification of Heterotopic Ossification. Orthopedics Vasileiadis, G. I., Itoigawa, Y., Amanatullah, D. F., Pulido-Sierra, L., Crenshaw, J. R., Huyber, C., Taunton, M. J., Kaufman, K. R. 2017; 40 (1): e54-e58

  Abstract

  The most widely used radiologic classification system for heterotopic ossification after total hip arthroplasty (THA) is the Brooker scale. In 2002, Della Valle et al proposed a modified rating system for heterotopic ossification to increase intraobserver reliability and interobserver agreement. To date, no study comparing these 2 classification systems has been conducted. Moreover, these studies were grossly underpowered. In the current study, 3 clinicians reviewed the charts of 236 patients with documented radiographic heterotopic ossification at least 2 months after THA and independently graded the amount of heterotopic ossification according to the Brooker and Della Valle classification systems. Then the intraobserver reliability and the interobserver agreement of each classification system were calculated with Cohen's kappa (κ) coefficient of agreement. The Brooker scale showed moderate to substantial intraobserver reliability (0.43≤κ<0.71), and the Della Valle classification system showed substantial intraobserver reliability (0.65≤κ<0.77). Both classification systems showed moderate interobserver agreement (0.40≤κ<0.60). Della Valle grade C (ie, presence of bone spurs from the pelvis or femur leaving less than 1 cm between opposing surfaces and apparent bone ankylosis) and Brooker grade IV had the best interobserver agreement. The best interobserver agreement for any grade was seen with grade C of the Della Valle classification system, which showed substantial interobserver reliability (0.60≤κ<0.80). The Della Valle classification system may be slightly better in patients with large amounts of heterotopic ossification, but both classification systems lack sufficient clarity and are open to significant subjective interpretation. [Orthopedics. 2017; 40(1):e54-e58.].

  View details for DOI 10.3928/01477447-20160926-05

  View details for PubMedID 27684082

• Cortical Strut Allograft Support of Modular Femoral Junctions during Revision Total Hip Arthroplasty. Journal of Arthroplasty Journal of Arthroplasty Lim, C. T., Amanatullah, D. F., Huddleston III, J. I., Hwang, K. L., Maloney, W. J., Goodman, S. B. 2017; 32(5): 1586-1592.
• Perioperative Physiotherapy in Total Knee Arthroplasty. Amanatullah, D. F., Joice, M. G., Bhowmick, S. Orthopedics, 20: 1-9.. 2017
• 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

• Intraobserver Reliability and Interobserver Agreement in Radiographic Classification of Heterotopic Ossification ORTHOPEDICS Vasileiadis, G. I., Itoigawa, Y., Amanatullah, D. F., Pulido-Sierra, L., Crenshaw, J. R., Huyber, C., Taunton, M. J., Kaufman, K. R. 2017; 40 (1): E54-E58

  View details for DOI 10.3928/01477447-20160926-05

  View details for Web of Science ID 000397082400008

• 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

• Proximal femoral reconstruction for failed internal fixation of a bisphosphonate-related femur fracture. Arthroplasty today Jethanandani, R. G., Nwankwo, C., Wolinsky, P. R., Giordani, M., Amanatullah, D. F. 2016; 2 (4): 153-156

  Abstract

  We present a case of a bisphosphonate-related femur fracture in an elderly woman, who failed treatment with both cephalomedullary nail and proximal femoral locking plate, leading to successful treatment with total hip arthroplasty. Hardware failure should be included in the differential of patients with previous internal fixation of bisphosphonate-related femur fracture that present with hip or groin pain. Arthroplasty can be an acceptable salvage option in an active elderly patient with a bisphosphonate-related femur fracture.

  View details for DOI 10.1016/j.artd.2016.04.001

  View details for PubMedID 28326420

• Metal in Total Hip Arthroplasty: Wear Particles, Biology, and Diagnosis ORTHOPEDICS Amanatullah, D. F., Sucher, M. G., Bonadurer, G. F., Pereira, G. C., Taunton, M. J. 2016; 39 (6): 371-379

  Abstract

  Total hip arthroplasty (THA) has been performed for nearly 50 years. Between 2006 and 2012, more than 600,000 metal-on-metal THA procedures were performed in the United States. This article reviews the production of metal wear debris in a metal-on-metal articulation and the interaction of cobalt and chromium ions that ultimately led to a dramatic decline in the use of metal-on-metal THA articulations. Additionally, the article reviews mechanisms of metal wear, the biologic reaction to cobalt and chromium ions, the clinical presentation of failing metal-on-metal articulations, and current diagnostic strategies. Further, the article discusses the use of inflammatory markers, metal ion levels, radiographs, metal artifact reduction sequence magnetic resonance imaging, and ultrasound for failed metal-on-metal THA procedures. When adopting new technologies, orthopedic surgeons must weigh the potential increased benefits against the possibility of new mechanisms of failure. Metal-on-metal bearings are a prime example of the give and take between innovation and clinical results, especially in the setting of an already successful procedure such as THA. [Orthopedics. 2016; 39(6):371-379.].

  View details for DOI 10.3928/01477447-20160719-06

  View details for Web of Science ID 000393108800042

  View details for PubMedID 27459144

• Calculating the Position of the Joint Line of the Knee Using Anatomical Landmarks. Orthopedics Pereira, G. C., Von Kaeppler, E., Alaia, M. J., Montini, K., Lopez, M. J., Di Cesare, P. E., Amanatullah, D. F. 2016; 39 (6): 381-386

  Abstract

  Restoration of the joint line of the knee during primary and revision total knee arthroplasty is a step that directly influences patient outcomes. In revision total knee arthroplasty, necessary bony landmarks may be missing or obscured, so there remains a lack of consensus on how to accurately identify and restore the joint line of the knee. In this study, 50 magnetic resonance images of normal knees were analyzed to determine a quantitative relationship between the joint line of the knee and 6 bony landmarks: medial and lateral femoral epicondyles, medial and lateral femoral metaphyseal flares, tibial tubercle, and proximal tibio-fibular joint. Wide variability was found in the absolute distance from each landmark to the joint line of the knee, including significant differences between the sexes. Normalization of the absolute distances to femoral or tibial diameters revealed reliable spatial relationships to the joint line of the knee. The joint line was found to be equidistant from the lateral femoral epicondyle and the proximal tibio-fibular joint, representing a reproducible point of reference for joint line restoration. The authors propose a simple 3-step algorithm that can be used with magnetic resonance imaging, computed tomography, or radiography to reliably determine the anatomical location of the joint line of the knee relative to the surrounding bony anatomy. [Orthopedics. 2016; 39(6):381-386.].

  View details for DOI 10.3928/01477447-20160729-01

  View details for PubMedID 27482732

• Calculating the Position of the Joint Line of the Knee Using Anatomical Landmarks ORTHOPEDICS Pereira, G. C., Von Kaeppler, E., Alaia, M. J., Montini, K., Lopopez, M. J., Di Cesare, P. E., Amanatullah, D. F. 2016; 39 (6): 381-386

  View details for DOI 10.3928/01477447-20160729-01

  View details for Web of Science ID 000393108800043

• 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

• Greater inadvertent muscle damage in direct anterior approach when compared with the direct superior approach for total hip arthroplasty. The bone & joint journal Amanatullah, D. F., Masini, M. A., ROGER, D. J., Pagnano, M. W. 2016; 98-B (8): 1036-1042

  Abstract

  We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches.In eight cadavers, the DA approach was performed on one side, and the DS approach on the other, a single brand of uncemented hip prosthesis was implanted by two surgeons, considered expert in their surgical approaches. Subsequent reflection of the gluteus maximus allowed the extent of muscle and tendon damage to be measured and the percentage damage to each anatomical structure to be calculated.The DA approach caused substantially greater damage to the gluteus minimus muscle and tendon when compared with the DS approach (t-test, p = 0.049 and 0.003, respectively). The tensor fascia lata and rectus femoris muscles were damaged only in the DA approach. There was no difference in the amount of damage to the gluteus medius muscle and tendon, piriformis tendon, obturator internus tendon, obturator externus tendon or quadratus femoris muscle between approaches. The posterior soft-tissue releases of the DA approach damaged the gluteus minimus muscle and tendon, piriformis tendon and obturator internus tendon.The DS approach caused less soft-tissue damage than the DA approach. However the clinical relevance is unknown. Further clinical outcome studies, radiographic evaluation of component position, gait analyses and serum biomarker levels are necessary to evaluate and corroborate the safety and efficacy of the DS approach. Cite this article: Bone Joint J 2016;98-B1036-42.

  View details for DOI 10.1302/0301-620X.98B8.37178

  View details for PubMedID 27482014

• Greater inadvertent muscle damage in direct anterior approach when compared with the direct superior approach for total hip arthroplasty BONE & JOINT JOURNAL Amanatullah, D. F., Masini, M. A., ROGER, D. J., Pagnano, M. W. 2016; 98B (8): 1036-1042

  View details for DOI 10.1302/0301-620X.98B8.37178

  View details for Web of Science ID 000380953100006

• Biomechanical Consequences of Anterior Femoral Notching in Cruciate-Retaining Versus Posterior-Stabilized Total Knee Arthroplasty. American journal of orthopedics (Belle Mead, N.J.) Jethanandani, R., Patwary, M. B., Shellito, A. D., Meehan, J. P., Amanatullah, D. F. 2016; 45 (5): E268-72

  Abstract

  Anterior femoral notching during total knee arthroplasty is a potential risk factor for periprosthetic supracondylar femur fracture. We conducted a study to determine if the design of the femoral implant changes the risk for periprosthetic supracondylar femur fractures after anterior cortical notching. An anterior cortical defect was created in 12 femoral polyurethane models. Six femora were instrumented with cruciate-retaining implants and 6 with posterior-stabilized implants. Each femur was loaded in external rotation along the anatomical axis. Notch depth and distance from anterior cortical notch to implant were recorded before loading, and fracture pattern was recorded after failure. There were no statistically significant differences in notch depth, distance from notch to implant, torsional stiffness, torque at failure, final torque, or fracture pattern between cruciate-retaining and posterior-stabilized femoral component designs. Periprosthetic fracture after anterior femoral notching is independent of the bone removed from the intercondylar notch. After notching, there likely is no significant difference in femoral strength in torsion between cruciate-retaining and posterior-stabilized designs.

  View details for PubMedID 27552464

• The biological response to orthopaedic implants for joint replacement: Part I: Metals. Journal of biomedical materials research. Part B, Applied biomaterials Gibon, E., Amanatullah, D. F., Loi, F., Pajarinen, J., Nabeshima, A., Yao, Z., Hamadouche, M., Goodman, S. B. 2016

  Abstract

  Joint replacement is a commonly performed, highly successful orthopaedic procedure, for which surgeons have a large choice of different materials and implant designs. The materials used for joint replacement must be both biologically acceptable to minimize adverse local tissue reactions, and robust enough to support weight bearing during common activities of daily living. Modern joint replacements are made from metals and their alloys, polymers, ceramics, and composites. This review focuses on the biological response to the different biomaterials used for joint replacement. In general, modern materials for joint replacement are well tolerated by the body as long as they are in bulk (rather than in particulate or ionic) form, are mechanically stable and noninfected. If the latter conditions are not met, the prosthesis will be associated with an acute/chronic inflammatory reaction, peri-prosthetic osteolysis, loosening and failure. This article (Part 1 of 2) is dedicated to the use of metallic devices in orthopaedic surgery including the associated biological response to metallic byproducts is a review of the basic science literature regarding this topic. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2016.

  View details for DOI 10.1002/jbm.b.33734

  View details for PubMedID 27328111

• Phlpp1 facilitates post-traumatic osteoarthritis and is induced by inflammation and promoter demethylation in human osteoarthritis OSTEOARTHRITIS AND CARTILAGE Bradley, E. W., Carpio, L. R., McGee-Lawrence, M. E., Becerra, C. C., Amanatullah, D. F., Ta, L. E., OTERO, M., GOLDRING, M. B., Kakar, S., Westendorf, J. J. 2016; 24 (6): 1021-1028

  Abstract

  Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability. OA is characterized by articular chondrocyte deterioration, subchondral bone changes and debilitating pain. One strategy to promote cartilage regeneration and repair is to accelerate proliferation and matrix production of articular chondrocytes. We previously reported that the protein phosphatase Phlpp1 controls chondrocyte differentiation by regulating the activities of anabolic kinases. Here we examined the role of Phlpp1 in OA progression in a murine model. We also assessed PHLPP1 expression and promoter methylation.Knee joints of WT and Phlpp1(-/-) mice were surgically destabilized by transection of the medial meniscal ligament (DMM). Mice were assessed for signs of OA progression via radiographic and histological analyses, and pain assessment for mechanical hypersensitivity using the von Frey assay. Methylation of the PHLPP1 promoter and PHLPP1 expression were evaluated in human articular cartilage and chondrocyte cell lines.Following DMM surgeries, Phlpp1 deficient mice showed fewer signs of OA and cartilage degeneration. Mechanical allodynia associated with DMM surgeries was also attenuated in Phlpp1(-/-) mice. PHLPP1 was highly expressed in human articular cartilage from OA patients, but was undetectable in cartilage specimens from femoral neck fractures (FNFxs). Higher PHLPP1 levels correlated with less PHLPP1 promoter CpG methylation in cartilage from OA patients. Blocking cytosine methylation or treatment with inflammatory mediators enhanced PHLPP1 expression in human chondrocyte cell lines.Phlpp1 deficiency protects against OA progression while CpG demethylation and inflammatory cytokines promote PHLPP1 expression.

  View details for DOI 10.1016/j.joca.2015.12.014

  View details for Web of Science ID 000376040400010

  View details for PubMedID 26746148

  View details for PubMedCentralID PMC4875839

• Antiglide plating of vertical medial malleolus fractures provides stiffer initial fixation than bicortical or unicortical screw fixation. Clinical biomechanics Wegner, A. M., Wolinsky, P. R., Robbins, M. A., Garcia, T. C., Maitra, S., Amanatullah, D. F. 2016; 31: 29-32

  Abstract

  Vertical shear fractures of the medial malleolus (44-A2 ankle fractures) occur through a supination-adduction mechanism. There are numerous methods of internal fixation for this fracture pattern.Vertical medial malleolus osteotomies were created in synthetic distal tibiae. The models were divided into four fixation groups: two parallel unicortical cancellous screws, two divergent unicortical cancellous screws, two parallel bicortical cortical screws, or an antiglide plate construct. Specimens were subjected to offset axial loading and tracked using high-resolution video.The antiglide plate construct was stiffer (P<0.05) than each of the other three constructs, and the bicortical screw construct was stiffer (P<0.05) than both unicortical screw constructs. The mean stiffness (standard deviation) was 111 (SD 35) N/mm for the parallel unicortical screw construct, 173 (SD 57) N/mm for the divergent unicortical screw construct, 279 (SD 30) N/mm for the bicortical screw construct, and 463 (SD 91) N/mm for the antiglide plate construct. The antiglide plate construct resisted displacement better (P<0.05) than each of the other three constructs. The mean force for 2mm of articular displacement was 284 (SD 51) N for the parallel unicortical screw construct, 339 (SD 46) N for the divergent unicortical screw construct, 429 (SD 112) N for the bicortical construct, and 922 (SD 297) N for the antiglide plate construct.An antiglide plate construct provides the stiffest initial fixation while withstanding higher load to failure for vertical medial malleolus fractures when compared to unicortical and bicortical screw fixation.

  View details for DOI 10.1016/j.clinbiomech.2015.10.005

  View details for PubMedID 26482240

• Minimally Invasive Total Hip Arthroplasty Medscape Drugs and Disease, http://emedicine.medscape.com/article/2000333-overview Amanatullah, D. F., Joice, M., Di Cesare, P. E. 2016
• Techniques to Manage Osteolysis around Well-fixed Acetabular Components Master Techniques in Orthopaedic Surgery: The Hip, 3rd Edition. Amanatullah, D. F., Maloney, W. J. edited by Berry, D. J., Maloney, W. J. Chapter 31. 2016: 411–419
• Taking the Big Bite: Rothman-Ranawat Traveling Fellows Chew on Their Lessons AAOS Now Wilson, M., Loganathan, B., Kamath, A., Amanatullah, D. 2016
• Pre-operative Planning The Adult Hip, Hip arthroplasty Surgery, 3rd Edition Pereira, G. C., Amanatullah, D. F., Di Ceasare, P. E. edited by Calaghan, J. J., Rosenberg, A. G., Rubash, H. E., Clohisy, J. C., Beaule, P. E., Della Valle, C. J. 2016 ; Chapter 50: 672–683
• 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

• Revision total hip arthroplasty after removal of a fractured well-fixed extensively porous-coated femoral component using a trephine. The bone & joint journal Amanatullah, D. F., Siman, H., Pallante, G. D., Haber, D. B., Sierra, R. J., Trousdale, R. T. 2015; 97-B (9): 1192-1196

  Abstract

  When fracture of an extensively porous-coated femoral component occurs, its removal at revision total hip arthroplasty (THA) may require a femoral osteotomy and the use of a trephine. The remaining cortical bone after using the trephine may develop thermally induced necrosis. A retrospective review identified 11 fractured, well-fixed, uncemented, extensively porous-coated femoral components requiring removal using a trephine with a minimum of two years of follow-up. The mean time to failure was 4.6 years (1.7 to 9.1, standard deviation (sd) 2.3). These were revised using a larger extensively porous coated component, fluted tapered modular component, a proximally coated modular component, or a proximal femoral replacement. The mean clinical follow-up after revision THA was 4.9 years (2 to 22, sd 3.1). The mean diameter of the femoral component increased from 12.7 mm (sd 1.9) to 16.2 mm (sd 3.4; p > 0.001). Two revision components had radiographic evidence of subsidence that remained radiographically stable at final follow-up. The most common post-operative complication was instability affecting six patients (54.5%) on at least one occasion. A total of four patients (36.4%) required further revision: three for instability and one for fracture of the revision component. There was no statistically significant difference in the mean Harris hip score before implant fracture (82.4; sd 18.3) and after trephine removal and revision THA (81.2; sd 14.8, p = 0.918). These findings suggest that removal of a fractured, well-fixed, uncemented, extensively porous-coated femoral component using a trephine does not compromise subsequent fixation at revision THA and the patient's pre-operative level of function can be restored. However, the loss of proximal bone stock before revision may be associated with a high rate of dislocation post-operatively. Cite this article: Bone Joint J 2015;97-B:1192-6.

  View details for DOI 10.1302/0301-620X.97B9.35037

  View details for PubMedID 26330584

• Revision total hip arthroplasty after removal of a fractured well-fixed extensively porous-coated femoral component using a trephine BONE & JOINT JOURNAL Amanatullah, D. F., Siman, H., Pallante, G. D., Haber, D. B., Sierra, R. J., Trousdale, R. T. 2015; 97B (9): 1192-1196

  View details for DOI 10.1302/0301-620X.97B9.35037

  View details for Web of Science ID 000360770000007

• Total Hip Arthroplasty After Lower Extremity Amputation ORTHOPEDICS Amanatullah, D. F., Trousdale, R. T., Sierra, R. J. 2015; 38 (5): E394-E400

  Abstract

  There are approximately 1.6 million lower extremity amputees in the United States. Lower extremity amputees are subject to increased physical demands proportional to their level of amputation. Lower extremity amputees have a 6-fold higher risk of developing radiographic osteoarthritis in the ipsilateral hip and a 2-fold risk of developing radiographic osteoarthritis in contralateral hip when compared with the non-amputee population. Additionally, there is a 3-fold increased risk of developing radiographic osteoarthritis in the ipsilateral hip after an above knee amputation when compared with a below knee amputation. The authors retrospectively reviewed 35 total hip arthroplasties after lower extremity amputation. The mean clinical follow-up was 5.3±4.0 years. The mean time from lower extremity amputation to total hip arthroplasty was 12.2±12.8 years after a contralateral amputation and 5.4±6.0 years after an ipsilateral amputation (P=.050). The mean time to total hip arthroplasty was 15.6±15.4 years after an above knee amputation and 6.4±6.1 years after a below knee amputation (P=.021). There was a statistically significant improvement in the mean Harris Hip Score from 35.9±21.8 to 76.8±12.8 with total hip arthroplasty after a contralateral amputation (P<.001). There also was a statistically significant improvement in the mean Harris Hip Score from 25.4±21.7 to 78.6±17.1 with total hip arthroplasty after an ispilateral amputation (P<.001). Three (17.7%) total hip arthroplasties after a contralateral amputation and 2 (11.1%) total hip arthroplasties after an ipsilateral amputation required revision total hip arthroplasty. Patients with an ipsilateral amputation or a below knee amputation progress to total hip arthroplasty faster than those with a contralateral amputation or an above knee amputation, respectively. Lower extremity amputees experience clinically significant improvements with total hip arthroplasty after lower extremity amputation.

  View details for DOI 10.3928/01477447-20150504-56

  View details for Web of Science ID 000356148900007

  View details for PubMedID 25970366

• Acetabular Fractures: What Radiologists Should Know and How 3D CT Can Aid Classification RADIOGRAPHICS Scheinfeld, M. H., Dym, A. A., Spektor, M., Avery, L. L., Dym, R. J., Amanatullah, D. F. 2015; 35 (2): 555-577

  Abstract

  Correct recognition, description, and classification of acetabular fractures is essential for efficient patient triage and treatment. Acetabular fractures may result from high-energy trauma or low-energy trauma in the elderly. The most widely used acetabular fracture classification system among radiologists and orthopedic surgeons is the system of Judet and Letournel, which includes five elementary (or elemental) and five associated fractures. The elementary fractures are anterior wall, posterior wall, anterior column, posterior column, and transverse. The associated fractures are all combinations or partial combinations of the elementary fractures and include transverse with posterior wall, T-shaped, associated both column, anterior column or wall with posterior hemitransverse, and posterior column with posterior wall. The most unique fracture is the associated both column fracture, which completely dissociates the acetabular articular surface from the sciatic buttress. Accurate categorization of acetabular fractures is challenging because of the complex three-dimensional (3D) anatomy of the pelvis, the rarity of certain acetabular fracture variants, and confusing nomenclature. Comparing a 3D image of the fractured acetabulum with a standard diagram containing the 10 Judet and Letournel categories of acetabular fracture and using a flowchart algorithm are effective ways of arriving at the correct fracture classification. Online supplemental material is available for this article.

  View details for DOI 10.1148/rg.352140098

  View details for Web of Science ID 000352561000021

  View details for PubMedID 25763739

• Revision total hip arthroplasty in patients with extensive proximal femoral bone loss using a fluted tapered modular femoral component. The bone & joint journal Amanatullah, D. F., Howard, J. L., Siman, H., Trousdale, R. T., Mabry, T. M., Berry, D. J. 2015; 97-B (3): 312-317

  Abstract

  Revision total hip arthroplasty (THA) is challenging when there is severe loss of bone in the proximal femur. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with severe proximal femoral bone loss treated with a fluted, tapered, modular femoral component. Between January 1998 and December 2004, 92 revision THAs were performed in 92 patients using a single fluted, tapered, modular femoral stem design. Pre-operative diagnoses included aseptic loosening, infection and peri-prosthetic fracture. Bone loss was categorised pre-operatively as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic fracture. The mean clinical follow-up was 6.4 years (2 to 12). A total of 47 patients had peri-operative complications, 27 of whom required further surgery. However, most of these further operations involved retention of a well-fixed femoral stem, and 88/92 femoral components (97%) remained in situ. Of the four components requiring revision, three were revised for infection and were well fixed at the time of revision; only one (1%) was revised for aseptic loosening. The most common complications were post-operative instability (17 hips, 19%) and intra-operative femoral fracture during insertion of the stem (11 hips, 12%). Diaphyseal stress shielding was noted in 20 hips (22%). There were no fractures of the femoral component. At the final follow-up 78% of patients had minimal or no pain. Revision THA in patients with extensive proximal femoral bone loss using the Link MP fluted, tapered, modular stem led to a high rate of osseointegration of the stem at mid-term follow-up. Cite this article: Bone Joint J 2015; 97-B:312-17.

  View details for DOI 10.1302/0301-620X.97B3.34684

  View details for PubMedID 25737513

• Effect of Heterotopic Ossification on Hip Range of Motion and Clinical Outcome JOURNAL OF ARTHROPLASTY Vasileiadis, G. I., Amanatullah, D. F., Crenshaw, J. R., Taunton, M. J., Kaufman, K. R. 2015; 30 (3): 461-464

  Abstract

  The utility of heterotopic ossification (HO) classification systems is debatable. The range of motion and Harris hip score (HHS) were calculated in 104 patients with known HO after total hip arthroplasty and 208 matched controls without HO. The patients with HO were radiographically divided into high and low grade HO groups. There was no statistically significant association of HHS with high or low grade HO. High grade HO had a statistically significant 6° loss of terminal hip flexion, 4° loss of abduction, and 6° loss of internal rotation at the hip. The small changes in terminal hip range of motion and lack of association with HHS may be the result of false radiographic continuity resulting in an overestimation of the disability in high grade HO.

  View details for DOI 10.1016/j.arth.2014.09.019

  View details for Web of Science ID 000353503500028

  View details for PubMedID 25449585

• Femoroacetabular Impingement: Current Concepts in Diagnosis and Treatment ORTHOPEDICS Amanatullah, D. F., Antkowiak, T., Pillay, K., Patel, J., Refaat, M., Toupadakis, C. A., Jamali, A. A. 2015; 38 (3): 185-199

  Abstract

  As a result of reading this article, physicians should be able to: 1. Identify the etiology of femoroacetabular impingement. 2. Assess femoroacetabular impingement on physical examination. 3. Recognize femoroacetabular impingement on imaging studies. 4. Discuss modern techniques to effectively treat femoroacetabular impingement, both open and arthroscopic. Femoroacetabular impingement (FAI) is a recently proposed concept describing abnormal anatomic relationships within the hip joint that may lead to articular damage. Impingement is caused by bony deformities or spatial malorientation of the femoral head-neck junction and/or the acetabulum. These abnormalities lead to pathologic contact and shearing forces at the acetabular labrum and cartilage during physiological hip motion. There is an increasing body of evidence that these forces lead to cartilage wear and eventual osteoarthritis. Treatment options for FAI are evolving rapidly. Although the gold standard remains open hip dislocation, arthroscopic techniques have shown significant promise. It is possible that early recognition and treatment of subtle deformity about the hip may reduce the rate of hip osteoarthritis in the future.

  View details for DOI 10.3928/01477447-20150305-07

  View details for Web of Science ID 000352155600024

  View details for PubMedID 25760499

• Revision total hip arthroplasty in patients with extensive proximal femoral bone loss using a fluted tapered modular femoral component BONE & JOINT JOURNAL Amanatullah, D. F., Howard, J. L., Siman, H., Trousdale, R. T., Mabry, T. M., Berry, D. J. 2015; 97B (3): 312-317

  View details for DOI 10.1302/0301-620X.97B3.34684

  View details for Web of Science ID 000351190500006

• Similar Clinical Outcomes for THAs With and Without Prior Periacetabular Osteotomy. Clinical orthopaedics and related research Amanatullah, D. F., Stryker, L., Schoenecker, P., Taunton, M. J., Clohisy, J. C., Trousdale, R. T., Sierra, R. J. 2015; 473 (2): 685-691

  Abstract

  Some patients opt to undergo conversion to a THA for continued pain or progression of hip arthritis after periacetabular osteotomy. Whether patients are at greater risk for postoperative complications, revision THA, poor clinical outcomes, or compromised radiographic results after periacetabular osteotomy is debatable.When compared with a matched cohort of patients who underwent THAs for developmental dysplasia of the hip (DDH) without previous periacetabular osteotomy, we asked whether a THA after a periacetabular osteotomy has (1) a higher complication rate, (2) a higher likelihood of resulting in revision THA, (3) comparable improvements in Harris hip score, and (4) comparable radiographic results.A multicenter retrospective review of 562 patients undergoing 645 periacetabular osteotomies was performed. Twenty-three hips in 22 patients underwent a THA after periacetabular osteotomy. The patients were matched for age, sex, and BMI with 23 hips in 23 patients with DDH undergoing THA without a history of periacetabular osteotomy. Minimum followup for both groups of patients was 2 years (mean, 10 ± 4 years and 6 ± 4 years, respectively). Comparisons were made to answer the study questions based on a retrospective review from prospectively maintained registries of clinical and radiographic information at two participating centers.With the numbers available, there was no difference in complication or revision rates between the two groups (p = 0.489 and 1.000, respectively); however, a post hoc power analysis showed our study was underpowered to detect a difference in the rate of postoperative complications or revision THA. There was marked improvement in Harris hip score with THA after periacetabular osteotomy (p < 0.001) and THA for DDH (p < 0.001), but there was no difference (p = 0.265) in the Harris hip score at final followup between either group. The acetabular component was placed at a mean of 17° more retroversion during THA after periacetabular osteotomy compared with THA for DDH (p = 0.002).This study did not detect any differences in the clinical outcomes in patients undergoing THA after periacetabular osteotomy done with a modern abductor-sparing approach when compared with a matched cohort undergoing THA for DDH. However, even with patients tallied across two high-volume centers during nearly 15 years, our study was underpowered to detect potentially important differences between the THA after periacetabular osteotomy group and the THA for DDH group. The data in this report are suitable as pilot data for future studies and for systematic reviews. Larger multicenter studies are needed to understand how the technical challenges of THA after periacetabular osteotomy affect postoperative complications and revision THA.Level III, therapeutic study.

  View details for DOI 10.1007/s11999-014-4026-7

  View details for PubMedID 25359629

  View details for PubMedCentralID PMC4294924

• Minimally Invasive Total Knee Arthroplasty Medscape http://emedicine.medscape.com/article/2000356-overview. Amanatullah, D. F., Di Cesare, P. E. 2015
• Osteonecrosis. Chapman's Comprehensive Orthopaedic Surgery. Arsoy, D., Amanatullah, D. F. 2015
• Polyethylene Liner Exchange and Pelvic Osteolysis. Master Techniques in Orthpaedic Surgery. Amanatullah, D. F., Maloney, W. J. 2015
• Total hip replacement in patients with Down syndrome and degenerative osteoarthritis of the hip. The bone & joint journal Amanatullah, D. F., Rachala, S. R., Trousdale, R. T., Sierra, R. J. 2014; 96-B (11): 1455-1458

  Abstract

  Dysplasia of the hip, hypotonia, osteopenia, ligamentous laxity, and mental retardation increase the complexity of performing and managing patients with Down syndrome who require total hip replacement (THR). We identified 14 patients (six males, eight females, 21 hips) with Down syndrome and degenerative disease of the hip who underwent THR, with a minimum follow-up of two years from 1969 to 2009. In seven patients, bilateral THRs were performed while the rest had unilateral THRs. The mean clinical follow-up was 5.8 years (standard deviation (sd) 4.7; 2 to 17). The mean Harris hip score was 37.9 points (sd 7.8) pre-operatively and increased to 89.2 (sd 12.3) at final follow-up (p = 1x10(-9)). No patient suffered a post-operative dislocation. In three patients, four hips had revision THR for aseptic loosening at a mean follow-up of 7.7 years (sd 6.3; 3 to 17). This rate of revision THR was higher than expected. Our patients with Down syndrome benefitted clinically from THR at mid-term follow-up.

  View details for DOI 10.1302/0301-620X.96B11.34089

  View details for PubMedID 25371456

• Total hip replacement in patients with Down syndrome and degenerative osteoarthritis of the hip BONE & JOINT JOURNAL Amanatullah, D. F., Rachala, S. R., Trousdale, R. T., Sierra, R. J. 2014; 96B (11): 1455-1458

  View details for DOI 10.1302/0301-620X.96B11.34089

  View details for Web of Science ID 000345026600006

• Non-Oncologic Total Femoral Arthroplasty: Retrospective Review JOURNAL OF ARTHROPLASTY Amanatullah, D. F., Trousdale, R. T., Hanssen, A. D., Lewallen, D. G., Taunton, M. J. 2014; 29 (10): 2013-2015

  Abstract

  Total femoral arthroplasty (TFA) is an option to amputation in the setting of excessive bones loss during revision total hip and knee arthroplasty. Twenty non-oncologic TFAs with a minimum of 2years follow-up were retrospectively reviewed. The average clinical follow-up was 73±49months. The incidence of new infection was 25% (5/20), while the overall infection rate was 35% (7/20). The incidence of primary hip instability was 10% (2/20), while the overall instability rate was 25% (5/20). Six patients (30%) required revision. The average pre-operative HHS was 30.2±13.1. The average post-operative HHS was 65.3±16.9. TFA is a viable alternative to amputation in non-oncologic patients with massive femoral bone deficiency. However, TFA performed poorly in the setting of infection and instability.

  View details for DOI 10.1016/j.arth.2014.05.012

  View details for Web of Science ID 000343159700024

  View details for PubMedID 25041874

• In Reply: Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases JOURNAL OF ARTHROPLASTY Amanatullah, D. F., Trousdale, R. T., Sierra, R. J. 2014; 29 (10): 2055-2055

  View details for DOI 10.1016/j.arth.2014.06.006

  View details for Web of Science ID 000343159700036

  View details for PubMedID 25070902

• Total knee arthroplasty after lower extremity amputation: a review of 13 cases. journal of arthroplasty Amanatullah, D. F., Trousdale, R. T., Sierra, R. J. 2014; 29 (8): 1590-1593

  Abstract

  Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation.

  View details for DOI 10.1016/j.arth.2014.03.041

  View details for PubMedID 24836176

• Torsional Properties of Distal Femoral Cortical Defects ORTHOPEDICS Amanatullah, D. F., Williams, J. C., Fyhrie, D. P., Tamurian, R. M. 2014; 37 (3): 158-162

  Abstract

  The optimal management of pathologic long bone lesions remains a challenge in orthopedic surgery. The goal of the current study was to investigate the effect of defect depth on the torsional properties of the distal femur. A laterally placed distal metaphyseal cylindrical defect was milled in the cortex of the distal femur in 20 composite models. The proximal extent of the defects was constant. By decreasing the radius of the cylinder that intersected this predefined cord, 4 different radii defining 4 different depths of resection of the distal femur were created for testing: 17%, 33%, 50%, and 67% cortical defects, when normalized to the width of the femur at the level of resection. Each femur was mounted into a hydraulic axial/torsion materials testing machine and each specimen underwent torsional stiffness testing and torsional failure in external rotation. The specimens with less than a 33% cortical loss consistently demonstrated a superiorly oriented spiral fracture pattern, while the specimens with greater than a 50% cortical loss consistently demonstrated an inferiorly oriented transverse fracture pattern. The cortical defects were all statistically (P<.05) less stiff in torsion as the defect grew larger. There was a strong linear correlation between the mean torsional stiffness and cortical defect size (r(2)=0.977). This observation is supported by finite element analysis. The amount of femur remaining is crucial to stability. This biomechanical analysis predicts a critical loss of torsional integrity when a cortical defect approaches 50% of the width of the femur.

  View details for DOI 10.3928/01477447-20140225-51

  View details for Web of Science ID 000332601700025

  View details for PubMedID 24762144

• The financial impact of the loss of county indigent patient funding on a single orthopedic trauma surgery service JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Forsh, D. A., Amanantullah, D. F., Coleman, S., Wolinsky, P. R. 2014; 76 (2): 529-533

  Abstract

  We examined the financial ramifications on the orthopedic trauma service after loss of payment to our institution for care of indigent patients. Our institution is the only Level I trauma center located within the county. Before mid-2009, county insurance-eligible patients treated at our institution had their health care paid for by the county. After mid-2009, the county no longer reimbursed our institution for care provided.A retrospective review was performed on 653 county patients treated by the four orthopedic trauma surgeons during a 4-year period including the 2 years before the loss of county payments as well as the 2-year period following the loss of payment. Data collected included demographics, admitting service, injuries treated, length of stay, surgeon billing, and reimbursement. We also classified the urgency of care that was rendered into one of three categories as follows: emergent, urgent, or elective.There was a higher frequency of emergent and urgent procedures and a lower frequency of elective cases performed in the noncontracted period versus the contracted period. During the contracted period, we billed and collected $1,161,036. After the loss of reimbursement from the county, we billed $870,590 and were paid $0. County reimbursements made up 33.5% of the total professional fees billed. There was a 20% net drop in total billing during the noncontracted period, of which the money not reimbursed by the county accounted for 31%.Despite the lack of county payment, our institution continues to provide care to the indigent population. This lack of payment may have significant long-term economic ramifications for the orthopedic trauma surgeons and for our institution. The financial burden preferentially falls on the "safety net" Level I trauma centers and the physicians who take care of patients with urgent and emergent injuries. This burden may be unsustainable in the future.Economic and value-based evaluation, level V.

  View details for DOI 10.1097/TA.0000000000000093

  View details for Web of Science ID 000336386100042

  View details for PubMedID 24458062

• Giant Cell Tumor of Bone ORTHOPEDICS Amanatullah, D. F., Clark, T. R., Lopez, M. J., Borys, D., Tamurian, R. M. 2014; 37 (2): 112-120

  Abstract

  EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Identify at-risk populations for giant cell tumor of bone. 2. Recognize the biology that drives giant cell tumor of bone. 3. Describe modern surgical and adjuvant techniques to effectively treat giant cell tumor of bone. 4. Recognize the complications associated with radiation therapy, poor resection, and adjuvant treatments. Giant cell tumor of bone (GCT) is a benign, locally aggressive bone tumor. Giant cell tumor of bone primarily affects the young adult patient population. The natural history of GCT is progressive bone destruction leading to joint deformity and disability. Surgery is the primary mode of treatment, but GCT has a tendency to recur locally despite a range of adjuvant surgical options. Pulmonary metastasis has been described. However, systemic spread of GCT rarely becomes progressive, leading to death. This review presents the clinicopathologic features of GCT and a historical perspective that highlights the current rationale and controversies regarding the treatment of GCT.

  View details for DOI 10.3928/01477447-20140124-08

  View details for Web of Science ID 000331879300031

  View details for PubMedID 24679193

• Non-oncologic Total Femoral Replacement: Retrospective Review Journal of Arthroplasty, epub ahead of print Amanatullah, D. F., Trousdale, R. T., Hanssen, A., Lewallen, D. G., Taunton, M. P. 2014
• Minimally Invasive Total Hip Arthroplasty Medscape http://emedicine.medscape.com/article/2000333-overview. Amanatullah, D. F., Di Cesare, P. E. 2014
• Total Hip Arthroplasty with and without Prior Periacetabular Osteotomy Clinical Orthopaedics and Related Research Amanatullah, D. F., Stryker, L., Schoenecker, P., Taunton, M. P., Clohish, J. C., Trousdale, R. T., Sierra, R. J. 2014
• Revision THA with Proximal Bone Deficiency using Fluted Tapered Modular Femoral Components. Bone and Joint Journal Amanatullah, D. F., Howard, J. L., Siman, H., Trousdale, R. T., Mabry, T. M., Berry, D. J. 2014
• Total Hip Arthroplasty after Lower Extremity Amputation Orthopedics Amanatullah, D. F., Trousdale, R. T., Sierra, R. J. 2014
• Peri-operative Management of the Total Knee: Patient Selection, Pain Management, Thromoprophylaxis, and Rehabilitation. Clinic Orthopaedic Practice. Amanatullah, D. F., Pallante, G., Paganano, M. W., Sierra, R. J. 2014
• Removal of Well-fixed Implants. Operative Techniques in Orthopaedic Surgery, 2nd Edition, awaiting publication Amanatullah, D. F., Pagnano, M. W. 2014
• Femoroacetabular Impingement: Current Concepts in Diagnosis and Treatment. Orthopedics, accepted, CME Amanatullah, D. F., Antkowiak, T., Pillay, K., Refaat, M., Jamali, A. A. 2014
• Effect of Heterotopic Ossification on Hip Range of Motion and Clinical Outcome Journal of Arthroplasty, accepted Vasileiadis, G. I., Amanatullah, D. F., Crenshaw, J., Pudillo, L., Taunton, M. P., Kaufman., K. 2014
• Distinct Patterns of Gene Expression in the Superficial, Middle and Deep Zones of Bovine Articular Cartilage Journal of Tissue Engineering and Regenerative Medicine Amanatullah, D. F., Yamane, S., Reddi , A. H. 2014; 8 (7)
• Total Hip Arthroplasty in Down Syndrome Bone and Joint Journal, accepted Amanatullah, D. F., Rachala, R., Sierra, R. J. 2014
• Minimally Invasive Total Hip Arthroplasty Medscape http://emedicine.medscape.com/article/2000333-overview. Amanatullah, D. F., Di Cesare, P. E. 2014
• Brachial Artery Avulsion Complicating a Supracondylar Humerus Fracture: A Case Report and Review Current Orthopaedic Practice Sheridan, K., Amanatullah, D. F., Voightlander, J. P., Ertl, J., Moehring, D. 2014; 25
• Giant Cell Tumor of Bone: Current Concepts in Diagnosis and Treatment. Orthopedics Amanatullah, D. F., Clark, T. R., Lopez, M. J., Borys, D., Tamurian, R. M. 2014; 37
• Recurrent Carpal Tunnel Syndrome Presenting with the Median Nerve Superficial to the Transverse Carpal Ligament Orthopedics, accepted Amanatullah, D. F., Gaskin, A., Allen, R. H. 2014
• Total Hip Arthroplasty after Lower Extremity Amputation Orthopedics Amanatullah, D. F. 2014
• Acetabular Fractures: What Radiologists Should Know and How 3D CT Images Can Aid Classification. RadioGraphics, accepted Scheinfeld , M., Amanatullah, D. F. 2014
• Similar Clinical Outcomes for Total Hip Arthroplasty with and without Prior Periacetabular Osteotomy Clinical Orthopaedics and Related Research, accpted Amanatullah, D. F., Stryker, L., Schoenecker, P., Taunton, M. P., Clohisy, J. C., Trousdale, R. T., Sierra, R. J. 2014
• Pre-operative Planning for the Adult Hip The Adult Hip, awaiting publication Pereira, G. C., Amanatullah, D. F., Di Ceasare, P. E. 2014
• Failure of a constrained acetabular liner without reinforcement ring disruption. American journal of orthopedics (Belle Mead, N.J.) Arthur, J. A., Amanatullah, D. F., Kennedy, G. D., Di Cesare, P. E. 2013; 42 (12): 566-568

  Abstract

  Several risk factors for dislocation after total hip arthroplasty (THA) have been identified including operative-, patient-, and implant-related factors. The following case report describes the dislocation of a revision THA without disruption of the constrained liner or containment ring. The possible mechanisms leading to this type of failure include lever-out impingement and poor abductor function, or tension secondary to prior surgery. Dislocation without disruption of containment ring has not been described for the Pinnacle Acetabular Cup with the Enhanced Stability Constrained Liner (DePuy Orthopaedics, Warsaw, Indiana).

  View details for PubMedID 24471147

• Identification of the Landmark Registration Safe Zones During Total Knee Arthroplasty Using an Imageless Navigation System JOURNAL OF ARTHROPLASTY Amanatullah, D. F., Di Cesare, P. E., Meere, P. A., Pereira, G. C. 2013; 28 (6): 938-942

  Abstract

  Incorrect registration during computer assisted total knee arthroplasty (CA-TKA) leads to malposition of implants. Our aim was to evaluate the tolerable error in anatomic landmark registration. We incorrectly registered the femoral epicondyles, femoral and tibial centers, as well as the malleoli and documented the change in angulation or rotation. We found that the distal femoral epicondyles were the most difficult anatomic landmarks to register. The other bony landmarks were more forgiving. Identification of the distal femoral epicondyles has a high inter-observer and intra-observer variability. Our observation that there is less than 2mm of safe zone in the anterior or posterior direction during registration of the medial and lateral epicondyles may explain the inability of CA-TKA to improve upon the outcomes of conventional TKA.

  View details for DOI 10.1016/j.arth.2012.12.013

  View details for Web of Science ID 000319846400013

  View details for PubMedID 23566700

• c-Maf Transcription Factor Regulates ADAMTS-12 Expression in Human Chondrogenic Cells CARTILAGE Hong, E., Yik, J., Amanatullah, D. F., Di Cesare, P. E., Haudenschild, D. R. 2013; 4 (2): 177-186

  Abstract

  ADAMTS (a disintegrin and metalloproteinase with thrombospondin type-1 motif) zinc metalloproteinases are important during the synthesis and breakdown of cartilage extracellular matrix. ADAMTS-12 is up-regulated during in vitro chondrogenesis and embryonic limb development; however, the regulation of ADAMTS-12 expression in cartilage remains unknown. The transcription factor c-Maf is a member of Maf family of basic ZIP (bZIP) transcription factors. Expression of c-Maf is highest in hypertrophic chondrocytes during embryonic development and postnatal growth. We hypothesize that c-Maf and ADAMTS-12 are co-expressed during chondrocyte differentiation and that c-Maf regulates ADAMTS-12 expression during chondrogenesis.Promoter analysis and species alignments identified potential c-Maf binding sites in the ADAMTS-12 promoter. c-Maf and ADAMTS-12 co-expression was monitored during chondrogenesis of stem cell pellet cultures. Luciferase expression driven by ADAMTS-12 promoter segments was measured in the presence and absence of c-Maf, and synthetic oligonucleotides were used to confirm specific binding of c-Maf to ADAMTS-12 promoter sequences.In vitro chondrogenesis from human mesenchymal stem cells revealed co-expression of ADAMTS-12 and c-Maf during differentiation. Truncation and point mutations of the ADAMTS-12 promoter evaluated in reporter assays localized the response to the proximal 315 bp of the ADAMTS-12 promoter, which contained a predicted c-Maf recognition element (MARE) at position -61. Electorphoretic mobility shift assay confirmed that c-Maf directly interacted with the MARE at position -61.These data suggest that c-Maf is involved in chondrocyte differentiation and hypertrophy, at least in part, through the regulation of ADAMTS-12 expression at a newly identified MARE in its proximal promoter.

  View details for DOI 10.1177/1947603512472697

  View details for Web of Science ID 000209218300008

  View details for PubMedID 26069660

• Subtrochanteric Fracture Following Removal of a Porous Tantalum Implant Case Reports in Orthopedics Amanatullah, D. F., Farac, R., McDonald, T. J., Moehring, H. D., Di Cesare, P. E. 2013
• Minimally Invasive Total Knee Arthroplasty Medscape http://emedicine.medscape.com/article/2000356-overview. Amanatullah, D. F., Di Cesare, P. E. 2013
• c-MAF Transcription Factor Regulates ADAMTS-12 Expression in Human Chondrocytes Cartilage Hong, E., Yik, J., Amanatullah, D. F., Di Cesare, P. E., Haudenschild, D. R. 2013; 4
• Minimally Invasive Total Knee Arthroplasty Medscape Amanatullah, D. F. 2013
• Wound Complications Surgery of the Hip Cheung, Y., Amanatullah, D. F., Di Cesare, P. E. 2013
• Case Report: Artificial Elevation of Prothrombin Time by Telavancin, Clinical Orthopaedics and Related Research Clinical Orthopaedics and Related Research Amanatullah, D. F., Lopez, M., Gosselin, R., Gupta, M. 2013; 471
• Free vascularized fibular transfer with langenskiöld procedure for the treatment of congenital pseudarthrosis of the forearm. Techniques in Hand and Upper Extremity Surgery Bauer, A. S., Singh, A. K., Amanatullah, D. F., Lerman, J. A., James, M. A. 2013; 17
• The application of minimally invasive surgical techniques. Part I: total hip arthroplasty. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Burrus, M. T., Sathappan, S. S., Levine, B., Di Cesare, P. E. 2012; 41 (10): E134-9

  Abstract

  Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If satisfactory alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

  View details for PubMedID 23376994

• The application of minimally invasive surgical techniques. Part II: total knee arthroplasty. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Burrus, M. T., Sathappan, S. S., Levine, B., Di Cesare, P. E. 2012; 41 (10): E140-4

  Abstract

  Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

  View details for PubMedID 23376995

• Identification of a 3Kbp Mechanoresponsive Promoter Region in the Human Cartilage Oligomeric Matrix Protein Gene TISSUE ENGINEERING PART A Amanatullah, D. F., Lu, J., Hecht, J., Posey, K., Yik, J., Di Cesare, P. E., Haudenschild, D. R. 2012; 18 (17-18): 1882-1889

  Abstract

  Expression of chondrocyte-specific genes is regulated by mechanical force. However, despite the progress in identifying the signal transduction cascades that activate expression of mechanoresponsive genes, little is known about the transcription factors that activate transcription of mechanoresponsive genes. The DNA elements that confer mechanoresponsiveness within a cartilage gene promoter have yet to be identified. We have established an experimental system to identify the DNA elements and transcription factors that mediate the mechanoresponse of a promoter to nominal compressive stress in primary human chondrocytes and stem cells in a three-dimensional culture system. Our results demonstrate that the proximal 3 Kb of the human cartilage oligomeric matrix protein promoter is sufficient to mediate a mechanoresponse in human articular chondrocytes and stem cells, and that the magnitude of mechanoresponse correlates to the regulation of the endogenous gene at the RNA and protein level. This information is critical to understanding how mechanical force regulates the transcriptional activation of cartilage genes in three-dimensional culture.

  View details for DOI 10.1089/ten.tea.2011.0497

  View details for Web of Science ID 000308704600014

  View details for PubMedID 22764748

• Effect of mini-fragment fixation on the stabilization of medial malleolus fractures JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Amanatullah, D. F., McDonald, E., Shellito, A., Lafazan, S., Cortes, A., Curtiss, S., Wolinsky, P. R. 2012; 72 (4): 948-953

  Abstract

  Oblique fractures of the medial malleolus can arise from the application of axial force at various anatomic positions of the ankle, including supination-external rotation, pronation-external rotation, or pronation abduction. Although a variety of techniques exist to provide fixation of horizontal medial malleolus fractures, the optimal technique and pattern for internal fixation remains unclear. The aim of this study was to evaluate the mechanical properties of four different fixation methods for fractures of the medial malleolus.Identical oblique osteotomies were created in synthetic distal tibiae using a jig. The specimens were divided into four fixation groups: contoured 2.0 mm mini-fragment T-plate, figure-of-eight tension band wire, construct two parallel 4.0 mm cancellous screws, and two divergent 4.0 mm cancellous screws. The specimens were tested using offset axial tension at 10 mm/min until 2 mm of joint line displacement.The average stiffness in tension and force at 2 mm of joint line displacement of the plate construct was significantly greater than any of the other constructs (p < 0.05), whereas the average stiffness in tension of the other three groups were not significantly different from each other (p > 0.05).Using a contoured 2.0 mm mini-fragment T-plate as the method of fixation resulted in an at least 25% stiffer construct during tension and required at least 24% more force for 2 mm of joint line displacement when compared with more traditional methods of fixation in an osteotomy model of an oblique medial malleolus fracture.

  View details for DOI 10.1097/TA.0b013e318249697d

  View details for Web of Science ID 000302784600033

  View details for PubMedID 22491610

• Effect of divergent screw fixation in vertical medial malleolus fractures JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Amanatullah, D. F., Khan, S. N., Curtiss, S., Wolinsky, P. R. 2012; 72 (3): 751-754

  Abstract

  This study qualified and evaluated the mechanical properties of three different screw orientations used for fixation of vertical shear fractures of the medial malleolus.Identical vertical osteotomies were created in synthetic distal tibiae using a jig. The specimens were assigned to one of the three fixation groups (n = 8 per group): (1) parallel: two 40 mm length, 4.0 mm diameter screws placed parallel to each other in the transverse plane; (2) convergent: two 40 mm length, 4.0 mm diameter screws placed 25 degree convergent to each other in the transverse plane; and (3) divergent: two 40 mm length, 4.0 mm diameter screws placed 15 degree divergent to each other in the transverse plane. The specimens were tested using offset axial loading at 1 mm/s until 2 mm of displacement.The average stiffness was 102 N/mm ± 51 N/mm for the parallel group, 109 N/mm ± 37 N/mm for the convergent group, and 185 N/mm ± 73 N/mm for the divergent group. The average stiffness of the divergent group was significantly greater than either the parallel (p < 0.05) or convergent (p < 0.05) groups. The divergent group was 81.4% more stiff than the parallel group and 69.7% more stiff than the convergent group. The average load at 2 mm of displacement was 324 N ± 87 N for the parallel group, 373 N ± 95 N for the convergent group, and 512 N ± 170 N for the divergent group. The average load at failure of the divergent group was significantly (p < 0.05) greater than the parallel groups. The divergent group was required 58.0% more force at 2 mm of displacement than the parallel group and 37.3% more force at 2 mm of displacement than the convergent group.The use of a divergent screw pattern resulted in a stiffer fixation construct that requires more force for 2 mm of displacement when used to stabilize an osteotomy model of vertical shear medial malleolus fractures.

  View details for DOI 10.1097/TA.0b013e31823b8b9f

  View details for Web of Science ID 000301371100046

  View details for PubMedID 22491565

• Patellar Polyethylene Spinout After Low-contact Stress, High-congruity, Mobile-bearing Patellofemoral Arthroplasty ORTHOPEDICS Amanatullah, D. F., Jamali, A. A. 2012; 35 (2): E272-E276

  Abstract

  A low-contact stress, high-congruity, mobile-bearing patellofemoral joint arthroplasty decreases the contact force in the patellofemoral joint, theoretically reducing patellar polyethylene wear and increasing implant longevity. This article describes the case of a 47-year-old obese woman who presented with pain and loss of extension after a low-contact stress, high-congruity, mobile-bearing patellofemoral joint arthroplasty. Radiographs revealed dislocation (ie, spinout) of the patellar polyethylene. Patellar polyethylene spinout is a rare complication of metal-backed, mobile-bearing patellar resurfacing. Theoretically, patellar polyethylene spinout in low-contact stress, high-congruity, mobile-bearing patellofemoral arthroplasty is related to implant design and the placement of the metal base plate. Ultimately, the articulation of low-contact stress, high-congruity, mobile-bearing patellofemoral arthroplasty may be too congruent to resist the forces of the patellofemoral joint, particularly in patients who are obese, and the patellar rotation allowed by this articulation may not be sufficient for all patients. Should patellar spinout occur, replacement of the polyethylene is not sufficient to correct the problem; hence, revision of the patellar and trochlear components is required because it remains unclear whether failure is secondary to patellar or trochlear design deficiencies.

  View details for DOI 10.3928/01477447-20120123-27

  View details for Web of Science ID 000300057300025

  View details for PubMedID 22310419

• Right Elbow Pain in a 21-year-old Pregnant Female Shoulder and Elbow Amanatullah, D. F., Bozzio, A. E., Mallon, Z. O., Mak, W. H., Borys, D., Tamurian, R. M. 2012; 4
• Minimally Invasive Total Hip Arthroplasty Medscape Drugs and Disease, http://emedicine.medscape.com/article/2000333-overview. Amanatullah, D. F., Joice, M., Di Cesare, P. E. 2012
• Surgical Intern Survival Guide Einstein Journal of Biology and Medicine Amanatullah, D. F. 2012; 27: 34-37
• Identification of a Mechanoresponsive 3 Kb Promoter Region in the Human Cartilage Oligomeric Matrix Protein Gene. Tissue Engineering Part A Amanatullah, D. F., Lu, J., Hecht, J., Posey, K., Yik, J., Di Cesare, P. E., Haudenschild, D. R. 2012; 18
• Intermediate-Term Radiographic and Patient Outcomes in Revision Hip Arthroplasty With a Modular Calcar Design and Porous Plasma Coating JOURNAL OF ARTHROPLASTY Amanatullah, D. F., Meehan, J. P., Cullen, A. B., Kim, S. H., Jamali, A. A. 2011; 26 (8): 1451-1454

  Abstract

  This study is a retrospective evaluation of the intermediate-term results of 26 consecutive revision total hip arthroplasties performed with a modular titanium, uncemented femoral component. The average patient age at the time of revision total hip arthroplasty was 72 years, and there were an equal number of males and females. The mean follow-up was 5.7 years (ranging from 4 to 11 years). No re-revision was necessary during this follow-up time. The mean Harris hip score improved significantly (preoperative and postoperative score was 50.7 and 89.6, respectively; P < .001). Postoperatively, Short Form 36 functional scores averaged 67.7 across 9 functional parameters. Our observed low revision rate and favorable patient-reported outcome scores support the continuous use of modular titanium, uncemented femoral components in revision total hip arthroplasty.

  View details for DOI 10.1016/j.arth.2010.12.026

  View details for Web of Science ID 000297389100052

  View details for PubMedID 21497483

• Current management options for osteonecrosis of the femoral head: part II, operative management. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Strauss, E. J., Di Cesare, P. E. 2011; 40 (10): E216-25

  Abstract

  Osteonecrosis of the femoral head is a multifactorial disease that can result in significant clinical morbidity and affects patients of any age, including young and active patients. Late sequelae of femoral head osteonecrosis include femoral head collapse and subsequent degeneration of the hip joint. A high index of suspicion and improved radiographic evaluation allow orthopedic surgeons to identify this disease at an earlier stage. Current management options for hip osteonecrosis have results that vary according to patient population and disease stage. Modifications of older techniques, as well as emerging technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis.

  View details for PubMedID 22263205

• Comparison of Surgical Outcomes and Implant Wear Between Ceramic-Ceramic and Ceramic-Polyethylene Articulations in Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Amanatullah, D. F., Landa, J., Strauss, E. J., Garino, J. P., Kim, S. H., Di Cesare, P. E. 2011; 26 (6): 72-77

  Abstract

  The results of a prospective multicenter trial comparing 357 hips randomized to total hip arthroplasty with either ceramic-ceramic or ceramic-polyethylene couplings are presented. No statistically significant difference in clinical outcomes scores between the ceramic-ceramic and ceramic-polyethylene groups was observed at any time interval. The mean linear rate was statistically lower (P < .001) in the ceramic-ceramic group (30.5 μm/year) when compared with the ceramic-polyethylene group (218.2 μm/year). The rates of ceramic implant fracture (2.6%) and audible component-related noise (3.1%) were statistically higher in the ceramic-ceramic group when compared with the ceramic-polyethylene group (P < .05). Lastly, there was no statistically significant difference in the dislocation or revision rate between the groups at the time of last clinical follow-up.

  View details for DOI 10.1016/j.arth.2011.04.032

  View details for Web of Science ID 000294393000014

  View details for PubMedID 21680138

• Current management options for osteonecrosis of the femoral head: part 1, diagnosis and nonoperative management. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Strauss, E. J., Di Cesare, P. E. 2011; 40 (9): E186-92

  Abstract

  Osteonecrosis of the femoral head is a multifactorial disease that can result in significant clinical morbidity and affects patients of any age, including young and active patients. Late sequelae of femoral head osteonecrosis include femoral head collapse and subsequent degeneration of the hip joint. A high index of suspicion and improved radiographic evaluation allow orthopedic surgeons to identify this disease at an earlier stage. Current management options for hip osteonecrosis have results that vary according to patient population and disease stage. Modifications of older techniques, as well as emerging technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis.

  View details for PubMedID 22022684

• Pelvic osteoid osteoma in a skeletally mature female. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Mallon, Z. O., Mak, W. H., Borys, D., Tamurian, R. M. 2011; 40 (9): 476-478

  Abstract

  Osteoid osteoma is the most common bone-producing tumor that typically presents with "throbbing night pain" and that improves dramatically with use of low-dose salicylates. Few cases of pelvic osteoid osteoma have been reported, and most have involved patients younger than age 30. Surgical excision classically has been the treatment of choice, but, recently, less invasive modalities, including radiofrequency ablation, have begun to supplant surgical management of osteoid osteoma, resulting in a decrease in the need for definitive surgical diagnosis and treatment. We present a rare case of osteoid osteoma in the pelvis of a woman older than age 30.

  View details for PubMedID 22022677

• Applying computer-assisted navigation techniques to total hip and knee arthroplasty. American journal of orthopedics (Belle Mead, N.J.) Amanatullah, D. F., Burrus, M. T., Sathappan, S. S., Levine, B., Di Cesare, P. E. 2011; 40 (8): 419-426

  Abstract

  Appropriate implant alignment is a major goal of total joint arthroplasty. Obtaining appropriate alignment typically involves making intraoperative decisions in response to visual and tactile feedback. Integrated computer-based systems provide the option of continuous real-time feedback and offer the potential to decrease intraoperative errors while enhancing the surgical learning experience. Computer-assisted orthopedic surgery helps the surgeon perform both intraoperative and postoperative technical audits of implant alignment. Improving implant alignment can be correlated with improved long-term clinical outcomes. However, despite emerging data, many surgeons remain wary of computer-assisted orthopedic surgery.

  View details for PubMedID 22016871

• Biomechanical properties of volar hybrid and locked plate fixation in distal radius fractures. journal of hand surgery Sokol, S. C., Amanatullah, D. F., Curtiss, S., Szabo, R. M. 2011; 36 (4): 591-597

  Abstract

  We compare the biomechanical properties of a volar hybrid construct to an all-locking construct in an osteoporotic and normal comminuted distal radius fracture model.Groups of 28 normal, 28 osteoporotic, and 28 over-drilled osteoporotic left distal radius synthetic bones were used. The normal group consisted of synthetic bone with a standard foam core. The osteoporotic group consisted of synthetic bone with decreased foam core density. The over-drilled osteoporotic group consisted of synthetic bone with decreased foam core density and holes drilled with a 2.3 mm drill, instead of the standard 2.0 mm drill, to simulate the lack of purchase in osteoporotic bone. Within each group, 14 synthetic bones were plated with a volar locking plate using an all-locking screw construct, and 14 synthetic bones were plated with a volar locking plate using a hybrid screw construct (ie, both locking and nonlocking screws). A 1-cm dorsal wedge osteotomy was created with the apex 2 cm from the volar surface of the lunate facet. Each specimen was mounted to a materials testing machine, using a custom-built, standardized axial compression jig. Axial compression was delivered at 1 N/s over 3 cycles from 20 N to 100 N to establish stiffness. Each sample was stressed to failure at 1 mm/s until 5 mm of permanent deformation occurred.Our results show no difference in construct stiffness and load at failure between the all-locking and hybrid constructs in the normal, osteoporotic, or over-drilled osteoporotic synthetic bone models. All specimens failed by plate bending at the osteotomy site with loss of height.Although volar locking plates are commonly used for the treatment of distal radius fractures, the ideal screw configuration has not been determined. Hybrid fixation has comparable biomechanical properties to all locking constructs in the fixation of metaphyseal fractures about the knee and shoulder and might also have a role in the fixation of distal radius fractures.

  View details for DOI 10.1016/j.jhsa.2010.12.032

  View details for PubMedID 21463723

• Biomechanical Properties of Volar Hybrid and Locked Plate Fixation in Distal Radius Fractures JOURNAL OF HAND SURGERY-AMERICAN VOLUME Sokol, S. C., Amanatullah, D. F., Curtiss, S., Szabo, R. M. 2011; 36A (4): 591-597

  View details for DOI 10.1016/j.jhsa.2010.12.032

  View details for Web of Science ID 000289493300004

• Transverse Deficiency in the Upper Limb Orthopaedic Knowledge Update: Pediatrics James, M. A., Amanatullah, D. F. 2011
• Intermediate-term Radiographic Patient Outcomes in Revision Hip Arthroplasty with a Modular Calcar Design and Plasma Porous Coating Journal of Arthroplasty Amanatullah, D. F., Meehan, J. P., Cullen, A. B., Kim, S. H., Jamali, A. A. 2011; 26
• Current Treatment Options for Osteonecrosis of the Femoral Head: Part 1, Diagnosis and Nonoperative Management. American Journal of Orthopedics Amanatullah, D. F., Strauss, E. J., Di Cesare, P. E. 2011; 40
• Current Treatment Options for Osteonecrosis of the Femoral Head: Part II, Operative Management American Journal of Orthopedics Amanatullah, D. F., Strauss, E. J., Di Cesare, P. E. 2011; 40
• Progression of aggressive metastatic carcinosarcoma after treatment of epithelioid osteosarcoma. Orthopedics Amanatullah, D. F., Ngann, K. K., Borys, D., Tamurian, R. M. 2010; 33 (6): 445-?

  Abstract

  Osteosarcoma is the most common primary malignant osseous neoplasm, constituting approximately 35% of skeletal malignancies. The different subtypes of osteosarcoma are differentiated based on clinical, histologic, and radiographic data, as well as the variable amount of osteoid produced by malignant cells. The epithelioid osteosarcoma subtype accounts for only 5.7% of all osteosarcomas and portends an extremely poor prognosis. The 5-year survival rate for patients with epithelioid osteosarcoma treated with surgery (with or without chemotherapy) is 13.5%. This is in direct contrast to the >70% ten-year survival rate of conventional osteosarcoma treated with surgery and chemotherapy. This article presents a fatal case of epithelioid osteosarcoma in an 11-year-old girl with right knee pain of 6 months' duration. Biopsy demonstrated morphologic findings consistent with high-grade osteosarcoma with epithelioid features. The epithelioid component was positive for vimentin and CD99; however, fluorescent in situ hybridization for the (11;22) translocation was negative. In this case, the epithelioid cells failed to respond to conventional or subsequent experimental chemotherapy for osteosarcoma and eventual metastasized to the lymph nodes and lungs despite multiple ablative surgeries. This case report supports the concept of carcinosarcoma with malignant cells lines arising from 2 different cellular lineages or a common cellular precursor. The epithelial component was more aggressive than the cells of mesenchymal origin, highlighting the need for continued research and a more favorable outcome for this rare subset of osteosarcoma.

  View details for DOI 10.3928/01477447-20100429-26

  View details for PubMedID 20806764

• Hip Resurfacing Arthroplasty: A Review of the Evidence for Surgical Technique, Outcome, and Complications ORTHOPEDIC CLINICS OF NORTH AMERICA Amanatullah, D. F., Cheung, Y., Di Cesare, P. E. 2010; 41 (2): 263-?

  Abstract

  Hip resurfacing arthroplasty has reemerged as a valid reconstruction option for the osteoarthritic hip. Patient selection is critical for excellent surgical outcomes, especially when compared with total hip arthroplasty. However, concerns regarding surgical technique and postsurgical complications persist. The authors review the evidence for surgical technique, outcomes, and complications related to modern metal-on-metal hip resurfacing arthroplasty.

  View details for DOI 10.1016/j.ocl.2010.01.002

  View details for Web of Science ID 000277461800015

  View details for PubMedID 20399365

• Selection of Aggressive Metastatic Carcinoma after Treatment of Epithelioid Osteosarcoma Orthopedics Amanatullah, D. F., Ngann, K. K., Borys, D., Tamurian, R. M. 2010; 33
• Alternative Fixation for Small Medial Malleolus Fractures Orthopedics Amanatullah, D. F., Wolinsky, P. R. 2010; 33
• PU.1 inhibits the erythroid program by binding to GATA-1 on DNA and creating a repressive chromatin structure EMBO JOURNAL Stopka, T., Amanatullah, D. F., Papetti, M., Skoultchi, A. I. 2005; 24 (21): 3712-3723

  Abstract

  Transcriptional repression mechanisms are important during differentiation of multipotential hematopoietic progenitors, where they are thought to regulate lineage commitment and to extinguish alternative differentiation programs. PU.1 and GATA-1 are two critical hematopoietic transcription factors that physically interact and mutually antagonize each other's transcriptional activity and ability to promote myeloid and erythroid differentiation, respectively. We find that PU.1 inhibits the erythroid program by binding to GATA-1 on its target genes and organizing a complex of proteins that creates a repressive chromatin structure containing lysine-9 methylated H3 histones and heterochromatin protein 1. Although these features are thought to be stable aspects of repressed chromatin, we find that silencing of PU.1 expression leads to removal of the repression complex, loss of the repressive chromatin marks and reactivation of the erythroid program. This process involves incorporation of the replacement histone variant H3.3 into nucleosomes. Repression of one transcription factor bound to DNA by another transcription factor not on the DNA represents a new mechanism for downregulating an alternative gene expression program during lineage commitment of multipotential hematopoietic progenitors.

  View details for DOI 10.1038/sj.emboj.7600834

  View details for Web of Science ID 000233118500004

  View details for PubMedID 16222338

• Eat to Live: The Revolutionary Formula for Fast and Sustained Weight Loss Einstein Journal of Biology and Medicine Amanatullah, D. F. 2004; 21
• The cell cycle in steroid hormone regulated proliferation and differentiation. Minerva endocrinologica Amanatullah, D. F., Zafonte, B. T., Pestell, R. G. 2002; 27 (1): 7-20

  Abstract

  Steroid hormones mediate pleiotropic cellular processes involved in metabolism, cellular proliferation, and differentiation. The ability of the cell to respond to its hormonal environment is transduced by nuclear receptors (NRs) that bind both hormone and DNA. Hence, NRs represent a link between the external hormonal milieu and the genes that control cell physiology. Therefore, understanding the effects of steroid hormones on proliferation and differentiation requires a knowledge of the cell cycle, the interaction of NRs at the level of transcription, and the potential areas of cross-talk between these two.

  View details for PubMedID 11845110

• The Importance of a Physician's Wit: A Critical Analysis of Science in Medicine Einstein Quarterly Journal of Biology and Medicine Amanatullah, D. F. 2002; 19
• Translational Research: From the Bench to the Bedside and Back Einstein Quarterly Journal of Biology and Medicine Amanatullah, D. F. 2001; 18
• Ras Regulation of Cyclin-dependent Immunoprecipitation Kinase Assays Methods in Enzymology Zafonte, B. T., Amanatullah, D. F., Sage, D., Augenlicht, L. H., Pestell, R. G. 2001; 333
• Ras Regulation of Cyclin D1 Promoter. Methods in Enzymology Amanatullah, D. F., Zafonte, B. T., Albanese, C., Fu, M., Messiers, C., Hassell, J., Pestell, R. G. 2001; 333
• Cell-cycle dysregulation in breast cancer: Breast cancer therapies targeting the cell cycle FRONTIERS IN BIOSCIENCE Zafonte, B. T., Hulit, J., Amanatullah, D. F., Albanese, C., Wang, C. G., Rosen, E., Reutens, A., Sparano, J. A., Lisanti, M. P., Pestell, R. G. 2000; 5: D938-D961

  Abstract

  Breast cancer is the most commonly diagnosed cancer in American women. The underlying mechanisms that cause aberrant cell proliferation and tumor growth involve conserved pathways, which include components of the cell cycle machinery. Proto-oncogenes, growth factors, and steroids have been implicated in the pathogenesis of breast cancer. Surgery, local irradiation, and chemotherapy have been the mainstay of treatment for early and advanced stage disease. Potential targets for selective breast cancer therapy are herein reviewed. Improved understanding of the biology of breast cancer has led to more specific "targeted therapies" directed at biological processes that are selectively deregulated in the cancerous cells. Examples include tamoxifen for estrogen receptor positive tumors and imunoneutralizing antibodies such as trastuzumab for Her2/neu overexpressing tumors. Other novel anticancer agents such as paclitaxel, a microtubule binding molecule, and flavopiridol, a cyclin dependent kinase inhibitor, exert their anticancer effects by inhibiting cell cycle progression.

  View details for Web of Science ID 000166736900004

  View details for PubMedID 11102317

• The integrin-linked kinase regulates the cyclin D1 gene through glycogen synthase kinase 3 beta and cAMP-responsive element-binding protein-dependent pathways JOURNAL OF BIOLOGICAL CHEMISTRY D'Amico, M., Hulit, J., Amanatullah, D. F., Zafonte, B. T., Albanese, C., Bouzahzah, B., Fu, M. F., Augenlicht, L. H., Donehower, L. A., Takemaru, K. I., MOON, R. T., Davis, R., Lisanti, M. P., Shtutman, M., Zhurinsky, J., Ben-Ze'Ev, A., Troussard, A. A., Dedhar, S., Pestell, R. G. 2000; 275 (42): 32649-32657

  Abstract

  The cyclin D1 gene encodes the regulatory subunit of a holoenzyme that phosphorylates and inactivates the pRB tumor suppressor protein. Cyclin D1 is overexpressed in 20-30% of human breast tumors and is induced both by oncogenes including those for Ras, Neu, and Src, and by the beta-catenin/lymphoid enhancer factor (LEF)/T cell factor (TCF) pathway. The ankyrin repeat containing serine-threonine protein kinase, integrin-linked kinase (ILK), binds to the cytoplasmic domain of beta(1) and beta(3) integrin subunits and promotes anchorage-independent growth. We show here that ILK overexpression elevates cyclin D1 protein levels and directly induces the cyclin D1 gene in mammary epithelial cells. ILK activation of the cyclin D1 promoter was abolished by point mutation of a cAMP-responsive element-binding protein (CREB)/ATF-2 binding site at nucleotide -54 in the cyclin D1 promoter, and by overexpression of either glycogen synthase kinase-3beta (GSK-3beta) or dominant negative mutants of CREB or ATF-2. Inhibition of the PI 3-kinase and AKT/protein kinase B, but not of the p38, ERK, or JNK signaling pathways, reduced ILK induction of cyclin D1 expression. ILK induced CREB transactivation and CREB binding to the cyclin D1 promoter CRE. Wnt-1 overexpression in mammary epithelial cells induced cyclin D1 mRNA and targeted overexpression of Wnt-1 in the mammary gland of transgenic mice increased both ILK activity and cyclin D1 levels. We conclude that the cyclin D1 gene is regulated by the Wnt-1 and ILK signaling pathways and that ILK induction of cyclin D1 involves the CREB signaling pathway in mammary epithelial cells.

  View details for Web of Science ID 000090003800039

  View details for PubMedID 10915780

• Cell-cycle dysregulation and the molecular mechanisms of prostate cancer FRONTIERS IN BIOSCIENCE-LANDMARK Amanatullah, D. F., Reutens, A. T., Zafonte, B. T., Fu, M. F., Mani, S., Pestell, R. G. 2000; 5: D372-D390

  Abstract

  Prostate cancer is the most common cause of non-cutaneous cancer in men and although frequently latent is the second commonest cause of death. Screening for the disease was historically based on symptoms of urethral obstruction, clinical examination of the prostate gland and serum measurements of prostate specific antigen. As prostate cancer growth in the early stages is enhanced by androgens, the mainstay of therapy has been androgen ablation by pharmaco-therapeutic or surgical means. The subsequent development of androgen therapy resistant prostate cancer in many patients, for whom therapeutic options remain limited, has led researchers to focus attention on understanding the molecular genetics of prostate cancer. The array of genetic abnormalities observed in prostate tumors, which include changes in components of the cell cycle, suggest the disease is quite heterogeneous and may require further sub-classification based on genetic markers. Such analyses may lead to identification of relevant new prognostic and therapeutic indicators. The advent of transgenic mouse models of prostate cancer may provide a critical tool for the implementation of rational genetic based therapeutics and alternate drug design.

  View details for Web of Science ID 000089662900001

  View details for PubMedID 10762592

• Cell-cycle Dysregulation and Molecular Mechanisms of Prostate Cancer Frontiers in Bioscience Amanatullah, D. F. 2000
• The Integrin-linked Kinase Regulates the Cyclin D1 Gene through Glycogen Synthase Kinase 3 and cAMP-responsive Element-binding Protein-dependent Pathways Journal of Biological Chemistry D'Amico, M. J., Hulit, J., Amanatullah, D. F., Zafonte, B. T., Albanese, C., Bouzahzah, B., Fu, M., Augenlicht, L. H., Donehower, L. A., Takemaru, K. I., Moon, R. T., Davis, R., Lisanti, M., Shtutman, M., Zhurinsky, J., Ben-Ze'ev,, A., Troussard, A. A., Dedhar, S., Pestell, R. G. 2000; 275
• Adenosine receptor mediates motility in human melanoma cells BIOCHEMICAL AND BIOPHYSICAL RESEARCH COMMUNICATIONS Woodhouse, E. C., Amanatullah, D. F., SCHETZ, J. A., Liotta, L. A., Stracke, M. L., Clair, T. 1998; 246 (3): 888-894

  Abstract

  Cell motility is an essential component of tumor progression and metastasis. A number of factors, both autocrine and paracrine, have been found to influence cell motility. In the present study, adenosine and adenine nucleotides directly stimulated chemotaxis of A2058 melanoma cells in the absence of exogenous factors. Three adenosine receptor agonists stimulated motility in the melanoma cells and two adenosine receptor antagonists strongly inhibited the chemotactic response to both adenosine and AMP. The chemotactic stimulation by adenosine and AMP was pertussis toxin sensitive. Otherwise unresponsive Chinese hamster ovary cells which were transfected with the adenosine A1 receptor cDNA acquired the direct, pertussis toxin sensitive, chemotactic response to adenosine, and this response was inhibited by adenosine receptor antagonists. These findings demonstrate that adenosine and adenine nucleotides are capable of stimulating chemotaxis of tumor cells mediated through an adenosine receptor, probably of the A1 subtype. The possibility of antimetastatic therapies based on inhibition of adenosine receptor activity is raised.

  View details for Web of Science ID 000074061900057

  View details for PubMedID 9618307

• Development of Metastases Cutaneous Oncology Woodhouse, E., Amanatullah, D. F., Duray, P., Liotta, L. 1998