Total joint arthroplasties (TJA) are some of the most commonly performed surgeries in the United States with the number of TJA expected to rise significantly over the next decade as the population ages and arthritic burden worsens. However, the rise in TJA volume correlates with a heightened risk of complications, notably prosthetic joint infections (PJI), despite their low occurrence rate of less than 2%. PJI imposes a significant burden on surgery success, patient well-being, and healthcare costs, with an estimated annual expense of 1.85 billion dollars for hip and knee PJI by 2030. This manuscript delves into the pathophysiology of PJI, exploring our current understanding of the role of bacterial biofilm formation on implanted foreign hardware, providing protection against the host immune system and antibiotics. The article reviews current agents and their efficacy in treating PJI, as well as their cytotoxicity toward native cells involved in wound healing, prompting the exploration of a novel citrate-based solution. The paper highlights the superior properties and efficacy of a novel citrate-based irrigation solution on the treatment and prevention of PJI via increased antimicrobial properties, greater biofilm disruption, increased exposure time, and reduced cytotoxicity compared to conventional solutions, positioning it as a promising alternative. It also provides a perspective on its clinical use in the operating theater, with a step-by-step approach in TJA, whether primary or revisionary.

Knee osteoarthritis (KOA) is characterized by low-grade inflammation, loss of articular cartilage, subchondral bone remodeling, synovitis, osteophyte formation, and pain. Strong, continuous pain may indicate the need for joint replacement in patients with end-stage OA, although postoperative pain (POP) of at least a two-month duration persists in 10-40% of patients with OA.
OBJECTIVE: The inflammation observed in joint tissues is linked to pain caused by the production of proinflammatory cytokines. Since the biosynthesis of cytokines requires energy, their production is supported by extensive metabolic conversions of carbohydrates and fatty acids, which could lead to a disruption in cellular homeostasis. Therefore, this study aimed to investigate the association between POP development and disturbances in energy metabolic conversions, focusing on carbohydrate and fatty acid metabolism.
METHODS: Peripheral blood samples were collected from 26 healthy subjects and 50 patients with end-stage OA before joint replacement surgery. All implants were validated by orthopedic surgeons, and patients with OA demonstrated no inherent abnormalities to cause pain from other reasons than OA disease, such as malalignment, aseptic loosening, or excessive bleeding. Pain levels were assessed before surgery using the visual analogue scale (VAS) and neuropathic pain questionnaires, DN4 and PainDETECT. Functional activity was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Three and six months after surgery, pain indices according to a VAS of 30 mm or higher were considered. Total RNA isolated from whole blood was analyzed using quantitative real-time RT-PCR (qRT-PCR) for the expression of genes related to carbohydrate and fatty acid metabolism. Protein levels of the examined genes were measured using an ELISA in the peripheral blood mononuclear cells (PBMCs). We used qRT-PCR because it is the most sensitive and reliable method for gene expression analysis, while an ELISA was used to confirm our qRT-PCR results.
RESULTS: Among the study cohort, 17 patients who reported POP demonstrated significantly higher (p < 0.05) expressions of the genes PKM2, LDH, SDH, UCP2, CPT1A, and ACLY compared to pain-free patients with KOA. Receiver-operating characteristic (ROC) curve analyses confirmed the association between these gene expressions and pain development post-arthroplasty. A principle component analysis identified the prognostic values of ACLY, CPT1A, AMPK, SDHB, Caspase 3, and IL-1β gene expressions for POP development in the examined subjects.
CONCLUSIONS: These findings suggest that the disturbances in energy metabolism, as observed in the PBMCs of patients with end-stage KOA before arthroplasty, may contribute to POP development. An understanding of these metabolic processes could provide insights into the pathogenesis of KOA. Additionally, our findings can be used in a clinical setting to predict POP development in end-stage patients with KOA before arthroplasty.

More than 700,000 people in the United States undergo total knee arthroplasty (TKA) each year. Chronic venous insufficiency (CVI) affects 5% to 30% of adults, sometimes resulting in leg ulceration. These CVI cases in TKAs have been associated with worse outcomes; however, we found no study differentiating CVI severity.
This retrospective study analyzed TKA outcomes at one institution from 2011 to 2021 using patient-specific codes. Analyses included short-term complications (< 90 days postoperative), long-term complications (< 2 years), and CVI status (yes/no; simple/complex/unclassified). Complex CVI consisted of pain, ulceration, inflammation, and/or other complications. Revisions within 2 years and readmissions within 90 days post-TKA were assessed. Composite complications included short-term and long-term complications, revisions, and readmissions. Multivariable logistic regressions predicted complication (any/long/short) as a function of CVI status (yes/no; simple/complex) and potential confounding variables. Of 7,665 patients, 741 (9.7%) had CVI. Among CVI patients, 247 (33.3%) had simple CVI, 233 (31.4%) had complex CVI, and 261 (35.2%) had unclassified CVI.
There was no difference in CVI versus control in composite complications (P = .722), short-term complications (P = .786), long-term complications (P = .15), revisions (P = .964), or readmissions (P = .438) postadjustment. Composite complication rates were 14.0% without CVI, 16.7% with complex CVI, and 9.3% with simple CVI. Complication rates differed between simple and complex CVI (P = .035).
Overall, CVI did not affect postoperative complications versus control. Patients who have complex CVI are at higher risk for post-TKA complications compared to those who have simple CVI.

BACKGROUND: Total cementless hip joint arthroplasty is a method commonly used in the treatment of advanced hip osteoarthritis. The aim of this paper is to present the early results of hip joint arthroplasty with the straight Zweymller stem.
METHODS: The study enrolled 117 patients (64 women and 53 men) who underwent a total of 123 hip joint arthroplasties with the straight Zweymller stem. The mean age of the patients at surgery was 60.8 years (range: 26-81 years). The mean follow-up period was 7.7 years (range: 5-12.6 years).
RESULTS: Pre-operative Merle dAubigne-Postel scores (modified by Charnley) of the study group were poor in all patients. Mean post-operative improvement was 6.3 points. The outcomes were classified as excellent in 42 cases (34.15%), good in 56 cases (45.53%), satisfactory in 14 (11.38%) and poor in 11 cases. Poor results were always associated with implant loosening. Heterotopic ossification was noted in 8 cases (6.5%). According to the Kaplan-Meier estimator, 5-year survival probability was 91.1% for the whole implant and 95.1% for the stem alone.
CONCLUSIONS: 1. Our follow-up data (from a mean follow-up period of more than 7 years) indicate that the straight Zweymller stem affords excellent clinical and functional results in patients operated on for advanced hip osteoarthritis. 2. In patients correctly qualified for this procedure, with good surgical technique and in the absence of complications, the risk of aseptic loosening is minimal. 3. As only medium-term follow-up data are available, there may be more cases of loosening (mainly of the acetabular cup) over time, indicating a need of regular long-term follow-up.

Revisions of total knee arthroplasties (TKAs) may require revision of one or both tibial and femoral components. Our purpose was to examine the clinical and functional outcomes in 1- versus 2-component TKA revisions.
We identified 92 1-component (tibial or femoral) revisions at a single center. Our inclusion criteria were isolated revision of the tibial or femoral components with a minimum 2-year follow-up. The included cases were matched 1:2 with a control group of 2-component revisions (tibial and femoral) by age, body mass index, American Society of Anesthesiologists score, and indication for revision. We collected demographics, complications, operative times, any subsequent rerevisions, and functional outcome scores.
The median follow-up time for the 1- and 2-component revision groups were 10 years (range, 3 to 17) and 8 years (range, 2 to 18), respectively. The most common complication after rerevision in both groups was stiffness at 9 of 92 (9.8%) and 9 of 170 (5.3%) in the 1- and 2-component groups, respectively (P = .20). The overall complication prevalence in the 1- and 2- component revision groups was similar 20 of 92 (22%) and 35 of 170 (21%), respectively (P = .87). Subsequent rerevisions for any indication were encountered in 12 of 92 (13.0%) of the 1-component and 18 of 170 (11%) in the 2-component groups (P = .69). There was no statistical difference in survivorship or functional outcomes scores between the groups.
Our results showed that isolated revision of a single TKA component is an acceptable option, with comparable functional outcomes, complications, and survivorships when compared with both-component revision. As such, a 1-component revision should be considered where appropriate.

BACKGROUND: With the development of hip arthroplasty, there are increasingly more indications for effective use of this surgical method. Endoprostheses are now being more and more commonly used in difficult cases of secondary coxarthrosis and in increasingly younger patients. The aim of this study is to present the early results of hip joint arthroplasty with the Zweymüller conical screw cup.
METHODS: The study enrolled 117 patients (64 women and 53 men) who underwent a total of 123 hip joint arthroplasties with the Zweymüller conical screw cup. The mean age of the patients at surgery was 60.8 years (range: 26-81 years). The mean follow-up period was 7.7 years (range: 5-12.6 years).
RESULTS: Pre-operative Merle d\'Aubigne-Postel scores (modified by Charnley) of the study group were poor in all patients. Mean post-operative improvement was 6.3 points. The outcomes were classified as excellent in 42 cases (34.15%), good in 56 cases (45.53%), satisfactory in 14 (11.38%) and poor in 11 cases. Poor results were always associated with implant loosening. Heterotopic ossification was noted in 8 cases (6.5%). According to the Kaplan-Meier estimator, 5-year survival probability was 91.1% for the whole implant and 94.3% for the stem alone.
CONCLUSIONS: 1. Our follow-up data (from a mean follow-up period of more than 7 years) indicate that the Zwey-müller conical screw cup affords excellent clinical and functional results in patients operated on for advanced hip osteoarthritis. 2. In patients correctly qualified for this procedure, with good surgical technique and in the absence of complications, the risk of aseptic loosening is minimal. 3. As only medium-term follow-up data are available, there may be more cases of loosening over time, indicating a need of regular long-term follow-up.

BACKGROUND: The aim of the paper is to describe the outcomes of hip arthroplasty with the anatomical AURA II stem (BIOMET).
METHODS: The study enrolled 189 patients (105 women and 84 men) who underwent a total of 213 hip arthroplasty procedures with the anatomical AURA II stem. Mean age of the patients at surgery was 61.7 years (range: 21 to 76 years) and mean follow-up period was 131.9 months (11 years).
RESULTS: Pre-operative Merle d\'Aubigne-Postel scores (modified by Charnley) of the study group were poor in all patients. Mean post-operative improvement in the scores was 6.8 points. Excellent results were obtained in 123 cases, good in 22, fair in 24 and poor in 44 cases. The poor results were always associated with acetabular cup loosening. A total of 13 (6.1%), patients developed heterotopic ossification. According to the Kaplan-Meier estimator, 10 years\' survival probability was 76.19% for the whole endoprosthesis and 100% for the stem alone.
CONCLUSIONS: 1. Our follow-up data from a mean of 11 years show that the use of the anatomical AURA II stem results in a considerable reduction in hip pain and produces good and lasting clinical outcomes. 2. With good surgical technique and in the absence of complications, the risk of aseptic loosening is minimal.

BACKGROUND: Glenoid component loosening is a common cause of failure after anatomic total shoulder arthroplasty. Prior studies of all-polyethylene glenoid implants with hybrid fixation did not show early glenoid radiolucency to be clinically significant. The purpose of this study was to determine the clinical significance of progression of radiolucency around the central peg of the glenoid component.
METHODS: We identified 73 shoulders that underwent primary anatomic total shoulder arthroplasty between January 1995 and May 2015 for osteoarthritis with an all-polyethylene pegged glenoid, with a minimum follow-up interval of 2 years between early and late follow-up. Demographic, radiographic (central-peg osteolysis [CPO] and central-peg grading [CPG]), and outcome variables comprising the Penn Shoulder Score (PSS) and revision surgery were collected. Clinical failure was defined as a PSS decrease >11.4 points (ie, PSS failure) or revision surgery.
RESULTS: The average patient age at surgery was 65 ± 7 years, and 63% of patients were men. The median initial follow-up period was 14 months (interquartile range, 12-25 months), and the final median follow-up period was 56 months (interquartile range, 47-69 months). Revision surgical procedures were performed in 4 patients, and 17 PSS failures occurred. We found that CPO at final follow-up, CPG progression, and worse PSS at follow-up were associated with revision surgery (P < .05). We also found younger age at surgery, CPO at final follow-up, CPG progression, and greater glenoid component retroversion at final follow-up to be associated with clinical failure (PSS failure or revision surgery) (P < .05). Multivariate analysis found only CPG progression to be associated with clinical failure (P < .001).
CONCLUSIONS: CPO and CPG progression were associated with clinical failure, defined as decreasing clinical outcome scores or revision surgery.

BACKGROUND: Both anatomic and reverse total shoulder arthroplasty are considered successful surgeries to treat a variety of painful shoulder conditions. Although implant survivorship for both is good to excellent in the long term, a variety of factors-clinical, technical, and psychosocial-may affect patient-reported outcomes after shoulder arthroplasty.
METHODS: A comprehensive review of the literature was performed systematically using keywords \"shoulder arthroplasty outcomes,\" \"psychosocial factors shoulder,\" \"shoulder replacement outcomes,\" \"depression shoulder arthroplasty,\" \"satisfaction shoulder arthroplasty,\" \"factors shoulder replacement,\" \"expectations shoulder arthroplasty,\" and \"predictors shoulder arthroplasty.\" Studies meeting the inclusion criteria were screened and analyzed. Type of surgery performed, sample size, outcome measures, and other factors influencing patient outcomes were recorded and analyzed.
RESULTS: Sixteen studies met the inclusion criteria. Six reviewed mental health disorders as predictors of postoperative outcome after shoulder arthroplasty. Of these, 4 found that disorders such a depression and anxiety were associated with increased risk of perioperative complications and lower final functional outcome scores. Two studies evaluated workers\' compensation status as a possible predictor of outcomes and found that patients with claims had lower satisfaction and outcome scores at final follow-up compared with those without claims. Two studies showed that preoperative opioid use was associated with lower outcome scores and overall satisfaction rate after shoulder arthroplasty. Three studies showed that higher patient confidence and preoperative expectations were correlated with better outcomes.
CONCLUSIONS: Our review shows that psychosocial factors may play just as important role in affecting patient outcomes after total shoulder arthroplasty as technical factors.

Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is associated with significant morbidity and cost. The purpose of this study was to determine how rates of perioperative complications, operative duration, and postoperative length of stay (LOS) in patients undergoing revision THA for PJI compare to primary THA and to revision THA for non-PJI.
We used the National Surgical Quality Improvement Program registry from 2005 to 2015 to identify all patients who underwent primary and revision THA. Patients were placed into cohorts based on the surgical procedure and by indication, including (1) primary THA, (2) revision THA for PJI, and (3) revision THA for non-PJI. Differences in 30-day postoperative medical complications, hospital readmissions, operative duration, and LOS were compared using bivariate and multivariate analyses.
One lakh fourteen thousand five hundred five THA patients were identified, with 102,460 (89.5%) patients undergoing a primary THA and 12,045 (10.5%) undergoing a revision procedure. Of the 12,045 revision procedures, 10,777 (89.5%) were for non-PJI indications and 1268 (10.5%) were for PJI. Relative to primary THA, patients undergoing revision THA for PJI had an increased rate of total complications (odds ratio [OR] 3.96), sepsis (OR 13.15), deep surgical site infections (SSIs, OR 8.58), superficial SSI (OR 2.14, P = .002), nonhome discharge (OR 1.85), readmissions (OR 2.46), LOS (+3.0 days), and operative duration (+61 minutes). Compared with non-PJI revisions, PJI revisions had an increased rate of total complications (OR 2.42), sepsis (OR 5.51), deep SSI (OR 2.12), nonhome discharge (OR 1.47), and LOS (+1.8 days).
Revision THA for PJI is associated with increased postoperative complications, nonhome discharge, and LOS relative to non-PJI revision THA. Separate care pathways and reimbursement bundles should be considered for patients with PJI.
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