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Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 20 June 2025 | Viewed by 9917

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Dr. Hendrik Kohlhof

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Guest Editor

Department of Orthopaedics, Hand- and Trauma Surgery, St. Antonius Hospital Cologne, Schillerstrasse 23, 50968 Cologne, Germany
Interests: hip; arthroplasty; knee surgery; knee injuries; cartilage; bone; fracture; trauma surgery; sports injuries; perioperative management; revision-arthroplasty; infection; orthogeriatrics; health economics; periprosthetic fractures

Special Issue Information

Dear Colleagues,

In recent years, the domain of arthroplasty has witnessed significant advancements, particularly in the area of knee and hip replacements, thereby revolutionizing joint replacement surgeries, and improving the quality of life for numerous patients suffering from joint degeneration and damage. Overall, the field of endoprosthetics is constantly evolving and improving. In particular, new developments in the areas of material research, biomechanics and surgical approaches, as well as perioperative management or pre- and postoperative patient support, have substantially improved treatment outcomes and patients’ quality of life with regard to demographic change.

In this Special Issue, we aim to collate papers that undercore the latest advancements in endoprosthetics, as well as highlight the experiences and insights of both patients and medical professionals.

Dr. Hendrik Kohlhof
Guest Editor

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Keywords

knee and hip replacements
joint replacement
biomechanics, revision arthroplasty
orthogeriatrics and perioperative management

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Published Papers (9 papers)

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Research

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9 pages, 861 KiB

Open AccessArticle

Synovial Glucose and Serum-to-Synovial Glucose Predict Failure After Acute Postoperative Infection in Total Knee Arthroplasty

by Marta Sabater-Martos, Laia Boadas, Laura Morata, Alex Soriano and Juan Carlos Martínez-Pastor

J. Clin. Med. 2025, 14(8), 2841; https://doi.org/10.3390/jcm14082841 - 20 Apr 2025

Viewed by 110

Abstract

Background: The treatment of periprosthetic joint infection (PJI) involves various strategies, with debridement, antibiotic, and implant retention (DAIR) being a preferred method for acute infections due to its lower morbidity. However, DAIR success rates vary widely from 30% to 80%. This study investigates the predictive value of synovial glucose and the serum-to-synovial glucose ratio for DAIR outcomes in acute postoperative PJI following total knee arthroplasty (TKA). Methods: This is a retrospective study of 32 DAIR cases, diagnosed with acute postoperative PJI after TKA. Synovial joint aspirations were performed on all patients. We collected all serological and synovial glucose levels. The serum-to-synovial glucose ratio was calculated. Results: Patients with synovial glucose levels below 44 mg/dL and a serum-to-synovial glucose ratio above 50% were identified as high risk for DAIR failure. High-risk patients exhibited a 31.3% failure rate, with half occurring within the first three months post-DAIR. No failures were observed in the low-risk group. Multivariate analysis did not find other significant predictors such as CRP levels, gender, or microbial cultures. Conclusions: Low synovial glucose levels and high serum-to-synovial glucose ratios are predictive of unsuccessful outcomes following DAIR procedures. Patients exhibiting lower synovial concentrations experienced early treatment failure. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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14 pages, 534 KiB

Open AccessArticle

Predictive Factors for Gait Recovery in Patients Undergoing Total Hip Arthroplasty: A Propensity Score Weighting Analysis

by Yuna Kim, Seo Young Kim, Sung Ryul Shim and Jung Keun Hyun

J. Clin. Med. 2025, 14(6), 1979; https://doi.org/10.3390/jcm14061979 - 14 Mar 2025

Viewed by 416

Abstract

Objectives: This paper’s objective was to identify clinical predictors, especially modifiable ones, associated with postoperative gait recovery in total hip arthroplasty (THA) patients, utilizing propensity score weighting (PSW) to control confounding factors. Methods: This retrospective cohort study included 221 patients who underwent primary unilateral THA. We used PSW analysis to balance patient characteristics. Univariate and multivariate logistic regression analyses were applied to determine predictors of improved gait recovery, assessing variables such as age, gender, and postoperative muscle strength. Results: Independent predictors of favorable gait recovery were male gender (Odds Ratio [OR]: 1.382; 95% Confidence Interval [CI]: 1.225–1.560; p < 0.001), younger age (OR: 0.990 per year; 95% CI: 0.985–0.995; p < 0.001), and postoperative hip flexor muscle strength greater than grade 3 (OR: 1.516; 95% CI: 1.177–1.953; p = 0.002). Muscle strength emerged as a modifiable factor, suggesting that targeted rehabilitation may enhance functional outcomes. Conclusions: Enhancing hip flexor strength postoperatively could significantly improve gait recovery in THA patients. These findings support developing individualized rehabilitation strategies to optimize functional outcomes. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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12 pages, 441 KiB

Open AccessArticle

Impact of Bariatric Surgery on Postoperative Outcomes, Complications, and Revision Rates in Total Knee Arthroplasty: A Big Data Analysis

by David Maman, Guy Eynhoren, Lior Ben-Zvi, Yaniv Steinfeld, Yaniv Yonai and Yaron Berkovich

J. Clin. Med. 2025, 14(4), 1187; https://doi.org/10.3390/jcm14041187 - 11 Feb 2025

Viewed by 927

Abstract

Background: Obesity is a major risk factor for osteoarthritis (OA) and negatively impacts both short-term and long-term outcomes following total knee arthroplasty (TKA). Bariatric surgery has been proposed as a strategy to improve surgical outcomes in obese patients; however, its effects on postoperative complications, hospital stay, healthcare costs, and revision rates remain insufficiently explored. This study investigates whether bariatric surgery before TKA is associated with improved outcomes. Methods: This retrospective cohort study utilized data from the Nationwide Inpatient Sample (NIS) from 2016 to 2019, including 2,519,099 TKA patients, of whom 56,291 had a history of bariatric surgery. Propensity score matching was applied to balance baseline characteristics between groups. Statistical analyses compared the length of hospital stay (LOS), total healthcare costs, postoperative complications, and revision rates. Results: Patients with a history of bariatric surgery exhibited significantly lower rates of sepsis, deep vein thrombosis (DVT), pulmonary embolism (PE), acute kidney injury (AKI), and ileus compared to those without. Additionally, these patients had a shorter LOS and slightly lower total hospital charges. However, the bariatric surgery group had higher rates of blood loss anemia, intraoperative fractures, and blood transfusions. Revision surgery rates were also higher in the bariatric surgery group, with mechanical loosening and prosthesis instability being more common etiologies. Conclusions: Bariatric surgery is associated with fewer early postoperative complications and shorter hospital stays in TKA patients, suggesting potential perioperative benefits. However, increased risks of blood loss anemia, intraoperative fractures, and revision surgery highlight the need for further research on long-term outcomes and alternative weight-loss strategies, such as pharmacologic interventions. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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12 pages, 1861 KiB

Open AccessArticle

The Influence of Kinematic Alignment on Patellofemoral Joint Biomechanics in Total Knee Arthroplasty

by Johanna-Maria Simon, Leandra Bauer, Christoph Thorwächter, Matthias Woiczinski, Florian Simon, Peter E. Müller, Boris M. Holzapfel and Thomas R. Niethammer

J. Clin. Med. 2024, 13(22), 6894; https://doi.org/10.3390/jcm13226894 - 16 Nov 2024

Cited by 3 | Viewed by 1236

Abstract

Background: Anterior knee pain is a prevalent issue post total knee arthroplasty, often necessitating revision surgery. Various factors contribute to this complication, including patellar maltracking and excessive patellofemoral load. Kinematic alignment has emerged as an alternative, showing promising outcomes in clinical studies. However, its impact on patellofemoral biomechanics needs to be more adequately understood. This study compared the effects of kinematically versus mechanically aligned total knee arthroplasty on patellofemoral joint biomechanics. Methods: Eight fresh-frozen human knee specimens underwent biomechanical testing in a knee rig setup, performing an active weight-loaded knee joint flexion of 30–130°. After the testing of native kinematics, kinematically and mechanically aligned total knee arthroplasty was performed using a medial pivot implant design without patellar resurfacing. Quadriceps force, retropatellar peak pressure and the retropatellar contact area were measured during knee flexion using a patellar pressure-sensitive film. Patella kinematics (shift and tilt) was tracked using an optoelectrical measurement system. Functional regressions were used to determine the influence of the alignment on the kinematics and loading of the knee joint. Results: Kinematically aligned total knee arthroplasty resulted in reduced quadriceps force during knee flexion compared to mechanically aligned total knee arthroplasty. Retropatellar peak pressure, retropatellar contact area and patella kinematics did not vary between the alignments. Conclusions: Kinematic alignment offers potential benefits in reducing quadriceps force during knee flexion, which may mitigate anterior knee pain risk. Further research is needed to elucidate its effects in varying anatomical conditions and alignment strategies. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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9 pages, 2458 KiB

Open AccessArticle

Assessment of a New Gait Asymmetry Index in Patients After Unilateral Total Hip Arthroplasty

by Jarosław Kabaciński, Lechosław B. Dworak and Michał Murawa

J. Clin. Med. 2024, 13(22), 6677; https://doi.org/10.3390/jcm13226677 - 7 Nov 2024

Viewed by 921

Abstract

Background/Objectives: Comparing a given variable between the lower extremities (LEs) usually involves calculating the value of a selected asymmetry index. The aim of this study was to evaluate the mean-dependent asymmetry index for gait variables. Methods: The three-point crutch gait asymmetry between the non-surgical LE (NS) and surgical LE (S) was assessed in 14 patients after unilateral total hip arthroplasty. An eight-camera motion capture system integrated with two force platforms was used. The values of the new gait asymmetry index (MA) were calculated for such variables as stance phase time (ST), knee flexion and extension range of motion (KFE RoM), hip flexion and extension range of motion (HFE RoM), and vertical ground reaction force (VGRF). Results: An analysis related to gait asymmetry showed significantly higher values for all variables for the NS than for the S (the MA ranged from 9.9 to 42.0%; p < 0.001). In the case of comparisons between the MA and other indices, the intraclass correlation coefficient ranged from 0.566 to 0.998 (p < 0.001) with Bland–Altman bias values that ranged from −18.2 to 0.3 %GC (ST), from 0.0 to 0.5° (KFE RoM), from −12.4 to 1.4° (HFE RoM), and from −11.9 to −0.1 %BW (VGRF). Conclusions: The findings revealed a prominent three-point crutch gait asymmetry for all variables, especially a disturbingly large asymmetry for the HFE RoM and VGRF. The comparisons also showed generally excellent or good agreement with the other indices. Furthermore, the mean MA result from n single values was the same as the MA result calculated using the mean values of a given variable. The MA, as an accurate asymmetry index, can be used to objectively assess pathological gait asymmetry. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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12 pages, 5422 KiB

Open AccessArticle

Ten-Year Results of the Fitmore^® Hip Stem with a Focus on Varus/Valgus Alignment and Subsidence—A Retrospective Monocentric Analysis

by Ronald Wanner, Christopher Butler Ransohoff, Tobias Wyss and Hubert Nötzli

J. Clin. Med. 2024, 13(18), 5570; https://doi.org/10.3390/jcm13185570 - 20 Sep 2024

Viewed by 1263

Abstract

Background: Hip arthroplasty is a common elective surgery worldwide, with rising numbers due to demographic changes and an emphasis on maintaining physical activity in the elderly. The development of new implant designs, especially shorter uncemented stems, has contributed to the advancement of minimally invasive implantation techniques. However, the long-term in vivo behaviour of these implants, particularly regarding subsidence, stability, and stress shielding, remains to be fully understood. Methods: This retrospective, monocentric cohort study analyses the long-term radiographic outcomes of the first 141 patients who underwent total hip arthroplasty with the Fitmore^® Hip Stem between June 2007 and December 2008. It focuses on subsidence, stability, varus–valgus alignment, and the influence of patient-related, anatomical, and surgical factors on implant behaviour over a 10-year follow-up period. Results: The average change in varus/valgus alignment was 0.7° into varus and the average subsidence was 1.7 mm over 10 years, with most changes occurring within the first six weeks postoperatively. The varus–valgus alignment and subsidence did not significantly change after the first year, indicating stable osteointegration of the implant. Neither patient factors (gender, age) nor surgical and implant factors (implantation angle, approach, stem family, size, total offset) had a significant influence on the long-term behaviour of the implant. Conclusions: The Fitmore^® Hip Stem shows highly reliable long-term stability and integration, unaffected by various patient, surgical, and implant factors, as confirmed by excellent register data. Nevertheless, monitoring of this and other new implants should be continued in order to determine implant behaviour, possible weaknesses, and indication limits at an early stage for the benefit of the patient. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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7 pages, 1930 KiB

Open AccessArticle

Usefulness of Elastic Bandage Compression Compared to Calf Massage to Prevent Venous Thromboembolism—A Retrospective Evaluation

by Keishi Kimura, Norio Imai, Asami Nozaki, Yoji Horigome, Hayato Suzuki and Hiroyuki Kawashima

J. Clin. Med. 2024, 13(15), 4355; https://doi.org/10.3390/jcm13154355 - 25 Jul 2024

Viewed by 1388

Abstract

Background: Manual calf massage and passive ankle motion (CaM) can reduce the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA). However, these methods cannot be used in all patients; thus, elastic bandage (EB) compression is an alternative method. The efficacy of EB compression in preventing VTE has not yet been investigated; thus, this study aimed to compare the effects of EB compression and manual calf massage. Methods: Of the 363 patients who underwent unilateral primary THA at our hospital between 1 August 2018 and 31 October 2023, CaM without anticoagulation therapy was administered to 206 patients (CaM group) and 157 patients underwent EB without anticoagulation therapy (EB group). Duplex ultrasonography was performed 7 days postoperatively to check for deep vein thrombosis (DVT) in both legs. Results: The surgical time (122.2 min vs. 155.5 min), the incidence of DVT (4.5% vs. 4.8%) and pulmonary thromboembolism (PTE) (0% vs. 0.7%), intraoperative bleeding (305.4 mL vs. 301 mL), and estimated actual blood loss (846.6 mL vs. 811.6 mL) were not significantly different between the CaM and EB group. However, there was one case of symptomatic PTE in the EB group. Conclusions: The incidences of DVT, PTE, and intraoperative bleeding were not significantly different between the groups. Moreover, EB can be administered to patients with DVT and is considered to be a DVT prophylaxis method that can be used in a larger number of patients. Therefore, we recommend that EB be performed in all the patients undergoing THA. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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Review

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14 pages, 286 KiB

Open AccessReview

Are Current Patient-Reported Outcome Measures Fit for Purpose to Evaluate Unicompartmental Knee Arthroplasty?

by John M. Bayram, Nicholas D. Clement, Andrew J. Hall, Phil Walmsley and Jon V. Clarke

J. Clin. Med. 2025, 14(1), 203; https://doi.org/10.3390/jcm14010203 - 2 Jan 2025

Viewed by 1058

Abstract

The optimal procedure for isolated end-stage medial compartment knee osteoarthritis (OA) remains uncertain, with debate persisting between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The aim of this narrative review is to evaluate current outcome measures in knee arthroplasty (KA) and explore how evolving patient populations and technological advancements may necessitate the use of different patient-reported outcome measures (PROMs) for evaluating UKA. While UKA offers potential advantages over TKA in early pain relief and functional outcomes, most randomised control trials using traditional PROMs have failed to show definitive superiority. The recent introduction of robotic assistance may have further enhanced the benefits of UKA. However, it remains uncertain whether the advantages outweigh the higher revision rates associated with UKA. Although traditional PROMs, such as the Oxford Knee Score or Knee Injury and Osteoarthritis Outcome Score, were designed for the KA population of 30 years ago, they continue to be employed today. The current KA population, particularly those undergoing UKA, are typically younger, physically fitter, and have higher functional demands than those for whom traditional PROMs were originally designed. As a result, these PROMs are now limited by ceiling effects. High-performance PROMs, such as the Forgotten Joint Score-12 or the metabolic equivalent of task score, have recently been utilised for high-demand patients and do not have postoperative ceiling effects. Return to work and sport are also important outcomes that are often overlooked for younger, high-demand patients. Future studies should aim to define the differences between UKA and TKA populations, identify patient factors that predict UKA success, and validate high-performance PROMs for UKA. This will provide deeper insights into the functional benefits of UKA and TKA, enabling patients and surgeons to make more informed decisions regarding implant selection. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

Other

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13 pages, 2937 KiB

Open AccessCase Report

Challenges of Hip Arthroplasty in a Paretic, Spastic Limb: A Case Study on Managing Femoral Neck Fracture Following Fixation Failure in a Hemiparetic Patient

by Izabela Dąbkowska, Lena Sobiech, Michał Merkisz, Karolina Turżańska, Tomasz Blicharski and Katarzyna Jankiewicz

J. Clin. Med. 2024, 13(14), 4023; https://doi.org/10.3390/jcm13144023 - 10 Jul 2024

Viewed by 1770

Abstract

Background: Hip fractures and strokes are prevalent and escalating issues in geriatric healthcare. The absence of standardized surgical protocols for patients with spastic hemiparesis and multiple comorbidities presents a significant medical challenge. Methods: This case study describes a 64-year-old male patient with left-sided hemiparesis and failed surgical treatment of a pertrochanteric fracture in a spastic limb. The patient was admitted to the Department of Rehabilitation and Orthopedics in December 2022 for diagnostics and to establish a treatment plan after five months of non-ambulatory status. Results: This study emphasizes the crucial role of preoperative preparation, involving botulinum toxin injections into spastic muscles and physiotherapy, to enhance the supportive function of the paretic limb and improve locomotion before prosthetic surgery. Conclusions: The management of hip fractures in patients with spastic paralysis requires a multidisciplinary approach and the development of standardized treatment protocols. This case underscores the importance of comprehensive pre- and postoperative rehabilitation to improve patient outcomes. Further research is needed to establish standardized rehabilitation protocols for spastic patients undergoing hip arthroplasty. Randomized controlled trials could provide valuable insights into the efficacy of various interventions. Full article

(This article belongs to the Special Issue Advancements in Total Joint Arthroplasty: Innovations, Outcomes and Challenges)

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