U.S. News evaluated nearly 4,500 hospitals in 14 specialties. Hospital performance was assessed based on various measures, including patient outcomes, level of nursing care, patient-reported experience, and available technology such as computer-assisted orthopedic surgery. The methodology factored in data from the Centers for Medicare & Medicaid Services, professional organizations, and medical specialists.

“We are proud to once again be recognized as a leader in orthopedics and rheumatology,” said HSS President and CEO Bryan T. Kelly, MD, MBA. “This distinction reflects the extraordinary expertise, dedication, and collaboration of the entire HSS team. For patients across the New York metropolitan region, it is also a powerful validation that the best orthopedic care in the country is available right here in their community. Through comprehensive musculoskeletal care, we help patients preserve mobility, enhance their quality of life, and extend their healthspan so they can continue doing what they need and love to do.”

“This recognition from U.S. News reflects HSS’s unwavering commitment to advancing musculoskeletal health through clinical excellence, innovation, and patient-centered care,” said Douglas E. Padgett, MD, surgeon-in-chief and medical director of HSS. “Perhaps the greatest measure of our impact is the trust of patients who travel to HSS from across the country and around the world seeking care have placed in us. This distinction reflects our dedication to achieving exceptional outcomes and our belief that preserving movement is the foundation of longevity and quality of life.”

Patients come to HSS from all 50 states and more than 100 countries, often for both common and complex medical conditions or challenging surgeries requiring highly specialized care. As a global destination for orthopedic and rheumatologic care, HSS brings together world-renowned physicians, advanced treatment approaches, and multidisciplinary teams dedicated to delivering personalized, evidence-based care for patients of all ages and activity levels.

“Our rankings reflect the extraordinary expertise, dedication, and innovation of the physicians, scientists, researchers, and care teams who make HSS a leader in rheumatology,” said Anca D. Askanase, MD, MPH, Chair of the Department of Medicine and Chief of the Division of Rheumatology at HSS. “Through groundbreaking research, advanced therapies, and highly personalized care, we are helping to transform the lives of patients living with complex autoimmune and inflammatory diseases.”

“The pace of discovery in musculoskeletal medicine is accelerating at an unprecedented rate,” said Joel Press, MD, Physiatrist-in-Chief at HSS. “Advances in artificial intelligence, data science, and precision medicine are helping researchers uncover new insights faster and translate those discoveries into more effective, personalized care. With HSS’s singular focus on musculoskeletal health and unmatched depth of clinical expertise, we are uniquely positioned to turn innovation into meaningful improvements in outcomes for patients everywhere.”

As the world’s leading academic medical center specializing in musculoskeletal health, HSS maintains among the lowest hospital readmission rates for orthopedics in the nation, and among the lowest rates for infection and complications. HSS is the worlds most awarded hospital in orthopedics by Newsweek each year since the “World’s Best Specialized Hospitals” survey was introduced in 2020.

In 2025, HSS clinicians and surgeons provided specialized care to more than 258,016 patients with orthopedic or rheumatologic conditions, such as pain or injury to the back, neck, or joints; osteoarthritis; rheumatoid arthritis; lupus; scleroderma; and psoriatic arthritis. HSS performed more than 45,864 orthopedic surgical procedures in 2025.

HSS is the official hospital of and provides team physicians to more than 25 high-performing sports teams and leagues, including the New York Giants, New York Knicks, New York Liberty, Brooklyn Nets, New York Mets, New York Red Bulls, TCS New York City Marathon, National Basketball Players Association, Major League Pickleball, US Youth Soccer, and UFC. It is designated a Medical Center of Excellence by Fédération Internationale de Football Association (FIFA).

Lymphatic vessels act as communication highways, carrying signals from tissues to the immune system to alert it to infection, injury, or disease. When this system does not function properly, the body may struggle to fight infections, respond to vaccines, repair tissue, or control inflammation.

The new findings show that Langerhans cells play a key role during early life by helping lymphatic vessels grow and develop properly in the skin. This early “setup” has long-term consequences, influencing how well the immune system functions later in life.

“Our study shows that immune cells in the skin do much more than respond to threats—they help build the infrastructure the immune system depends on,” said senior author Theresa T. Lu, MD, PhD, who holds the St. Giles Chair for Research in the HSS Research Institute and is a member of Pediatric Rheumatology at HSS. “If this process is disrupted early in life, it can have lasting effects on immune health. Our results also underscore the critical role of skin health in regulating lymphatic vessel development and immune system function in health and disease.”

“These findings advance our understanding of how early-life biological processes influence long-term immune function,” explained JiHyun Sim, PhD, first author and Postdoctoral Fellow at HSS. “We are hoping to further understand if this physiologic process is disrupted to contribute to autoimmune disease.”

Key Findings

• Early-life development matters: Proper formation of lymphatic vessels in childhood is essential for strong immune responses in adulthood.
• New role for Langerhans cells: Beyond their known immune functions, these cells help guide the growth and programming of lymphatic vessels.
• Long-term impact: When Langerhans cells are reduced or impaired early in life, the immune system may be less effective later on.

Implications for Patients and Providers

The research suggests that conditions affecting skin health in early life—such as severe sunburn, burns, or certain autoimmune diseases like lupus—could interfere with Langerhans cells and, in turn, disrupt lymphatic development. This may contribute to weaker immune responses later in life, including reduced effectiveness of vaccines, increased susceptibility to infections, impaired healing, and potential autoimmune complications.

“These findings highlight the importance of protecting skin health early in life,” said Dr. Lu. “They also open the door to new approaches that could strengthen immune function by targeting the lymphatic system.”

A New Way of Thinking About Immune Health

The study adds to a growing body of evidence showing that early-life health and environmental factors can shape disease risk in adulthood. It also identifies a previously unknown mechanism by which immune cells influence tissue development—not just immune activation.

By uncovering how Langerhans cells regulate lymphatic vessel growth, researchers hope to pave the way for future strategies to improve immune responses and prevent disease across the lifespan.

Authors: JiHyun Sim, PhD, Richard Bell, PhD, Yurii Chinenov, PhD, Zhonghui Feng, PhD, Susan Chyou, BA, William D. Shipman, MD, PhD, Lionel Ivashkiv, MD, Theresa T. Lu, MD, PhD

“As GLP-1 medications increase in popularity, the effect of these drugs in patients undergoing surgery raises concerns for anesthesiologists,” says Oliver PF Panzer, MD, anesthesiologist at HSS and author of both studies. “We seek to better understand the usage and impact of GLP-1s on patients undergoing surgery so we can adapt the management of these patients to maximize their safety.”

Study: Cross Sectional Assessment of Preoperative Gastric Content with Ultrasound in Patients Taking GLP-1 Agonists

In the study “Cross Sectional Assessment of Preoperative Gastric Content with Ultrasound in Patients Taking GLP-1 Agonists,” researchers set out to explore how GLP-1 medications affect gastric emptying in patients scheduled for surgery. Food retained in the stomach can increase the risk of regurgitation and pulmonary aspiration of gastric contents, a serious, life-threatening complication during general anesthesia.

“Previous studies show patients using the GLP-1 agonist semaglutide (Ozempic, Wegovy, and Rybelsus) experience slower gastric emptying, which can result in residual gastric contents even when these patients follow standard preoperative fasting guidelines,” says Dr. Panzer. “We became concerned that patients taking GLP-1s may not be adequately protected from aspiration during anesthesia under the current guidelines.”

“The goal of this study was to look at the incidence of full stomach in patients taking GLP-1s compared to patients not taking the drugs,” says Dr. Panzer. “We also wanted to look at fasting times to detect whether people on GLP-1s who fast longer than the guidelines recommend trend toward being less full.”

In the multi-center, prospective, cross-sectional observational study, researchers used ultrasound to assess the preoperative incidence of full stomach in elective surgery patients taking weekly injectable GLP-1s compared to elective surgery patients not taking the drugs. A total of 354 patients were included in the study between August 29, 2023, and January 31, 2025. Ultrasound was performed by an anesthesiologist in the preoperative holding area, with clear fluid >1.5ml/kg or solid content indicating a full stomach. All institutions followed American Society of Anesthesiology “nothing by mouth” (NPO) fasting guidance (8 hours for heavy fatty foods; 6 hours for light meals; 2 hours for clear liquids).

Dr. Panzer and colleagues found no significant difference in the incidence of full stomach between patients taking GLP-1s and those who do not. Overall fasting times for solids tended to be longer in full patients in the GLP-1 group compared to the control group (23.73 vs 16.63 hours) but did not reach statistical significance.

“This multicenter study showed no difference in the rate of full stomachs between the GLP-1 group and the control group, which stands in contrast to what most studies have shown so far,” says Dr. Panzer. “One possible explanation for our result is that our patients report higher average fasting times (18.5 hours) than patients at other institutions. However, there may be other factors that warrant further investigation.”

“We hope to follow up this study with research that examines whether 24 hours of solid food fasting is helpful in reducing full stomach in patients on GLP-1s,” says Dr. Panzer. “Another question is whether pausing GLP-1s prior to surgery may have an impact on full stomach. Although the current guidance says to continue taking GLP-1s before surgery because stopping the drug poses its own health risks, it’s a question worth exploring.”

Study: Institutional Trends in GLP-1 Agonist Use Among Hip and Knee Arthroplasty Patients, 2021–2024

In the study, “Institutional Trends in Glucagon-Like Peptide-1 Receptor Agonist Use Among Hip and Knee Arthroplasty Patients, 2021–2024,” researchers explore the prevalence of glucagon-like peptide-1 (GLP-1) agonist use among patients undergoing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) at HSS.

“As usage of GLP-1s continues to expand in the general population, we wanted to capture the incidence and type of GLP-1 usage among patients undergoing hip and knee arthroplasty,” says Dr. Panzer.

The researchers retrospectively reviewed the records of 45,537 adult patients who underwent primary or revision THA or TKA between January 4, 2021, and December 31, 2024. Dr. Panzer and colleagues found GLP-1 use increased significantly in that period, rising from 3.69% in 2021 to 12.84% in 2024.  Semaglutide and tirzepatide were the most common agents, accounting for 88% of all GLP-1 use in 2024. Higher rates of GLP-1 use were seen in patients with significant comorbidities such as hypertension, diabetes, or heart failure, and in Black patients.  

“We also saw a significant decrease in the number of GLP-1 users with diabetes in this time period, suggesting that more patients are using these medications for other reasons such as weight loss,” notes Dr. Panzer.

“We will continue to examine GLP-1 usage in the surgical orthopedic population so we can ensure patients on these drugs can have surgery safely,” says Dr. Panzer. “We’re just at the beginning of this investigative journey, so there is a lot more insight to come.”

These studies contribute important early evidence to help guide emerging perioperative considerations for patients using GLP‑1 medications.

References:

Study 1: Cross Sectional Assessment of Preoperative Gastric Content with Ultrasound in Patients Taking GLP-1 Agonists

Authors: Oliver Panzer, Maya Tailor, Juliet E. Rowe, Michael Singleton, William Manson, Hari Kalagara, Nibras Bughrara, Anahita Dabo-Trubelja, Marissa Weber, Eric Heinz, Stephen C. Haskins, William P. Qiao, Miriam Sheetz, Alex Illescas, Kayla Bernstein, Mariel Maramba, Mahtab Sheikh, Jayanta Chowdhury, Sheila Carr, Tatum Gee, Eduard Shaykhinurov, Justas Lauzadis, Jashvant Poeran, Anahi Perlas

Study 2: Institutional Trends in Glucagon-Like Peptide-1 Receptor Agonist Use Among Hip and Knee Arthroplasty Patients, 2021–2024

Authors: Juliet Rowe, Maya Tailor, Alexandra Sideris, Alex Illescas, Jawad Saleh, Jashvant Poeran, Daniel Maalouf, Oliver Panzer

What follows are highlights from these studies:

HSS Study Uses Machine Learning to Predict Risk of Long-Term Pain After Knee Replacement Surgery

A new study led by researchers at HSS used a type of AI known as machine learning (ML) to identify key clinical and biological factors that raise a person’s risk of having persistent pain after total knee arthroplasty (TKA). Risk factors included elevated levels of certain inflammatory cytokines (proteins) in the blood, severe preoperative pain, and a longer period of tourniquet use in the operating room.

“These findings highlight the importance of incorporating biological markers like cytokine levels with patient-specific pain profiles and what the surgeon does during the operation to more accurately predict the risk of long-term pain after surgery,” says Meghan Kirksey, MD, PhD, an anesthesiologist at HSS and senior author of the study.

ML is a specialized approach that uses algorithms and statistical models to analyze patterns in large amounts of data to learn, predict, and make recommendations.

“Machine learning is allowing us to look at patient and clinician information in new ways,” says Alexandra Sideris, PhD, Director of the HSS Pain Prevention Research Center and a coauthor of the study. “It gives us a multidimensional approach to understanding patients’ pain experience that we didn’t have in our arsenal even five or 10 years ago.”

One in five people has significant knee pain months after having TKA, also known as total knee replacement surgery. “The lingering pain greatly affects their daily activities and quality of life, so that’s why it’s an important focus for us,” explains Dr. Sideris.

Persistent postoperative pain (PPP) is typically flagged when a patient has lasting pain at the site of the operation that is above a four on a scale of zero to 10 and severely impacts their activities of daily living three to six months after surgery.

The researchers used four different ML models to analyze data from a previously published study that collected comprehensive clinical information and blood samples from 160 patients before and after TKA at HSS. The new study identified key predictors associated with PPP beyond risk factors that were already known such as sex (women tend to have a higher risk), preexisting pain, and mental health issues like anxiety and depression.

The findings showed that having high blood levels of an inflammatory marker called TARC immediately after surgery raises the risk of PPP. “This molecule hasn’t been extensively studied in pain, but the evidence shows that it was consistently associated with persistent pain six months after surgery across all four ML models we tested,” notes Dr. Kirksey.

Other top predictors of PPP that emerged from the analysis included a higher preoperative pain score at rest, longer tourniquet time (a tourniquet is a device that squeezes the leg to help clear the area of blood flow during surgery), and higher blood levels of other inflammatory cytokines right after surgery.

In this study, researchers entered 318 clinical and biological characteristics collected from patients in the older study and asked each of the ML models to figure out the most important features associated with pain after TKA. The researchers also evaluated the accuracy of the ML models they used and found that XGBoost was the most informative.

“To my knowledge, this is the first study that looked at all of this information and tried to make sense of the best ML approach to use,” says Dr. Sideris. “What is exciting to us is that there was one feature – TARC – that consistently popped up across all four models and it wasn’t on anybody’s radar beforehand…this gives us hope that ML can help us identify with high integrity targets that haven’t been studied before.”

The researchers note that more research is needed to know if their findings can be used to impact clinical care. “Our goal is to be able to use these tools and data to tailor pain management strategies, prevent long-term complications, and personalize treatment decisions,” says Dr. Kirksey.

HSS AI Analysis Reveals What Patients Are Googling About Local Anesthesia

A new study by researchers at HSS used AI to systematically evaluate the types of questions that patients are Googling related to regional (local) anesthesia, identify websites that are frequently presented in search results, and assess the quality of the information provided.

“We knew that patients frequently search for information about anesthesia online, but we wanted to know exactly what they were looking for so that we could proactively address these topics and concerns in our conversations in the clinic and our patient education materials,” says Jashvant Poeran, MD, PhD, Director of Research in the Department of Anesthesiology, Critical Care and Pain Management at HSS and lead author of the study.

The analysis found that most patients’ questions focused on risks, complications, and details surrounding medications, awareness during sedation, nerve block duration, and the recovery process. The study also found that while the overall quality of information accessed during Google searches was accurate, the source of that information was not always clear.

Anesthesiologists see patients in the clinic for a short period to prepare them for surgery and manage expectations.

“There’s so much information being conveyed during that limited time that sometimes patients forget what to ask, or they don’t even know what they should be asking during the visit,” explains Dr. Poeran. “Our study results will help us anticipate some of their questions and give us a starting point when we sit down with them so it’s not so much of a guessing game.”

The researchers entered seven search terms into Google Web Search: “regional nerve block,” “regional anesthesia,” “peripheral nerve block,” “pain block,” “neuraxial anesthesia,” “epidural anesthesia,” and “spinal anesthesia.” The top 200 questions in the “People Also Ask” section and its associated websites were collected, totaling 1,400 question and website combinations.

The authors then used AI to categorize themes and assess website quality. They found that most questions pertained to facts around risks and complications, comparisons between different techniques and approaches, technical details, and indications.

“We were expecting questions around risks and complications, but it was surprising that so many patients were looking at technical details, specifically around sedation,” notes Dr. Poeran. “They were not always aware that you can be awake for a peripheral nerve block, for example.”

Because patients’ questions are linked to specific websites, researchers also wanted to know where patients were being referred to and how reliable the information presented was. The AI analysis found that 55% of websites were academic, 19% were government, and 11% were public/social media sources. Information on government and academic/hospital websites scored the highest in terms of accuracy, and medical practice websites scored the lowest.

Dr. Poeran cautioned that some patients’ questions are nuanced, and online information can bias a person in the wrong direction.

“For example, if you ask whether regional anesthesia is better than general anesthesia you will be able to get generic information about those approaches online, but you need to talk to your doctor to get a more personalized recommendation based on your specific circumstances,” says Dr. Poeran.

While the study revealed important questions, it’s not all-encompassing. “There will be questions that aren’t captured by this study, but anesthesiologists can use this data to guide their consultations with patients scheduled for surgery, provide more-informative patient education materials, and refer them to the most reliable websites for more information,” notes Dr. Poeran.

He plans to continue leveraging AI in his future research endeavors.

“Based on the information we gathered, we will update our educational materials with the questions we now know patients ask most often and may even provide it in different languages and reading levels,” says Dr. Poeran. “We can then use AI to see how that information is perceived and understood by patients, study differences in search terms entered in different languages, etc.”

The medication, suzetrigine (JOURNAVX®), was FDA-approved in January 2025 and became available at HSS in April 2025. It is the first non-opioid pain reliever released in more than 25 years.

Alexandra Sideris, PhD, Director of the Pain Prevention Research Center at HSS, and Faye Rim, MD, FAAPMR, a physiatrist and pain management specialist within the Department of Anesthesiology, Critical Care & Pain Management, co-led the study.

One advantage of the new medication is that it works differently from standard over-the-counter pain relievers and stronger medications like opioids.

“What's exciting about this new medication is that it is targeting pain signal on the nerves outside of the brain, so you're presumably getting to the acute pain source right at the time where that happens,” Dr. Sideris said. "Early studies also suggest that it's devoid of those classical addictive properties that opioids have.”

It’s even more targeted than local anesthetics, which block pain messengers known as sodium channels. Instead, suzetrigine blocks just one sodium channel, Nav1.8, which means patients should experience fewer side effects and more targeted pain relief.

HSS was an early adopter in New York City to add suzetrigine to its formulary, and Dr. Rim was instrumental in bringing it to surgical patients. Patients managed by the Perioperative Pain Service often have complex needs that opioids alone may not be able to meet. Some patients may have other conditions that contraindicate the use of opioids. suzetrigine presents a novel, non-habit-forming option that can either replace or augment opioid use after surgery.

For this study, the team evaluated 103 HSS patients who took suzetrigine after undergoing a variety of surgical procedures, but primarily joint arthroplasty or spine surgery. Eight patients (7.8%) experienced at least one adverse reaction during admission, likely related to the drug, and ended up stopping the medication. The remaining 95 patients (92.2%) generally tolerated it well.

“The longer-term goal is to see if adding on suzetrigine actually decreases your need for opioids or if it is an effective option for patients undergoing major orthopedic surgery who cannot tolerate opioids,” Dr. Sideris said.

Pain has historically been a challenging area for drug development, in part because preclinical models do not always predict human response.

“Unfortunately, many things that work in animals just haven't translated into humans, and it's been a quest to understand [why],” Dr. Sideris said.

But this drug’s novel approach makes it an exciting advance in the field and one that HSS pain researchers were eager to capitalize on. This initial study gives a first look at how suzetrigine is tolerated in surgical patients at HSS, with an ongoing study in patients undergoing total hip replacements, and more research planned in patients knee, and spine surgery. Further studies will evaluate who may benefit from the medication the most, and who is more likely to require additional support. Currently, it is not a first-line medication, but Dr. Rim anticipates that will change as the drug becomes more widely available and additional evidence emerges on its efficacy in various surgical populations.

“We need to look more carefully at why certain patients may not do as well on this medication as we think they would,” she said. “It’s not a panacea, but it's definitely promising.”

She added that HSS was an obvious choice for the medication’s early adoption due to the institution’s reputation for cutting-edge science and advanced care.

“HSS is known for being innovative and this falls in line with that,” Dr. Rim said. “We want to try to utilize anything that's safe and effective within an arsenal to make sure patients recover well and become functional.”

The first of the three studies, “Aspirin Versus Potent VTE Chemoprophylaxis (VTEC) in Total Knee Arthroplasty: Reduced Postoperative Pain and Complications with Aspirin Use,” examined the experience of total knee arthroplasty (TKA) patients with postoperative pain who were also taking blood thinners. The study included 28,169 patients treated between 2016 and 2023; 18,413 received aspirin while 9,756 received a potent VTE.. Patients were monitored for 90 days following their procedure. The findings suggest that aspirin should be considered the preferred option for reducing postoperative pain in TKA patients.

Patients on more-potent blood thinners tend to experience more pain, swelling and inflammation after surgery, said Brian P. Chalmers, MD, a hip and knee surgeon at HSS and one of the study’s authors. “We have always known that non-steroidal anti-inflammatory medications can improve patients’ swelling and inflammation after surgery. However, the traditional thought and belief has been that we should avoid those in patients on anticoagulation. Our data show there is less risk and less postoperative pain when these patients are utilizing aspirin.”   

A second study, “The Effect of Concomitant Use of Potent Anticoagulation and Anti-Inflammatories on Early Outcomes of Total Hip Arthroplasty,” retrospectively evaluated 5,881 total hip arthroplasty patients who were on anticoagulation. The surgeries were performed between 2016 and 2023; of those patients, 4,867 were concomitantly prescribed NSAIDs and 1,040 received anticoagulation alone. Researchers concluded that the concomitant use of NSAIDs in patients on anticoagulants did not increase the risk of wound-related bleeding complications.

“The conventional thinking has often been that patients on an anticoagulant should not be on an NSAID, that there is going to be bleeding, more risk of wound problems and additional complications. But based on our retrospective data, we did not see increased risk in patients using both anticoagulation and NSAIDs. We did see some additional benefits, including less pain and a somewhat easier recovery,” Dr. Chalmers stated. “NSAIDs appear to be safe in this setting and may help decrease postoperative pain and reduce opioid use following surgery.”

The final study, “Cefazolin and the R-1 Side Chain: Why Your Joint Arthroplasty Patients With Cephalosporin Allergy Can Safely Be Given Cefazolin,” assessed the safety and effectiveness of the antibiotic Cefazolin in patients with documented cephalosporin allergies. This is the first study to evaluate these questions.

From 2016 to 2024, researchers compared patients with a reported cephalosporin allergy who received perioperative cefazolin with those who received alternative antibiotic prophylaxis. This study included 89,993 hip and knee arthroplasty patients. Of these, 1,267 had a documented allergy. The study resulted in zero incidence of IgE-mediated or “severe” type IV allergic reactions, concluding that cefazolin can be safely administered to most patients with an existing cephalosporin allergy.

“When patients have a mild allergic reaction, there is often a reflex to give them another antibiotic in a different family of drugs. However, alternative options aren’t always as effective,” said Matthew S. Austin, MD, hip and knee surgeon at HSS and a study author. “Clear protocols should be put in place to guide decision-making when managing these types of allergies.”

These findings underscore HSS’s ongoing commitment to challenging conventional assumptions and using data-driven research to refine perioperative care. The studies highlight how targeted medication strategies can improve safety, reduce complications and enhance outcomes for patients undergoing hip and knee arthroplasty.

Study Details 

“Aspirin Versus Potent VTE Chemoprophylaxis in Total Knee Arthroplasty: Reduced Postoperative Pain and Complications with Aspirin Use”

 Alex Anatone, Alexis Gabriel Gonzalez, Richard Hwang, David Andrew Kolin, Aaron Ira Weinblatt, Amar S Ranawat, Alejandro Gonzalez Della Valle, Brian Chalmers

“The Effect of Concomitant Use of Potent Anticoagulation and Anti-Inflammatories on Early Outcomes of Total Hip Arthroplasty”

Alexis Gabriel Gonzalez, Aaron Ira Weinblatt, Agnes Cororaton Jones, Stephen Lyman, Richard Hwang, Alex Anatone, Carlo Marega, Alejandro Gonzalez Della Valle, Brian Chalmers

“Cefazolin and the R-1 Side Chain: Why Your Joint Arthroplasty Patients With Cephalosporin Allergy Can Safely Be Given Cefazolin”

Josef Jolissaint, Katherine E Mallett, Andrew Thomson, Alberto V Carli, Matthew Austin

Read the full article at healio.com.

A pars fracture ­— also called spondylolysis — is a break in the pars interarticularis, a narrow area of bone connecting two vertebrae in the spine. It typically occurs in the lumbar spine (lower back). About 7 percent of all adolescents experience a pars fracture, and that number can rise to as much as 50 percent among teens engaged in high-risk sports such as gymnastics, football, and soccer.

While these injuries can heal on their own after a six- to eight-week break from sports, one in five adolescents continues to experience a non-healing fracture (nonunion). The pain often returns after resuming activity, and some athletes have been told to quit sports entirely. "Nonunion can cause persistent back pain and, in certain cases, even require lumbar fusion later in life if the fracture results in a vertebral slip, where the vertebrae slip out of place," explained Austin Kaidi, MD, an orthopedic surgery resident at HSS and the study's lead author.

About seven years ago, HSS spine surgeon Sheeraz Qureshi, MD, Co-Chief of HSS Spine and the study's senior author, began using a spine surgery robot to plan the placement of surgical screws in novel ways. His work sparked a shift in the way the HSS surgeons approached pars fracture repairs.

The new minimally invasive technique involves the placement of a single screw through a 1 cm incision — far smaller than traditional surgery to repair a pars fracture, which is performed through a larger incision and requires bone grafting. The robotic procedure is performed on an outpatient basis and is associated with an easier, shorter recovery.

Study: Robotic Pars Repair Allows Early Return to Activity for Adolescents with Symptomatic Spondylolysis: A Case Series

Dr. Kaidi, Dr. Qureshi, and their colleagues performed a retrospective review of nine adolescent patients with lumbar spondylolysis (mean age 16) who had robotic-assisted pars repair at HSS using the single-screw technique. Patients had endured back pain before the surgery for an average of 8 months. After surgery, they participated in an 8-week physical therapy program that started with walking and gradually re-introduced sports-specific exercises.

After a mean follow-up of 11.4 months, five patients had returned to the same or an even higher level of sports. One patient had residual back pain and did not return to sports. Three patients had CT scans at one year demonstrating union of the fracture. The athletes were able to return to activity in as little as six weeks. "Although nonsurgical treatment should always be tried before considering surgery, we were surprised by the effectiveness of this technique for enabling athletes to return to sport," said Dr. Kaidi.

HSS is a leader in robotic-assisted single-screw pars repair and one of only a handful of institutions worldwide who have published on this technique. This study is the largest series ever reported in these patients.

"This safe and effective procedure is changing the way the medical community thinks about these injuries. We are moving away from 'do nothing for 6 weeks' to a more elegant, proactive solution," concluded Dr. Qureshi. “Early minimally invasive spine surgery can prevent future complications. We're not only caring for patients while they are young, but also helping them in the long run.”

Reference

Robotic Pars Repair Allows Early Return to Activity for Adolescents with Symptomatic Spondylolysis: A Case Series

Authors: Austin Kaidi MD, MSc, Michelle Zabat, MD, Amy Xu, MD, Adin Ehrlich, BS, Tomoyuki Asada, MD, PhD, Harvinder Sandhu, MD, Russel Huang, MD, Sravisht Iyer, MD, and Sheeraz Qureshi, MD, MBA

A recent study conducted by researchers at HSS and presented at the American Association of Hip and Knee Surgeons (AAHKS) annual meeting demonstrated that there is a way for outcomes following hip and knee replacement surgeries to be measured more efficiently without compromising accuracy. Alexander S. McLawhorn, MD, MBA, hip and knee surgeon at HSS and one of the authors of the study, shared his perspective.

At HSS, we are dedicated to ensuring patient experience and safety remain our top priorities, while also reducing the unnecessary regulatory burden for the hospital. This study indicated that outcome measurement after hip and knee replacement can be accurate and reliable even if hospitals don’t collect PROMs for a majority of patients. More than 740,000 Medicare beneficiaries undergo primary total hip or knee replacement each year, that number is expected to increase to 1.2 million by the year 2030, making this a critical time to address this topic.

 Capturing feedback from as many patients as possible can become an administrative burden for everyone involved. There are many different stakeholders when it comes to PROMs, including regulatory, research and clinical teams. Each of these areas requests PROMs from patients at different points in their journey, uses PROMs differently, and requires different levels of reporting for their needs.

-Alexander S. McLawhorn, MD, MBA

Our proposed solution is collecting carefully chosen samples, which can still lead to accurate results. For very high-volume institutions like HSS, you are not losing any accuracy in terms of your measurement by measuring fewer patients. Our research also suggests that this more efficient approach could result in a significant overall reduction in administrative burden, particularly since most total hip and knee replacements are performed at high-volume centers. The net effect would be a large reduction in unnecessary data collection, an increase in operational efficiency and cost savings.

This approach is not applicable to all institutions. In fact, our findings revealed that lower-volume institutions may not experience the same benefit of a streamlined process. If a low-volume hospital only submits 50% of their cases, you may have very inaccurate assessment of quality. In some cases, you may need 100% reporting for some very low volume institutions.

HSS undertook this research because of our dedication to advancing patient safety and care quality. It is important that patients know the measures of quality for different institutions. What we are proposing is a strategy that will allow patients to receive information in a more efficient way. This research is intended to move a very important policy conversation forward. Changes involving CMS can take a significant amount to implement.  If we are able to adapt this common-sense approach patients and healthcare institutions everywhere will benefit.

HSS has been and will continue to be a leader in this space and instrumental in defining these tools now and well into the future.  

The Quiet Knee protocol, which some HSS surgeons began implementing several years ago, takes a more conservative approach to knee replacement recovery than traditional clinical protocols. This new technique focuses on controlling inflammation and swelling postoperatively through restricted mobility and passive range of motion (ROM) and aggressive cryotherapy (icing) for the first 10 days immediately following surgery. This contrasts with standard protocols, which often emphasize early and aggressive movement that can cause inflammation in surgical tissue that is healing.

All HSS total knee replacement patients from 2020 to 2024 were retrospectively reviewed as part of the study. A Quiet Knee group consisting of 271 patients received structured postoperative care and monitored telerehabilitation. One comparison group was given Quiet Knee guidance verbally, while a second cohort followed traditional early motion postoperative therapy.   

 “Patients are told they have to work really hard to get motion back after surgery—the no pain, no gain type of mentality,” said Brian P. Chalmers, MD, a hip and knee surgeon at HSS and one of the authors of the study. “The problem with that is that the more patients do in the early period of recovery—the more they bend, the more they are up and walking—the more the knee will swell.”

Every person undergoing TKA experiences pain and swelling after surgery, but the intensity differs, making the patient’s recovery process more challenging and often more painful than most other surgeries.

“It’s not uncommon to see a counterproductive early physical therapy program that is too aggressive,” Dr. Chalmers said. “In these cases, the knee becomes very swollen, which causes patients to have more pain. As the knee becomes more inflamed and patients are able to bend it less, it just becomes a cycle.”

Under the Quiet Knee protocol, patients avoid intensive physical therapy immediately after surgery, allowing the body time to heal before progressing to motion and other strength work. Early results suggest this approach helps set the stage for a smoother long-term recovery. The study also showed that the protocol significantly reduced 90-day opioid exposure by more than 25%.

“This isn't a surgeon-driven protocol or a research-driven protocol. It's a physiology-driven protocol,” said Michael P. Ast, MD, Chief of the Knee Service and Chief Medical Innovation Officer at HSS and co-author of the study. “It is a recognition of what the human body goes through in recovery from surgery. It is a very logical way of respecting the body's inflammatory response to trauma. Early on after surgery, less really is more. That is really the guiding principle of this protocol.”

Study Details

A Retrospective Cohort-Based Analysis of the “Quiet Knee” Protocol After Primary Total Knee Arthroplasty

Pravjit Bhatti, Lauren Moeller, Michael P Ast, Tony Sicheng Shen, Peter Keyes Sculco, David Jacob Mayman, Brian Chalmers

HSS researchers piloted and evaluated a custom-tailored AI (CTAI) platform that was trained on patient education content developed and approved by HSS surgeons. They found that patients were able to easily access and interact with the chat bot, which provided on-demand, personalized, accurate information about their surgery.

“Our study showed that most patients found the technology easy to use and helpful in making them feel ready and confident going into surgery,” says Eytan M Debbi, MD, PhD, hip and knee replacement surgeon at HSS and senior author of the study.

HSS investigators partnered with Aidify to develop the CTAI agent to address patient questions related to total joint arthroplasty (TJA) procedures such as hip and knee replacement surgery. Orthopedic surgeons at HSS trained the chat bot with their specific surgical protocols so that patients could receive personalized content that reflects their expertise.

Patients undergoing orthopedic procedures frequently face confusion and anxiety before surgery and are often dissatisfied with printed educational materials that can be hard to understand and not tailored to their needs. However, patients in the study gave Aidify high marks for responses that were useful, understandable, and complete.

“This platform can provide round-the-clock access to reliable, doctor-specific guidance and reduce the risk of getting inaccurate or irrelevant information from other general-purpose tools like Google or Chat GPT,” says Karlos Zepeda, DO, clinical research coordinator at HSS and lead author of the study.

The study included 40 patients scheduled to undergo TJA at HSS. Among the 32 patients who used the chat bot, about 85% said they understood the responses to their questions and 75% reported that it helped them feel well prepared for surgery. More than 80% of patients stated they would recommend the platform to others.

“I think patients get a lot of comfort knowing they have access to the chat bot because it gives them the sense that they can always be in contact with our office and get their questions answered whenever they need it,” explains Dr. Debbi.

Patients in the study were emailed a link to the interactive platform trained on information about the surgery they were going to have. They could then type their questions into the chat bot and get responses instantly.

The CTAI tool addressed a wide range of questions that focused mostly on concerns leading up to surgery and on recovery. These included activity guidelines, medications, what to expect after surgery, dietary guidance, pain management, wound care, and potential complications. The bulk of patients’ questions came in before surgery, while the number and frequency of questions diminished after surgery.

“Our findings show that CTAI improves patients’ health literacy, which enables more understanding, confidence, and preparedness before surgery,” says Dr. Zepeda. “This directly impacts patients’ overall satisfaction and care experience.”

The most unexpected finding, according to the authors, was the number of study participants who were able to access and navigate the platform. Most people who need TJA are over the age of 55, so there was a concern that older patients in the study might have some difficulty using AI technology.

“I was surprised that older patients were able to deal with the technology as easily as they did and be as satisfied as they were with it,” observes Dr. Debbi, who adds that some patients preferred interacting with the chat bot over their surgeon. “Surgeons cannot be available to patients 24 hours a day, but AI can review things with multiple patients at a time, whenever and as many times as they want without physician burnout, so that’s a huge benefit.”

CTAI streamlines communication and reduces the burden of repetitive or nonurgent questions on busy clinical staff. “The power of AI can extend the surgeon and their team to more patients by efficiently addressing patient concerns in real time and ensuring that they consistently receive the right information exactly as their surgeon intended,” explains Dr. Zepeda.

If the platform doesn’t know the answer to a question or there is an emergency, it will prompt the patient to contact their doctor’s office, call 911, and/or use the My Chart/Epic patient portal to send in their question to the appropriate provider, who would be notified of the issue and respond or escalate as needed. 

“We are still in the research phase and very carefully monitor every question that comes in to make sure nothing slips through the cracks,” notes Dr. Zepeda.

The study authors agree that their findings support continued refinement of CTAI as a tool to improve the delivery of patient education and care at HSS, but more research is needed to expand its use. For example, the technology does not currently have access to specific patient information.

“Only when we are confident in the technology and that patient information is secure will we enable AI to fully interact with patients’ electronic medical record and integrate it as standard of care at HSS,” says Dr. Debbi. “The potential of CTAI is unlimited. The sky’s the limit and we’re just scratching the surface right now.”

Challenges of Pediatric MRIs

A typical MRI is not only loud and confining but also very sensitive to motion, requiring subjects to lie still during the 20- to 80-minute procedure, which is a major challenge for pediatric patients. Consequently, sedation is used in up to 28% of pediatric MRIs, and reports show this number is increasing.

While sedation can facilitate successful imaging—and is considered relatively safe—relying on this strategy for young MRI patients poses potential risks, including cardiopulmonary issues and allergic reactions. Additionally, the combination of MRIs and sedation can cause anxiety for children and their parents and prolong recovery.

Researchers found that avoiding anesthesia—and post-anesthetic recovery—through CCLS interventions improves the overall efficiency of the MRI process, benefiting both families and care teams.

“Without anesthesia, children can avoid the need for an IV, they don’t need to fast prior to the MRI, and they don’t need to extend their hospital-related experience to recover,” says lead study author Jessica H. Heyer, MD, pediatric orthopedic and spine surgeon at HSS. “And from a hospital perspective, it enables children to have an MRI even when an anesthesiologist is not available.”

The American Academy of Pediatrics stresses that these types of nonpharmacological interventions “must be considered as standard procedure in infants, children, and adolescents undergoing MRI,” supporting the approach taken in this study.

Benefits of Avoiding Sedation

For this retrospective cohort study, HSS researchers looked at 1,936 patients between the ages of 4 and 12 who, in total, received 2,319 MRI scans over an eight-year period. They found that no child who received CCLS intervention prior to and/or during the procedure required IV sedation during MRI.

Despite the study’s remarkable success rate, Dr. Heyer notes that there are always exceptions: “Sedation-free MRI may be more difficult for very young children, those who need longer scans, children with cerebral palsy, and for those who need a head, brain, or neck MRI."

While all children can greatly benefit from CCLS intervention, Dr. Heyer notes that children between ages 5 and 10 appear to show the strongest results. Study co-author Melissa Collins, MS, senior child life specialist at HSS, adds that this strategy is particularly valuable for children with sensory processing issues or those with a history of negative medical experiences. “For example, children who’ve been told a procedure wouldn’t hurt and then were held down or experienced pain are less likely to trust medical professionals and medical environments,” she says.

Effective Child Life Techniques

The researchers examined several CCLS techniques, including guided imagery, distraction strategies, and caregiver involvement, but the most helpful strategy is “appropriate preparation based on the patient's developmental age,” says Collins. “MRI anxiety typically stems from uncertainty, so it’s important to provide children with accurate expectations, so they’re able to prepare and cope more effectively.” Collins suggests showing children a video of an MRI that walks them through each step and what they’ll see, hear, and feel during the scan to help take away some of the fear of the unknown. “It also helps to reiterate that nothing is going to touch them or hurt them,” she says.

At the Lerner Children’s Pavilion, one or both parents are always encouraged to accompany their child into the MRI suite. Children are also invited to bring a favorite soft, metal-free toy into the MRI unit and are given mirrored glasses so they can see their caregiver or the technologist behind them throughout the MRI. To celebrate their bravery, each child receives a small reward at the end of the exam.

Looking Forward

“Our research demonstrates that with proper preparation and support, we can transform a potentially stressful medical procedure into a positive experience for children,” concludes Dr. Heyer. “By reducing the need for sedation, we’re not only reducing medical risks but also empowering children to actively participate in their healthcare journey, potentially making future medical encounters less intimidating.”

Reference:

Tracey OC, Zucker C, Wisch J, Adhiyaman A, Thakur A, Collins M, Parise J, Denneen J, Jaramillo D, Potter H, Ipp L, Heyer JH. Not Just Fun and Games: Certified Child Life Specialists Improve Success Rates of Young Children Undergoing MRI Studies without Anesthesia. Presented at: Pediatric Orthopaedic Society of North America (POSNA) Annual Meeting, 2025

Thestrup J, Hybschmann J, Madsen TW, et al. Nonpharmacological interventions to reduce sedation and general anesthesia in pediatric MRI: a meta-analysis. Hosp Pediatr. 2023;13(10):e301-e313. Accessed May 14, 2025, at https://doi.org/10.1542/hpeds.2023-007289

Uffman JC, Tumin D, Raman V, Thung A, Adler B, Tobias JD. MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO. J Am Coll Radiol. 2017 July;14(7):924-930. Accessed May 14, 2025, at https://www.jacr.org/article/S1546-1440(17)30121-7/abstract

Study: Prevalence of cannabidiol use in patients undergoing sports medicine procedures on the knee, shoulder, or hip: A survey study 

Researchers set out to determine the prevalence of cannabidiol (CBD) use in patients scheduled to undergo a sports medicine procedure at HSS. “We know that managing post-operative pain with opioids carries risks, including addiction. A promising alternative gaining attention is cannabidiol, a non-intoxicating derivative of the cannabis plant that is federally legal in the United States,” said Alexandra Sideris, PhD, director of the Pain Prevention Research Center at HSS. The study was presented at the 50th Annual ASRA Meeting in Orlando, Florida on May 1. 

Reports from the National Survey on Drug Use and Health indicate that adults ages 18-35 are the most frequent self-reporters of cannabis use. “Our study aimed to shed light on the prevalence of self-medication with CBD in adults scheduled for elective sports medicine surgery on the knee, hip or shoulder, evaluating the effects in this patient population,” Dr. Sideris explained. 
Researchers emailed anonymous surveys to 470 patients between September 2024 and December 2024. Out of 159 respondents, 39% of patients reported having tried CBD. Approximately one-third indicated that they used CBD on an as-needed basis, primarily for pain or to help them sleep. Most patients used gummies, and 44% purchased them from a dispensary. One-third of the respondents indicated that CBD was either moderately or very helpful. 

“At HSS, ongoing data collection and analysis will further elucidate the perceived efficacy of cannabidiol and the potential for changes to prescription medication use with the incorporation of CBD,” Dr. Sideris noted. 

With respect to the President’s Choice award, she commented, “It is an honor to have one of the top professional organizations in the field of regional anesthesia and pain medicine highlight the collaborative work of our department's Pain Prevention Research Center. The award reflects our dedication to innovations in patient care and underscores the greater scientific community's acknowledgements of our efforts.” 

Study: Opioid Consumption During Hospitalization Across Manual, Computer- and Robotic-Assisted Total Hip Replacement

In the second study to win a President’s Choice award, HSS researchers found that patients who had robotic-assisted total hip replacement (THR) surgery needed less opioid medication during hospitalization compared to patients who had computer-assisted or manual THR. The research was presented at the ASRA meeting on May 2. 

“Effective pain management while limiting opioid consumption following total hip replacement is imperative, as it facilitates immediate postoperative function and leads to better long-term outcomes,” said Periklis Giannakis, MD, a research fellow at HSS. “While patient characteristics are important factors associated with pain control, surgical technique is also relevant. We aimed to determine if the way hip replacement was performed had an effect on the need for opioid medication after surgery.” 
Analyzing a multi-institutional database with almost 100,000 hip replacement cases, Dr. Giannakis and colleagues found that robotic-assisted hip replacement was associated with the lowest total opioid consumption during hospitalization. He noted that while the exact mechanism is unknown, reduced soft tissue trauma and a more precise robotic-assisted surgery may contribute to less acute inflammation and less pain immediately after the procedure. 

Regarding his President’s Choice award, Dr. Giannakis commented, “Receiving President’s Choice recognition is a great honor for me and a testament to the collaboration and important research that we conduct at HSS.” He notes that future collaborative studies between the Department of Anesthesiology, the Pain Prevention Research Center and the Adult Reconstruction and Joint Replacement Service at HSS will seek to obtain more specific data, such as which robotic- and computer-assisted systems were used, with the ultimate goal of optimizing postoperative pain control. 

References: 
Prevalence of cannabidiol use in patients undergoing sports medicine procedures on the knee, shoulder, or hip: A survey study 
Authors: Sophia Madjarova BA, Arjun Khorana BS, William Chan MEng, Answorth Allen MD, Riley Williams MD, Benedict Nwachukwu MD, MBA, Alexandra Sideris PhD. 
Opioid Consumption During Hospitalization Across Manual, Computer- and Robotic-Assisted Total Hip Arthroplasty 
Authors: Periklis Giannakis, MD, Juliet E. Rowe, MPH, Lisa Reisinger, MD, Alex Illescas, MPH, Alexandra Sideris, PhD, Crispiana Cozowicz, MD, Junying Wang, MPH, Sophia T. Zhuang, Jiabin Liu, MD, PHD, Lazaros Poultsides, MD, PHD, Robert G. Marx, MD, Alejandro Gonzalez Della Valle, MD, Jashvant Poeran, MD, PhD, Stavros G. Memtsoudis, MD, PhD, MBA. 
 

There are currently no objective biomarkers for concussion, an invisible injury and form of mTBI, which often remains difficult to diagnose and treat. Although there are broad consensus guidelines, individual treatment decisions for this heterogeneous injury are largely left to the discretion of the physician. Previous studies have suggested a link between C-reactive protein (CRP), an inflammatory biomarker in the blood, and TBI, but the relationship is still under-explored. Because the underlying pathophysiology remains poorly understood, it remains challenging to create a treatment plan, noted Ayse Erdemir, clinical research coordinator at HSS, and first author of both studies.

“Currently there are no established pharmacological treatments for mTBI,” Erdemir noted. Standard treatment involves physical therapy, guided exercise, and lifestyle modifications, with some options for treating headache, head pressure, and insomnia, common symptoms that can impact recovery. While previous studies of amitriptyline in this population have been inconclusive, the team's research provides new data which may support its use in specific circumstances.

These studies, if further validated, have the potential to influence the treatment of mTBI, she added.

For the first retrospective study of 383 concussion patients, researchers focused on measurements of high sensitivity CRP (hsCRP), an inflammatory biomarker in the blood. Erdemir pointed out, “We found that higher levels of hsCRP were associated with more frequent reporting of symptoms like sadness and trouble falling asleep. Notably, patients with abnormal hsCRP took longer to recover compared to those with normal levels. These patients also tended to be older and have higher BMI.”

Additionally, she said "The findings suggest that hsCRP could potentially be a candidate for inclusion in biomarker panels for acute mTBI assessment, but more research is needed to understand its long-term role in tracking symptom resolution and recovery."

The results also offer a possible new insight into the pathophysiology of the disease, suggesting that, at least in some patients, the concussion may be characterized by low levels of inflammation in the brain that resolves with tailored treatment paradigms.

For the second study, the researchers analyzed data from the same group of patients, focusing on those who were prescribed amitriptyline. They found that patients who had received the drug more often had histories of depression, anxiety, and migraines, and also had more severe concussion symptoms than those who did not receive the medication. Even though their concussions appeared to be more complex and severe, patients in the amitriptyline group recovered at the same rate as more straightforward cases.

“Amitriptyline seems to play a supportive role in helping patients with more frequent and severe baseline symptoms to recover,” said Erdemir. “A tool to treat headache and insomnia in concussion patients doesn’t just improve quality of life throughout recovery; it may also facilitate and potentially expedite recovery. Restoring normal sleep and improving sleep quality is especially important to helping the brain heal from mTBI.”

While researchers believe patients with more severe concussions are more likely to benefit, the drug may still be prescribed in other patients to relieve symptoms.

More research is clearly needed to develop clinical applications. Researchers hope to follow up by analyzing longitudinal trends of hsCRP across recovery, to further support its use as a biomarker. Additional study of amitriptyline should include a randomized, controlled trial comparing the medication to placebo as well as other medications used to treat headache.

References:

High-sensitivity C-Reactive Protein (hsCRP): Retrospective Study of Potential Blood Biomarker of Inflammation in Acute Mild Traumatic Brain Injury (mTBI)

Authors: Guzide Ayse Erdemir, Niluckshi Pitigala, Joseph T. Nguyen, Teena Shetty, MD, MPhil, FAAN (HSS).

Amitriptyline for Acute Mild Traumatic Brain Injury (mTBI)

Authors: Guzide Ayse Erdemir, Niluckshi Pitigala, Joseph T. Nguyen, Teena Shetty, MD, MPhil, FAAN (HSS).

“As an increasing number of younger adults in their 40s and 50s consider total knee replacement, many wonder how long knee implants last before requiring a revision procedure,” says William J. Long, MD, FRCSC, an HSS hip and knee surgeon and the senior author of the study. “The findings from our study—the largest and longest follow-up of patients under 55 undergoing total knee replacement—confirm that young patients can be confident their initial knee implants will allow them to pursue a high level of activity and more than likely last the rest of their lives.”

HSS orthopedic surgeons designed the longitudinal study to track outcomes for patients 55 years of age and younger who had total knee replacements between 1977 and 1992. During that period, they used knee prostheses known as the Insall-Burstein I and Insall-Burstein II—predecessors of implants used today that provide posterior stability. Both designs were conceived and developed at HSS. Previously, the investigators conducted patient follow-ups at 10, 25, and 30 years following surgery.

For this final report, Dr. Long and colleagues analyzed outcomes after 40 years for 81 patients aged 33 to 55 years. The analysis included 107 knees in total. Overall, 70% of patients in the study had no revision procedures in their lifetime. Patients were three to four times more likely to have passed away after 40 years than to have required a revision. Remarkably, among the 49 patients who received the original Insall-Burstein I prostheses, 80% did not have any revision surgeries.

“Considering that today's knee replacements have addressed the pitfalls leading to the majority of revisions for mechanical issues in Insall-Burstein I and Insall-Burstein II implants, these are very reassuring findings," says Dr. Long.

Dr. Long also examined six patients (eight knees) in person, and lead and presenting author Aaron Weinblatt, BA, contacted many more patients by phone. There were no signs of loosening nor were there any changes in symmetry or alignment of the original components. Additionally, patients reported an ongoing improved level of activity after surgery.

This was supported by patient-reported activity data collected for eight patients (10 knees) and measured using the Tegner Activity Scale (TAS). Before undergoing total knee replacement, the average TAS score was only 1.5, indicating they could work in a sedentary job and walk on uneven ground but not hike or backpack. At 40 years, their average TAS score was 2.7, indicating the ability to work in light labor occupations and participate in recreational activities such as swimming and walking in forests.

“Patients requiring a total knee replacement should not delay having surgery,” Dr. Long says. “Our study results highlight that those who undergo knee replacement sooner are more likely to maintain a high level of activity that contributes to a healthy, longer-term lifespan.”

Dr. Long adds that a previous HSS study published in 2014 at the 30-year follow-up showed that for the small percentage of patients who required revisions, the vast majority were doing well, with an average TAS score of 3.0, a good range of motion and no signs of loosening. ²

Authors: Aaron I. Weinblatt, BA, Victoria E. Bergstein, BA, Walter L. Taylor, MPhil, BS, Stephen Lyman, PhD, Felix C. Oettl, MD, W. Norman Scott, MD, FAAOS, William J. Long, MD, FRCSC.

Reference:

¹ Weinblatt AI, Bergstein VE, Taylor WL, Lyman S, Oettl FC, Scott WN, Long WJ. Total knee replacement in young, active patients: long-term follow-up and functional outcome: A final follow-up of previous report. Accessed February 10, 2025, at https://submissions.mirasmart.com/AAOS2025/Itinerary/PresentationDetail.aspx?evdid=2532

² Long WJ, Bryce CD, Hollenbeak CS, Benner RW, Scott WN. Total knee replacement in young, active patients: long-term follow-up and functional outcome: a concise follow-up of a previous report. J Bone Joint Surg Am. 2014 Sep 17;96(18):e159. Accessed February 19, 2025, at  https://pubmed.ncbi.nlm.nih.gov/25232089/  

“These findings give some reassurance to female patients that there are physiological reasons why they are having more pain,” says Bella Mehta, MBBS, MS, rheumatologist at HSS and lead author of the study. “Our work may also help us develop better therapies, especially for women with more severe symptoms.”

The study enrolled 135 patients with knee OA who were scheduled to have total knee replacement. A total of 82 participants were female. Researchers analyzed patient-reported symptoms of pain, histology (tissue samples removed during surgery and examined under the microscope) and genetic markers of inflammation in the blood.

The study found that women with knee OA had higher markers of inflammation in their blood, increased tissue inflammation and widespread cartilage loss. This corresponds with the study’s findings that women reported higher levels of pain, even at night when at rest.

The findings also revealed specific genetic expression patterns in women that notably increased synovial tissue inflammation. This occurs when the synovium, the thin layer of tissue above the cartilage that helps lubricate the knee joint, becomes inflamed and painful.

“Traditionally, it was thought that knee osteoarthritis was caused by years of significant wear and tear on the cartilage in the knee joint, but synovial inflammation is now known to play a big role in this condition,” notes Dr. Mehta.

Knee osteoarthritis is the most common type of arthritis in the world. Most people over the age of 65 have some form of it, with around 70% to 80% experiencing symptoms of pain and stiffness.

Pain is typically reported more frequently in women with knee OA than in men. Dr. Mehta suggests several theories as to why, including:

-Mechanical differences between men and women. A woman’s pelvis or hip bone is shaped differently than men so they can accommodate having babies. This has implications on the knee joint, which may increase osteoarthritis and pain.

-Hormonal differences in estrogen and progesterone after menopause, which may make women more prone to osteoarthritis.

-Differences in genetics. Women are born with two X chromosomes, whereas men have an X and a Y chromosome. The second X chromosome expresses certain genes that increase the likelihood for women to have osteoarthritis.

“It’s not that women complain of more pain. There are objective, physiological differences that we have seen between men and women that can explain this,” says Dr. Mehta. “For example, they have increased markers of inflammation in their blood, inflammatory gene expression and more mechanical stress and cartilage loss in the knee, all contributing to more pain even at rest.”

Currently, first-line treatments for people with knee OA include medications to manage pain, and exercise to strengthen the muscles and ligaments around the knees. However, if there is no improvement, surgery is recommended.

Researchers continue to look for ways to improve treatment options for knee OA. “There may be certain immunomodulatory agents that target the genetic mechanisms driving tissue inflammation in women, but more research is needed to better understand these genes and their role in accelerating knee osteoarthritis in females,” says Dr. Mehta.  

What follows are highlights from these studies:

Factors Associated with Infant Feeding Behaviors Among Women with Systemic Rheumatic Diseases

While guidelines provide recommendations on which medications for rheumatic diseases are safe during breastfeeding, limited research has explored what factors influence the decision to breastfeed among patients with these conditions. HSS researchers leveraged data from the Rheumatology Women’s Reproductive Health and Wellness Cohort to better understand the range of influences.

The cohort included 158 patients who reported on infant-feeding practices. Among those, 56% had systemic rheumatic diseases. The data showed that among these patients, about two-thirds breastfed at some point, while about one-third exclusively formula fed. The participants also reported their satisfaction levels with infant feeding, with only breast discomfort and lack of milk production being associated with lower satisfaction.

The investigators found that although the medications that the patients were taking for their rheumatic disease influenced their infant-feeding practices, disease-agnostic factors also played an important role. These factors included the experiences of friends and family, social media, and workplace policies, among others.

“It’s important to be mindful that these are things that influence people’s practices,” says Sarah B. Lieber, MD, MS, rheumatologist at HSS.

Dr. Lieber explains that rheumatologists are uniquely positioned to study this topic, as they typically care for patients over many years, including during pregnancy and the postpartum period. “We develop close relationships with our patients and they frequently seek our guidance on a wide range of issues,” she says. “Research like this allows us to expand our focus beyond rheumatology-specific concerns, addressing other important factors that may not have been addressed in other contexts to ensure that we honor their preferences with regard to infant feeding.”

Authors: Sarah B. Lieber, MD, MS; Lucy Masto, BS; Amaya Smole, BA; Ranqing Lan, MA; Michael Parides, PhD; Jonah M. Levine, BA; Bessie Stamm, BA; Caroline H. Siegel, MD, MS; Lisa A. Mandl, MD, MPH; Michael D. Lockshin, MD; Medha Barbhaiya, MD, MPH; and Lisa R. Sammaritano, MD.

Predicting Adverse Pregnancy Outcomes in Women with Systemic Lupus Erythematosus: External Validation of the PROMISSE Model Using Multiple Independent Cohorts

Lupus is associated with severe adverse pregnancy outcomes, including pre-eclampsia, very early preterm deliveries, and in rare cases, fetal death. Fortunately, these occur in only 20% of patients. Early identification of women with SLE who are at high risk of pregnancy complications is vital. A team led by HSS investigators followed more than 400 pregnant patients with lupus — all of whom were enrolled in the PROMISSE Study, a multicenter, multiethnic/racial study — with the goal of using clinical features and laboratory tests to identify those patients at high risk for pregnancy complications. They identified two promising algorithms for predicting poor pregnancy outcomes using PROMISSE data.

The goal of the current work was to externally validate these two models to test their transportability to other populations. In this study, the group obtained data from 966 pregnant lupus patients from six independent cohorts treated at centers in the United States and Europe, a demonstration of global collaboration. Groups that shared data for the validation were from South Carolina, Manhattan, and the Bronx, as well as Germany, Italy, and France. The patient populations varied, with some groups being predominantly white, while others were predominantly Black — either African American or Afro-Caribbean.

The PROMISSE model used statistics and machine learning to create prediction algorithms based on thousands of data points from 400 patients. The new findings with the additional patients confirmed that the algorithms can reliably predict pregnancy outcomes by assessing factors such as the presence of specific autoantibodies, disease activity, blood pressure, medications, and patients’ race and ethnicity. They demonstrate the geographic transportability of the best-performing algorithms. “The study reassured us that this model performs well across a diverse range of patient populations,” says Jane E. Salmon, MD, co-principal investigator and rheumatologist at HSS.

“More than 80% of lupus patients are likely to have an uncomplicated pregnancy, and they should be able to enjoy this time without having to worry. We are now better able to predict risk,” Dr. Salmon adds. “For those at higher risk, we can closely monitor and recommend clinical trials aimed at preventing complications.”

The team also included co-principal investigator and biostatistician Mimi Kim, ScD, and machine learning expert Melissa Fazzari, MS, PhD. Their next step is to develop a publicly available online risk calculator, a tool to allow obstetricians, rheumatologists, and other healthcare providers to better guide their patients based on individualized assessments.

Authors: Melissa Fazzari (Albert Einstein College of Medicine); Jane E. Salmon, MD; Marta Guerra, MS; Nathalie Costedoat-Chalumeau (Inserm; Paris, France); Veronique Le Guern (Cochin Hospital; Paris, France); Gaëlle Guettrot-Imbert (Cochin Hospital, Paris, France); Marta Mosca (University of Pisa; Italy); Dina Zucchi (University of Pisa; Italy); Chiara Tani (University of Pisa; Italy); Rebecca Fischer-Betz (Uniklinik Düsseldorf, Düsseldorf, Germany); Isabell Haase (Heinrich-Heine University Düsseldorf; Düsseldorf, Germany); Anna Broder (Hackensack Network; New Jersey); Navneet Kaur (Touro University Medical Group, Sacramento); Jill Buyon (NYU Grossman School of Medicine); Brooke Cohen (NYU Grossman School of Medicine); Diane Kamen (Medical University of South Carolina); Jessica English (Medical University of South Carolina); Anna Arar (Medical University of South Carolina); and Mimi Kim (Albert Einstein College of Medicine).

Quality Improvement Initiative to Increase Contraception Screening and Documentation for Reproductive-Aged Women Prescribed Teratogenic Medications in an Academic Rheumatology Center

Contraception use among patients with rheumatologic diseases who are taking medications that may cause fetal defects is low. They are not always counseled on contraceptive options or prescribed effective contraception. In addition to primary care providers and gynecologists, rheumatologists play an important role in contraception counseling for patients with rheumatic disease. However, there are several barriers to rheumatologists providing contraception counseling to patients. Documentation of contraception use in patients with rheumatic disease is poorly standardized nationally. Researchers from HSS, who previously looked at developing a more streamlined process for documentation of sexual activity and contraception in these patients, expanded their work in this new study to improve documentation in this patient population.

In the study, they implemented a pop-up alert in the electronic health record across all ambulatory areas. Over a period of 24 weeks, the alert was set to trigger during clinical visits for female patients between the ages of 18 and 50 who were taking one of these high-risk medications. The alert reminded the nurses to ask about patients’ sexual activity and contraceptive use and document it in the medical record.

Despite the initiative, the investigators found that for the most part, documentation rates did not increase significantly over the time period, except in the unit where the project had previously been piloted. “In that unit, we had nursing champions who were invested in the process and understood the importance of asking these questions,” says Nancy Pan, MD, rheumatologist at HSS. “They can encourage their colleagues to help, including by suggesting ways to normalize what is often a sensitive topic with patients yet is critical to providing the best medical care possible for them.” She adds that despite these results, she and her colleagues learned from this program and that their findings are prompting new interventions to optimize contraception documentation, counseling, and ultimately referrals to women’s health providers.

“When patients choose to take these medications, we always make sure to counsel them on contraception,” Dr. Pan says. “However, as a patient’s personal circumstances can change, it’s essential that we reassess their needs regularly. Optimizing documentation of contraception is an important first step to achieving improved health outcomes in these patients.”

Authors: Caroline H. Siegel, MD, MS; Avi Mikhaylov; Emily Wu; Deanna Jannat-Khah, DrPH; Erika Abramson (Weill Cornell Medicine), Lisa R. Sammaritano, MD; and Nancy Pan, MD.^.

Robert F. Spiera, MD, Director of the Scleroderma, Vasculitis, and Myositis Center at Hospital for Special Surgery (HSS), helped lead this latest analysis which was presented at the ACR Convergence 2024, the annual meeting of the American College of Rheumatology. The study built on the pivotal ADVOCATE trial, focusing on patients with the most severe manifestations of vasculitis in the ENT region, which has historically been harder to treat.

Avacopan (Tavneos, Amgen) was approved by the US Food and Drug Administration in 2021 for the treatment of severe active anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis, a rare autoimmune disorder that can cause potentially life-threatening inflammation by restricting blood flow to vital organs. 

Once considered a fatal condition, ANCA associated vasculitis is now treatable, especially if identified early and treated with appropriate immunsosuppressive medications. Avacopan is a targeted therapy that offers a safer and more effective alternative to prednisone which had traditionally been a mainstay of remission induction therapy in these disorders but carries with it high risks such as infections, weight gain, diabetes, and bone thinning.

While the original ADVOCATE trial established the avacopan as an improved treatment option, the new analysis zeroes in on a group of patients whose disease has historically been more difficult to treat – those with ENT involvement. These patients often experience debilitating symptoms such as pain, hearing loss, and chronic inflammation, which severely impact quality of life.

“We know patients with this disease often achieve remission in their kidneys and lungs, but ENT disease frequently becomes a significant factor impacting their quality of life,” Dr. Spiera said. “This analysis provides crucial insights, showing that avacopan not only brings faster relief but sustains improvement over time in patients with those manifestations.”

The new analysis focused on a subgroup of 144 patients from the ADVOCATE trial, all of whom had severe ENT symptoms. Findings revealed that patients treated with avacopan showed significant improvements as early as week 4, with results continuing to favor avacopan over prednisone at week 52. Remarkably, 71% of these patients reached remission at 26 weeks, closely mirroring the remission rates in the broader trial.

Beyond clinical improvement, patients taking avacopan reported higher quality of life scores compared to the group taking prednisone. “Avacopan offers these patients a real opportunity to live with fewer limitations,” noted Dr. Spiera.

Equally important, the study showed that avacopan’s safety profile was comparable to that of prednisone, with similar rates of adverse events such as infections.

“These encouraging results underscore the importance of considering avacopan, for patients with microscopic polyangiitis and granulomatosis with polyangiitis with active ENT symptoms,” Dr. Spiera said.

Advancements in surgical techniques and the increased use of a medication called tranexamic acid for preventing and controlling bleeding have made it possible for many patients undergoing knee replacement to avoid needing a transfusion, which requires hospital admission for at least a day.

Despite these advancements, it was believed that patients with RA undergoing orthopedic surgeries had an elevated risk of transfusion since they tend to have higher rates of anemia compared to the individuals without the disease. RA occurs in about 1% of the general American population.² About 4% of patients having joint replacement surgeries at HSS have the disease.

“Learning that rheumatoid arthritis was not a transfusion risk factor was unexpected,” said HSS rheumatologist Susan M. Goodman, MD, co-author of the study. “However, we believe presurgical care, including proactively managing chronic anemia before surgery, played a key role in minimizing transfusion risk.”

For their study, Dr. Goodman, HSS rheumatologist Linda A. Russell, MD, and colleagues analyzed hospital records for more than 29,000 patients who had a single total knee arthroplasty procedure at HSS from February 2016 to December 2022. A total of 822 patients, or 2.8%, received transfusions. The transfusion rate declined significantly during the study period from 5.7% in 2016 to 0.9% in 2022.

The investigators reviewed patient demographics such as age and sex, preoperative hemoglobin levels, RA diagnosis and the use of tranexamic acid during surgery, and then looked for associations with transfusion risk.

“In addition to finding that rheumatoid arthritis was not a transfusion risk factor, analysis revealed that a higher preoperative hemoglobin level and the use of tranexamic acid significantly decreased transfusion risk, while being male and having a greater burden of other diseases increased risk,” said HSS pre-doctoral student and research assistant Stephen Batter, BA, the presenting author of the poster summarizing the study.

The research team plans to use their unexpected findings to develop a tool to identify patients with different levels of transfusion risk based on preoperative hemoglobin level, sex, age and health status. This initiative may help orthopedic surgeons better anticipate which patients can safely avoid transfusion and may be suitable candidates for outpatient knee replacement surgery.

Authors: Stephen Batter, BA, Huong Do, MA, Dongmei Sun, PhD, Ahmed Deeb, BA, Trang Bui, MD, Jason L. Blevins, MD, Mark P. Figgie, MD, Gwo-Chin Lee, MD, J. Alex B. Gibbons, BA, Bella Mehta, MD, MS, MBBS, Susan M. Goodman, MD, Linda Russell, MD.

Reference:

¹ Batter S, Do H, Sun D, Deeb A, Bui T, Blevins J, Figgie M, Lee G, Gibbons J, Mehta B, Goodman S, A Russell L. Investigating Predictors of Transfusion in Rheumatoid Arthritis and Osteoarthritis Patients Undergoing Knee Arthroplasty [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/investigating-predictors-of-transfusion-in-rheumatoid-arthritis-and-osteoarthritis-patients-undergoing-knee-arthroplasty/. Accessed October 10, 2024.

² Xu Y, Wu Q. Prevalence Trend and Disparities in Rheumatoid Arthritis among US Adults, 2005-2018. J Clin Med. 2021;10(15):3289. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8348893/. Accessed October 10, 2024.

The study, presented today at the annual meeting of the American College of Rheumatology, ACR Convergence 2024, was led by researchers at the University of Colorado School of Medicine in collaboration with investigators from HSS and other centers within the Accelerating Medicines Partnership® Program: Rheumatoid Arthritis and Systemic Lupus Erythematosus (AMP® RA/SLE) Network.¹

“These research findings validate the importance of certain immune cells in the development of RA, particularly in how they drive the change from asymptomatic to symptomatic,” said Laura Donlin, PhD, scientist and co-director of the HSS Precision Medicine Program and co-principal investigator of the National Institutes of Health-supported AMP Rheumatoid Arthritis research consortium. “We hope that one day we can use these insights to stop RA before it even begins.”

Rheumatoid arthritis is a type of inflammatory arthritis that can occur when specific types of immune cells attack the body’s healthy tissues, resulting in pain, swelling and stiffness in joints. It can also result in problems in other areas of the body, such as the heart, lungs, eyes, nerves and skin. Diagnosis typically relies on an evaluation by a rheumatologist for clinical signs and symptoms supported by further evidence from X-rays and blood tests.

For the study, the participating rheumatologists collected tissue and blood samples from patients who either had RA or were considered at risk due to specific antibodies, called ACPA, in their blood and having a first-degree relative with the disease. Researchers at the Broad Institute of MIT and Harvard then used advanced single-cell sequencing techniques to analyze the samples and compared the results to those from healthy individuals.

The analysis found higher numbers of certain immune cells in the patients at risk for RA, including CCR2+ T helper cells, T peripheral helper cells, type 1 T helper cells, and granzyme B-positive memory T helper cells. Advanced sequencing also gave the investigators a better understanding of which genes were activated in these cells, offering insight into how the immune cells in patients with RA differ from those in at-risk individuals and healthy people.

“We knew that the presence of ACPA in blood and having a first-degree relative with rheumatoid arthritis indicate risk, but this new research has allowed us to learn more about the underlying biology driving increased risk,” said HSS rheumatologist Susan M. Goodman, MD, a co-author of the study. “These insights will pave the way toward helping us develop a new tool for determining which patients may benefit from early intervention.”

“There is some evidence that existing RA drugs, such as abatacept or rituximab, may help prevent the disease, but they are relatively expensive and come with side effects,” said co-author S. Louis Bridges, Jr., MD, PhD, physician-in-chief and chief of the Division of Rheumatology at HSS. “Pending validation in larger studies, the new patterns of immune cells identified in this research could represent potential targets for the development of new, more effective therapies.”

HSS Authors: S. Louis Bridges, Jr., MD, PhD, Vivian P. Bykerk, BSc, MD, FRCPC, Susan M. Goodman, MD, Laura Donlin, PhD.

Reference:

¹ Inamo J, Keegan J, Griffith A, Ghosh T, Horisberger A, Howard K, Pulford J, Murzin E, Hancock B, Eisenhaure T, Dominguez S, Gurra M, Gurajala S, Jonsson A, Seifert J, Feser M, Norris J, Cao Y, Apruzzese W, Bridges S, Bykerk V, Goodman S, Donlin L, Firestein G, Bathon J, Hughes L, Tabechian D, Filer A, Pitzalis C, Anolik J, Moreland L, Hacohen N, Guthridge J, James J, Cuda C, Perlman H, Brenner M, Raychaudhuri S, Sparks J, Holers M, Deane K, Lederer J, Rao D, Zhang F. Deciphering Pathogenic Phenotypes by Multi-modal Deep Single-cell Blood Immunophenotyping in Individuals At-risk for Rheumatoid Arthritis [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/deciphering-pathogenic-phenotypes-by-multi-modal-deep-single-cell-blood-immunophenotyping-in-individuals-at-risk-for-rheumatoid-arthritis/. Accessed October 10, 2024.

The study examined how patients engage with the digital world using real-time data from Google Trends. The patterns reveal not only how rheumatoid conditions affect daily life, but also reflect patients’ digital behavior as they turn to online resources for answers and support.

“Our work provides a clearer view of what patients are actually searching for and enables us to address their needs more effectively,” says Bella Mehta, MBBS, MS, MD, rheumatologist at HSS and senior author of the study.

Researchers selected a range of keywords and topics related to symptoms and treatment of rheumatic diseases. They found that online searches for symptoms consistent with rheumatoid or inflammatory arthritis, such as joint pain and swollen hands, spiked between 5:00 am and 7:00 am, when patients are likely at peak discomfort. In contrast, searches for medications like methotrexate, which is one of the standard medications for RA, were higher at night. This indicates that patients are actively seeking relief after experiencing pain throughout the day and into the evening.

“By identifying the times when patients most frequently experience and seek relief for their symptoms, we can optimize medication schedules and enhance patient support to provide more targeted care,” says Dr. Mehta. “This personalized approach not only improves the effectiveness of treatments but also helps patients better manage their conditions.”

This data-driven approach also fosters better communication between patients and providers, opening the door for more-informed discussions about symptom patterns and treatment options. “This allows us to be more responsive to patients’ needs and offer interventions that align with their daily challenges, leading to better health outcomes,” explains Dr. Mehta.

For example, many people with rheumatoid diseases search for dietary advice or other alternative treatments online, yet this is a conversation that rarely happens during clinical visits. Research studies like this can help bridge these gaps, creating more opportunities for physicians to talk to their patients about appropriate care options, rather than patients relying on potentially ineffective or harmful information online.

“By paying attention to these online behaviors, we can reduce the disconnect between the healthcare system and the individuals we serve, ensuring that we provide more empathetic, timely, and patient-centered care,” says Dr. Mehta.