TKA, also known as total knee replacement, is one of the most common elective surgeries in the United States, with over 700,000 cases performed each year. In spite of advances in surgical techniques and antibiotic regimens, infection following TKA remains a devastating complication that has led to a greater focus on controllable risk factors.

“Historically, it’s been said that the higher a surgeon’s volume, the lower the rate of infection, and the corollary is that low-volume surgeons are considered to have a higher risk of infection,” says senior author Geoffrey H. Westrich, MD, hip and knee surgeon at HSS. “We wanted to take a closer look at this historic paradigm to determine if surgeon volume independently affects infection outcomes at a high-volume orthopedic center that places great importance on infection prevention.

“At HSS, we perform thousands of joint replacements each year and we have an incredibly robust infection prevention program that has resulted in infection rates that are among the lowest in the nation,” Dr. Westrich continues. “However, the biggest problem with infection research is that because our rates are so low, it’s hard to isolate the impact of individual surgeon volume from the many institutional factors that influence outcomes.”

The researchers conducted a retrospective review of prospectively collected data at HSS that included all TKA procedures (33,747) performed between January 1, 2018, and December 30, 2024. A total of 52 surgeons were stratified by annual TKA case volume into three categories: low (<50 cases/year), high (50–250 cases/year), and ultra-high (>250 cases/year). Infection outcomes, including superficial surgical site infections (SSI) and deep periprosthetic joint infections (PJI), were monitored for 90 days postoperatively using a dedicated surveillance program in accordance with National Healthcare Safety Network (NHSN) criteria.

The study found the low-volume group had an average operative time of 112.2 minutes, a PJI rate of 0.3%, and an SSI rate of 0.2%. The high-volume group had an average operative time of 96.5 minutes, a PJI rate of 0.3%, and an SSI rate of 0.1%. The ultra-high-volume group had an average operative time of 90.5 minutes, a PJI rate of 0.2%, and SSI rate of 0.1%. Despite differences in operative time, there were no statistically significant differences in infection rates across the three surgeon volume groups with respect to both SSI and PJI.

Dr. Westrich notes that infection rates for TKA across the surgeon volume groups are extremely low compared to other hospitals in New York State. “Our HSS  infection rates, which range from 0.1% to 0.3%, are among the lowest in the New York State and in our country,” he says. “At other New York State hospitals, infection rates can be as high as 2.0% or ten times higher than our institution.”

“Our findings demonstrate that at a high-volume academic orthopedic center, infection rates following total knee replacement remain uniformly low regardless of individual surgeon volume,” says Dr. Westrich. “This flies in the face of what we’ve been told historically about surgeon volume and infection rates. It’s not just the surgeon, it’s the institution that drives safety.”

“At HSS, controlling the risk of infection is among our highest priorities and most important accomplishments,” explains Dr. Westrich.  “Our low infection rates are achieved with a robust infection-control committee, extensive patient education, state-of-the-art operating rooms, infection-reducing surgical practices, enhanced sterilization methods, and highly disciplined infection-control practices. Together, these factors outweigh the volume of the individual surgeon.”

To improve patient safety and quality care at orthopedic centers, Dr. Westrich emphasizes the importance of strengthening institutional infrastructure and quality-improvement programs, rather than limiting low-volume surgeons’ access to TKA.  “Our study shows that even if you bring a surgeon on staff who is just starting out in their career, that doesn’t mean a patient going to that surgeon is at a greater risk of infection.  A rigorous, comprehensive approach to patient care with relentless focus on infection control at every stage provides the greatest protection from infection.”

Authors:  Josef Jolissaint, MD; Andrew Thomson, BA; Alexandra Grizas, MPH; Andy Miller, MD; and Geoffrey H. Westrich, MD

HSS hip and knee surgeon Geoffrey H. Westrich, MD, and his colleagues found no difference in hospital length of stay, complications, hospital readmission within 90 days of surgery, or rates of revision surgery at two-year patient follow-up. The findings were presented today at the American Academy of Orthopaedic Surgeons 2022 Annual Meeting in Chicago.

With respect to time spent in the operating room (OR), researchers found that using the cementless implant reduced OR time by 25%, saving an average of 27 minutes. “In a cementless total knee replacement, you do not have to wait for the cement to harden and dry like you do in a cemented knee replacement,” explained Brian P. Chalmers, MD, hip and knee surgeon at HSS and study co-author.

“Reduced time in the OR under anesthesia is advantageous to patients, but that is not the only potential benefit of the cementless prosthesis,” added Dr. Westrich, who is also the research director emeritus of the Adult Reconstruction and Joint Replacement Service at HSS. “With the cementless knee replacement, the components are press fit into place for ‘biologic fixation,’ which basically means the bone will grow into the implant. If there is initial biologic fixation, implant loosening over time should be less likely and a total knee replacement could potentially last much longer.”

In a traditional knee replacement, implant components are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement starts to loosen from the bone and/or the implant. When it wears out or loosens, patients generally need a second knee replacement, known as a revision surgery.

Dr. Westrich believes that a well-designed cementless implant will make loosening over time less likely, enabling a total knee replacement to last much longer. Implant longevity is an important consideration, especially for younger patients with arthritis who opt for joint replacement to maintain their active lifestyle. They generally put more demands on their joint, causing more wear and tear and potential loosening. The cemented knee implant used in a traditional joint replacement usually lasts 15 to 20 years.

“Cementless implants have been used successfully in total hip replacement surgery for many years. It has been much more challenging to develop a cementless prosthesis that would work well in the knee because of the knee’s particular anatomy,” Dr. Westrich explained.

“In the past, a number of cementless knee implants were shown to have design flaws, with loosening from the tibia,” he added. “The newer cementless prosthesis used in our study did not demonstrate this type of loosening as in previous published studies. We set out to see how the implant fared in HSS patients.” 

Researchers reviewed 598 primary unilateral total knee replacements at HSS (170 cementless and 428 cemented) of the same design from 2016 to 2018. Demographic information, operative details and any complications were obtained from patients’ medical records. Patients undergoing the cementless procedure were younger overall, with a mean age of 63, versus 68 for those having a traditional cemented knee replacement. Good bone quality is important in the success of cementless knee fixation. Therefore, orthopedic surgeons preferentially select younger patients for the cementless procedure, Dr. Chalmers noted.

There was no statistically significant difference in hospital length of stay, complications, or hospital readmission for a problem in the first 90 days after surgery. Ninety-six percent of cementless knee replacement patients versus 95% of those with a cemented knee replacement maintained their implant without the need for revision surgery at two-year follow-up.

“The biggest question now is whether or not cementless total knee replacement will have better long-term durability and fixation than cemented knee replacement,” Dr. Chalmers said. “Following these patients to assess long-term outcomes is the next step.” 

Authors: Alioune Diane, Brian P. Chalmers, MD, Geoffrey H. Westrich, MD (HSS), Kyle Alpaugh, MD (Massachusetts General Hospital), Michael P. Ast, MD, Seth A. Jerabek, MD, Yu-Fen Chiu, MS (HSS).

“The use of computer-assisted navigation and robotic assistance for total knee replacement has increased tremendously and shows no sign of slowing down,” Dr. Westrich said. “Among American Association of Hip and Knee Surgeons attending the 2020 annual meeting, 77% of respondents indicated that they used technology in their surgical cases. The most common reason they cited was to increase surgical precision.”

Dr. Westrich and colleagues set out to update the literature on technology-assisted knee replacement trends. They also sought to review the 90-day complication rate requiring readmission to the hospital after surgery. “Although both computer-assisted navigation and robotic-assisted knee replacement have demonstrated increased precision with component positioning and alignment, it is unclear if this translates into improved clinical outcomes,” Dr. Westrich explained.

Using a large national database, the researchers compiled information on more than 1.3 million patients who underwent a primary, elective total knee replacement between 2010 and 2018. Patients were divided into three groups: those who had conventional surgery; individuals who had technology-assisted knee replacement with computer navigation; and patients who had robotic-assisted joint replacement surgery.

Dr. Westrich and colleagues found that the use of robotic-assisted knee replacement grew considerably from 2010 to 2018, with an increase in utilization nationwide of more than

2,200%. The largest increase took place between 2016 and 2018.

Surgery with robotic-assistance also led to a lower complication rate. “Robotic-assisted surgery had significantly lower odds of all-cause 90-day complications requiring readmission to the hospital, with a rate of 1.57%, compared to conventional knee replacement, which had a complication rate of 2.55%,” Dr. Westrich noted. “The data imply that for every 102 patients treated with robotic-assisted knee replacement, one readmission may be avoided.”

Joint replacement, whether conventional or assisted with technology, is highly successful overall in relieving arthritis pain and improving quality of life, Dr. Westrich notes. “The advantage of the robotic system is that it allows us to customize the procedure for each patient,” he explains. “It enables optimal alignment and positioning of the knee implant, as well as optimal ligament balancing, important to the long-term success of the surgery.”

Several robot-assisted knee-replacement systems are on the market. Dr. Westrich uses technology that takes a CT scan of the patient’s knee prior to surgery. The scan is then uploaded into the system software, where a 3D model of the joint is be created. The 3D model is used to plan and assist in performing the joint replacement.

In the operating room, the orthopedic surgeon controls a robotic arm that uses computer‐guided mapping software, similar to GPS, integrated into the surgical instruments to position the implant in the knee joint. The digital tracking system constantly monitors and updates the patient’s anatomy and enables the surgeon to make real‐time adjustments to optimize implant placement, alignment, ligament balance and joint motion. This provides each patient with a personalized surgery tailored to his or her individual anatomy.

“With more accurate alignment and positioning, the implant should experience less wear and friction, and it could ultimately last longer,” says Dr. Westrich. He notes that additional studies looking at long-term outcomes will be needed to see if this is the case.

HSS is the world’s largest academic medical center specialized in musculoskeletal health, spanning orthopedics, rheumatology and related disciplines. The HSS Research Institute maintains 20 laboratories dedicated to solving debilitating orthopedic and rheumatic conditions such as arthritis, bone and soft tissue injuries, autoimmune diseases, and musculoskeletal pain and deformities. There, more than 300 dedicated personnel focus on tissue repair, improving surgical outcomes, autoimmunity and inflammation, genomics, new treatments, and precision medicine.

“HSS has a long history of contributing to the collective base of clinical and basic science knowledge and finding healthcare solutions for complex conditions,” said Louis A. Shapiro, President and CEO, HSS. “We’re proud that through the joint efforts of our institution and philanthropic support, we will have the ability to make a strong impact on this growing and vital area of research.”

“As experts in inflammatory disorders and in the development of interventions for overactive immune responses, the clinicians and researchers at HSS are well-positioned to investigate many of the adverse effects of COVID-19,” says Lionel B. Ivashkiv, MD, Chief Scientific Officer at the HSS Research Institute. “This includes studying the causes of these adverse effects as well as how to prevent and treat them.”What follows are descriptions of the first group of funded projects in basic/translational research:

Activation of pDCs by SARS-CoV-2 and Its Impact on Macrophage Response

Principal Investigator: Franck Barrat, PhD

Co-Investigator: Marie-Dominique Ah Kioon, PhD

This project will study cell types that are responsible for cytokine storm syndrome — the hyperactive immune response seen in people with COVID-19 — by looking at how certain immune cells are activated by SARS-CoV-2. Research in mice infected with SARS-CoV, a coronavirus similar to the one that causes COVID-19, has suggested that plasmacytoid dendritic cell precursors (pDCs) are key to the immune response to infection. These pDCs activate macrophages, which in turn secrete cytokines. In the SARS-CoV research, depletion of pDCs appeared to protect the mice from lethal lung injury. Using blood samples from donors, the investigators will study the pathway by which pDCs activate macrophages and look at ways to therapeutically block that process.

Inhibiting RNA Polymerase II Transcription Complexes in Macrophages to Target COVID-19–Associated Cytokine Storm

Principal Investigator: Inez Rogatsky, PhD

Co-Investigators: Steven Josefowicz, PhD, and Robert P. Fisher, MD, PhD

This pilot project will dissect the role of macrophages in SARS-CoV-2-induced acute respiratory distress syndrome (ARDS), the main driver of COVID-19-associated mortality. We will test small-molecule inhibitors of RNA Polymerase II (Pol II) transcription complexes for their ability to modulate type I interferon and inflammatory pathways in monocytes/macrophages. This research will be done using cultured macrophages as well as donor blood and blood from COVID-19 patients.

Mechanisms of Cytokine Storm in Patients with COVID-19

Principal Investigator: Mary K. Crow, MD

Co-Investigators: Mikhail Olferiev, MD, and Lionel B. Ivashkiv, MD

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease. The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm and compare them to those patients who do not, to compare the immune response before and after patients are given the anti-inflammatory drug anakinra, and to identify measures that suggest patients are more likely to decline and eventually require mechanical ventilation. The research will employ blood samples from HSS patients who are being treated for COVID-19 at New York–Presbyterian Hospital and who meet certain other qualifications.

What follows are descriptions of the first group of funded projects in the areas of clinical and health outcomes research:

Response to and Recovery from TKA in Patients with Antibodies to SARS-CoV-2

Principal Investigator: Miguel Otero, PhD

Co-Investigators: Meghan Kirksey, MD, PhD, and Peter K. Sculco, MD

It is unknown if people who have been exposed to COVID-19 may be at higher risk of experiencing an abnormal immune response following surgery, resulting in poor outcomes. This study will evaluate the response to and recovery from total knee arthroplasty (TKA) in people who have antibodies to COVID-19 — a marker of exposure. This study will include both patients who have COVID-19 antibodies and those who don’t, to act as controls. Patients will be followed for six weeks after surgery and evaluated for the presence of certain immune markers in the blood, as well as symptoms of inflammation including pain and stiffness in the joint.

SARS-CoV-2 Exposure and the Role of Vitamin D Among Hospital Employees

Principal Investigator: Emily M. Stein, MD, MS

Co-Investigators: Theresa T. Lu, MD, PhD; Andy O. Miller, MD; Jeri Nieves, PhD; and Alana Serota, MD

It is unknown if people with vitamin D deficiency may be more likely to become infected with COVID-19. This study will investigate vitamin D status and associated immune markers as risk factors for COVID-19 infection in a cohort of healthcare workers. Healthcare workers are at higher risk of contracting COVID-19 than the general population, making them a good group to study. Vitamin D is critical for immune function and is known to be protective against respiratory-tract infection and tuberculosis. This prospective, observational study will follow healthcare workers at HSS and at other healthcare facilities for one year, to determine whether levels of vitamin D and certain immune cells in the blood make someone more susceptible to COVID-19 infection.

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients in New York City

Principal Investigator: Medha Barbhaiya, MD, MPH

Co-Investigators from HSS: Lisa Mandl, MD, MPH; Catherine MacLean, MD, PhD; Vinicius Antao, MD, PhD; Jane Salmon, MD; and Mayu Sasaki, MPH

Other Co-Investigators: Candace Feldman, MD, MPH (of Brigham and Women’s Hospital); Debra D’Angelo, MS (of Weill Cornell Medicine)

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators will assemble a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients. Patients will also be studied prospectively to determine whether there’s a relationship between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Assessment of Surgical Outcomes in the COVID-19 Pandemic Era

Principal Investigator: Andy O. Miller, MD

Co-Investigators: Scott A. Rodeo, MD, and Mark Fontana, PhD

Investigators will implement a patient registry to evaluate how COVID-19 affects outcomes and complication rates after orthopedic surgery. This registry, along with COVID-19 screening procedures, will provide the tools to address specific research questions. Among these questions are determining the incidence of current and prior infection among the HSS surgical population, the clinical features associated with current and prior infections in this patient population, and whether COVID-19 status affects short-term complication rates.

What follows is a description of an integrated multidisciplinary study being undertaken jointly by the Adult Reconstruction and Joint Replacement (ARJR) Perioperative Research Group, Anesthesiology and Rheumatology:

Prediction and Prevention of Postoperative Blood Clots in COVID-19 Patients

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Co-Investigators: ARJR surgeons: Alejandro Gonzalez Della Valle, MD; Jason Blevins, MD; David J. Mayman, MD; Peter K. Sculco, MD; Geoffrey H. Westrich, MD and Thomas P. Sculco, MD

Medicine/Rheumatology: Medha Barbhaiya, MD, MPH; Doruk Erkan, MD, MPH; Deanna Jannat-Khah, DrPH

Pathology: Thomas W. Bauer, MD, PhD

Anesthesiology: Stavros G. Memtsoudis, MD, PhD, MBA; Alexandra Sideris, PhD

ARJR: Amethia Joseph, MHA; Ethan Krell, MS

Weill Cornell Medicine: Raymond David Pastore, MD

Recent literature suggests that one of the major complications seen in people with COVID-19 is thrombosis (the formation of blood clots) due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. As elective surgeries resume, those with prior exposure to SARS-CoV-2 will inevitably present for treatment, and some may have perioperative management considerations related to their risk of deep-vein thrombosis. This project will use, a noninvasive device that can determine clotting risks, to investigate whether people who have had COVID-19 have a more dysfunctional endothelium preoperatively and at 24 hours after surgery. The investigators will measure antiphospholipid antibodies and inflammatory markers, and evaluate the prevalence of asymptomatic post-operative deep-vein thrombosis in people who undergo TKR and have SARS-CoV-2 antibodies.

COVID-19 Translational Research Core at HSS

Principal Investigator: Theresa Lu, MD, PhD

Co-Investigators: Jessica Andrés-Bergós, PhD; Miguel Otero, PhD and Emily M. Stein, MD, MS

The COVID-19 Translational Research Core (TRC) was designed to fill critical gaps in the resources needed to promote the broad range of COVID-19–related clinical and translational research at HSS. The TRC will provide consultation on the design and implementation of COVID-19 research in the areas of orthopedics, rheumatology and metabolic bone disease; support for a COVID-19 biobank; and technical expertise and facilities required for clinical and translational researchers working on COVID-19–related projects. The TRC staff will help to acquire, house, and track biospecimens from investigator-initiated COVID-19–related research studies.

“I have always been a very active, outdoorsy nature lover, enjoying activities such as mountain climbing, biking, kayaking and rock-climbing all around the world with my family, as well as ballet dancing,” Ms. Hitchcock wrote on “Back in the Game,” the HSS patient blog. “By 2009 I was in constant pain and barely able to walk, much less dance or climb. Within a month of my total knee replacement I was back in the ballet studio doing my barre exercises and I climbed Mt Katahdin in Maine, crossing the ‘Knife’s Edge’ 11 months later. Dr. Westrich truly gave me back my life! With my new knee I was able to take a rock-climbing trip to Thailand in 2014 to celebrate our children’s’ PhDs! What fun!”

Over the years, Ms. Hitchcock has enjoyed numerous active vacations with her family. She has visited Zimbabwe, Botswana, Borneo and other exotic locales. In addition to climbing, she continues to go hiking, bicycling and has taken up snorkeling. She recently returned from an adventure vacation in New Zealand with her husband and daughter, which included mountain climbing and kayaking.

Ms. Hitchcock is among a growing number of baby boomers who refuse to slow down, despite joints worn out by years of activity, an injury or the passage of time. “I’m seeing more people in their 40’s and 50’s who refuse to be sedentary and, like Diane, will do what it takes to enjoy their active lives,” Dr. Westrich says. “Over the past few years, advances in joint implant design and surgical technique provide even more options for younger patients.” Robotic-assisted surgery and a newer cementless implant could lead to a longer-lasting knee replacement, he says.

Along with Dr. Westrich, Ms. Hitchcock credits two other highly specialized orthopedic surgeons at HSS with helping her maintain her active lifestyle. In addition to her knee replacement at age 56, she had a spinal fusion with Dr. Federico Girardi in 2017 and shoulder replacement surgery with Dr. Lawrence Gulotta in 2018.

She says each surgery has helped her enjoy life again. “Never once did any of my doctors at HSS express the notion that these goals were too extreme for someone my age,” she explains. Major surgery is never a walk in the park, but Ms. Hitchcock didn’t hesitate. She took each surgery and recovery very seriously, taking time off from work and vigorously adhering to her physical therapy regime after each procedure. She speaks very highly of all three of her HSS physicians, and says she had excellent outcomes after surgery.

 Her doctors applaud the motivation of Diane and others who wish to enjoy the physical and psychological benefits of exercise at every age. “Why give up years of an active lifestyle,” Dr. Westrich says, “when newer options are available to allow patients with arthritis or another orthopedic condition to live life to the fullest?”

Mr. Benfante, who lives in Yorktown, New York, says he learned that robotic-assisted surgery enables orthopedic surgeons to perform the procedure with pinpoint accuracy, and this was important to him. The FDA-approved system starts with a CT scan to create a 3D virtual model of the patient’s unique anatomy. During the procedure, a robotic arm assists surgeons in performing an ultra-precise knee replacement customized for each patient.

Mr. Benfante wanted a joint replacement specialist trained in the use of the robotic system and found Geoffrey H. Westrich, MD, director of Research in the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS).

“The extreme accuracy provided by the robotic-assisted system could potentially improve the longevity of a knee or hip replacement. This is an important consideration, especially for younger patients," says Dr. Westrich. "Studies have shown that optimal alignment and positioning of the implant are critical for the long term success of a joint replacement.”

Another major advance is a cementless knee replacement in which cement is no longer needed to attach the implant to the bone. “This, we feel, may also lead to a joint replacement that lasts longer and may not require a revision surgery in the future,” Dr. Westrich said. “The cementless knee replacement, which is FDA-approved for use with a robotic system, combines two of the most recent knee replacement advancements into one high tech procedure that aims to benefit patients.”

The length of time a joint replacement will last is an important consideration, especially for younger patients in their 40s or 50s, like Mr. Benfante. The standard knee implant used in joint replacement usually lasts a long time – generally 15 to 20 years – but it doesn’t last indefinitely. When the implant wears out or loosens, patients generally need a second knee replacement, known as a revision surgery. Dr. Westrich believes the cementless knee replacement implanted with robotic-assisted surgery could change that. “The combination of these two major technological advances has dramatically changed the way I do knee replacements,” said Dr. Westrich.

Statistics show that increasing numbers of younger people are having a joint replacement because they don’t want arthritic pain to slow them down. Once they have a knee replacement, these active patients generally put more demands on their joint, causing more wear and tear, according to Dr. Westrich. With a conventional cemented prosthesis, chances are they’ll need another surgery down the road. This often has to do with loosening of the implant from the bone, much like a cemented crown on a tooth.

In a standard knee replacement, the components of the implant are secured in the joint using bone cement. It’s a tried and true technique that has worked well for decades. But eventually, over time, the cement starts to loosen from the bone and/or the prosthesis. “With the new cementless prosthesis, the components are press fit into place for ‘biologic fixation,’ which basically means that the bone will grow into the implant,” Dr. Westrich explains. “In addition, more accurate positioning of the implant is critical, and robotic-guidance allows for pinpoint accuracy.”

With biologic fixation, many joint replacement specialists believe that loosening over time could be less likely. “A total knee replacement could potentially last much longer, even for a patient’s lifetime,” Dr. Westrich says.

“Cementless implants have been used in total hip replacement surgery for many years and essentially replaced cemented implants for the same reason. Because of the knee’s particular anatomy, it has been much more challenging to develop a cementless prosthesis that would work well in the knee,” he explains. “Now I believe the time has come. Major advances in design, technology and biomaterials have paved the way for a viable cementless knee implant.”

Candidates for the cementless procedure are generally patients under 70 with good bone quality to promote biological fixation. In addition to younger patients, the cementless implant may also prove to be a good option for patients with excess weight who tend to put more stress on their joint replacement and cement has been shown to loosen prematurely.

Studies are under way to see how patients with cementless knee replacements do over the long term. As for Mr. Benfante, he says his quality of life has improved tremendously since his knee replacement. “I’m 100 percent after the surgery, no questions asked. In some ways, I’m probably better than I was,” he says. “I don’t experience pain. I can go for a walk.” He is also back to one of his favorite activities - working out at the gym.

Additional coverage: Painweek.org

Co-author Geoffrey H. Westrich, MD, hip surgeon at HSS provided further commentary on the outcome, and cited, "Our results demonstrated that there was no difference in Opioid Related Symptom Distress Scale scores, numerical rating pain scores with physical therapy, or mean oral morphine equivalents between the two groups." Additionally, Dr. Westrich noted, "Secondary outcomes, including time to discharge, other descriptions of pain outcomes, satisfaction, and cognitive effects were not different between groups. Patient satisfaction was graded on a numerical rating scale from 1 to 10 (with 10 being the most satisfied) and both groups had a rating of 9 out of 10 indicating excellent patient satisfaction with our low opioid multimodal pain management protocol with oral and intravenous acetaminophen."

With regard to the challenges facing multimodal anesthesia, Dr. Westrich said, "It is really the variability in patients’ response to pain management. Some patients need no narcotics, some standard strength narcotics, and some more potent narcotics and we never know until after surgery. We just need to have a solid protocol and be prepared. Having said that, the utilization of a multimodal protocol, in general, requires less narcotics and attacks the pain pathways from different angles."

Read the full article at ryortho.com.

In the Q&A, Dr. Westrich explains that his study highlights the HSS multimodal analgesia protocol as an effective method of pain control for patients having hip surgery with very high patient satisfaction.

"Every patient is different, and how to optimize multimodal therapy for a given patient is an important field of research.  At HSS, research is ongoing in the area of pain management, including both randomized trials of various other pain medications and also other pain management protocols.  Clearly, our ability to reduce pain following surgery is of paramount importance and we will continue to focus our efforts to achieve these goals," says Dr. Westrich.

Read the full article at MedicalResearch.com.

The researchers found that both forms of acetaminophen worked equally well. The paper, titled, "IV vs. Oral Acetaminophen as a Component of Multimodal Analgesia After Total Hip Arthroplasty: A Randomized, Double Blinded, Controlled Trial," was presented today at the American Academy of Orthopaedic Surgeons Annual Meeting in Las Vegas. 

The study has also been published online in advance of print publication in the Journal of Arthroplasty. "At a time when health care costs are increasingly under the microscope, the study supports the use of oral acetaminophen, which is less costly and less invasive to administer," said Geoffrey H. Westrich, MD, the director of research for the Adult Reconstruction and Joint Replacement Service at HSS who presented the study.  

More than 500,000 hip replacements are performed in the United States each year. Although narcotic medication is often part of the pain management plan after surgery, the opioid epidemic has prompted researchers to look for ways to minimize their use.

"A multifaceted pain management plan is standard for all patients having joint replacement surgery at HSS," explained Dr. Westrich. "Known as 'multimodal analgesia', it entails the use of several different anesthetic agents and medications both during and after surgery to control pain and reduce side effects."
 
All 154 patients in the study had hip replacement surgery at HSS. They all received the standard multifaceted pain control protocol after surgery and were randomly assigned to one of two groups. One group received intravenous acetaminophen, while the other group was given the oral pill form. Neither the patients nor their doctors knew which individuals were receiving intravenous versus oral acetaminophen. Those getting IV acetaminophen also received a placebo in pill form, and those given oral acetaminophen received a placebo IV solution.

When they launched the study, the researchers thought intravenous acetaminophen might provide a benefit in terms of pain management, as it reaches the blood stream more quickly than the pill form. But the study found that both worked equally well. 

"Patients in both groups had low pain scores with activity, minimal opioid-related side effects, and limited opioid usage," Dr. Westrich said. "The big picture highlights multimodal analgesia overall as an effective method of pain control after joint replacement surgery."

"How to optimize multimodal therapy for a given patient remains a 'Holy Grail' of research for this field," said Jacques T. YaDeau, MD, PhD, an anesthesiologist at HSS and study author. "At HSS, there is ongoing research on this topic, including both randomized trials and 'big-data' analysis."

For the second procedure, known as a revision knee replacement, Ms. Lucanto went to a different orthopedic surgeon: a doctor specializing in revision surgery. This time she consulted with Geoffrey H. Westrich, MD, the Director of Research for the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS) in New York City.  

Dr. Westrich assures his patients that orthopedic surgeons and anesthesiologists at HSS have conducted numerous research studies and have developed a protocol that aims to ensure pain is well managed after surgery. 

"Of course, every patient is different, but we have found that 'multimodal analgesia' – the administration of two or more drugs targeting multiple pain pathways – is very effective in managing pain," Dr. Westrich notes. "In addition to the epidural anesthesia used during knee replacement, anesthetic pain medication is now administered inside the joint itself during surgery, and the patient then receives the multimodal pain control protocol after the procedure."

Ms. Lucanto says it worked like a charm. Although revision knee replacement is more demanding on the patient than a primary knee replacement, she says pain was not an issue after the second surgery.    

On the Hospital for Special Surgery web portal known as "Back in the Game," patients can post their experiences. Ms. Lucanto wrote: "On October 4, 2018, I underwent a left knee revision at HSS located in New York City. My surgeon and hero was Dr. Westrich. It was one of the best experiences in my life, seriously. I went in on a Thursday and I left the next day, walking on my own with the help of a cane. After two weeks… I went back to work!" (https://backinthegame.hss.edu/story/susan-lucanto/)

Ms. Lucanto also described how her second surgery differed from her original knee replacement:  "When I was waiting on the day of the revision surgery, I was scared of what I was facing. My original left knee replacement in April 2009 was extremely painful. However, I am totally blown away by how different my knee replacement surgery in April 2009 was from my left knee revision this past October. There was hardly any pain with the revision. With the (first knee) replacement, I was out-of-work for 3 months."

"Multimodal analgesia means using many different ways to reduce pain," explains Jacques T. YaDeau, MD, PhD, an anesthesiologist in the Department of Anesthesiology, Critical Care & Pain Management at Hospital for Special Surgery. "This allows a reduction in both pain and side effects. Most patients at HSS receive a spinal or epidural for the main anesthetic. This is a neuraxial anesthetic, which means it is administered around the nerves of the central nervous system, and this reduces postoperative pain because the brain does not ‘see’ the pain during surgery."

Dr. YaDeau explains that in addition to the epidural, the multimodal protocol includes nerve blocks to reduce pain in both the front and the back of the knee; the injection of a local anesthetic into the surgical site at the end of the surgery; and pain management following surgery, which may include anti-inflammatory drugs, acetaminophen and generally, some narcotic pain medication. 

"Most, but not all patients still use some opioids, but the amount used is much less than patients used to need," he adds. "Sometimes there are patient-specific reasons not to receive some aspects of this multimodal therapy, but typically knee replacement patients at HSS receive most or all of these components."

"Clearly, we have seen many advances – and changes – over the years in the way we manage pain after joint replacement. We now know that although opioid medication is highly effective and often part of the overall pain management plan after surgery, it should be used in the lowest dose needed to provide pain relief and for the shortest amount of time necessary," Dr. Westrich notes. 

Ms. Lucanto says that by the time she went home the day after revision knee replacement, she no longer needed opioid medication and only took over-the-counter extra-strength Tylenol for pain management. Indeed, she was so pleased with her recovery that she told a patient she met in physical therapy about her experience. "The woman has very bad arthritis in both knees, but says she is 'terrified' to have knee replacement because she’s afraid of the pain. I don’t think anyone should have to suffer with arthritis, especially when these pain blockers can make the surgery a lot easier."
 
Dr. Westrich, Dr. YaDeau and their colleagues at HSS continuously strive to improve patient care, and studies are ongoing in the realm of pain management. "Our ultimate goal is to have a greater understanding of which multimodal pain protocol is best for a given patient, aiming to minimize the amount of narcotics and limit the side effects associated with such medications," Dr. Westrich said. "We hope to optimize this in future research."

The study looked at patient outcomes from modular dual mobility implants for revision hip surgeries and found that surgeries with this implant resulted in a very low rate of instability for the revision patients with good functional improvement and a low rate of re-operation.

"While longer-term follow-up is needed to fully assess the newer device, in our study there was clearly a benefit provided by the dual mobility implant in the first few years following revision surgery," said Dr. Westrich. "Modular dual mobility is being used more and more as surgeons see the benefits. In our study it markedly decreased the risk of further surgery and dislocation. We now have an implant that can make revision surgery safer with a less risk of complications."

Read the full article at RyOrtho.com.

"We are now telling patients that when we operate on them, there's a really good chance that the replacement can last the rest of their life," said Dr. Westrich.

"Even in younger patients, the plastics have gotten so much better, using highly cross-linked polyethylene, and the designs have improved so that patients in their 40s and 50s can expect to have the prosthesis for a very long time," he added.

Read the full article at medpagetoday.com.

As with all surgical procedures, the possibility of a complication exists, and dislocation is the most common problem. The risk of dislocation is higher in patients who have had a second hip replacement, known as revision surgery. Some people need a revision surgery many years after their first hip replacement when the original implant wears out. Hip instability after joint replacement is another reason a patient might need a revision surgery.    

Research conducted by Dr. Geoffrey Westrich and colleagues at Hospital for Special Surgery (HSS) and other joint replacement centers indicates that a newer type of artificial hip known as a "modular dual mobility" implant could be a good option for patients who need a revision surgery. Their study was presented at the annual meeting of the American Association of Hip and Knee Surgeons in Dallas this month.

"Although the concept of dual mobility was originally developed in France in the 1970s, the technology is relatively new in the United States," says Dr. Westrich, director of research of the Adult Reconstruction and Joint Replacement Service at HSS. "Our study found that the newer technology with modular dual mobility components offered increased stability, lowering the risk of dislocation, without compromising hip range of motion in patients having a revision surgery."

"Dual mobility" refers to the bearing surface of the implant - where the joint surfaces come together to support one’s body weight. A hip replacement implant is a ball-in-socket mechanism, designed to simulate a human hip joint. Typical components include a stem that inserts into the femur (thigh bone), a ball that replaces the round head of the thigh bone, and a shell that lines the hip socket. 

Modular dual mobility implants provide an additional bearing surface compared to a traditional implant. With the dual mobility hip, a large polyethylene plastic head fits inside a polished metal hip socket component, and an additional smaller metal or ceramic head is snap-fit within the polyethylene head.

"Currently, there are few large-scale outcome studies on the modular dual mobility device in revision hip replacement," Dr. Westrich noted. "We set out to determine the rate of dislocation and the need for another surgery following revision hip replacement using this implant and report on the functional outcomes."

The study included 370 patients who underwent revision hip replacement with the dual mobility implant between April 2011 and April 2017. The average patient age at the time of surgery was 65.8 years. Clinical, radiographic and patient reported-outcome information was collected.

To be included in the final report, patients needed to be seen for follow-up for at least two years after their surgery, and the average follow-up was 3.3 years. "At the latest follow-up, we found that surgery with the dual mobility implant resulted in a very low rate of instability for the revision patients, namely 2.9 percent, with good functional improvement and a low rate of reoperation," Dr. Westrich noted. "While longer-term follow-up is needed to fully assess the newer device, in our study there was clearly a benefit provided by the dual mobility implant in the first few years following revision surgery."

HSS hip and knee surgeon Geoffrey H. Westrich, MD, explained that "there are studies that show aspirin alone is very effective, and a more potent anticoagulant may not be needed for standard-risk patients."

This article appeared in the August 2018 print issue.

If a patient has osteoarthritis, Dr. Westrich cautioned to avoid arthroscopic surgery. "It does nothing to relieve arthritis pain," he said.

For rheumatoid arthritis in the knee, typical treatment involves corticosteroid injections, over the counter pain relievers and physical therapy.

This article appeared in the June 2018 print issue.

"[Joint replacement] procedures are now state of the art, with newer implant technology, excellent pain relief and return to function," he says, adding that improved technology has also allowed "younger and younger patients to undergo joint replacement surgery."

Read the complete article at blog.arthritis.org.

HSS hip & knee surgeon Geoffrey H. Westrich, MD performed the surgery.

"It was the best decision of my life, aside from marrying my wife. Now, I'll be sitting and watching TV, and all of a sudden I realize that I have no pain. I can walk for miles in New York City pain-free," said Harbour.

Dr. Westrich said "most books about medical procedures are written by doctors or other healthcare professionals. It's always fascinating to hear the patient's perspective. The book contains a lot of good information and can be very helpful for other patients considering hip replacement or scheduled for the procedure."

This article originally appeared at wicz.com.

Dr. Westrich told OTW, "dislocation is one of the most common complications following THR [total hip replacement] surgery and is quite disheartening for both the patient and the surgeon. Now that we have an implant that can greatly reduce the incidence of dislocation following THR, surgeons have a tool that can provide all the benefits of THR without the same risk of dislocation."

Read the full article at ryortho.com [subscription required].

Dislocation is one of the most common complications after hip replacement and the number one reason for revision surgery. A study by Geoffrey Westrich, MD, research director of the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS), found that patients who received a newer implant known as a "dual mobility" hip replacement had zero dislocations. In comparison, study patients who received a traditional fixed bearing hip implant had a dislocation rate of 5 percent.

The research, which focused on patients under 55 years old, was presented today at the American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans.

"We were especially interested in seeing how the younger patient population fared because they are generally more active and put more demands and stress on their hip after joint replacement, and this increases the risk of dislocation," Dr. Westrich explained.

Although the concept of dual mobility was originally developed in France in the 1970s, the technology is relatively new in the United States. "Dual mobility" refers to the bearing surface of the implant - where the joint surfaces come together to support one’s body weight.

A hip replacement implant is a ball-and-socket mechanism, designed to simulate a human hip joint. Typical components include a stem that inserts into the femur (thigh bone), a ball that replaces the head of the thigh bone, and a shell that lines the hip socket.

"Dual-mobility hip components provide an additional bearing surface," Dr. Westrich explains. "A large polyethylene plastic head fits inside a polished metal hip socket component, and an additional smaller metal or ceramic head is snap-fit within the polyethylene head. Dual mobility means that there are two areas of motion, improving the range of movement and reducing the risk of dislocation."

Dr. Westrich and colleagues compared the dual mobility system with the traditional fixed bearing system in two age-matched groups of patients who had a primary total hip replacement over the same time period. There were 136 patients in each group with a mean age of 48.

At three-year follow-up, the researchers found that the patients who received the dual mobility implant had no dislocations. In the group receiving the standard fixed bearing implant, seven patients, or 5.1 percent, had a dislocation and needed a revision surgery.

"Total hip replacement is increasingly being performed in younger patients," Dr. Westrich said.

"The results of our study are encouraging for this active, high demand group of patients and may lessen concerns for dislocation. More research is needed to see how dual mobility implants perform over the long term."

Researchers at HSS tracked the weight of almost 7,000 patients who underwent knee or hip replacement. According to the article, only 30 percent lost weight.

Geoffrey H. Westrich, MD, hip & knee surgeon at HSS and lead author of the study, explained that "most patients have good intentions, but for many, it's a challenge to make the [necessary] lifestyle changes."

He noted that exercise and weight loss are essential for long-term joint health.

"[Regular exercise] keeps the muscles that support the joint replacement as strong as possible and helps absorb stress on the artificial joint. And a healthy weight can prevent or slow the progression of arthritis in other weight-bearing joints," Dr. Westrich said.

"Even mild exercise a few times a week or eliminating some extra calories daily can be beneficial," he added.

This article appeared in the February 2018 print issue.

Geoffrey H. Westrich, MD, hip & knee surgeon at HSS, said that the clinical guidelines from the American Academy of Orthopedic Surgeons (AAOS) also recommend nondrug treatments before medications such as strengthening muscles with low-impact aerobic exercises.

"Physical therapy or a home exercise program with muscle strengthening may also help patients manage their pain, increase activity and potentially improve their quality of life," Dr. Westrich noted.

If patients have severe arthritis, Dr. Westrich said that joint replacement surgery may be the best option for permanent pain relief.

Read the full article at blog.arthritis.org