What Do Hip and Knee Arthroplasty Surgeons Agree on? Moving Forward Collectively

Total hip and knee arthroplasty procedures have helped improve the lives of countless numbers of patients. However, although there is global agreement on the technical goals of these procedures, patients and surgeons worldwide may face unique issues and conditions that can influence treatment philosophies and affect the delivery of care. In August 2024, more than 500 academic hip and knee arthroplasty specialists gathered in Istanbul, Turkey, for the first meeting of the World Experts in Arthroplasty. The goal was to highlight the similarities and dissimilarities in the approach to current controversies in total hip arthroplasty (THA) and total knee arthroplasty (TKA) . Organized by a large executive committee from around the globe, delegates were tasked with investigating the evidence on 64 controversial topics in THA/TKA today. Under the guidance of Dr. Mohit Bhandari and his team at McMaster University, a systematic review using a strict protocol was performed, and the results and recommendations were presented during the meeting for discussion and voting. The meeting was conducted without industry support to minimize bias. The meeting was supported through an educational grant from Acibadem University. There was immense energy in the meeting room over 2 days with lively discussions and, at times, passionate disagreements. We all came away wiser and more appreciative that we are all trying to deliver excellent care to our patients but practice under different conditions and circumstances. The meeting accomplished its goal of defining controversial topics that were not controversial anymore. Topics for which numerous studies existed and a definite conclusion(s) could be gleaned. The full recommendation and supporting rationale will be published in The Journal of Arthroplasty. Top issues in which the experts agreed on included the following: (1) There is no need to use a surgical drain after routine primary arthroplasty (85% agreement) (2) Tranexamic acid should be administered to ALL patients (except those who have an allergy to the drug) undergoing total joint arthroplasty (TJA) (97% agreement) (3) Aspirin is an effective agent against venous thromboembolic disease after TJA (85% agreement) (4) Patients should be weight-bearing when obtaining preoperative radiographs (90% agreement) (5) Intravenous corticosteroids (dexamethasone) should be administered to all patients undergoing TJA (90% agreement) (6) Intravenous heparin should not be administered to patients undergoing TJA (94% agreement) (7) Urinary catheters should not be routinely used for patients undergoing TJA, even in patients receiving regional anesthesia (85% agreement) (8) Smoking cessation should be implemented before elective TJA (93% agreement) (9) Clear contraindications for performing bilateral TJA under the same anesthesia exist, and they were outlined (94%) (10) Patellar resurfacing (versus not resurfacing) does not affect the outcome of primary TKA (83% agreement) (11) The use of ceramic femoral heads reduces the incidence of adverse local tissue reactions in primary THA (90% agreement) (12) Some femoral stem designs increase the risk of adverse local tissue reaction (and perhaps should be discontinued) (96% agreement) (13) There is minimal role for the use of resurfacing hip arthroplasty except in VERY select patients (87% agreement) (14) The surgical approach does not seem to affect the outcome of primary THA (92% agreement) (15) The use of robotics does not improve the outcome of primary THA (91% agreement) (16) The commonly cited 4 centimeters for limb lengthening for patients who have developmental dysplasia (dislocation) of the hip undergoing THA is not accurate (84% agreement) (17) Dual mobility bearing surfaces should only be used in patients at high risk of dislocation after THA (90% agreement) (18) There is no difference in outcome of revision THA when modular versus monoblock femoral stem is used (93% agreement) (19) In addition to being used during impaction grafting, cemented femoral stem can be used in other circumstances during revision THA (92% agreement) (20) Isolated exchange of femoral head and liner to address instability should only be reserved for patients who have wear of the bearing surface (90% agreement). We also identified topics/issues that are in desperate need of evidence, which are listed below. (1) Does robotic surgery in arthroplasty increase the risk of complications? (2) Does outpatient TJA improve outcomes for patients? (3) Should hardware be removed concurrently or staged for patients undergoing conversion TJA? (4) Should patient activity be restricted after routine primary TJA? (5) Is there a difference in the outcome of unicompartmental knee arthroplasty when mobile versus fixed bearing is used? (6) What factors determine the use of a tibial stem during primary TKA? (7) Does evidence support the use of all polyethylene tibial components during primary TKA? (8) Is there a difference in the outcome of primary TKA when mechanical versus kinematic alignment is used? (9) Does the surgical approach affect the outcome of primary TKA? (10) What is the optimal positioning for the acetabular implant (high versus anatomic) in patients who have dysplasia (dislocation) of the hip undergoing THA? (11) What nonarthroplasty options are available for patients who have early-stage osteonecrosis of the femoral head? (12) What are the indications (and outcomes) for modern hinged prostheses in patients undergoing TKA? Today, contributions, innovations, and advancements in hip and knee arthroplasty are global phenomena. We should acknowledge that as we seek to answer and solve bigger questions such as what is the best way to manage prosthetic joint infections or to improve patient satisfaction in TKA, the solutions will not come from one institution or one country but from the cumulative wisdom and energy of every dedicated scholar from around the globe. The meeting concluded with Dr. Bhandari's inspirational speech calling to action an assembly of global research consortiums that can take on some of these studies and generate the much-needed evidence. By one estimate, the number of arthroplasty procedures being performed by the experts and their institutions exceeds 500,000 per year. That should be enough to get us started.

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