Background: Periacetabular osteotomy (PAO) is the most common treatment for symptomatic acetabular dysplasia, or developmental dysplasia of the hip (DDH), in skeletally mature patients. The purpose of this multicenter cohort study was to delineate the long-term radiographic natural history of the dysplastic hip following PAO. Methods: We evaluated all patients undergoing PAO from 1996 to 2012 at 3 academic institutions in the United States. Inclusion criteria were PAO for DDH with a minimum 5-year radiographic follow-up. Exclusion criteria were PAO for isolated acetabular retroversion, neurogenic dysplasia, Legg-Calvé-Perthes disease, and prior hip surgery including osteotomies and arthroscopy. There were 288 patients, 83% of whom were women; the mean age and body mass index (BMI) were 29 years and 25 kg/m², respectively. The mean clinical and radiographic follow-up was 9.2 years (range, 5.0 to 21.1 years). Every preoperative and postoperative hip radiograph was assessed to determine the degree of osteoarthritis according to the Tönnis classification. Survivorship was analyzed by multistate modeling, enabling assessment of progression through the Tönnis grades rather than just individual transitions as with Kaplan-Meier techniques. Results: At the time of final follow-up, 144 patients (50%) had progressed at least 1 Tönnis grade, with 42 patients (14.6%) undergoing total hip arthroplasty. The mean number of years spent in each Tönnis grade following PAO was 19 for Tönnis grade 1, 8 for Tönnis grade 2, and 4 for Tönnis grade 3. The probability of progression to total hip arthroplasty increased significantly on the basis of a higher initial Tönnis grade (p < 0.001). The most marked difference occurred between Tönnis grade 0 or 1 and Tönnis grade 2; for Tönnis grade 1, the probability of progression to total hip arthroplasty at 5 and 10 years was 2% and 11%, respectively, compared with 23% and 53%, respectively, for Tönnis grade 2. Conclusions: PAO effectively alters the natural history of DDH. Precise radiographic progression based on the Tönnis grade can now be used to ascribe prognosis for the native hip. Importantly, this investigation demonstrates a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Chest X-rays (CXR) are essential for diagnosing a variety of conditions, but when used on new populations, model generalizability issues limit their efficacy. Generative AI, particularly denoising diffusion probabilistic models (DDPMs), offers a promising approach to generating synthetic images, enhancing dataset diversity. This study investigates the impact of synthetic data supplementation on the performance and generalizability of medical imaging research. The study employed DDPMs to create synthetic CXRs conditioned on demographic and pathological characteristics from the CheXpert dataset. These synthetic images were used to supplement training datasets for pathology classifiers, with the aim of improving their performance. The evaluation involved three datasets (CheXpert, MIMIC-CXR, and Emory Chest X-ray) and various experiments, including supplementing real data with synthetic data, training with purely synthetic data, and mixing synthetic data with external datasets. Performance was assessed using the area under the receiver operating curve (AUROC). Adding synthetic data to real datasets resulted in a notable increase in AUROC values (up to 0.02 in internal and external test sets with 1000% supplementation, p-value <0.01 in all instances). When classifiers were trained exclusively on synthetic data, they achieved performance levels comparable to those trained on real data with 200%-300% data supplementation. The combination of real and synthetic data from different sources demonstrated enhanced model generalizability, increasing model AUROC from 0.76 to 0.80 on the internal test set (p-value <0.01). Synthetic data supplementation significantly improves the performance and generalizability of pathology classifiers in medical imaging. Dr. Gichoya is a 2022 Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program and declares support from RSNA Health Disparities grant (#EIHD2204), Lacuna Fund (#67), Gordon and Betty Moore Foundation, NIH (NIBIB) MIDRC grant under contracts 75N92020C00008 and 75N92020C00021, and NHLBI Award Number R01HL167811.

Aims: The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation.Methods: Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded.Results: Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report “much better” joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all).Conclusion: The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty.Cite this article: Bone Joint J 2023;105-B(5):526–533.

Update: This article was updated on December 6, 2019, because of a previous error. On page 1936, in Table VII, “Performance of the Bearing Surface Algorithm,” the row that had read “Bearing surface predicted by algorithm” now reads “Bearing surface predicted by algorithm*.” An erratum has been published: J Bone Joint Surg Am. 2020 Jan 2;102(1):e4. Update: This article was updated on March 31, 2020, because of a previous error. On page 1934, in Table IV (“THA Bearing Surface-Related Keywords in Operative Notes”), the row that had read “Femoral stem; stem; HFx-stem; femoral component; femoral component/stem; permanent prosthesis; stem fem cemented” now reads “Femoral head; ball; delta head; delta ceramic head; ion treated; BIOLOX delta; ceramic head; ceramic femoral head; ceramic offset head; ceramic (size) head; alumina ceramic head; alumina prosthetic head; alumna ceramic head; BIOLOX ceramic head; BIOLOX delta head; BIOLOX femoral head; BIOLOX delta ceramic head.” An erratum has been published: J Bone Joint Surg Am. 2020 May 6;102(9):e43. Background: Manual chart review is labor-intensive and requires specialized knowledge possessed by highly trained medical professionals. Natural language processing (NLP) tools are distinctive in their ability to extract critical information from raw text in electronic health records (EHRs). As a proof of concept for the potential application of this technology, we examined the ability of NLP to correctly identify common elements described by surgeons in operative notes for total hip arthroplasty (THA). Methods: We evaluated primary THAs that had been performed at a single academic institution from 2000 to 2015. A training sample of operative reports was randomly selected to develop prototype NLP algorithms, and additional operative reports were randomly selected as the test sample. Three separate algorithms were created with rules aimed at capturing (1) the operative approach, (2) the fixation method, and (3) the bearing surface category. The algorithms were applied to operative notes to evaluate the language used by 29 different surgeons at our center and were applied to EHR data from outside facilities to determine external validity. Accuracy statistics were calculated with use of manual chart review as the gold standard. Results: The operative approach algorithm demonstrated an accuracy of 99.2% (95% confidence interval [CI], 97.1% to 99.9%). The fixation technique algorithm demonstrated an accuracy of 90.7% (95% CI, 86.8% to 93.8%). The bearing surface algorithm demonstrated an accuracy of 95.8% (95% CI, 92.7% to 97.8%). Additionally, the NLP algorithms applied to operative reports from other institutions yielded comparable performance, demonstrating external validity. Conclusions: NLP-enabled algorithms are a promising alternative to the current gold standard of manual chart review for identifying common data elements from orthopaedic operative notes. The present study provides a proof of concept for use of NLP techniques in clinical research studies and registry-development endeavors to reliably extract data of interest in an expeditious and cost-effective manner.

Background: Distal femoral replacement (DFR) is a salvage option for complex primary and revision total knee arthroplasty (TKA). Although excellent immediate fixation and weight-bearing are achieved, there is a paucity of data on long-term outcomes of TKA with DFR. The purpose of the present study was to determine implant survivorship, clinical outcomes, and radiographic results of TKAs with contemporary DFR components in a large series. Methods: We identified 144 consecutive TKAs performed with DFR for non-oncologic indications from 2000 to 2015 at a single academic institution. Indications for the index DFR included 66 (46%) for native (n = 11) or periprosthetic (n = 55) femoral fracture, 40 (28%) for staged treatment of periprosthetic joint infection, 28 (19%) for aseptic TKA loosening, and 10 (7%) for other indications. Porous metal cones were used to augment femoral fixation in 28 patients (19%) and tibial fixation in 38 patients (26%). Outcomes included cumulative incidence of revision and reoperation (utilizing a competing risk model), Knee Society scores, and radiographic results. The mean age at the time of index DFR was 72 years, and 65% of patients were female. The mean follow-up was 5 years (range, 2 to 13 years) for the 111 patients who did not undergo revision, had not died, and were not lost to follow-up. Results: The 10-year cumulative incidences of revision for aseptic loosening, all-cause revision, and any reoperation were 17.0%, 27.5%, and 46.3%, respectively. There was an increased risk of reoperation in patients who underwent index DFR for aseptic TKA loosening (hazard ratio [HR], 2.30; p = 0.026) or periprosthetic joint infection (HR, 2.18; p = 0.022) compared with periprosthetic or native femoral fractures. However, there was no difference in risk of revision for aseptic loosening or all-cause revision based on the original operative indication. The mean Knee Society score increased from 45 preoperatively to 71 at the time of the latest follow-up (p < 0.001). Radiographic loosening was observed in 8 unrevised DFRs (7%). There were 7 above-the-knee amputations performed at the time of the final follow-up, all for intractable periprosthetic joint infection. Conclusions: TKAs with contemporary DFR had high 10-year cumulative incidences of both revision and reoperation, underscoring the salvage nature of this procedure as a final reconstructive option. Most patients experienced substantial clinical improvements with this end-stage revision procedure. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.