Abstract
Background
Our study evaluated 90-day outcomes of patients treated preoperatively with glucagon-like peptide-1 receptor agonists (GLP-1) or bariatric surgery compared to no weight loss intervention prior to total hip arthroplasty (THA) and total knee arthroplasty (TKA).
Methods
A multicenter institutional cohort of patients undergoing primary THA (n = 5710) and TKA (n = 6770) from 2023 to 2024 was identified. Preoperative weight-loss strategies included no intervention (89%), perioperative use of GLP-1 (10%), or prior bariatric surgery (1%). Ninety-day readmissions and reoperations were compared among groups. Subanalyses were performed stratifying obesity (body mass index) classification and diabetes mellitus status vs others to contextualize these independent risk factors.
Results
Among all patients undergoing THA and TKA, those who had undergone bariatric surgery experienced significantly higher reoperation rates at 90 days compared to those without intervention and GLP-1 groups (2.2 vs 0.5 vs 0.8%, respectively; P = .014). For THA, both the no intervention and GLP-1 groups had significantly lower readmission rates compared to the bariatric surgery group (4.4 vs 6.5 vs 8.8%, respectively; P = .04) and lower reoperation rates (0.4 vs 1.4 vs 2.2%; P = .006). For TKA, there were no significant differences in readmission (P .47) or reoperation rates (P ≥ .067) among the groups or by body mass index class and diabetes mellitus status.
Conclusions
Compared to no weight loss intervention, patients utilizing perioperative GLP-1s demonstrated similar 90-day readmission and reoperation rates after primary THA and TKA. Those with prior bariatric surgery showed the greatest risk of readmission and reoperation, particularly after THA.
Level of Evidence
IV, Retrospective Review.
Keywords: Total joint arthroplasty, Obesity, Weight-loss surgery, Complications, Glucagon-like-peptide-1 receptor agonist
Introduction
Several approaches are available to optimize body mass index (BMI) and reduce perioperative complications prior to primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), including structured lifestyle modification programs (diet and exercise), pharmacologic treatment options, and bariatric surgical procedures. While diet and exercise remain foundational approaches, their effectiveness in achieving meaningful preoperative weight loss has been variable, often limited by patient adherence and comorbidities. Bariatric surgery has also been studied, although outcomes have been mixed, and standardized recommendations are still evolving [[1], [2], [3], [4]].
Glucagon-like peptide-1 receptor agonists (GLP-1), initially developed for glycemic control in patients with diabetes, have emerged as a promising pharmacologic strategy for preoperative BMI optimization in total joint arthroplasty (TJA). These incretin analogs exert their effects by enhancing insulin secretion and suppressing glucagon, delaying gastric emptying through increased sympathetic activity, and reducing appetite via hypothalamic pathways [5,6]. In THA patients with diabetes mellitus (DM), the use of a specific GLP-1, semaglutide, has correlated with lower 90-day readmission and periprosthetic joint infection (PJI) rates over 2 years, without significant differences in other medical or implant-related complications, length of stay, or healthcare costs [7]. Similarly for TKAs in DM patients, semaglutide was associated with reduced risks of sepsis, PJI, and readmission, with trends toward lower revision rates and postoperative costs; however, increased risks of myocardial infarction, acute kidney injury, pneumonia, and hypoglycemia were noted [8].
While GLP-1 research continues to grow, early studies on THA and TKA patient populations are limited by heterogeneity, limitations ascribed to large databases, and a lack of comparison to traditional weight-loss strategies. Our study aimed to compare the outcomes of obese patients treated preoperatively with bariatric surgery or glucagon-like peptide-1 receptor agonist (GLP-1) compared to no intervention prior to THA and TKA.
Materials and methods
After institutional review board approval was obtained, a multicenter institutional cohort of patients undergoing primary THA (n = 5710) and TKA (n = 6770) was identified from January 1, 2023, to December 31, 2024. Exclusion criteria included conversion or revision total joint arthroplasties, unicompartmental knee arthroplasty, hemiarthroplasty, and nonelective surgical indications. Patients were categorized according to preoperative weight-loss strategy, including no intervention/control, active perioperative GLP-1 use, or any history of prior bariatric surgery. Routine patient demographics and perioperative comorbidities were collected via electronic chart review. The primary outcomes compared were 90-day readmissions and reoperations between groups.
The TJA process at all institutional sites followed a contemporary practice of patient selection and optimization, education and expectation management, surgical team expertise and teamwork, and evidence-based protocol for pain management, mobilization, and acute follow-up. Patients were indicated for primary THA and TKA by high-volume adult reconstruction surgeons. Prior to the surgical date, a complete preoperative medical evaluation by medical and/or anesthesia providers at the same institution was performed, whereby the present BMI, current use of GLP-1s, or bariatric surgery was verified. Considerable heterogeneity existed in GLP-1 medication selection and dosing; however, semaglutide was the most commonly utilized agent accounting for 42% of prescriptions. Patients on GLP-1s were instructed to hold the medication 5 days prior to the surgical date according to the institutional guidelines. After surgery and discharge, acute follow-up was performed via electronic patient portal and prescheduled routine outpatient visits during the 90-day global period to capture all readmissions or reoperations. Readmissions were defined as a full return admission to the hospital, excluding isolated emergency department visits, for medical or surgical intervention, and reoperations were noted as any return to the operating room.
After exclusions, the weight loss groups included intervention/controls (n = 11,427), active perioperative GLP-1 use (n = 1248), or any history of prior bariatric surgery (n = 135). The mean age was 68 years (range, 14-95), 56% were female, and mean BMI was 31.5 kg/m2 (range, 14-62.2) (Table 1). A subgroup analysis of BMI classification according to the Centers for Disease Control of the no intervention group was compared against GLP-1 and bariatric surgery groups to contextualize obesity risk [9]. The BMI classification patients within the no-intervention group were 5432 (48%) = normal weight, 5089 (44%) overweight (BMI <30 kg/m2), and 906 (8%) morbidly obesity (BMI >40 kg/m2). The rate of DM was significantly different between no intervention, GLP-1s, and bariatric surgery groups (15.7 vs 65.5 vs 34.8%, respectively, P < .001); therefore, an additional subgroup analysis was performed comparing nondiabetic, no intervention patients to those with and without DM in GLP-1 and bariatric surgery groups to contextualize diabetic risk.
Table 1.
A comparison of baseline characteristics between weight loss interventions in patients with no intervention: glucagon-like peptide-1 agonists or bariatric surgery prior to total hip and knee arthroplasty.
| Baseline patient characteristics | No interventiona N = 11,427 |
GLP-1 usea N = 1248 |
Bariatric surgerya N = 135 |
P valueb |
|---|---|---|---|---|
| Smoker (yes) | 328 (2.9%) | 37 (3.0%) | 0 (0.0%) | .09 |
| BMI (kg/m2) | 30.3 (26.6, 34.7) | 35.7 (31.5, 40.2) | 35.4 (30.7, 39.4) | <.001 |
| Albumin (g/dL) | 4.3 (4.1, 4.5) | 4.3 (4.1, 4.5) | 4.2 (4.0, 4.4) | <.001 |
| Creatinine (mg/dL) | 0.9 (0.8, 1.1) | 0.9 (0.8, 1.1) | 0.8 (0.7, 0.9) | <.001 |
| DM, type II (yes) | 1798 (15.7%) | 805 (64.5%) | 47 (34.8%) | <.001 |
| Hemoglobin A1C (%) | 5.6 (5.3, 6.0) | 6.0 (5.5, 6.7) | 5.3 (5.0, 5.6) | <.001 |
| Hemoglobin (g/dL) | 13.8 (12.9, 14.7) | 13.7 (12.7, 14.7) | 13.4 (12.5, 14.0) | <.001 |
Bolded values are significant values P < .05.
n (%); median (Q1, Q3).
Fisher’s exact test; Kruskal-Wallis rank sum test.
Statistical analysis
The number and percentage of patients were used to summarize categorical variables, while the median and range were used to summarize continuous variables. Comparisons between groups for categorical variables were made using Fisher’s exact tests. Kruskal-Wallis tests were used for comparing continuous variables between groups. P values <.05 were considered statistically significant. Statistical analysis was performed using R Statistical Software (version 4.4.1; R Foundation for Statistical Computing, Vienna, Austria).
Results
Among all patients undergoing THA and TKA, there was no overall difference in 90-day readmission rates (P = .23). However, compared to controls and GLP-1 groups, bariatric surgery patients experienced more than twice the rate of 90-day reoperation (0.5 vs 0.8 vs 2.2%, respectively; P = .01) (Table 2). The most common reason for reoperation in each cohort was prosthetic joint infection, with the bariatric cohort experiencing the highest percentage at 66%, followed by 60% in the GLP-1 group, and 59% in the controls.
Table 2.
A comparison of readmission and reoperation rates and etiologies among weight loss interventions in patients with no intervention: glucagon-like peptide-1 agonists or bariatric surgery prior to total hip and knee arthroplasty.
| Readmissions/Reoperations and etiologies | No interventiona N = 11,427 |
GLP-1 usea N = 1248 |
Bariatric surgerya N = 135 |
P valueb |
|---|---|---|---|---|
| Readmissions total | 477 (4.2%) | 58 (4.6%) | 9 (6.7%) | .23 |
| Medical | 280 (2.5%) | 26 (2.1%) | 4 (3.0%) | |
| Surgical | 112 (1.0%) | 13 (1.0%) | 4 (3.0%) | |
| Unrelated | 85 (0.7%) | 19 (1.5%) | 1 (0.7%) | |
| Reoperation total | 53 (0.5%) | 10 (0.8%) | 3 (2.2%) | .014 |
| Dislocation | 3 (0.0%) | 1 (0.1%) | 0 (0.0%) | |
| Prosthetic joint infection | 31 (0.3%) | 6 (0.5%) | 2 (1.5%) | |
| Stiffness | 5 (0.0%) | 1 (0.1%) | 0 (0.0%) | |
| Instability | 4 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| Aseptic loosening | 3 (0.0%) | 1 (0.1%) | 0 (0.0%) | |
| Arthrofibrosis | 1 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| Extensor mechanism disruption | 2 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| Wound dehiscence | 3 (0.0%) | 1 (0.1%) | 0 (0.0%) | |
| Periprosthetic fracture | 1 (0.0%) | 0 (0.0%) | 1 (0.7%) |
Bolded values are significant values P < .05.
n (%); median (Q1, Q3).
Fisher’s exact test; Kruskal-Wallis rank sum test.
When stratified by BMI class (Table 3), there was no significant difference in 90-day readmission rates for controls and GLP-1 groups (≤4.8 vs 6.5%, P = .15) or controls and bariatric surgery groups (≤4.3 vs 6.7%, P = .47). Compared to nonobese controls, significantly higher reoperation rates existed in those with BMI >40 kg/m2 and GLP-1 groups (0.3 vs 0.8 and 0.8%, respectively, P = .03). The bariatric surgery group demonstrated the highest 90-day reoperation rate (2.2%, P = .005).
Table 3.
Comparison of readmission and reoperation rates across cohorts with the no intervention (control) group stratified by body mass index (BMI).
| All THA and TKA BMIs vs GLP-1 | Control BMI<30 |
Control BMI 30-39.9 |
Control BMI>40 |
GLP-1 use | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 221 (4.1%) | 217 (4.3%) | 39 (4.3%) | 58 (4.6%) | .8 |
| Reoperationsa | 17 (0.3%) | 29 (0.6%) | 7 (0.8%) | 10 (0.8%) | .031 |
| All THA and TKA BMIs vs bariatric surgery | Control BMI<30 |
Control BMI 30-39.9 |
Control BMI>40 |
Bariatric surgery | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 221 (4.1%) | 217 (4.3%) | 39 (4.3%) | 9 (6.7%) | .47 |
| Reoperationsa | 17 (0.3%) | 29 (0.6%) | 7 (0.8%) | 3 (2.2%) | .005 |
| THA BMIs vs GLP-1 | Control BMI<30 |
Control BMI 30-39.9 |
Control BMI>40 |
GLP-1 use | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 119 (4.2%) | 95 (4.8%) | 16 (4.9%) | 32 (6.5%) | .15 |
| Reoperationsa | 7 (0.2%) | 13 (0.7%) | 2 (0.6%) | 7 (1.4%) | .005 |
| THA BMIs vs bariatric surgery | Control BMI<30 | Control BMI 30-39.9 |
Control BMI>40 |
Bariatric surgery | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 119 (4.2%) | 95 (4.8%) | 16 (4.9%) | 4 (8.7%) | .32 |
| Reoperationsa | 7 (0.2%) | 13 (0.7%) | 2 (0.6%) | 1 (2.2%) | .034 |
| TKA BMIs vs GLP-1 | Control BMI<30 |
Control BMI 30-39.9 |
Control BMI>40 |
GLP-1 use | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 102 (3.9%) | 122 (3.9%) | 23 (4.0%) | 26 (3.4%) | .94 |
| Reoperationsa | 10 (0.4%) | 16 (0.5%) | 5 (0.9%) | 3 (0.4%) | .47 |
| TKA BMIs vs bariatric surgery | Control BMI<30 |
Control BMI 30-39.9 |
Control BMI>40 |
Bariatric surgery | P valueb |
|---|---|---|---|---|---|
| Readmissionsa | 102 (3.9%) | 122 (3.9%) | 23 (4.0%) | 5 (5.6%) | .81 |
| Reoperationsa | 10 (0.4%) | 16 (0.5%) | 5 (0.9%) | 2 (2.2%) | .067 |
Bolded values are significant values P < .05.
n (%).
Fisher’s exact test; Kruskal-Wallis rank sum test.
For THAs, the control and GLP-1 groups demonstrated a significantly lower 90-day readmission rate compared to bariatric surgery (4.4 vs 6.5 vs 6.5 vs 8.8%, respectively, P = .04). Reoperation rates were also found to be significantly different among the 3 cohorts (0.4 vs 1.4 vs 2.2%, P < .01) (Table 3). Stratified by BMI, there was no difference in 90-day THA readmission rates (P = .32) between groups; however, compared to normal weight controls, there was a significantly higher rate of reoperation for the GLP-1 group (≤0.7 vs 1.4%, P = .01) and the bariatric surgery group (≤0.7 vs 2.2%, P = .03). When comparing the no intervention and GLP-1 cohorts without DM after THA, the GLP-1 patients with DM had significantly higher rates of readmissions (3.7 vs 3.8 vs 8.2%, P = .002) and reoperations (0.3 vs 1.1 vs 1.6%, P = .005) (Table 4). The bariatric surgery patients with DM demonstrated the highest rate (11.8%, P = .076) of THA readmissions.
Table 4.
Comparison of readmission and reoperation rates in each weight-loss intervention stratified by diabetes mellitus status.
| THA and GLP-1 | No intervention, BMI <40, no DM | GLP-1, no diabetes | GLP-1, DM | P valueb |
|---|---|---|---|---|
| Readmissionsa | 156 (3.7%) | 7 (3.8%) | 25 (8.2%) | .002 |
| Reoperationsa | 14 (0.3%) | 2 (1.1%) | 5 (1.6%) | .005 |
| THA and bariatric surgery | No intervention BMI <40, no DM | Bariatric surgery, no DM | Bariatric surgery, DM | P valueb |
|---|---|---|---|---|
| Readmissionsa | 156 (3.7%) | 2 (6.9%) | 2 (11.8%) | .076 |
| Reoperationsa | 14 (0.3%) | 1 (3.4%) | 0 (0.0%) | .15 |
| TKA and GLP-1 | No intervention BMI <40, no DM | GLP-1, no DM | GLP-1, DM | P valueb |
|---|---|---|---|---|
| Readmissionsa | 177 (3.7%) | 5 (1.9%) | 21 (4.2%) | .27 |
| Reoperationsa | 20 (0.4%) | 2 (0.8%) | 1 (0.2%) | .42 |
| TKA and bariatric surgery | No intervention BMI <40, no DM | Bariatric surgery, no DM | Bariatric surgery, DM | P valueb |
|---|---|---|---|---|
| Readmissionsa | 177 (3.7%) | 4 (6.8%) | 1 (3.3%) | .36 |
| Reoperationsa | 20 (0.4%) | 2 (3.4%) | 0 (0%) | .037 |
n (%).
Fisher’s exact test; Kruskal-Wallis rank sum test.
For TKAs, there were no significant differences in rates of 90-day readmission (P ≥ .47) or reoperation (P ≥ .067) across all comparisons or when stratified by BMI. Similarly, those with and without DM among the GLP-1 group did not show significant differences in readmissions (P = .27) or reoperations (P = .42) after TKA (Table 4). However, the bariatric surgery cohort without DM demonstrated the highest rate (3.4%, P = .037) of TKA reoperations.
Discussion
While preoperative BMI optimization is essential for THA and TKA, lifestyle modifications, pharmacologic therapies, and bariatric surgery each have varying impacts on perioperative outcomes. Our study aimed to evaluate the comparative effects of no intervention, GLP-1 use, and prior bariatric surgery on short-term outcomes following THA and TKA. We found that while there were no differences in overall 90-day readmission rates among the cohorts, patients with prior bariatric surgery demonstrated significantly higher 90-day reoperation rates, particularly following THA. In contrast, GLP-1 use was associated with comparable readmission and reoperation rates to controls, suggesting that pharmacologic weight reduction may represent a safe and effective optimization strategy.
Bariatric surgery has long been considered a preoperative optimization strategy for obese arthroplasty candidates, with several studies showing reduced operative times and shorter lengths of stay [10,11]. However, the benefits in terms of long-term arthroplasty outcomes remain inconsistent [12,13]. Post-bariatric patients often experience iron deficiency, vitamin D insufficiency, and bone loss, which may predispose them to wound-healing complications, fractures, or implant failure [10,14]. In the current study, this was reflected by the significantly higher reoperation rates among bariatric surgery patients, particularly in THA. These findings align with prior literature reporting an elevated revision risk and inferior implant survivorship following bariatric procedures, likely attributable to altered bone metabolism and nutritional deficiencies [14,15].
Moreover, a recent meta-analysis found that while bariatric surgery did not significantly reduce the long-term risk of periprosthetic infection, fracture, or revision across TKA/THA, it did identify an increased risk of hip dislocation in the THA subgroup [16]. Taken together, the evidence suggests that while bariatric surgery may offer perioperative logistical benefit (eg, shorter hospital stay, lower operative time), it does not uniformly confer improved long-term arthroplasty outcomes and may introduce specific musculoskeletal and bone-health risks that warrant careful preoperative planning. In contrast, GLP-1 receptor agonists offer a noninvasive alternative that promotes weight loss and metabolic improvement without the catabolic or malabsorptive sequelae associated with surgical weight loss [5,17,18].
Our findings align with recent large-scale database and meta-analytic studies demonstrating favorable short-term outcomes associated with GLP-1 use in THA and TKA patients [6,19]. A systematic review and meta-analysis of 346,899 patients found that GLP-1 users had reduced 90-day readmissions and PJI rates after TKA, and lower revision risk after THA, without an increase in aspiration or pulmonary complications [6]. Similarly, in their systematic review, Chan et al. [19] reported that perioperative GLP-1 use was associated with fewer medical and surgical complications overall, reinforcing the perioperative safety of these agents.
Several recent retrospective studies have reported consistent trends. In TKA, the use of semaglutide was associated with lower sepsis, PJI, and readmission rates, as well as a trend toward reduced revision surgery and postoperative costs. However, an increased risk of myocardial infarction and pneumonia was noted [8]. For THA, preoperative exposure to semaglutide was associated with fewer PJIs and readmissions within 2 years, without an increase in systemic or implant-related complications [7]. In morbidly obese TKA patients, GLP-1 receptor agonist use decreased both medical and surgical complications [20]. Additionally, as few as 3 months of preoperative semaglutide use was associated with reduced postoperative adverse events in patients with type II diabetes undergoing TKA [15]. Finally, a meta-analysis examining the effect of BMI on the efficacy of semaglutide in TKA found that the benefit persisted across BMI categories [21].
These reduced acute risks associated with GLP-1s likely stem from their synergistic effects: improved glycemic control lowers the risk of infection and wound complications; weight loss and decreased inflammation reduce metabolic stress and joint loading; and direct anti-inflammatory action on cytokines like interleukin-6 and tumor necrosis factor alpha enhances the local tissue response [[22], [23], [24]]. However, DM appears to remain a dominant risk factor for complications after THA, even when weight-loss interventions are used. Our findings showed GLP-1 patients with diabetes had significantly higher readmission and reoperation rates compared to nondiabetic cohorts, while bariatric surgery patients with diabetes demonstrated the greatest risk. These findings suggest that metabolic disease may outweigh the benefits of preoperative weight-loss strategies, underscoring the need for aggressive glycemic optimization and multidisciplinary planning.
Despite the growing appeal of GLP-1s for preoperative weight management, several perioperative risks warrant caution. These agents delay gastric emptying, raising concern for aspiration during anesthesia—a rare but potentially life-threatening complication. Although extensive cohort studies have not shown a statistically significant increase in aspiration pneumonia [[25], [26], [27]], elevated residual gastric contents remain a consistent finding, prompting the continue evolution of guidelines and individualized risk assessments [[28], [29], [30], [31]]. Based on consensus-based guidance from the American Society of Anesthesiologists, the current accepted practice has included holding daily GLP-1 receptor agonists on the day of elective surgery and withholding weekly GLP-1 receptor agonists for 1 week prior to the procedure [32].
Additionally, other data suggest a possible association with increased myocardial infarction risk in specific populations, though further validation is needed [33]. Another consideration is the transient nature of GLP-1-induced weight loss; patients often regain weight upon discontinuation, which may negatively impact long-term implant survivorship due to increased mechanical loading [34,35]. Given these uncertainties, orthopedic surgeons may be cautiously optimistic that GLP-1 use may offer perioperative advantages; however, much remains unknown about their long-term implications in arthroplasty patients.
This study is not without limitations. First, the retrospective design introduces potential selection bias and residual confounding, despite similar baseline characteristics across groups. Although contemporary protocols were in place during the study period, the multicenter nature of the enterprise introduced variability in anesthesia practices, surgeon/surgical techniques, and patient experience, all of which may have influenced 90-day outcomes. Data on the specific GLP-1 agent utilized, dose, duration, and effect (ie, amount of preoperative and postoperative weight loss) were not uniformly available. Additionally, the timing of prior bariatric surgery relative to arthroplasty could not be reliably validated, limiting assessment of potential nutritional deficiencies that may influence postoperative complications and outcomes. The overall number of bariatric patients was small, which limited the power to detect rare complications. Furthermore, low event rates and small bariatric cohort limited the feasibility of multivariable or propensity-adjusted analyses; therefore, stratified analyses were performed by BMI and diabetes status to contextualize key baseline differences. Finally, longer-term implant survivorship and weight-loss effects beyond 90 days were not evaluated; however, the cohort can be followed to provide future insight into such outcomes.
Conclusions
This multicenter cohort of primary THA and TKA patients showed that GLP-1 therapy was not associated with increased short-term postoperative complications and was associated with lower rates of postoperative infection and readmission. In contrast, a history of bariatric surgery was associated with higher complication rates. These findings reflect observed associations within an observational cohort and should not be interpreted as evidence of causality. While GLP-1s provide a promising, noninvasive alternative to perioperative weight optimization, essential questions remain regarding their long-term implications in TJA. Until more definitive data are available, surgeons should approach these patients with careful multidisciplinary planning and individualized risk assessment.
Funding
The authors wish to acknowledge a grant from the American Joint Replacement Registry (AR76312) as a funding source for the study.
Conflicts of interest
C.K. Ledford is a paid consultant for Stryker and is a board member/committee appointments for AAHKS and AAOS. A.P. Mika is a board member/committee appointments for AAHKS. L.S. Spencer-Gardner is a paid consultant for Medacta and is a board member/committee appointments for AAHKS. C.P. Hannon receives royalties from Enovis and Zimmer Biomet; is a paid consultant for Signature Orthopaedics, Enovis, and Vertex Pharmaceuticals; owns stock or stock options in Cherish Health; and is a board member/committee appointments for AAHKS and AAOS. H.D. Clarke receives royalties from Restore 3D/ConforMIS, Zimmer Biomet, and Aspire-ISE/Optimus; is a paid consultant for Restore 3D/ConforMIS and Zimmer Biomet; and is an unpaid consultant for OSSO VR; owns stock or stock options in Aspire-ISE/Optimus; receives royalties, financial, or material support from Elsevier; and is a board member/committee appointments for AAHKS, AAOS, and The Knee Society. M.P. Abdel receives royalties from Stryker, OsteoRemedies, and Springer; is a board member/committee appointments for AAHKS and International Orthopedic Education Network. B.D. Springer receives royalties from Stryker and OsteoRemedies; is a paid consultant for Convatec, is a board member/committee appointments for International Orthopedic Education Network, The Hip Society, and American Joint Replacement Registry; and owns stock or stock options in Osteal and MiCare Path; the other author declares no potential conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2026.101988.
CRediT authorship contribution statement
Cameron K. Ledford: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Funding acquisition, Conceptualization. Aleksander P. Mika: Writing – original draft, Investigation, Formal analysis, Data curation. Ramiro J. Lopez: Writing – original draft, Investigation, Formal analysis, Data curation. Luke S. Spencer-Gardner: Writing – review & editing, Validation, Supervision, Conceptualization. Charles P. Hannon: Writing – review & editing, Validation, Supervision, Conceptualization. Henry D. Clarke: Writing – review & editing, Validation, Supervision, Methodology, Conceptualization. Matthew P. Abdel: Writing – review & editing, Validation, Supervision, Project administration, Methodology, Conceptualization. Bryan D. Springer: Writing – review & editing, Visualization, Validation, Supervision, Project administration, Methodology, Funding acquisition, Conceptualization.
Footnotes
Investigation performed at the Mayo Clinic, Jacksonville, FL, Rochester, MN, and Scottsdale, AZ.
Appendix A. Supplementary data
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