Isolated lateral-sided knee pain in total knee arthroplasty. A review.

Isolated lateral-sided knee pain is a unique problem following total knee arthroplasty (TKA). Reported causes include soft tissue impingement against extruded cement, an overhanging tibial tray, remnant osteophytes rubbing against the iliotibial band (ITB), popliteal tendon impingement, fabella syndrome, and synovial tissue impingement in the lateral gutter. In addition, iliotibial band traction syndrome secondary to guided motion Bi-cruciate stabilizing knee arthroplasty has been recognized as a new clinical entity. Initial work up should include ruling out the most common causes of painful TKA including infection, aseptic loosening, and instability. Radiographs and CT scan are utilized to identify potential source of pain. Ultrasound evaluation (with elicited probe tenderness) can increase diagnostic accuracy. Ultrasound guided local anesthetic injections can confirm the source of pain. Anti-inflammatory medications, physical therapy with ITB stretches, and therapeutic local steroid injections are initial treatment modalities. Satisfactory resolution of symptoms may require surgical intervention directed at the specific cause and may avoid the morbidity associated with revision TKA.

Diagnosis of Waldenstrom Macroglobulinemia Using Postoperative Histopathology During Routine Total Knee Arthroplasty: A Case Report.

CASE: We present a 63-year-old patient diagnosed with Waldenstrom macroglobulinemia (WM) through histopathology of bone tissue after total knee arthroplasty for routine osteoarthritis. The patient, surgical team, and the pathologist were unaware of this diagnosis before the surgery. CONCLUSION: The cost-effectiveness of routine histopathologic examination of bone cuts and synovial samples after total joint arthroplasty continues to be a source of debate. Our case highlights an example of the utility of histopathology because it led to the early detection of WM, resulting in prompt treatment to improve quality of life.

Surgeon-administered intraoperative brachial plexus block for open shoulder surgery - a novel and safe technique.

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

Total Hip Arthroplasty in Cirrhosis is Associated with Increased Complications during the Hospital Stay, Length of Stay, and Cost of Care: A Propensity Matched Database Study.

Objectives: The aim of the study is to evaluate the impact of cirrhosis on inpatient hospital complications and healthcare costs in elective Total Hip Arthroplasty (THA). Methods: A 4-year retrospective analysis of the Nation Inpatient Sample (NIS) database, who underwent elective THA stratified by the presence or absence of cirrhosis was performed (2016-19). The records of specific postoperative complications, the cost of care (COC), and the length of stay (LOS) were evaluated by statistical analysis. Results: The NIS database identified 367,894 patients who underwent THA, of which 1,134 (0.3%) were cirrhotic. In the unmatched analysis, patients with cirrhosis showed significantly elevated rates (P< 0.05) of in-hospital complications compared to non-cirrhotic controls, including mortality (0.7% vs. 0.1%), acute renal failure (9.2% vs. 2.5%), blood loss anemia (30.4% vs. 19.5%), pneumonia (1.1% vs. 0.3%), periprosthetic fracture (3% vs. 1.2%), dislocations (2.5% vs. 1.4%), infection (4.2% vs. 1%), wound dehiscence (0.8% vs. 0.1%) and blood transfusion (11.3% vs. 3.5%). After propensity matching, significantly higher rates of blood loss anemia (30.4% vs. 26.7%; P=0.05), periprosthetic dislocations (2.4% vs. 1%; P=0.008), and infections (4.2% vs. 2.7%, P=0.05) were seen in the cirrhotic cohort, while the rate of pulmonary embolism was significantly lower (0% vs. 0.8%, P=0.002), as was myocardial infarction (0.08% vs. 0.7%, P=0.017). Concerning LOS in the hospital, patients with cirrhosis stayed significantly longer in both the unmatched (4.2 vs. 2.3 days; P <0.001) and matched (4.2 vs. 3.68; P=0.016) controls. The average COC was greater in the cirrhotic group, with a mean value of $90,264 vs. $66,806.31 (P<0.001) in the unmatched and $90,624 vs. $80,676.87 (P=0.001) in the matched cohort. Conclusion: Cirrhosis is associated with longer lengths of stay, higher hospital costs, and a greater risk of perioperative in-hospital complications such as blood loss anemia, dislocation, and infection after THA. This data could assist during preoperative patient counseling and improve the strategies for effectively utilizing the finite healthcare resources without compromising patient care and financial compensation from payers.

Total Knee Arthroplasty in Patients with Spinal Cord Injury: Impact on Medical Complications, Hospital Costs and Length of Stay.

INTRODUCTION: Patients with spinal cord injury (SCI) with degenerative joint disease of the knee may require total knee arthroplasty (TKA). This study examines the demographic and immediate postoperative outcomes of patients with SCI who undergo TKA. METHODS: Admissions data for TKA and SCI were analyzed from the National Inpatient Sample database using International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. An extensive array of preoperative and postoperative variables was compared among SCI TKA patients and non-SCI TKA patients. An unmatched and matched analysis using a 1:1 propensity match algorithm was conducted to compare the two groups. RESULTS: Patients with SCI tend to be younger and have a 7.518 times greater risk of acute renal failure, 2.3 times greater risk of blood loss, and higher risk of local complications, including periprosthetic fracture and prosthetic infection. The average length of stay in the SCI cohort was 2.12 times greater, with a 1.58 times higher mean total incurred charge than the non-SCI group. CONCLUSION: SCI is associated with an increased risk of acute renal failure, blood loss anemia, periprosthetic fractures and infections, a longer length of stay, and greater incurred charges in TKA patients. STUDY DESIGN: Retrospective study.

Using Biceps Tendon Autograft as a Patch in the Treatment of Massive Irreparable Rotator Cuff Tears Improves Patient-reported Outcome Scores: A Systematic Review.

Purpose: To review the clinical studies describing the use of ipsilateral biceps tendon autograft for bridging irreparable massive rotator cuff tears (MRCTs). Methods: A systematic review was conducted of MEDLINE, Embase, Cochrane, CINAHL, and Scopus databases using search terms "massive rotator cuff tear," "irreparable rotator cuff tear," and "long head of the biceps tendon." Only clinical human studies in which the biceps tendon was used as a bridging graft in MRCTs were included. All review studies, technique papers, and studies describing the use of biceps tendon as superior capsular reconstruction equivalent or rotator cable were excluded. Results: A total of 45 studies were initially identified, of which only 6 studies met the inclusion criterion. All studies were retrospective in nature, with a total of 176 patients. All studies reported a clinically significant improvement in postoperative functional outcomes, although this was not compared to a control group in all the studies. Pain was assessed using the visual analog scale (VAS) in 4 studies, and all reported an improvement in postoperative VAS ranging from 5 to 6 points. One study reported an improvement in pain scale from Japanese Orthopedic Association from 13.1 to 22.5 (9 points). One study did not report a VAS score as this study was published before the VAS score was developed. All the reported studies saw improvements in range of motion. Conclusions: The use of the long head of the biceps tendon as an interposition/bridging patch to augment the MRCT repair can reduce the VAS score, improve elevation and external rotation, and improve clinical and functional outcomes. Level of Evidence: IV, systematic review of Level III and IV studies.

Association Between Prosthetic Knee Effusions and Phosphodiesterase Type-5 Enzyme Inhibitor Use After Total Knee Arthroplasty: A Case Report.

CASE: Phosphodiesterase type-5 enzyme (PDE5) inhibitors are well tolerated and used to treat erectile dysfunction. We report a case of prosthetic knee effusions associated with PDE5 inhibitor use in a 65-year-old man after total knee arthroplasty (TKA). PDE5 inhibitor treatment was stopped, and the patient had no further episodes of painful effusions. CONCLUSION: This report describes a previously unknown adverse effect of PDE5 inhibitor use in a prosthetic joint after TKA. We hope to encourage physicians managing patients after joint replacement to be aware of the association between PDE5 inhibitor use and recurrent joint effusions to improve postoperative outcomes.

A simple tool for volar tilt restoration during volar plate osteosynthesis of distal radius fracture: A technical note.

Anatomical restoration of volar tilt is a technical challenge in a displaced distal radius fracture with a dorsally angulated fracture pattern accompanied by dorsal metaphyseal comminution. We adopted a reduction technique using a mini-Hohmann retractor, to accomplish the desired volar tilt in a controlled fashion. We would like to present this technical note through a case example describing the technique specifics along with one-year postoperative outcomes.

Complications During the Hospital Stay, Length of Stay, and Cost of Care in Parkinson Patients Undergoing Total Knee Arthroplasty: A Propensity Matched Database Study.

BACKGROUND: Patients with Parkinson disease (PD) undergoing total knee arthroplasty (TKA) can present with a unique subset of challenges during their hospital stay. The literature is limited to single-center studies with a small number of patients. This study was aimed to analyze the inpatient complications, length of stay (LOS), and cost of care (COC) associated after TKA with PD over 4 years (2016 to 2019). METHODS: In this retrospective cohort study, we used National Inpatient Sample (NIS) database data from 2016 to 2019 and compared in-hospital complications, LOS, and COC among patients undergoing TKA with and without PD. RESULTS: The National Inpatient Sample database is used to identify 558,371 patients (555,289 without PD and 3,082 with PD) who underwent TKA. After propensity-matching, there was an increased incidence of blood loss anemia (PD group 22.3%, control group 13.5%, P ≤ 0.01), periprosthetic dislocations (1.5% in PD group, 0.4% in control group, P < 0.001), and periprosthetic mechanical complications including but not limited to periprosthetic fractures, knee dislocations, patellar maltracking, and subluxations (1.1% in PD group, 0.6% in control group, P = 0.024) in the PD group. The other in-hospital complications including mortality, acute renal failure, myocardial infarction, pneumonia, pulmonary embolism, deep vein thrombosis, periprosthetic fracture, and wound dehiscence showed no notable differences. The average total incurred charges for the PD group were higher, with a mean of $67,581.58 (SD $44,554.64), than that in the control group, with a mean of $64,795.51 (SD $45,841.25) (P < 0.001). The average LOS was higher in the PD group with a mean of 2.7 days (SD = 1.93) compared with the control group (mean = 2.3, SD = 1.73 days, P < 0.001). CONCLUSIONS: An increased incidence of complications such as acute blood loss anemia, periprosthetic mechanical complications, and increased COC, but no difference in LOS was noted in patients undergoing TKA with PD. This information can be useful to make an informed decision regarding patient care and preferred healthcare setup for TKA in patients with PD.

Superior Capsular Reconstruction Using the Biceps Tendon in the Treatment of Irreparable Massive Rotator Cuff Tears Improves Patient-Reported Outcome Scores: A Systematic Review.

Purpose: To systematically evaluate the clinical outcomes of superior capsular reconstruction (SCR) using the long head of the biceps tendon for irreparable massive rotator cuff tears. Methods: Multiple electronic databases were searched for studies treating massive and/or irreparable rotator cuff tears with SCR using the biceps tendon while retaining its proximal attachment to the superior glenoid. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flowchart was created. All the included studies were assessed for quality with the Modified Coleman Methodology Score. Multiple variables including patient demographic characteristics, functional scores, visual analog scale (VAS) scores, and complications were extracted and analyzed. Results: Seven studies were included in this review, with a total of 133 patients. The age range of patients was 39 to 82 years, and the duration of follow-up ranged from 6 to 40.7 months. Various validated scoring systems were used for functional outcome evaluation in all studies; all of them showed postoperative improvement greater than the minimal clinically important difference. The VAS score improvement ranged from 3.8 to 7.1. Five studies reported improvement in shoulder forward elevation, with a range of 22° to 95°. Three studies reported retear rates of 21%, 37%, and 66% on postoperative magnetic resonance imaging scans. Two studies reported complications, with the first study reporting revision surgery in 4 of 35 patients and the second study reporting 1 infection and 1 case of deltoid detachment (open procedure) among 17 patients. Conclusions: SCR using the long head of the biceps tendon is a safe and effective procedure. VAS and patient-reported outcome scores showed significant improvement with minimal short-term complications. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis.

Lumbar spinal steroid injections (LSSI) are universally used as preferred diagnostic or therapeutic treatment options before major spinal surgeries. Some recent studies have reported higher risks of surgical-site infection (SSI) for spinal surgeries performed after injections, while others have overlooked such associations. The purpose of this study is to systematically review the literature and perform a meta-analysis to evaluate the associations between preoperative LSSI and postoperative infection following subsequent lumbar decompression and fusion procedures. Three databases, namely PubMed, Scopus, and Cochrane Library, were searched for relevant studies that reported the association of spinal surgery SSI with spinal injections. After the comprehensive sequential screening of the titles, abstracts, and full articles, nine studies were included in a systematic review, and eight studies were included in the meta-analysis. Studies were critically appraised for bias using the validated MINOR (methodological index for non-randomized studies) score. The odds ratio (OR) and 95% confidence interval (CI) were calculated. Subgroup analysis was performed according to the time between LSSI and surgery and the type of lumbar spine surgery. Meta-analysis showed that preoperative LSSI within 30 days of lumbar spine surgery was associated with significantly higher postoperative infection compared with the control group (OR,1.79; 95% CI, 1.08-2.96). Based on subgroup analysis, lumbar spine fusion surgery within 30 days of preoperative LSSI was associated with significantly high-infection rates (OR, 2.67; 95% CI, 2.12-3.35), while no association was found between preoperative LSSI and postoperative infection for lumbar spine decompression surgeries. In summary, given the absence of high-level studies in the literature, careful clinical interpretation of the results should be performed. The overall risk of SSI was slightly higher if the spinal surgery was performed within 30 days after LSSIs. The risk was higher for lumbar fusion cases but not for decompression-only procedures.