Significant Cost Savings and Improved Early Clinical Outcomes in Medicare Patients Utilizing a Clinician-Controlled Telerehabilitation System Following Total Knee Arthroplasty.

BACKGROUND: The costs and benefits of different rehabilitation protocols following total knee arthroplasty are unclear. The emergence of telerehabilitation has introduced the potential for enhanced patient convenience and cost reduction. The purpose of this study was to assess the cost difference between standard physical therapy (SPT) and a telerehabilitation home-based clinician-controlled therapy system (HCTS). METHODS: A prospectively enrolled, consecutive series of 109 Medicare patients who received SPT were compared to 101 Medicare patients who were treated with a HCTS. The analysis focused on total rehabilitation costs and the assessment of outcome measures: knee range of motion, visual analog scale pain levels, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement. RESULTS: The HCTS group demonstrated not only statistically significantly lower average costs but also faster and sustained knee range of motion improvements. Furthermore, in comparison to SPT, the HCTS group exhibited superior visual analog scale pain scores and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement functional scores at all assessment points postoperatively, which were statistically significant (all P < .001) and surpassed the minimal clinically important difference thresholds. CONCLUSIONS: The HCTS used in this study exhibited a remarkable cost-saving advantage of $2,460 per patient compared to standard therapy. As approximately 500,000 primary total knee arthroplasties in the United States are covered by Medicare annually, a switch to HCTS could yield total cost savings of more than $1.23 billion per year for our taxpayer-funded health care system. Furthermore, the HCTS cohort demonstrated superior functional outcomes and improved pain scores across all assessment time points, exceeding the minimal clinically important difference.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

A distinct human cell type expressing MHCII and RORγt with dual characteristics of dendritic cells and type 3 innate lymphoid cells.

Recent studies have characterized various mouse antigen-presenting cells (APCs) expressing the lymphoid-lineage transcription factor RORγt (Retinoid-related orphan receptor gamma t), which exhibit distinct phenotypic features and are implicated in the induction of peripheral regulatory T cells (Tregs) and immune tolerance to microbiota and self-antigens. These APCs encompass Janus cells and Thetis cell subsets, some of which express the AutoImmune REgulator (AIRE). RORγt+ MHCII+ type 3 innate lymphoid cells (ILC3) have also been implicated in the instruction of microbiota-specific Tregs. While RORγt+ APCs have been actively investigated in mice, the identity and function of these cell subsets in humans remain elusive. Herein, we identify a rare subset of RORγt+ cells with dendritic cell (DC) features through integrated single-cell RNA sequencing and single-cell ATAC sequencing. These cells, which we term RORγt+ DC-like cells (R-DC-like), exhibit DC morphology, express the MHC class II machinery, and are distinct from all previously reported DC and ILC3 subsets, but share transcriptional and epigenetic similarities with DC2 and ILC3. We have developed procedures to isolate and expand them in vitro, enabling their functional characterization. R-DC-like cells proliferate in vitro, continue to express RORγt, and differentiate into CD1c+ DC2-like cells. They stimulate the proliferation of allogeneic T cells. The identification of human R-DC-like cells with proliferative potential and plasticity toward CD1c+ DC2-like cells will prompt further investigation into their impact on immune homeostasis, inflammation, and autoimmunity.

Cementless Versus Cemented Total Knee Arthroplasty: Concise Midterm Results of a Prospective Randomized Controlled Trial.

BACKGROUND: We previously reported the 2-year results of a prospective randomized controlled trial of cementless versus cemented total knee arthroplasty (TKA) implants of the same design. The purpose of the present study was to provide concise results at intermediate-term follow-up. METHODS: The original study included 141 TKAs (76 performed without cement and 65 performed with cement). Since then, 8 patients died and 4 withdrew. Of the remaining 129 patients, 127 (98%) were available for analysis. Survivorship analysis was performed; Oxford Knee, Knee Society, and Forgotten Joint Scores were calculated; and radiographs reviewed. Mean follow-up was 6 years. RESULTS: The survivorship free of any revision was 100% in both groups. There were no differences between the groups in any patient-reported functional outcome measure (p = 0.2 to 0.5). However, a higher percentage of patients in the cementless TKA group were either extremely or very satisfied with their overall function (p = 0.01). Radiographically, there was no evidence of implant loosening in either group. CONCLUSIONS: At 6 years, there were no differences between cementless and cemented TKA implants of the same design in terms of survivorship, clinical, or radiographic outcomes. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Chitranjan S. Ranawat Award: Tourniquet Use Does Not Impact Trajectory of Total Knee Arthroplasty Early Recovery: A Prospective, Randomized Controlled Trial.

BACKGROUND: The impact of tourniquet use on recovery after total knee arthroplasty (TKA) remains controversial. The purpose of this prospective, single blinded, randomized controlled trial was to investigate the effect of tourniquet use on early recovery after TKA using a smartphone app-based patient engagement platform (PEP) with a wrist-based activity monitor to obtain more robust data on early recovery. METHODS: There were 107 patients undergoing primary TKA for osteoarthritis who were enrolled (54 tourniquet [TQ+]; 53 no tourniquet [TQ-]). All patients utilized a PEP and wrist-based activity sensor for 2 weeks preoperatively and 90 days postoperatively to collect Visual Analog Scale (VAS) pain scores and opioid consumption, as well as weekly Oxford Knee Score (OKS) and monthly Forgotten Joint Score (FJS). There was no difference in demographics between groups. Formal physical therapy assessments were performed preoperatively and 3 months postoperatively. Independent sample t-tests were used for continuous data and Chi-square and Fisher's exact tests were used for discrete data. RESULTS: Tourniquet use did not have a statistically significant impact on daily VAS pain or opioid consumption during the first 30 days postoperatively (P > .05). Tourniquet use did not have a significant impact on OKS or FJS at 30 or 90 days postoperatively (P > .05), or on performance of formal physical therapy testing at 3 months postoperatively (P > .05). CONCLUSION: Using a digital technology to collect daily patient data, we found that tourniquet use has no clinically significant negative impact on pain and function in the first 90 days after primary TKA.

Posterior Approach Total Hip Arthroplasty Utilizing a Monoblock Dual-Mobility Construct Without Posterior Hip Precautions: A Series of 580 Hips With One Dislocation.

BACKGROUND: Instability remains a devastating complication following total hip arthroplasty. Here we describe a mini-posterior approach with a monoblock dual-mobility implant without "traditional posterior hip precautions" yielding excellent results. METHODS: There were 580 consecutive hips in 575 patients who underwent total hip arthroplasty utilizing a monoblock dual-mobility implant and a mini-posterior approach. With this technique, the acetabular component positioning does not rely on tradition intra-operative radiographic abduction and anteversion goals but rather uses patient-specific anatomic landmarks (anterior acetabular rim and, when visible, the transverse acetabular ligament) to set cup position; stability is assessed with a significant, dynamic intra-operative test of range of motion. Patients' mean age was 64 years (range, 21 to 94), and 53.7% were women. RESULTS: Mean abduction was 48.4° (range, 29° to 68°) and mean anteversion was 24.7° (range, -1° to 51°). Patient Reported Outcomes Measurement Information System scores improved in every measured domain from preoperative to final postoperative visit. There were seven (1.2%) patients who required reoperation, with mean time to reoperation of 1.3 months (range, one to 176 days). Only one patient (0.2%) who had a preoperative history of spinal cord injury and Charcot arthropathy dislocated. CONCLUSION: A posterior approach hip surgeon may want to consider using a monoblock dual-mobility construct and avoidance of traditional posterior hip precautions to achieve early hip stability with an extremely low dislocation rate and high patient satisfaction scores.

A Home-Based, Remote-Clinician-Controlled, Physical Therapy Device Leads to Superior Outcomes When Compared to Standard Physical Therapy for Rehabilitation After Total Knee Arthroplasty.

BACKGROUND: The optimal postoperative rehabilitation regimen following total knee arthroplasty (TKA) is not clearly defined. The advent of telerehabilitation offers potential for increased patient convenience and decreased cost, while maintaining similar outcomes to traditional physical therapy (PT). Therefore, we evaluated a novel, home-based, clinician-controlled, multi-modal evaluation and therapy device with telerehabilitation functionality for TKA. METHODS: A total of 135 consecutive TKA patients receiving standard therapy protocol (STP) were compared to 135 consecutive patients receiving a home-based clinician-controlled therapy system (HCTS). Outcomes were assessed at 2, 6, and 12 weeks, including visual analog scale (VAS) for pain, knee injury and osteoarthritis outcome score JR (KOOS JR), and knee range of motion (ROM) measured by the same certified physical therapists. RESULTS: Postoperative knee ROM was greater in the HCTS group at all time points throughout the study period (P < .001 at 2, 6, and 12 weeks). VAS and the KOOS JR functional scores were statistically better (P < .001) in the HCTS group at all time points and exceeded the threshold for minimal clinically important difference (MCID) for both VAS and KOOS JR. There were significantly fewer cases of arthrofibrosis requiring manipulation under anesthesia (MUA) in the HCTS group (1.48 versus 4.44%). CONCLUSION: Following TKA, a novel, home-based, clinician-controlled, multi-modal therapy device was superior to standard PTduring the first 12 weeks postoperatively for ROM, KOOS JR, and VAS (with all scores exceeding the MCID) and had substantially fewer manipulations for arthrofibrosis.

Manipulation Under Anesthesia is Safe After Cementless Total Knee Arthroplasty: A Multicenter Study.

BACKGROUND: Cementless total knee arthroplasty (TKA) is thought to facilitate durable, biological fixation between the bone and implant. However, the 4-12 weeks required for osseointegration coincides with the optimal timeframe to perform a manipulation under anesthesia (MUA) if a patient develops postoperative stiffness. This study aims to determine the impact of early MUA on cementless fixation by comparing functional outcomes and survivorship of cementless and cemented TKAs. METHODS: A consecutive series of patients who underwent MUA for postoperative stiffness within 90 days of primary, unilateral TKA at 2 academic institutions between 2014 and 2018 were identified. Cases involving extensive hardware removal were excluded. Cementless TKAs undergoing MUA (n = 100) were propensity matched 1:1 to cemented TKAs undergoing MUA (n = 100) using age, gender, body mass index, and year of surgery. Both groups had comparable baseline Knee Injury and Osteoarthritis Outcome Scores (KOOS), Short Form (SF)-12 Physical, and SF-12 Mental scores. MUA-related complications as well as postoperative KOOS and SF-12 scores were compared. RESULTS: MUA-related complications were equivalently low in both groups (P = .324), with only 1 patella component dissociation in the cementless group. No tibial or femoral components acutely loosened in the perioperative period. Postoperative KOOS (P = .101) and SF-12 Mental scores (P = .380) were similar between groups. Six-year survivorship free from any revision after MUA was 98.0% in both groups (P = 1.000). CONCLUSION: Early postoperative MUA after cementless TKA was not associated with increased MUA-related complications or worse patient-reported outcomes compared to cemented TKA. Short-term survivorship was also comparable, suggesting high durability of the bone-implant interface.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method.

BACKGROUND: Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS: Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS: Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION: Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

A Short-Term Multicenter Analysis of Radiolucent Lines in a Single Uncemented Rotating Platform Implant for Total Knee Arthroplasty.

Background: Uncemented total knee arthroplasty is increasing as a potential solution for aseptic loosening via biologic fixation and to increase operative efficiency. However, postoperative radiolucent lines (RLLs) remain a concern for some clinicians. We report on a multicenter analysis of these RLLs over a 2-year period to identify their incidence, progression, and clinical significance. Material and methods: Institutional review board approval was obtained for this retrospective, multicenter case series. A total of 312 patients treated with a single cruciate-retaining, fully porous coated femoral and tibial component design were included in the study. All patients were evaluated clinically and radiographically in the early postoperative period and at final follow-up (average 2.0 years). Average age of the study group was 58.2 years, and average body mass index was 30.7. Of the total, 66% were male, and 34% were female. Two independent surgeons evaluated the radiographs at the initial postoperative visit and at the most recent follow-up for RLLs. Knee Society Scores and range of motion (ROM) were collected at each visit. Results: We identified RLLs in 25% of patients. All RLLs were less than 1 mm in size and located at the periphery of the tibial implant. None of the RLLs were progressive. At the final follow-up, compared with early postoperative imaging, no new RLLs were identified. Average ROM in flexion was 124 degrees, and the average Knee Society Scores at the most recent clinical follow-up was 96. Conclusion: RLLs are commonly seen following cementless TKA, most commonly underneath the tibial tray. Based on this data set, there does not appear to be progression of these RLLs with time, and they do not appear to have an effect on ROM or clinical outcome at 2 years.

James A. Rand Young Investigator's Award: Questioning the "Nickel Free" Total Knee Arthroplasty.

BACKGROUND: A study was performed to measure metal ions present in the knee joint after performing a total knee arthroplasty (TKA) with standard cobalt chromium (CoCr) components as well as with "nickel-free" oxidized zirconium femoral and titanium tibial (OxZr/Ti) components. METHODS: Knee joint fluid was collected prior to arthrotomy, and on postoperative day one to determine the amount of metal debris generated when performing a TKA with standard instrumentation from consecutive cases with CoCr components (n = 24) and OxZr/Ti components (n = 16). RESULTS: CoCr implant patients had statistically higher levels of nickel (Ni) (29.7%, P = .033), cobalt (Co), (1,100.7%, P < .0001) and chromium (Cr) (118.9%, P < .0001) postoperatively. The cutting blocks and sawblades do not contain Co, which therefore must have come from the components. The metal ions generated from the sawblades and cutting blocks, therefore, could be discerned from the OxZr/Ti whose components don't contain Co, Cr, or Ni. The OxZr patients had significantly higher Cr (9.5×, P < .001) and Ni (5.1×, P < .001) post-TKA vs pre-TKA; Co levels were not significantly different as expected with the absence of Co in the components (P = .60). The Ni levels generated in performing an Oxinium TKA was 3.3 times higher than when performing a CoCr TKA (1.37 vs. 41 ppb, P < .001). CONCLUSIONS: The substantial degree of Ni generation resulting from performing a hypoallergenic "nickel-free" TKA calls into questions the rationale of utilizing more expensive lower Ni components on the basis of known or suspected Ni or Cr allergy.

Implant Malalignment may be a Risk Factor for Poor Patient-Reported Outcomes Measures (PROMs) Following Total Knee Arthroplasty (TKA).

BACKGROUND: Implant malalignment may be a risk factor for poor patient-reported outcomes measures (PROMs) following total knee arthroplasty (TKA). METHODS: Postoperative surveys were administered to assess PROMs regarding satisfaction, pain, and function in 262 patients who underwent surgery at 4 centers in the U.S. and U.K (average age, 67.2) at a mean 5.5 years after primary TKA. Postoperative distal femoral angle (DFA), proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured, and outliers were recorded. PROMs were compared between patients with aligned versus malaligned knees using univariate analysis. RESULTS: Patients with DFA, PTA, and PSA outliers were more likely to experience similar or decreased activity levels postoperatively than patients with no alignment outliers, as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA, PTA, and PSA outliers were significantly more likely to be dissatisfied with their ability to perform activities of daily living (ADLs), as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA and PSA outliers were more likely to be dissatisfied with their degree of pain relief, as were patients with 2 outliers of any kind (P < .05). Finally, patients with DFA and PSA outliers, as well as those with 1 outlier of any kind, were more likely to be dissatisfied with their overall knee function (P < .05). CONCLUSION: DFA, PTA, and PSA outliers represent a significant risk factor for decreased satisfaction with activities of daily living(ADLs), pain relief, and knee function, as well as decreased activity levels. LEVEL OF EVIDENCE: Level III.

The Impact of Component Design and Fixation on Stress Shielding After Modern Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) tibial baseplate thickness, metallurgy, and implant fixation with cement may influence stress shielding. The purpose of the present study is to compare bone mineral density of 2 cemented and press-fit TKA designs with differing tibial baseplate thicknesses and metallurgy over a 2-year period to assess for changes in stress shielding. METHODS: One-hundred one TKAs were performed in this Institutional Review Board-approved, prospective study. There were 4 cohorts: DePuy Attune cemented and press-fit, and Stryker Triathlon cemented and press-fit. The Attune tibial baseplate was thicker; both cemented tibial and femoral components were cobalt-chromium. The DePuy Attune press-fit had a cobalt-chromium sintered bead porous coating while the Stryker Triathlon was 3-dimensional printed highly porous titanium alloy. All patients had quantitative dual-energy X-ray absorptiometry scans performed at baseline (4-6 weeks postoperatively) and at 1 and 2 years postoperatively. Stress shielding was evaluated by comparing percent change in bone mineral density in 11 radiographic zones over 2 years. RESULTS: Over a 2-year period, there were no differences in stress shielding on the tibial side in either cemented or press-fit between Stryker Triathlon and DePuy Attune; however, there were differences on the femoral side. The press-fit tibial components of the Stryker Triathlon and DePuy Attune had either similar or less stress shielding over a 2-year period compared to their cemented counterparts. CONCLUSION: This study comparing 2 TKA implants with differing tibial tray thickness did not find significant differences in tibial stress shielding between designs. There was a difference in stress shielding on the femoral side between designs, suggesting that longer term follow-up is warranted.

Neuraxial anaesthesia is associated with improved outcomes and reduced postoperative complications in patients undergoing aseptic revision total hip arthroplasty.

BACKGROUND: As the incidence of primary total hip arthroplasty (THA) continues to increase, revision THA (rTHA) is becoming an increasingly common procedure. rTHA is widely regarded as a more challenging procedure, with higher complication rates and increased medical, social and economic burdens when compared to its primary counterpart. Given the complexity of rTHA and the projected increase in incidence of these procedures, patient optimisation is becoming of interest to improve outcomes. Anaesthetic choice has been extensively studied in primary THA as a modifiable risk factor for postoperative outcomes, showing favourable results for neuraxial anaesthesia compared to general anaesthesia. The impact of anaesthetic choice in rTHA has not been studied previously. METHODS: A retrospective study was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent rTHA between 2014 and 2017 were divided into 3 anaesthesia cohorts: general anaesthesia, neuraxial anaesthesia, and combined general-regional (neuraxial and/or peripheral nerve block) anaesthesia. Univariate and multivariate analyses were used to analyse patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post-hoc analysis. RESULTS: In total, 5759 patients were identified. Of these, 3551 (61.7%) patients underwent general anaesthesia, 1513 (26.3%) patients underwent neuraxial anaesthesia, and 695 (12.1%) patients underwent combined general-regional anaesthesia. On multivariate analysis, neuraxial anaesthesia was associated with decreased odds for any-one complication (OR 0.635; p < 0.001), perioperative blood transfusion (OR 0.641; p < 0.001), and extended length of stay (OR 0.005; p = 0.005) compared to general anaesthesia. CONCLUSIONS: Relative to those receiving general anaesthesia, patients undergoing neuraxial anaesthesia are at decreased risk for postoperative complications, perioperative blood transfusions, and extended length of stay. Prospective controlled trials should be conducted to verify these findings.

Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty.

Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.

Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles.

AIMS: Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. METHODS: A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. RESULTS: A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. CONCLUSION: Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.

Clinical impact of component placement in manually instrumented total knee arthroplasty : a systematic review.

AIMS: The goal of the current systematic review was to assess the impact of implant placement accuracy on outcomes following total knee arthroplasty (TKA). METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Ovid Medline, Embase, Cochrane Central, and Web of Science databases in order to assess the impact of the patient-reported outcomes measures (PROMs) and implant placement accuracy on outcomes following TKA. Studies assessing the impact of implant alignment, rotation, size, overhang, or condylar offset were included. Study quality was assessed, evidence was graded (one-star: no evidence, two-star: limited evidence, three-star: moderate evidence, four-star: strong evidence), and recommendations were made based on the available evidence. RESULTS: A total of 49 studies were identified for inclusion. With respect to PROMs, there was two-star evidence in support of mechanical axis alignment (MAA), femorotibial angle (FTA), femoral coronal angle (FCA), tibial coronal angle (TCA), femoral sagittal angle (FSA), femoral rotation, tibial and combined rotation/mismatch, and implant size/overhang or offset on PROMs, and one-star evidence in support of tibial sagittal angle (TSA), impacting PROMs. With respect to survival, there was three- to four-star evidence in support FTA, FCA, TCA, and TSA, moderate evidence in support of femoral rotation, tibial and combined rotation/mismatch, and limited evidence in support of MAA, FSA, and implant size/overhang or offset impacting survival. CONCLUSION: Overall, there is limited evidence to suggest that PROMs are impacted by the accuracy of implant placement, and malalignment does not appear to be a significant driver of the observed high rates of patient dissatisfaction following TKA. However, FTA, FCA, TCA, TSA, and implant rotation demonstrate a moderate-strong relationship with implant survival. Efforts should be made to improve the accuracy of these parameters in order to improve TKA survival. Cite this article: Bone Joint J 2021;103-B(9):1449-1456.

Telemedicine for patients undergoing arthroplasty : access, ability, and preference.

AIMS: The purpose of this study was to determine the access to and ability to use telemedicine technology in adult patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), and to determine associations with the socioeconomic characteristics of the patients, including age, sex, race, and education. We also sought to understand the patients' perceived benefits, risks, and preferences when dealing with telemedicine. METHODS: We performed a cross-sectional survey involving patients awaiting primary THA and TKA by one of six surgeons at a single academic institution. Patients were included and called for a telephone-administered survey if their surgery was scheduled to be between 23 March and 2 June 2020, and were aged > 18 years. RESULTS: The response rate was 52% (189 of 363 patients). A total of 170 patients (90.4%) reported using the internet, 177 (94.1%) reported owning a device capable of videoconferencing, and 143 (76.1%) had participated in a video call in the past year. When asked for their preferred method for a consultation, 155 (82.8%) and 26 (13.9%) ranked in-person and a videoconference as their first choice, respectively. The perceived benefits of telemedicine consultations included reduced travel to appointments (165 (88.2%) agreed) and reduced cost of attending appointments (123 (65.8%) agreed). However, patients were concerned that they would not establish the same patient-physician connection (100 (53.8%) agreed), and would not receive the same level of care (52 (33.2%) agreed) using telemedicine consultations compared with in-person consultations. CONCLUSION: Most patients undergoing arthroplasty have access to and are capable of using the technology required for telemedicine consultations. However, they still prefer in-person consultations due to concerns that they will not establish the same patient-physician connection and will not receive the same level of care, despite the benefits of reducing the time spent in travelling and the cost of attending appointments, and the appointments being easier to attend. Cite this article: Bone Joint J 2021;103-B(7 Supple B):98-102.

Modular dual mobility total hip arthroplasty is a viable option for young, active patients : a mid-term follow-up study.

AIMS: Dual mobility (DM) implants have been shown to reduce the dislocation rate after total hip arthroplasty (THA), but there remain concerns about the use of cobalt chrome liners inserted into titanium shells. The aim of this study was to assess the clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) at mid-term follow-up in young, active patients receiving a modular DM THA. METHODS: This was a prospective study involving patients aged < 65 years, with a BMI of < 35 kg/m2, and University of California, Los Angeles activity score of > 6 who underwent primary THA with a modular cobalt chrome acetabular liner, highly cross-linked polyethylene mobile bearing, and a cementless titanium femoral stem. Patient-reported outcome measures, whole blood metal ion levels (µg/l), and periprosthetic femoral BMD were measured at baseline and at one, two, and five years postoperatively. The results two years postoperatively for this cohort have been previously reported. RESULTS: A total of 43 patients were enrolled. At minimum follow-up of five years, 23 (53.4%) returned for clinical and radiological review, 25 (58.1%) had metal ion analysis performed, 19 (44.2%) underwent dual energy x-ray absorptiometry scans, and 25 (58%) completed a pain-drawing questionnaire. The mean modified Harris Hip Scores improved significantly from 54.8 (SD 19) preoperatively to 93.08 (SD 10.5) five years postoperatively (p < 0.001). One patient was revised for aseptic acetabular loosening. The mean cobalt levels increased from 0.065 µg/l (SD 0.03) to 0.08 (SD 0.05) and the mean titanium levels increased from 0.35 (SD 0.13) to 0.78 (SD 0.29). The femoral BMD ratio decreased in Gruen Zone 1 (91.9%) at five years postoperatively compared with the baseline scores at six weeks potoperatively. The femoral BMD ratio was maintained in Gruen zones 2 to 7. CONCLUSION: The use of a modular DM component and a cementless, tapered femoral stem shows excellent mid-term survivorship with minimal concerns for corrosion and metal ion release in a cohort of young, active patients undergoing primary THA. Cite this article: Bone Joint J 2021;103-B(7 Supple B):73-77.