High Rate of Concomitant Lumbo-Sacral Spine Pathology in the Setting of Hip Abductor Tendon Repair.

BACKGROUND: Hip abductor deficiency is a common cause of lateral hip pain in middle-aged patients. Identifying upstream muscle denervation originating in the lumbo-sacral spine could potentially impact the management of patients who have abductor deficiency. The purpose of this study was to estimate the prevalence of lumbo-sacral pathology (L4 to S1) in patients undergoing hip abductor tendon repair. METHODS: All cases of primary hip abductor repair performed at a tertiary care center between January 2010 and December 2021 were reviewed. Patients were classified into the following groups: A) confirmed L4 to S1 disease based on preoperative or perioperative L4 to S1 interventions (ie, surgery, epidural injections, and/or positive electromyography findings); B) radiographic evidence on lumbar spine magnetic resonance imaging demonstrating nerve compression at L4 to S1; and C) no evidence of L4 to S1 disease. RESULTS: There were 131 cases of primary hip abductor repair that were included. Over 80% of patients were women, who had a mean age of 64 years (range, 20 to 85). There were thirteen patients (9.9%) who underwent concomitant total hip arthroplasty (THA). Of the included patients, 29% (n = 38) were categorized into group A, 12% (n = 16) into group B, and 59% (n = 77) into group C. Patients who had L4 to S1 pathology were older than patients who did not have L4 to S1 pathology (67 versus 61 years, P = .004). Of the patients undergoing concomitant THA and hip abductor repair, 54% demonstrated evidence of lumbo-sacral spine pathology. CONCLUSIONS: Over 40% of patients undergoing isolated hip abductor tendon repair and >50% of patients undergoing concomitant hip abductor tendon repair and THA demonstrated evidence of L4 to S1 disease perioperatively. Patients demonstrating symptomatic hip abductor deficiency should be screened for concomitant lower lumbo-sacral spine pathology.

Short Term Outcomes (Average Follow-Up of 2.4 Years) of a Constrained Acetabular Liner in Primary and Revision Total Hip Arthroplasty.

BACKGROUND: As instability continues to be a burden post-total hip arthroplasty (THA), there has been a controversial discussion on the ideal implant choice. We report the outcomes of a modern constrained acetabular liner (CAL) system in primary and revision THA at an average follow-up of 2.4 years. METHODS: We performed a retrospective study of all patients undergoing primary and revision hip arthroplasty and being implanted with the modern CAL system from 2013 to 2021. We identified 31 hips, of which 13 underwent primary THA and the remaining 18 underwent revision THA for instability. RESULTS: Of those implanted with CAL primarily, 3 had concomitant abductor tear repair and gluteus maximus transfer, 5 had Parkinson's disease, 2 had inclusion body myositis, 1 had amyotrophic lateral sclerosis, and the remaining two were over 94 years of age. All patients implanted with the CAL had active instability post-primary THA and underwent only liner and head exchange without revision of the acetabular or femoral components. At an average follow-up of 2.4 years (ranging from 9 months to 5 years and 4 months), we had 1 case (3.2%) of dislocation post-CAL implantation. None of the patients undergoing surgery with CAL for active instability had a redislocation. CONCLUSION: In conclusion, a CAL provides excellent stability in both primary THA in high-risk individuals and revision THA in cases of active instability. There were no dislocations when using a CAL to treat active instability post-THA.

Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial.

BACKGROUND: Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS: This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS: Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS: Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

Muscle recovery after total hip arthroplasty: prospective MRI comparison of anterior and posterior approaches.

INTRODUCTION: The direct anterior approach (DAA) and the posterior approach (PA) are 2 common total hip arthroplasty (THA) exposures. This prospective study quantitatively compared changes in periarticular muscle volume after DAA and PA THA. MATERIALS: 19 patients undergoing THA were recruited prospectively from the practices of 3 fellowship-trained hip surgeons. Each surgeon performed a single approach, DAA or PA. Enrolled patients underwent a preoperative MRI of the affected hip and two subsequent postoperative MRIs at around 6 weeks and 6 months after surgery. Clinical evaluations were done by Harris Hip Score at each follow-up interval. RESULTS: MRIs or 10 DAA and 9 PA patients were analysed. Groups did not differ significantly with regard to BMI, age, or preoperative muscle volume. 1 DAA patient suffered a periprosthetic fracture and was excluded from the study. DAA hips showed significant atrophy in the obturator internus (-37.3%) muscle at early follow-up, with persistent atrophy of this muscle at the final follow-up. PA hips showed significant atrophy in the obturator internus (-46.8%) and externus (-16.0%), piriformis (-8.12%), and quadratus femoris muscles (-13.1%) at early follow-up, with persistent atrophy of these muscles at final follow-up. Loss of anterior capsular integrity was present at final follow-up in 2/10 DAA hips while loss of posterior capsular integrity was present in 5/9 PA hips. There was no difference in clinical outcomes. DISCUSSION: This study demonstrates that DAA showed less persistent muscular atrophy than PA. Regardless of surgical approach, a muscle whose tendon is detached from its insertion is likely to demonstrate persistent atrophy 6 months following THA. Although the study was not powered to compare clinical outcomes, it should be noted that no significant difference in patient outcomes was observed.

The Future is Non-cemented Total Knee Arthroplasty: Volume Trends at the Hospital for Special Surgery.

INTRODUCTION: The optimal fixation method for total knee arthroplasty (TKA) is still a debate. Cemented fixation has excellent long-term results and is the gold standard. However, longevity in the younger, heavier, and more active population is suboptimal. Cementless TKA offers the opportunity to gain biological fixation and overcome these shortcomings. METHODS: This is a retrospective review of all consecutive cementless TKA procedures performed at a single academic institution from 2016 until 2020. Demographics, aseptic revisions, and septic revisions were pulled from the electronic medical record. The number of yearly implanted cementless TKA prosthesis was determined to analyze utilization trends. RESULTS: Eight-hundred and two patients were identified with a mean age of 61.57 ± 7.78 years, and a mean of BMI 32.12 ± 5.98 kg/m2. The mean time to revision was 12.31 ± 13.91 months. There were four septic failures and nine aseptic failures during the study period. Of these nine aseptic failures only five were due to mechanical loosening. There was a yearly linear increase in the use of cementless fixation. CONCLUSION: Cementless fixation is here to stay, and its use will continue to increase. Early and mid-term outcomes have been excellent thus far. Changing clinical practice takes time but we have already seen this transition take place in total hip arthroplasty. As technology and design continue to evolve, we believe it is a possibility.

Improved Sexual Function After Total Hip and Knee Arthroplasty for Osteoarthritis.

Osteoarthritis of the hip and knee is known to affect sexual activity. For patients with osteoarthritis, pain during sexual activity can lead to decreased quality of life and other associated health issues. The authors designed a prospective study to evaluate the effect of total hip arthroplasty and total knee arthroplasty on the psychosocial and physical aspects of sexuality pre- and postoperatively. Between April 2009 and December 2011, patients received questionnaires in the mail preoperatively. They were asked to return the preoperative questionnaire before surgery and the postoperative questionnaire 6 months after surgery. Data were analyzed to evaluate the psychosocial and physical aspects of sexuality and participants' subjective assessment of their appearance. Preoperatively, 91% and 67% of patients reported psychosocial and physical issues, respectively. After the arthroplasty procedure, 84% (P<.001) and 47% (P<.001) of patients reported improvement psychosocially and physically, respectively. Of the patients, 16% reported that arthroplasty adversely affected sexual function, with their predominant fear being joint damage (63%). A greater number of women and patients undergoing hip procedures reported improvement in sexual activity after surgery compared with men (P=.02) and patients undergoing knee procedures (P=.002). Both hip and knee osteoarthritis and arthroplasty had a significant effect on overall sexual function-psychosocially, physically, and in terms of patients' assessment of their external appearance-with higher rates of improvement seen after hip arthroplasty. Because of the effect of osteoarthritis and arthroplasty on sexual function, this topic should be addressed both pre- and postoperatively. [Orthopedics. 2021;44(2):111-116.].

Biomechanical Assessment of a Novel Posterior Soft Tissue Repair Technique in Primary Total Hip Arthroplasty.

INTRODUCTION: Instability is one of the most common complications after total hip arthroplasty (THA), particularly when using the posterior approach. Repair of the posterior capsule has proven to significantly decrease the incidence of posterior hip dislocation. The purpose of the present study is to evaluate if a racking hitch knot utilizing a 2mm braided polyblend suture provides a stronger repair of the posterior soft tissues when compared to a traditional repair utilizing a non-absorbable suture after a posterior approach to the hip. MATERIALS AND METHODS: Ten cadaveric hips from donors, who were at a mean age of 80 ± 9 years old at the time of death, were evaluated after posterior soft tissue repair utilizing two different techniques. Five specimens were repaired utilizing a racking hitch knot with a 2mm braided polyblend suture (FiberTape®, Arthrex GmbH, Naples, Florida) and five other specimens were repaired with a traditional repair using a no. 2 non-absorable suture (FiberWire®, Arthrex GmbH, Naples, Florida). Cadaveric specimens were matched based upon age, sex, and laterality. Biomechanical tensile testing using the Instron E10000 Mechanical Testing System and the mechanisms of failure (MOF) were assessed. RESULTS: The ultimate load to failure was three times higher using braided polyblend sutures (390.00 ± 129.08 N) compared to non-absorbable sutures (122.81 ± 82.41 N) after posterior soft tissue repair (p<0.01). In the braided polyblend suture cohort, the mechanism of failure most commonly occurred as the braided suture pulled through the posterior soft tissues. However, in the non-absorbable suture repair, failure took place at the suture knot. CONCLUSION: The use of our posterior capsular repair utilizing a braided polyblend suture and racking hitch knot provides for a stronger repair of the posterior soft tissues when compared to non-absorbable suture repair following a posterior approach to the hip joint.

Clinical Outcomes of a Modern Total Knee Arthroplasty Prosthesis Compared to Its Predecessor at 5-Year Follow-Up: Matched Pair Analysis.

BACKGROUND: Residual pain is an important cause of patient dissatisfaction after total knee arthroplasty (TKA). A recent study at our institution found that a modern prosthesis was associated with less residual and anterior knee pain at 2-year follow-up when compared to its predecessor. The aim of this study is to evaluate these implants at 5-year follow-up. METHODS: From July 2012 to December 2013, 100 consecutive modern TKAs were identified from our prospective Institutional Review Board approved database. All patients with 5-year clinical follow-up (n = 77) were matched in a one-to-one fashion based on age, gender, body mass index, and follow-up with a predecessor TKA. Clinical outcomes were assessed with a patient-administered questionnaire for specifically anterior knee pain, painless noise, painful crepitation, and satisfaction. Overall function was assessed using Knee Society Scores and Western Ontario and McMaster University Osteoarthritis Index. RESULTS: At 5-year follow-up, there were no significant differences between the modern TKA and a predecessor TKA in the Knee Society pain or function scores (P = .24 and P = .54, respectively). The overall prevalence of residual pain was less with the modern TKA compared to its predecessor (19.5% vs 36.3%; P = .02), but the prevalence of isolated anterior knee pain was similar in both cohorts (11.7% vs 22.1%; P = .09). There was no difference in painless noise (19.5% vs 13.3%; P = .28) or satisfaction scores (7.9 ± 2.4 vs 7.6 ± 2.6; P = .25) between the modern and predecessor cohorts. CONCLUSION: At 5-year follow-up, we found that both the modern and predecessor prostheses provided excellent clinical outcomes. The modern TKA was associated with less residual pain compared to its predecessor, but we were unable to detect differences in the prevalence of isolated anterior knee pain, painless noise, Knee Society Scores, or radiographic evaluation.

Early failure of a modern moderately cross-linked polyethylene acetabular liner.

Modern polyethylene components for total hip arthroplasty have shown excellent long-term wear properties. However, among 204 primary total hip arthroplasty procedures performed by one surgeon using the Exactech Connexion GXL Liner, we identified 5 cases of severe polyethylene wear and osteolysis which occurred within 5 years of the index surgery. Among the 5 cases, all patients had a size 36 head with an acetabular component from size 52 to 56 mm. All patients had a UCLA activity scale score of at least 6 at the time that the osteolysis was detected. The average wear rate was 0.265 mm ± 0.207 mm per year. This review of 5 cases of catastrophic early polyethylene wear demonstrates a concerning trend with the use of the Exactech Connexion GXL liner. Further investigation is warranted to evaluate material characteristics which may have caused this accelerated wear and to prevent recurrences of this complication in the future.

Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty.

¼ Operative intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (THA). ¼ Direct repair of the abductor mechanism onto the greater trochanter can be used in patients who present with instability <15 months following primary THA. ¼ Augmentation of soft tissue with acellular dermal allografts can be considered for patients with abductor avulsion that requires posterior capsular reconstruction. ¼ The Achilles tendon + calcaneal bone allograft is indicated for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and have tissue inadequacy in the posterior wall of the hip joint. ¼ The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus. ¼ Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks. ¼ The latissimus dorsi tendon transfer should be reserved as a reconstructive procedure for patients with acute abductor insufficiency, such as those who have undergone extensive tumor resection. ¼ Synthetic mesh can be used to enable capsular reconstruction and prosthesis stabilization in patients undergoing salvage procedures for tumors of the hip and associated soft tissues. ¼ Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components. ¼ The fascia lata plasty is indicated for patients with recurrent posterior instability without an identifiable cause. ¼ Although the quality of literature is limited, surgical interventions utilizing techniques of soft-tissue augmentation have shown promising outcomes with regard to pain relief, limping, ambulation, and the reduction of instability following THA.

Soft-Tissue Balancing Technology for Total Knee Arthroplasty.

¼ Improperly balanced total knee arthroplasties are at increased risk for complications including residual pain and/or instability, which are often corrected by a revision surgical procedure. ¼ Because of the morbidity and financial burden associated with revision total knee arthroplasty, different technological applications, such as tibial insert sensors and computer-assisted gap balancing, are being used to assist with soft-tissue balancing during primary total knee arthroplasty. ¼ Computer-assisted gap balancing increases the accuracy of mechanical alignment and improves the precision of balancing flexion and extension gaps during total knee arthroplasty. It is unclear whether this translates to improved short-term or long-term outcome measures. Considerations of this technology include increased cost, increased operative time, and a steep learning curve. ¼ Intraoperative sensors increase the accuracy of balancing by quantifying the mediolateral intercompartmental load distribution through the range of motion, which may lead to improved outcome scores, patient satisfaction, higher activity levels, and decreased pain. The advantages of this technology compared with computer assistance include decreased cost and no disruption of operative time or workflow. Limited availability with constrained implants, limited implant choices, and a lack of long-term follow-up data have reduced utilization of intraoperative sensors. ¼ Computer-assisted gap balancing and intraoperative sensors are not yet universally accepted, and the cost-benefit ratio associated with their use remains a consideration in today's cost-conscious health-care environment. Future research should focus on longer-term follow-up to evaluate implant survivorship, cost-effectiveness, and clinical outcomes.

Increased utilization of constraint in total knee arthroplasty following anterior cruciate ligament and multiligament knee reconstruction.

AIMS: Anterior cruciate ligament (ACL) and multiligament knee (MLK) injuries increase the risk of development of knee osteoarthritis and eventual need for total knee arthroplasty (TKA). There are limited data regarding implant use and outcomes in these patients. The aim of this study was to compare the use of constrained implants and outcomes among patients undergoing TKA with a history of prior knee ligament reconstruction (PKLR) versus a matched cohort of patients undergoing TKA with no history of PKLR. PATIENTS AND METHODS: Patients with a history of ACL or MLK reconstruction who underwent TKA between 2007 and 2017 were identified in a single-institution registry. There were 223 patients who met inclusion criteria (188 ACL reconstruction patients, 35 MLK reconstruction patients). A matched cohort, also of 223 patients, was identified based on patient age, body mass index (BMI), sex, and year of surgery. There were 144 male patients and 79 female patients in both cohorts. Mean age at the time of TKA was 57.2 years (31 to 88). Mean BMI was 29.7 kg/m2 (19.5 to 55.7). RESULTS: There was a significantly higher use of constrained implants among patients with PKLR (76 of 223, 34.1%) compared with the control group (40 of 223, 17.9%; p < 0.001). Subgroup analysis showed a higher use of constrained implants among patients with prior MLK reconstruction (21 of 35, 60.0%) compared with ACL reconstruction (55 of 188, 29.3%; p < 0.001). Removal of hardware was performed in 69.5% of patients with PKLR. Mean operative time (p < 0.001) and tourniquet time (p < 0.001) were longer in patients with PKLR compared with controls. There were no significant differences in rates of deep vein thrombosis, pulmonary embolism, infection, transfusion, postoperative knee range of movement (ROM), or need for revision surgery. There was no significant difference in preoperative or postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores between groups. CONCLUSION: Results of this study suggest a history of PKLR results in increased use of constrained implants but no difference in postoperative knee ROM, patient-reported outcomes, or incidence of revision surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):77-83.

A comparison of clinical and patient-reported outcome measures of TKR: Comparison of Asian to North American patients.

BACKGROUND: Cultural differences between continents may also affect the outcome on interventions. This study compared an Asian and North American cohort of total knee replacement (TKR) patients. QUESTIONS/PURPOSES: This study aims to compare the patient-reported outcome measures as well as a functional outcome after TKR between these two different patient populations with a different cultural societal background in two different countries. PATIENTS AND METHODS: A retrospective study on two cohorts of 76 Asian TKR patients and 64 North American TKR patients were compared. Demographics, patient-reported outcome measures (Knee Society Score (KSS), Patient-Administered Questionnaire (PAQ), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), knee range of motion (RoM), and radiographic component position were compared. RESULTS: The Asian cohort had more females compared to the North American and significantly worse preoperative RoM, and worse KSS function score and PAQ pain scores. The preoperative KSS knee score and WOMAC scores were comparable between the two groups. Postoperatively, the differences in WOMAC and KSS knee scores were significant, while KSS function and PAQ were comparable between groups. CONCLUSIONS: Even though Asian TKR patients had significantly worse preoperative scores, their postoperative outcomes were comparable to North Americans. The higher preoperative functional deficit and the higher pain levels in the Asian population might be due to cultural differences and/or socioeconomic reasons, which made Asian patients present with more severe conditions in the preoperative consultation for a possible surgical treatment compared to North Americans. More research is needed to investigate the difference between these cultural impacts on TKR outcomes. LEVEL OF EVIDENCE: Level III/Retrospective cohort study.

Addition of Adductor Canal Block to Periarticular Injection for Total Knee Replacement: A Randomized Trial.

BACKGROUND: Periarticular injection is a popular method to control postoperative pain after total knee replacement. An adductor canal block is a sensory block that can also help to alleviate pain after total knee replacement. We hypothesized that the combination of adductor canal block and periarticular injection would allow patients to reach discharge criteria 0.5 day faster than with periarticular injection alone. METHODS: This prospective trial enrolled 56 patients to receive a periarticular injection and 55 patients to receive an adductor canal block and periarticular injection. Both groups received intraoperative neuraxial anesthesia and multiple different types of pharmaceutical analgesics. The primary outcome was time to reach discharge criteria. Secondary outcomes, collected on postoperative days 1 and 2, included numeric rating scale pain scores, the PAIN OUT questionnaire, opioid consumption, and opioid-related side effects. RESULTS: There was no difference in time to reach discharge criteria between the groups with and without an adductor canal block. The Wilcoxon-Mann-Whitney odds ratio was 0.87 (95% confidence interval [CI], 0.55 to 1.33; p = 0.518). The median time to achieve discharge criteria (and interquartile range) was 25.8 hours (23.4 hours, 44.3 hours) in the adductor canal block and periarticular injection group compared with 26.4 hours (22.9 hours, 46.2 hours) in the periarticular injection group. Patients who received an adductor canal block and periarticular injection reported lower worst pain (difference in means, -1.4 [99% CI, -2.7 to 0]; adjusted p = 0.041) and more pain relief (difference in means, 12% [99% CI, 0% to 24%]; adjusted p = 0.048) at 24 hours after anesthesia. There was no difference in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores). CONCLUSIONS: The time to meet the discharge criteria was not significantly different between the groups. In the adductor canal block and periarticular injection group, the patients had lower worst pain and greater pain relief at 24 hours after anesthesia. No difference was noted in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores). LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Role of Anatomical Patella Replacement on Anterior Knee Pain.

BACKGROUND: Anterior knee pain (AKP) remains a complex issue affecting patient satisfaction after total knee arthroplasty. Several radiographic parameters have been shown to be causative factors with various designs. The aim of this study is to evaluate the known radiographic parameters of AKP and clinical outcomes (ie, AKP) in the setting of a modern prosthesis with an anatomic patella button. METHODS: Between July 2012 and December 2013, 90 total knee arthroplasties received 3 skyline views taken at 30°, 45°, and 60°. A patient-administered questionnaire was administered at 2-year follow-up to assess the incidence of AKP, painless noise, and satisfaction. Radiographs were analyzed for patellofemoral overstuffing, patellar tilt, and patellar displacement, and evaluated the patella resection angle. RESULTS: On the patient-administered questionnaire, 10 (11.1%) patients reported AKP of a mild-to-moderate nature. Thirty-one had the best view at 30 Merchant views, 24 had best views at 45, and 35 had best views at 60. We found that patellar resection angle correlated with AKP (odds ratio 1.21, P = .044) and painless noise (odds ratio 1.22, P = .034). Patellar displacement and patellofemoral stuffing did not correlate with AKP or painless noise. No radiographic measurements correlated with changes in Knee Society Score pain or function scores or range of motion. CONCLUSION: We found that a patellar resection angle correlated with the incidence of AKP and painless noise at 2-year follow-up. We failed to find any correlation with patellofemoral overstuffing, patellar displacement, or patellar tilt with clinical outcomes. We recommend the use of 3 Merchant views to fully evaluate the patellofemoral joint.

Single- Versus Double-Row Repair of Hip Abductor Tears: A Biomechanical Matched Cadaver Study.

PURPOSE: The purposes of this study were (1) to evaluate the percentage of gluteus medius and minimus tendon footprint restoration that can be achieved with fixation using single-row repair versus double-row repair and (2) to evaluate the yield load of a repair of the gluteus medius and minimus tendon using single-row versus double-row repair techniques. METHODS: Twelve human fresh-frozen cadaveric hip specimens (6 matched pairs, 4 female, mean age 47.5 ± 14.5 years) were tested. Specimens were excluded if they had any prior hip surgery or injury, if any abnormality of the tendon was noted on dissection, or if they had a body mass index <20 or >35 or a T-score <2.0 on dual-energy x-ray absorptiometry scanning. Matched pairs were randomized to receive either double-row repair with 2 standard suture anchors and 2 knotless anchor devices or a single-row repair with suture anchors only. The percentage of the footprint area covered after repair was determined using a computer-assisted digitization algorithm. With a mechanical testing system, each repaired specimen was tested for mechanical strength first with cyclic loading and then load to failure testing. RESULTS: Footprint coverage of the lateral facet was significantly greater for double-row repair (mean 76.6%) compared with single-row repair (mean 50.3%) (P = .03). There was no significant difference between single- and double-row repair for posterior-superior or anterior facet coverage. Mechanical testing showed a higher mean yield load for double-row anchor repair (197.6 ± 61.7 N vs 163.5 ± 35.4 N for single-row repair), but this did not reach statistical significance (P = .15). The predominant mode of failure was suture pullout through the musculotendinous unit (9/12 specimens: 5 double-row and 4 single-row). CONCLUSIONS: For hip abductor tears, double-row suture repair yields improved footprint coverage compared with single-row repair. Although it did not reach statistical significance, there was a higher mean yield load in the double-row group. CLINICAL RELEVANCE: Double-row suture fixation technique for hip abductor tears maximizes strength and footprint coverage of the repair.

Addition of Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee and Adductor Canal Block to Periarticular Injection Enhances Postoperative Pain Control in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Periarticular injections (PAIs) are becoming a staple component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the posterior knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee arthroplasty, but supporting literature remains rare. We hypothesized that the addition of ACB and IPACK to PAI would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone. METHODS: This triple-blinded randomized controlled trial included 86 patients undergoing unilateral total knee arthroplasty. Patients either received (1) a PAI (control group, n = 43) or (2) an IPACK with an ACB and modified PAI (intervention group, n = 43). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption. RESULTS: The intervention group reported significantly lower NRS pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval], -3.3 [-4.0 to -2.7]; P < .001). In addition, NRS pain scores on ambulation on POD 0 (-3.5 [-4.3 to -2.7]; P < .001) and POD 2 (-1.0 [-1.9 to -0.1]; P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less opioid consumption (P = .005, postanesthesia care unit, P = .028, POD 0), less intravenous opioids (P < .001), and reduced need for intravenous patient-controlled analgesia (P = .037). CONCLUSIONS: The addition of IPACK and ACB to PAI significantly improves analgesia and reduces opioid consumption after total knee arthroplasty compared to PAI alone. This study strongly supports IPACK and ACB use within a multimodal analgesic pathway.

Patients Discharged to Inpatient Rehabilitation Facilities Undergo More Diagnostic Interventions With No Improvement in Outcomes.

The purpose of this study was to determine if there is a difference in the number of diagnostic tests and interventions, pain and function scores, or satisfaction of patients discharged to inpatient rehabilitation facilities vs to home. From February to May 2015, 171 consecutive patients were prospectively recruited following primary total knee arthroplasty. Six weeks postoperatively, based on the patients' recollections, the number and types of diagnostic imaging tests, number of blood transfusions, and overall satisfaction whether discharged to inpatient rehabilitation facilities (n=85) or to home (n=86) were assessed. A significantly greater proportion of patients discharged to inpatient rehabilitation facilities reported undergoing at least 1 diagnostic imaging test compared with patients discharged to home (25.9% vs 8.1%; P=.013). Multivariate logistic regressions revealed that patients discharged to an inpatient rehabilitation facility were more likely to have a greater number of diagnostic tests (odds ratio, 5.01; 95% confidence interval, 1.69-14.92; P=.004) and radiographs (odds ratio, 16.10; 95% confidence interval, 1.54-169.70; P=.020) performed. There was no significant difference in readmission rates for patients discharged to home (2.3%) vs to an inpatient rehabilitation facility (0%) (P=.246). No significant differences were observed in postoperative Knee Society pain or function scores (P=.083 and P=.057, respectively) or visual analog scale satisfaction scores (P=.206). Twenty-nine (34.1%) patients were discharged under the care of the visiting nurse service after leaving the rehabilitation facility. Patients discharged to an inpatient rehabilitation facility underwent more diagnostic testing, especially radiographs, than patients discharged to home. There were no clinically relevant differences in Knee Society pain or function scores or patient satisfaction. [Orthopedics. 2018; 41(6):e841-e847.].

Preoperative Physical Therapy Education Reduces Time to Meet Functional Milestones After Total Joint Arthroplasty.

BACKGROUND: As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty. QUESTIONS/PURPOSES: Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery? METHODS: Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively). RESULTS: The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups. CONCLUSIONS: Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS. LEVEL OF EVIDENCE: Level II, therapeutic study.