Excellent 10-Year survivorship of robotic-arm-assisted unicompartmental knee arthroplasty.

Introduction: Robotic-arm-assisted unicompartmental knee arthroplasty (UKA) is an excellent solution for patients suffering from single-compartment knee arthritis. While outcomes tend to be favorable for UKAs, revision operations, commonly due to component malpositioning and malalignment resulting in accelerated wear, are a major concern. Intraoperative technologies, such as robotic assistance, can help better ensure that implants are positioned based on a patient's specific anatomy and mechanical physiology. However, long-term survivorship and patient-reported satisfaction with robotic-assisted UKAs are limited. Therefore, the purpose of this study was to assess the 10-year outcomes of patients who underwent robotic-arm-assisted unicompartmental knee arthroplasty. Specifically, we evaluated: 1) 10-year survivorships; 2) patient satisfaction scores; and 3) re-operations. Methods: From a single surgeon and single institution, 185 patients who had a mean age of 65 years (range, 39 to 92) and a mean body mass index of 31.6 (range, 22.4 to 39) at a mean of 10 years follow-up were evaluated (range, 9 to 11). For all patients, the same robotic-assistive device was utilized intraoperatively, and all patients underwent standardized physical therapy and received standardized pain control management. Then 10-year survivorships with Kaplan-Meir curves, patient satisfaction evaluations with a 5-point Likert scale, and re-operations were assessed as primary outcomes. Results: Overall implant survivorship was 99%, with only two patients requiring revision surgery. There was one patient who was converted to a total knee arthroplasty, while the other patient underwent polyethylene exchange at 5 weeks for an acute infection with successful implant retention. Overall, 97% of the patients were satisfied with their postoperative outcomes, with 81% of patients reporting being very satisfied. There were two other patients who required arthroscopic intervention: one to remove a cement loose body, the other to remove adhered scar from the fat pad and the anterior cruciate ligament. Conclusion: This study is one of the first to provide longer-term (mean 10-year) survivorship and patient-reported satisfaction outcomes for robotic-assisted UKA patients. These data show strong support for utilizing this surgical technique, as nearly all patients maintained their original prostheses and reported being satisfied after a mean of 10 years. Therefore, based on these results, we recommend the use of robotic assistance when performing UKAs.

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.

Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection.

This review discusses the correction of coronal deformity and intercompartmental imbalance through bone resection in total knee arthroplasty (TKA). To achieve functional knee balance, coronal, rotational, and sagittal alignment are critical to successful patient outcomes. Though variations in coronal alignment are debated as a correlate to positive results, advancements in utilizing implant position, alignment, and soft tissue balance to improve patient outcomes and function are an evolving discussion. This study draws upon existing literature, clinical studies, and surgical techniques related to TKA, including advancements in navigation and robotics. The study highlights the importance of individualized alignment strategies for varus and valgus knees. While mechanical neutral alignment has shown excellent long-term data, reevaluating the anatomic recreation of the patient's joint line obliquity is now being studied extensively. Sensor data and navigation systems contribute to improved outcomes and patient satisfaction. The evolution of navigation and robotics has led surgeons to achieve their target angles consistently and accurately; now, the discussion is around the most effective alignment targets. The classification of various phenotypes assists in the proposed starting points for implant position, but soft tissue tension is required in the input data to achieve global balance and stable motion. Each approach's advantages and limitations are considered. In conclusion, achieving optimal coronal alignment, joint line obliquity, and soft tissue balance is crucial for successful TKA outcomes. Personalized alignment philosophies, supported by three-dimensional data and sensor technology, are evolving to minimize critical errors and enhance functional results. Robotic assistance and future advancements in artificial intelligence and machine learning hold promise for further improving TKA outcomes in the quest for soft tissue stabilization.

Robotic-Arm Assisted Lateral Unicompartmental Knee Arthroplasty: Case Series with Minimum Five-Year Follow-Up.

INTRODUCTION: Lateral unicompartmental knee arthroplasty has been shown to be a successful treatment modality for isolated lateral osteoarthritis (OA) of the knee. The reproduction of proper knee kinematics, limb alignment, as well as proper soft tissue balancing and component positioning have been shown to be of the utmost importance for a successful unicompartmental knee arthroplasty (UKA). Robotic assistance has shown to be a reliable tool in order to replicate these factors, as compared to manual instrumentation alone. Recent studies have shown the potential of robotic-assisted surgery in controlling these surgical factors for medial UKA; however, studies assessing outcomes of robotic-assisted lateral UKA (RAUKA) are lacking. Therefore, a retrospective single-center study was performed to assess outcomes of lateral RAUKA. MATERIALS AND METHODS: Patients who underwent lateral RAUKA from a single surgeon at a central institution between January 2008 and June 2017 were identified. All patients received a lateral UKA with a fixed-bearing metal backed onlay tibial component. Patients over the age of 18, with at least a five-year follow-up and a lateral UKA were contacted by phone and asked a series of questions to determine satisfaction and survivorship. Each patient was asked in a "yes" or "no" manner, if they have had their implant revised or reoperated for any reason, and a 5-point Likert scale was used to assess satisfaction. RESULTS: Data was collected from 50 patients (53 knees). Of the patients that responded: 32 (60%) were right knees; 32 (60%) were female, and average follow-up was 7.6 years (5-14 years). Of the 53 knees, one had a revision (98% survivorship). Excluding the revision, 51 (98%) of the included cases were either "very satisfied" or "satisfied" with their surgery. DISCUSSION/CONCLUSIONS: Robotic-arm assisted lateral UKA was found to have high survivorship and a satisfaction rate in patients that had at least a five-year follow-up. In the future, larger prospective comparison studies with longer follow-ups are necessary to adequately compare survivorship and satisfaction rates of robotic-assisted lateral UKA to conventional UKA.

Mid-Term Survivorship, Radiographic and Functional Outcomes of Robotic-Assisted Unicompartmental Knee Arthroplasty.

INTRODUCTION: The use of robotic-arm assistance for medial unicompartmental knee arthroplasty (RAUKA) has become an area of interest to overcome technical challenges, improve accuracy, and optimize patient outcomes. Due to the rise in osteoarthritis (OA) and robotic assistance, well-powered long-term studies are warranted. The aim of this study was to analyze midterm survivorship, radiographic changes, range of motion (ROM), and patient-reported outcome measurements (PROMs) of RAUKA. MATERIALS AND METHODS: Patients who underwent RAUKA for medial compartmental OA were identified from April 2009 to May 2014. The query yielded 162 knees with a mean follow up of 6.5 years. Primary endpoints were to compare survivorship, final mechanical axis alignment, radiographic changes, mean ROM, and changes to the following PROMs: Knee Society Score (KSS), International Knee Documentation Committee (IKDC), and Oxford Knee Score (OKS). Statistical analyses were primarily descriptive. A p-value less than 0.05 was considered statistically significant. RESULTS: There were no revisions of the primary implant, one case required exchange of polyethylene bearing and debridement for deep infection, and five cases required additional surgical intervention with implant retention. Overall survivorship was 100%. Radiographic assessment demonstrated no mechanical loosening or osteolysis surrounding the implant. Mean ROM was 3 to 121.9º. Patients demonstrated a mean functional KSS of 78.55, IKDC of 78.22, and OKS of 43.94. CONCLUSIONS: The study supports excellent mid-term outcomes in patients undergoing RAUKA for medial compartment OA. Longer term follow-up studies are necessary to determine the efficacy of this technology for patients undergoing RAUKA for medial compartment OA.

Accuracy of Intraoperative Mechanical Axis Alignment to Long-Leg Radiographs following Robotic-Arm-Assisted Unicompartmental Knee Arthroplasty.

Improper alignment and implant positioning following unicompartmental knee arthroplasty (UKA) has been shown to lead to postoperative pain and increase the incidence of revision procedures. The use of robotic-arm assistance for UKA (RAUKA) has become an area of interest to help overcome these challenges. The accuracy of intraoperative alignment compared with standing long-leg X-rays postoperatively following medial RAUKA has been in question. Therefore, the purpose of this study was to (1) determine final mean intraoperative coronal alignment in extension utilizing an image based intraoperative navigation system, and (2) compare final intraoperative alignment to 6-week weight-bearing (WB) long-leg X-rays. Patients who underwent RAUKA for medial compartmental osteoarthritis were identified from January 1, 2018, to August 31, 2019, through our institution's joint registry. The query yielded 136 (72 right and 64 left) patients with a mean age of 72.02 years and mean body mass index (BMI) of 28.65 kg/m2 who underwent RAUKA. Final intraoperative alignment was compared with WB long leg X-rays 6 weeks postoperatively by measuring the mechanical alignment. Statistical analysis was primarily descriptive. Pearson's correlation coefficient was used to determine the relationship between intraoperative alignment to 6-week alignment. A p-value of <0.05 was considered statistically significant. Mean intraoperative coronal alignment after resections and trialing was 4.39 varus ± 2.40 degrees for the right knee, and 4.81 varus ± 2.29 degrees for the left knee. WB long-leg X-rays 6 weeks postoperatively demonstrated mechanical axis alignment for the right and left knees to be 3.01 varus ± 2.10 and 3.7 varus ± 2.38 degrees, respectively. This resulted in a change in alignment of 1.36 ± 1.76 and 1.12 ± 1.84 degrees for the right and left knees, respectively (p < 0.05). Pearson's correlation coefficient demonstrated a correlation of 0.69 between intraoperative to long-leg-X-ray alignment. RAUKA demonstrates excellent consistency when comparing postoperative WB long-leg X-rays to final intraoperative image-based non-WB alignment.

Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study.

AIMS: The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. METHODS: This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants. RESULTS: There were significant improvements in PROMs over time between preoperative, one- to two-year, and > two-year follow-up, with a mean FJS of 17.5 (SD 18.2), 70.2 (SD 27.8), and 76.7 (SD 25.8; p < 0.001); mean KOOS JR of 51.6 (SD 11.5), 85.1 (SD 13.8), and 87.9 (SD 13.0; p < 0.001); and mean pain scores of 65.7 (SD 20.4), 13.0 (SD 19.1), and 11.3 (SD 19.9; p < 0.001), respectively. There were eight superficial infections (0.9%) and four revisions (0.5%). CONCLUSION: RA-TKA demonstrated consistent clinical results across multiple institutions with excellent PROMs that continued to improve over time. With the ability to achieve target alignment in the coronal, axial, and sagittal planes and provide intraoperative real-time data to obtain balanced gaps, RA-TKA demonstrated excellent clinical outcomes and PROMs in this patient population.Cite this article: Bone Jt Open 2022;3(7):589-595.

Sensor-guided Knee Surgery Provides Improved Patient Outcomes and Cost Savings in a 90-day Bundle.

In an era when the costs of surgical care are becoming increasingly scrutinized, the introduction of new technologies that may improve clinical outcomes can be limited due to economic constraints. Thus, bundled care payment models have emerged to reduce costs, improve outcomes and increase overall value. Since a bundle is a single reimbursement per episode of care that includes the surgical costs, as well as postoperative care and rehabilitation, cost savings are generally achieved through a reduction of services, complications and/or materials used. The present study demonstrates significant cost savings with a 90-day bundle for sensor-assisted total knee arthroplasty (TKA).

How wait-times, social media, and surgeon demographics influence online reviews on leading review websites for joint replacement surgeons.

OBJECTIVE: With the growth and popularity of the internet, physician review websites are being utilized more frequently by patients to learn about and ultimately select their provider. These sites allow patients to comment on the care they received in a public forum for others to see. With outcome and "quality" measures being used to dictate reimbursement formulas; online patient reviews may affect a physician's compensation in the near future. Therefore, it is of paramount importance for physicians to understand how best to portray themselves on social media and other internet sites. METHODS: In this retrospective study, we identified 145 arthroplasty surgeons via the AAHKS database. Then, surgeon data was collected from Healthgrades (HG) and Vitals (V). We identified if the surgeon had social media (SM) accounts by using google search. The number of ratings and comments, overall rating, reported wait-times and physician SM presence were analyzed with univariate, bivariate and multivariate analyses. RESULTS: 64% of surgeons had a SM presence, and younger surgeons with SM had lower distribution of wait-times. A SM presence correlated with significantly higher frequency of total ratings and comments. Both review sites showed that younger physicians with a SM presence had increased frequency of ratings and comments and a quicker office wait-times. SM presence did not impact the overall scores on either website. CONCLUSION: Having SM presence is correlated with increased number of ratings and comments on physician review sites, possibly revealing an increased likelihood of these physicians encouraging their patients to engage with them via the internet. SM presence did not correlate with higher review scores, displaying that there are many complex factors that go into a physician score outside of SM and internet appearance. Future studies should explore patient comments on these sites to understand additional factors that may optimize a patient's experience.

Comparison of implant related complications amongst patients with opioid use disorder and non-users following total knee arthroplasty.

BACKGROUND: The influence of opioid use disorder on implant related complications, infection and readmission rates, and total global episode-of-care costs following primary total knee arthroplasty (TKA) is limited. AIM: To examine whether opioid abuse in patients undergoing primary TKA. METHODS: A retrospective analysis of the Medicare dataset, using the PearlDiver database, from 2005-2014 comparing outcomes in patients with opioid abusers (OUD) to non-opioid abusers (NOU) undergoing primary TKA was performed. Patient outcomes were analyzed including implant complications, readmission rates, and day-of-surgery and 90-d cost. Statistical analysis was performed with R (University of Auckland, New Zealand) calculating odds-ratio (OR) along with their respective 95% confidence interval (95%CI) and P-values. RESULTS: The OUD group was at greater odds of having implant related complications overall (20.84% vs 11.25%; OR: 2.07; 95%CI: 1.93-2.23; P < 0.001). Revision (OR: 2.07; 95%CI: 1.11-3.84; P < 0.001), infection (OR: 1.92; 95%CI: 1.72-2.18; P < 0.001), periprosthetic fractures (OR: 1.83; 95%CI: 1.16-4.79; P < 0.001), and 90-d readmission rates (OR: 1.47, 95%CI: 1.35-1.61, P < 0.001) were also significantly increased. OUD patients also incurred in higher day-of-surgery and total global 90-d episode-of-care costs compared to NOU. CONCLUSION: Patients with OUD show an increased risk of complications compared to the non-opioid users group. Appropriate recognition, pre-surgical optimization, and patient education are essential to mitigate these complications and improve patient outcome.

Sleep Apnea Increases Ninety-Day Complications and Cost Following Primary Total Joint Arthroplasty.

BACKGROUND: Sleep apnea (SA) negatively affects bone mineralization, cognition, and immunity. There is paucity in the literature regarding the impact of SA on total joint arthroplasty (TJA). The purpose of this study is to compare complications in patients with and without SA undergoing either total knee (TKA) or total hip arthroplasty (THA). METHODS: A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with and without SA on the day of the primary TJA were queried using the International Classification of Diseases, ninth revision codes. Patients were matched by age, gender, Charlson Comorbidity Index), and body mass index. Patients were followed for 2 years after their surgery. Ninety-day medical complications, complications related to implant, readmission rates, length of stay, and 1-year mortality were quantified and compared. Logistic regression was used to calculate odds ratios (OR) with their respective 95% confidence interval and P values. RESULTS: After the random matching process there were 529,240 patients (female = 271,656, male = 252,106, unknown = 5478) with (TKA = 189,968, THA = 74,652) and without (TKA = 189,968, THA = 74,652) SA who underwent primary TJA between 2005 and 2014. Patients with SA had greater odds of developing medical complications following TKA (OR 3.71) or THA (OR 2.48). CONCLUSION: The study illustrates an increased risk of developing postoperative complications in patients with SA following primary TJA. Surgeons should educate patients on these adverse effects and encourage the use of continuous positive airway pressure which has been shown to mitigate many postoperative complications.

Racial Disparities in Revision Total Knee Arthroplasty: Analysis of 125,901 Patients in National US Private Payer Database.

INTRODUCTION: There is a relative paucity of studies that characterized racial disparities in revision total knee arthroplasty (TKA). Therefore, this study was specifically conducted to evaluate the following: (1) incidence; (2) annual burden; (3) causes; and (4) age group distribution of revision TKA among different racial groups in the US sample population. METHODS: The PearlDiver database was utilized to identify patients with knee osteoarthritis (OA) who underwent primary then subsequent revision TKA from January 2007 to December 2014. Patients were stratified by race, and subset stratification by age was also performed. In each racial cohort, the overall incidence of revision TKA, annual revision burdens, and causes of revisions were calculated and compared. Additionally, a sub-analysis for the incidence of revision TKA stratified by age, in each cohort, was performed. Statistical analysis was performed to demonstrate revision incidence, burden, causes, and age distribution. RESULTS: Revision incidence and burden were the highest in the African-American cohort (12.4%, 11.1%), (p < 0.001) and was lowest in the Asian cohort (3.4%, 3.3%) (p < 0.001). Across all cohorts, mechanical complications of the joint prosthesis were the most common cause of revision followed by periprosthetic joint infection, while contracture was the least common (p < 0.001). Subset analysis by age revealed that the highest incidence of revision TKA was in patients less than 40 years old in the Caucasian cohort (27.1%). The African-American (17.8%), other races (7.9%), and Hispanic (16.5%) cohorts had the highest incidence of revision in the 40 to 64 years age range. Among the Asian (4.1%) and Native American (9.7%) cohorts, revision incidence was highest in patients older than 65 years. CONCLUSION: The present study demonstrated that racial disparities, highlighted by previous studies mainly in primary TKA, extend to influence revision TKA. Among the studied racial cohorts, race may affect outcomes and our results will help expand the current literature particularly on its role in revision TKA.

Value comparison of humeral component press-fit and cemented techniques in reverse shoulder arthroplasty.

BACKGROUND: Press-fit humeral fixation for reverse shoulder arthroplasty (RSA) has been shown to have loosening rates and outcomes similar to a cemented technique; however, increased value has not been reported. The purpose of this study was to determine whether the press-fit technique could improve the value of RSA using the procedure value index (PVI). METHODS: Primary RSA patients with complete hospitalization cost data, preoperative and minimum 2-year postoperative Simple Shoulder Test (SST) scores, and postoperative satisfaction were included. The PVI was calculated as improvement in the SST score (in units of minimal clinically important difference) divided by total cost and normalized. Itemized cost data were obtained from hospital financial records and categorized. Radiographic complications, infections, and revisions were noted. Comparisons were made between the press-fit and cemented RSA cohorts. RESULTS: A total of 176 primary RSA patients (83 cemented and 93 press fit) met the inclusion criteria (mean follow-up period, 44.6 months). Surgical indications (except failed rotator cuff repair), baseline SST scores, and demographic characteristics were similar. The calculated minimal clinically important difference for the SST score was 3.98. The average PVI was significantly greater in the press-fit cohort (1.51 vs 1.03, P < .001), representing a 47% difference. SST score improvement was not significantly different (P = .23). However, total hospitalization costs were significantly lower for the press-fit cohort ($10,048.89 vs $13,601.14; P < .001). CONCLUSION: Use of a press-fit technique led to a 47% increase in value over a cemented technique. This appeared to be a function of decreased total costs rather than increased outcome scores.

Preoperative Hypoglycemia Increases Infection Risk After Trigger Finger Injection and Release.

BACKGROUND: Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release. METHODOLOGY: A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes. RESULTS: The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003). CONCLUSIONS: Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.

The procedure value index: a new method for quantifying value in shoulder arthroplasty.

BACKGROUND: The purpose of this study was to introduce the procedure value index (PVI) and apply this value instrument to shoulder arthroplasty. The PVI uses the value equation in units of minimal clinically important difference (MCID) to provide an objective system of quantifying value-driven care. Secondarily, we describe the PVI for both primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) to highlight value differences between these patient populations. METHODS: Patients undergoing primary shoulder arthroplasty with minimum 2-year follow-up were identified retrospectively. MCIDs were determined for the Simple Shoulder Test (SST) score, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and Single Assessment Numeric Evaluation (SANE) score. Cost data were reported as total hospitalization costs, total charges, and total reimbursements. The PVI was calculated as the ratio of outcome improvement in units of MCID over the cost of care. Mean PVIs for TSA and RSA were compared. RESULTS: Five hundred thirty-four patients met the inclusion criteria. MCIDs for the SST, ASES, VAS pain, and SANE scores were 3.61, 29.49, 3.28, and 37.05, respectively. With the exception of the ASES score, improvements in units of MCID were not different between TSA and RSA. However, total hospitalization costs and charges were significantly higher for RSA (P < .001). PVIs based on total hospitalization costs and total charges for the SST, ASES, and VAS pain scores were significantly greater for TSA (P < .05). No other PVI was significantly different. CONCLUSIONS: The PVI was greater for TSA when total hospitalization costs and total charges were considered. The PVI helps highlight value differences in shoulder arthroplasty.

Preoperative Hypoglycemia and Hyperglycemia Are Related to Postoperative Infection Rates in Implant-Based Breast Reconstruction.

OBJECTIVES: Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk. METHODS: A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes. RESULTS: The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia (<70 mg/dL). CONCLUSIONS: The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014.

The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Albumin, Prealbumin, and Transferrin May Be Predictive of Wound Complications following Total Knee Arthroplasty.

Nutritional status has become increasingly important in optimizing surgical outcomes and preventing postoperative infection and wound complications. However, currently, there is a paucity in the orthopaedics literature investigating the relationship between nutritional status and wound complications following total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine the prevalence of (1) postoperative infections, (2) wound complications, (3) concomitant infection with wound (CoIW) complication, and (4) infection followed by wound complication by using (1) albumin, (2) prealbumin, and (3) transferrin levels as indicators of nutritional status. These four different outcome measures were chosen as they are encountered commonly in daily clinical practice. A retrospective review of a national private payer database for patients who underwent TKA with postoperative infections and wound complications stratified by preoperative serum albumin (normal: 3.5-5 g/dL), prealbumin (normal: 16-35 mg/dL), and transferrin levels (normal: 200-360 mg/dL) between 2007 and 2015 was conducted. Patients were identified by Current Procedural Terminology (CPT), International Classification of Disease, ninth revision (ICD-9) codes, and Logical Observation Identifiers Names and Codes (LOINC). Linear regression was performed to evaluate changes over times. Yearly rates of infection, as well as a correlation and odds ratio analysis of nutritional laboratory values to postoperative complications, were also performed. Our query returned a total of 161,625 TKAs, of which 11,047 (7%) had postoperative wound complications, 18,403 (11%) had infections, 6,296 (34%) had CoIW, and 4,877 (4%) patients with infection developed wound complications. Albumin was the most commonly ordered laboratory test when assessing complications (96%). Wound complications, infections, CoIW, and infection with wound complications after were higher in those below the normal range: albumin <3.5 g/dL (9, 14, 6, and 5%), prealbumin <15 mg/dL (20, 23, 13, and 12%), and transferrin <200 mg/dL (12, 17, 6, and 6%). Preoperative albumin, prealbumin, and transferrin values falling below the normal range represented an increased risk for postoperative complications. Those patients who were in the normal range, however, did not have an increased risk. Therefore, our results suggest that preoperative nutritional optimization can play an important role in reducing the risk for postoperative complications.

CANNABIS USE INCREASES RISK FOR REVISION AFTER TOTAL KNEE ARTHROPLASTY.

As an increasing number of states begin to legalize marijuana for either medical or recreational use, it is important to determine its effects on joint arthroplasty. The purpose of this study is to determine the impact of cannabis use on total knee arthroplasty (TKA) revision incidence, revision causes, and time to revision by analyzing the Medicare database between 2005 and 2014. A retrospective review of the Medicare database for TKA, revision TKA, and causes was performed utilizing Current Procedural Terminology (CPT) and International Classification of Disease ninth revision codes (ICD-9). Patients who underwent TKA were cross-referenced for a history of cannabis use by querying ICD-9 codes 304.30-32 and 305.20-22. The resulting group was then longitudinally tracked postoperatively for revision TKA. Cause for revision, time to revision, and gender were also investigated. Our analysis returned 2,718,023 TKAs and 247,112 (9.1%) revisions between 2005 and 2014. Cannabis use was prevalent in 18,875 (0.7%) of TKA patients with 2,419 (12.8%) revisions within the cannabis cohort. Revision incidence was significantly greater in patients who use cannabis (p < 0.001). Time to revision was also significantly decreased in patients who used cannabis, with increased 30- and 90-day revision incidence compared to the noncannabis group (P < 0.001). Infection was the most common cause of revision in both groups (33.5% nonusers versus 36.6% cannabis users).Cannabis use may result in decreasing implant survivorship and increasing the risk for revision within the 90-day global period compared to noncannabis users following primary TKA.

Sensor-Based Soft Tissue Balancing in Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a highly successful procedure with utilization expected to grow substantially over the coming decades. However, the revision burden has not concurrently improved, with over 30% of revisions related to technical imperfections (Mulhall KJ, Ghomrawi HM, Scully S, Callaghan JJ, Saleh KJ, Clin Orthop Relat Res 446:45, 2006; Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM, Clin Orthop Relat Res 404:7, 2002; Wylde V, Hewlett S, Learmonth ID, Dieppe P, Pain 152(3):566, 2011). Accurate alignment and soft tissue balancing have been identified as important factors in mitigating these risks. Historically, accuracy relating to soft tissue balance has relied upon surgeon experience and subjective tactile feel. This chapter will explore the utilization of intraoperative sensors related to soft tissue balancing in total knee arthroplasty.