The effects of tourniquet on cement penetration in total knee arthroplasty.

PURPOSE: Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS: A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS: A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION: Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

Increased Rates of Tibial Aseptic Loosening in Primary Cemented Total Knee Arthroplasty With a Short Native Tibial Stem Design.

BACKGROUND: Emerging evidence has suggested that both obesity and a short, native tibial stem (TS) design may be associated with early aseptic loosening in total knee arthroplasty. The use of short, fully cemented stem extensions may mitigate this risk. As such, we devised a multicenter study to confirm or negate these claims. METHODS: A search of our institutional research databases was done. A minimum 2-year time from index procedure was selected. Cohorts were created according to patient body mass index and the presence (stemmed tibia [ST]) or absence (nonstemmed tibia [NST]) of a short TS extension. Kaplan-Meier survival analyses for aseptic loosening and log-rank tests were done. RESULTS: A total of 1,350 patients were identified (ST = 500, NST = 850). The mean time to the final follow-up in cases without aseptic loosening for the ST cohort was 3.5 years (2.8-6.3) and 5.0 years (2.9-6.3) for the NST cohort (P < 0.001). Kaplan-Meier survival analysis at 6 years was superior for the ST cohort (100%, 98.5%; P = 0.025), and a trend toward superior 5-year survival was observed for body mass index <40 kg/m2 (99.1%, 93.2%; P = 0.066). The mean time to aseptic loosening was 2.4 years (0.9-4.5), with approximately 40% occurring within the first 2 years. CONCLUSIONS: Short, native TS design is associated with early aseptic loosening in primary cemented total knee arthroplasty. This can be mitigated through the use of an ST. More cost-effective solutions include (1) use of implants with longer native stem designs or (2) redesign of short TS implants.

Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review.

This systematic review evaluated the combined effects of obesity and surgical approach on periprosthetic joint infection (PJI) rates after total hip arthroplasty (THA). Wound complication and PJI rates were elevated among patients with body mass index (BMI) of 30 kg/m2 or greater and 35 kg/m2 or greater, respectively, with the direct anterior approach (DAA). A BMI of 30 kg/m2 or greater also increased the risk of PJI with the posterior approach. Patients with BMI of 30 kg/m2 or greater undergoing anterolateral approach THA did not have increased risk of PJI. Patients with elevated BMI (≥30 kg/m2) are at risk for PJI, regardless of approach. Patients undergoing DAA THA who have BMI of 35 kg/m2 or greater may have an increased risk of PJI compared with those undergoing THA with other approaches. [Orthopedics. 2022;45(2):e67-e72.].

Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention.

BACKGROUND: Post-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. METHODS: All male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. RESULTS: Two hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m2. The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69. CONCLUSION: Urodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.

Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Additional Cost Without Improving Outcomes.

BACKGROUND: Recent evidence has demonstrated that formal physical therapy (PT) may not be required for most patients undergoing total hip (THA) and knee (TKA) arthroplasty. This study compared the differences in costs and functional outcomes in patients receiving formal PT and those who did not follow primary THA and TKA. METHODS: We queried claims data from a single private insurer identifying patients who underwent primary THA or TKA from 2015 to 2017 in our practice. Demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care were recorded. Outcomes were compared between patients using self-directed home exercises, home PT, outpatient PT, or both home and outpatient PT. A multivariate analysis was performed to identify significant predictors of outcomes. RESULTS: Of the 2971 patients included in analysis, patients using both services had higher 90-day PT costs (mean $2091, P < .001) than those using home PT alone ($1146), outpatient PT alone ($1356), or no formal PT ($0). Home PT had the greatest cost per visit for both private insurance patients ($177/visit) and Medicare Advantage patients ($157/visit), but patients using both home PT and outpatient PT services had the greatest overall PT cost, $2091 for private insurance and $1891 for Medicare Advantage. Patients who used home PT were at significantly higher risk of both complications (odds ratio = 3.21; 95% confidence interval, 2.1-4.9; P < .001) and readmissions (odds ratio = 3.4; 95% confidence interval, 2.1-5.5; P < .001). CONCLUSION: Participation in formal PT accounts for up to 8% of the episode of care following THA and TKA. The role of formal PT for most patients should take into account the cost-effectiveness of the intervention.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty.

BACKGROUND: With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA. METHODS: At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites. RESULTS: Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient. CONCLUSION: Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

The trends in robotic-assisted knee arthroplasty: A statewide database study.

OBJECTIVE: Recent technological advancements have led to the utilization of robotic-assisted knee arthroplasty (raKA) in the operating room. METHODS: All patients who underwent knee arthroplasty from 2009 to 2013 in NYS SPARCS were reviewed. raKAs and non-raKAs were compared for utilization and institutional trends. RESULTS: Robotic-assistance increased by 500%. 80% of raKAs were performed in teaching hospitals. The trend increase was greater in teaching hospitals. Blood transfusion rates differed between raKA and non-raKA (6.6% vs. 10.9%, p < 0.001). CONCLUSION: raKA utilization increased in NYS, moreso within teaching hospitals. raKA transfusion rates were lower but higher in teaching hospitals, potentially related to learning curve.

Motion analysis in the axial plane after realignment surgery for adolescent idiopathic scoliosis.

BACKGROUND: This study aimed to define changes occurring in axial plane motion after scoliosis surgery in patients with adolescent idiopathic scoliosis (AIS) using gait analysis. Pre- and postoperative axial plane motion was compared to healthy/control subjects. This may potentially improve our understanding of how motion is impacted by deformity and subsequent surgical realignment. METHODS: 15 subjects with AIS underwent pre- and postoperative radiographic and gait analysis, with focus on axial plane motion (clockwise [CW] and counterclockwise [CCW]). Age, weight, and gender-matched controls (n = 13) were identified for gait analysis. Control, preoperative and postoperative groups were compared with paired student's t-tests. RESULTS: Surgical realignment resulted in significantly decreased in upper thoracic, thoracic, thoracolumbar and lumbar Cobb angles pre-to-postoperatively (36.7° vs. 15.2°, 60.1° vs. 25.6°, 47.7° vs. 17.7° and 27.2° vs. 4.8°, respectively) (all p < 0.05), with no significant change in thoracic kyphosis, lumbar lordosis, central sacral vertical line, pelvic incidence, and sagittal vertical axis. However, pelvic tilt significantly increased from 4.9° to 8.1° (p = 0.035). Using gait analysis: preoperative thoracic axial rotation differed (mean CW and CCW rotation was 1.9° and 3.1° [p = 0.01]), whereas mean CW & CCW pelvic rotation remained symmetric (2.0° and 3.0°; p = 0.44). Postoperatively, CCW thoracic rotation range of motion decreased (CW: 0.6° and CCW: 1.4°; p = 0.31). No significant difference in postoperative pelvic rotation occurred (1.1° and 3.4°; p = 0.10). Compared to controls, AIS patients demonstrated no significant difference in total CW & CCW thoracic motion relative to the pelvis both pre- (14.9° and 12.3°, respectively; p = 0.45) and postoperatively (12.9° and 12.3°, respectively; p = 0.82). SIGNIFICANCE: AIS patients demonstrated abnormal gait patterns in the axial plane compared to normal controls. After surgical realignment and de-rotation, marked improvement in axial plane motion was observed, highlighting how motion analysis can afford surgeons three-dimensional perspective into the patient's functional status.

Positioning-Related Neuromonitoring Change During Anterior Cervical Discectomy and Fusion.

BACKGROUND: Intraoperative neuromonitoring (ION) signal changes during spine surgery may portend a potentially catastrophic neurologic injury that, if identified and addressed expediently, may allow the surgeon to take correction actively and prevent permanent neurologic injury. CASE DESCRIPTION: We report a case of transient loss in somatosensory evoked potentials signals during anterior cervical discectomy and fusion (ACDF) C4-7, which was mainly attributed to shoulder traction using a special device. The signal loss returned immediately after the release of should traction. CONCLUSIONS: The use of multimodality ION is recommended for ACDF with shoulder traction to prevent postoperative neurologic deficit associated with a position-related injury. Baseline ION should be established before positioning.

Limb Salvage Versus Amputation in Conventional Appendicular Osteosarcoma: a Systematic Review.

The overall survivorship in patients with appendicular osteosarcoma has increased in the past few decades. However, controversies and questions about performing an amputation or a limb salvage procedure still remain. Using three peer-reviewed library databases, a systematic review of the literature was performed to evaluate all studies that have evaluated the outcomes of appendicular osteosarcoma, either with limb salvage or amputation. The mean 5-year overall survivorship was 62% for salvage and 58% for amputation (p > 0.05). At mean 6-year follow-up, the local recurrence rates were 8.2% for salvage and 3.0% for amputation (p > 0.05). Additionally, at mean 6-year follow-up, the rate for metastasis was 33% for salvage and 38% for amputation (p > 0.05). The revision rates were higher with salvage (31 vs. 28%), and there were more complications in the salvage groups (52 vs. 34%; p > 0.05). Despite the heterogeneity of studies available for review, we observed similar survival rates between the two procedures. Although there was no significant statistical difference between rates of recurrence and metastasis, the local recurrence rate and risk of complications were higher for limb salvage as compared to amputation. Cosmetic satisfaction is often higher with limb salvage, whereas long-term expense is higher with amputation. Overall, current literature supports limb salvage procedures when wide surgical margins can be achieved while still retaining a functional limb.

The Effects of Meniscal Geometry on Susceptibility for Meniscal and ACL Injury in Non-Arthritic Knees: A Retrospective Case-Control Study.

Prior studies have not found significant differences in meniscal parameters between patients with meniscal and ligamentous injury and those without. The purpose of this study was to determine whether such relationships exist. Clinical records and magnetic resonance images of three subject groups were reviewed. Group 1 solely had meniscal tears (medial/lateral), Group 2 had meniscal tears with concurrent ACL tears, and Group 3 had healthy knees. The mean age of subjects included was 35.9 years (range 8.2-72.6). The height, width, diagonal, slope, and cross-sectional area for the anterior and posterior horns of the lateral and medial menisci were assessed. Normal distribution of data was confirmed by the Shapiro-Wilk test and analysis of variance with a post hoc Tukey's test was used to assess potential differences. p < 0.05 was set as the level of significance. There was no difference between the meniscal slopes of patients with and without meniscal tears (p = 0.77-1.0). Meniscal height (p = 0.0001-0.024) and width (p = 0.0001-0.046) demonstrated significant differences in all horns. Cross-sectional area was larger in the torn group (p = 0.0001-0.012). To compare intact and torn menisci, a logistical regression model was used and found to be significantly different from the constant model (p < 0.0001). Predictive success was 80.5%. A logistical regression model was used comparing undamaged menisci with torn menisci with accompanying anterior cruciate ligament (ACL) tear and was significant (p < 0.0001). A larger cross-sectional meniscal area in both the anterior and posterior horns of both menisci was a risk factor for isolated meniscal tears and combined meniscal and ACL tears. It has been postulated that certain demographic variables, such as gender, age, and body mass index, may be risk factors associated with ACL and meniscal injuries. However, the relationship between intrinsic morphology, namely meniscal size and shape, and risk of injury is unclear. The majority of studies have focused on meniscal morphology/geometry and its association with degenerative tears in patients with end-stage osteoarthritis rather than on acute meniscoligamentous injury. In this study of non-arthritic knees, a larger cross-sectional meniscal area in both the anterior and posterior horns of both menisci was a risk factor for having both an isolated meniscal tear as well as a combined meniscal and ACL tear. With advances in the field of meniscal repair, particularly with allograft procedures, more attention should be paid to meniscal cross-sectional area because it may play a role in the natural history of knee injury.

Reconstruction Plate-Based Antibiotic Cement Spacers: Clinical Outcomes and Description of Technique.

The standard of care for chronic deep peri-prosthetic hip infection is a two-stage exchange with placement of a temporary antibiotic cement spacer and treatment with intravenous antibiotics. Several commercially available cement spacer options exist. We report on a novel antibiotic spacer that may be an efficient, cost-effective alternative. Medical records of all patients treated for deep peri-prosthetic hip infection after total hip arthroplasty between 2004 and 2012 were reviewed. Each antibiotic spacer was constructed from a 12- to 16-hole recon plate bent to provide adequate soft tissue tension and a cement ball that matched the acetabulum. Premature failure of the plate and duration of implantation were measured. Failure was defined as fracture of the plate or dissociation of the cement head from the plate. Costs were compared with commercially available cement spacers. A total of 24 spacers were identified in 21 patients (mean age 68.9 years, mean body-mass index 26.4). The mean time between spacer placement and re-implantation was 6.4 months (range: 1.8-18 months). One patient had an indolent infection that was unresponsive to antibiotic therapy and required a hip disarticulation. At the time of reimplantation, 17 of 17 handmade spacers had no failures. Of the premade spacers, six of the seven had no failures. One premade spacer fractured at the femoral component trunion. The cost of the plate and antibiotic cement was $909-1000, approximately $5000 less than premade spacers. Antibiotic spacers can be readily constructed intraoperatively and offer good clinical outcomes with a low incidence of failure. This type of spacer saved $5000 per patient.

Rotational Deformity of the First Ray Precludes Accurate Distal Metatarsal Articular Angle Measurement in Hallux Valgus.

The routine workup of hallux valgus includes measurements of the distal metatarsal articular angle (DMAA). However, this angle may not be a reliable measurement when rotational deformities occur. Eight matched cadaveric feet were evaluated radiographically using fluoroscopy. The intermetatarsal angle (IMA), hallux valgus angle, and DMAA were evaluated as a baseline. Then, we assessed whether axial rotation of 15°, 30°, 45°, and 60° affected the accuracy of the IMA and the DMAA significantly. Statistical evaluation was performed using Student's t tests and analysis of variance. The IMA remained stable for each anterior-posterior image despite rotation of the distal segment, with a mean difference of less than 2.5°. However, the DMAA was not constant, having different angles of rotation through the osteotomy site. We were able to demonstrate that measurement of the DMAA varies significantly with rotation of the distal first metatarsal. Using the DMAA to assess first metatarsophalangeal joint congruency should be done cautiously because it may estimate unreliably and inaccurately the 3D deformity often encountered in pathologic hallux valgus.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013.

BACKGROUND: Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013. METHODS: A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges. RESULTS: There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size. CONCLUSION: Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

Have the Annual Trends of Total Knee Arthroplasty in Rheumatoid Arthritis Patients Changed?

As the use of disease modifying antirheumatic drugs have increased, it remains unclear whether or not this has affected the rates of total knee arthroplasty (TKA) in rheumatoid arthritis (RA) patients. Therefore, the purpose of this study was to evaluate the annual trends of RA patients who underwent TKA. Specifically, we evaluated: (1) the annual trends of TKAs due to RA in the United States population; and (2) the annual trends in the proportion of TKAs due to RA in the United States. The Nationwide Inpatient Sample was used to identify all patients who underwent TKA between 2002 and 2013 (n = 6,492,873). Then, we identified TKA patients who had a diagnosis of RA, defined by the International Classification of Diseases, Ninth Revision (ICD-9) code 714.0. The incidence of TKAs with a diagnosis of RA in the United States was calculated using the U.S. population as the denominator. Regression models were used to analyze the annual trends of RA in patients who underwent TKA. A total of 209,332 RA patients were identified who underwent TKA. The annual prevalence of RA in patients who underwent TKA slightly increased, from 33.2 per 1,000 TKAs in 2002 to 35 per 1,000 TKAs in 2013 (R2 = 0.254, p = 0.095). The annual number of TKAs with a diagnosis of RA increased by 93.1% from 11,618 to 22,430. After normalizing for the U.S. population, the incidence of TKAs with RA increased from 5.4 to 9.2 TKAs per 1 million U.S. adults (incidence rate ratio [IRR] = 1.05; 95% confidence interval [CI], 1.05-1.05; p < 0.001). In 2002, 11,618 (3.31%) TKAs, and in 2013, 22,430 (3.50%) TKAs were due to RA. The prevalence of RA in those who underwent TKA remained the same from 2002 to 2013 (coefficient = 0.02; 95% CI, -0.01 to 0.05; p = 0.095). The results of this study demonstrated that the rates of TKA performed in RA patients have remained relatively stable. Furthermore, there may have been a decline in the rate of RA patients undergoing TKA, due to an increase in the U.S. population by approximately 28.8 million during the study period.

Have the annual trends of total hip arthroplasty in rheumatoid arthritis patients decreased?

BACKGROUND: Rheumatoid arthritis (RA) is characterized by chronic systemic and synovial inflammation, resulting in damage to both cartilage and bone. Medical treatment, which has increasingly relied upon disease modifying anti-rheumatic drugs (DMARDs), may fail to slow disease progression and limit joint damage, ultimately warranting surgical intervention. Up to 25% of RA patients will require lower extremity total joint arthroplasty. Though total hip arthroplasty (THA) is known to improve quality of life and functional measures, clarification is still required with respect to the impact of increased DMARD use on annual rates of THA. Thus, the purpose of this study was to evaluate: (I) the annual trends of THAs due to RA in the United States population; (II) the annual trends in the proportion of THAs due to RA in the United States. METHODS: This study utilized the Nationwide Inpatient Sample (NIS) to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, THA patients who had a diagnosis of RA, which was defined by the International Classification of Disease 9th revision diagnosis code 714.0, were identified. The incidence of THAs with a diagnosis of RA in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of RA in patients who underwent THA. RESULTS: Review of the database identified 90,487 patients who had a diagnosis of RA and underwent THA from 2002 to 2013. The annual prevalence of RA in those who underwent THA slightly decreased over the specified time period, with 28.7 per 1,000 THAs in 2002 and 28.6 per 1,000 THAs in 2013; however, this change was not statistically significant (R2=0.158, P=0.200). CONCLUSIONS: The annual rates of THA among RA patients did not show any significant change between 2002 and 2013. DMARD use has decreased both disease progression and joint destruction, and DMARDs are now often utilized as primary treatment. The increase in population of the country during the study period may have overestimated THA trends. Moreover, patients may be more likely to opt for surgical management, given the advances in operative techniques as well as peri- and post-operative course.

Have the Yearly Trends of Total Hip Arthroplasty in Ankylosing Spondylitis Patients Decreased?

INTRODUCTION: Ankylosing spondylitis (AS) is characterized by spinal inflammation and structural damage, primarily to the axial skeleton and sacroiliac joints. Between 25% and 70% of patients may experience progressive peripheral joint involvement, which, despite advancement in pharmacologic therapy, may necessitate surgical intervention. Total hip arthroplasty (THA) yields improved pain and functional outcomes for AS patients with hip involvement. It is unclear whether the annual rates of patients undergoing THA have changed due to newer pharmacologic management. Therefore, the purpose of this study was to evaluate the annual trends of AS patients who underwent THA. Specifically, we evaluated: 1) the annual trends of THAs due to AS in the United States population, and 2) the annual trends in the proportion of THAs due to AS in the United States. MATERIALS AND METHODS: This study used the Nationwide Inpatient Sample to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, an additional query was performed to identify THA patients who had a diagnosis of AS, defined by the International Classification of Disease 9th revision diagnosis code 720. The incidence of THAs with a diagnosis of AS in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of AS in patients who underwent THA. RESULTS: Review of the database identified 5,562 patients with AS who underwent THA. The overall annual prevalence of THA in the AS population significantly decreased during the 12-year study period from 2.24 per 1,000 THAs in 2002 to 1.73 per 1,000 THAs in 2013 (R2=0.445; p=0.018). CONCLUSION: Annual THA trends in AS patients have significantly declined from 2002 to 2013. This decline may be attributed to improvements in medical management that delay the time from disease onset to requirement of a THA. Since THA is an option with advanced disease, the observed declining trends may indicate the efficacy of current medical management.

A Case for the Brace: A Critical, Comprehensive, and Up-To-Date Review of Static Progressive Stretch, Dynamic, and Turnbuckle Braces for the Management of Elbow, Knee, and Shoulder Pathology.

BACKGROUND: Non-operative management of the elbow, shoulder, and knee typically includes braces, such as the: static progressive stretch (SPS), turnbuckle, and dynamic. However, a paucity of literature exists comparing these three bracing modalities. Therefore, the purpose of this study was to evaluate the current literature on the various bracing modalities for physicians and patients managing elbow, shoulder, or knee joint complications. Specifically, we compared the use of 1) static progressive stretch, 2) dynamic, and 3) turnbuckle braces for the a) elbow, b) knee, and c) shoulder. MATERIALS AND METHODS: A PubMed search on dynamic, SPS, and turnbuckle bracing for the elbow, knee, and shoulder joints was performed. Studies that addressed clinical outcomes and relied primarily on the brace for improvement of patient outcomes and not on surgery were included. Because individually-fabricated braces are extremely costly, require great fabrication skill, and are unique to the patient they were specifically designed for, their results are not generalizable to the greater patient population and were, therefore, not included in this analysis. A total of 14 elbow, 24 knee, and 4 shoulder studies met criteria. RESULTS: Elbow-Patients wore the SPS brace for 90 minutes, compared to 8 hours for the turnbuckle and 20 hours for the dynamic brace. The SPS and turnbuckle brace had similar increases in range of motion (ROM) of 37°. The SPS brace was found to provide patients with the greatest reduction in flexion contracture, 26°. There are similar increases in flexion ROM between the SPS and dynamic elbow bracing modalities. Shoulder- The mean duration of use for an SPS was only six weeks compared to the two months required for the dynamic shoulder brace. The dynamic shoulder brace protocol involved upwards of 24 hours per day or night as patients were instructed to wear the brace at all times. Patients treated with both the SPS and dynamic braces had excellent pain outcomes. Knee-The most commonly followed SPS knee brace protocol was one to three sessions per day which lasted from seven to nine weeks, while for the dynamic brace the time period ranged from six to eight weeks. The SPS brace reported a mean increase in ROM of 31°. There was a lack of evidence for the dynamic and turnbuckle knee braces for their accurate assessment. The SPS studies reported the greatest response to flexion improvement with a mean increase of flexion by 22°. Meanwhile, the reported mean flexion increase with a dynamic knee brace was only 7°. CONCLUSION: Based on the most current literature available, the authors highly recommend the use of SPS for the elbow, shoulder, and knee. Static progressive stretch bracing has an easy patient protocol, a short duration of use, and excellent outcomes. Additionally, the lack of evidence for turnbuckle and dynamic braces is concerning. Overall, the static progressive stretch brace has shown excellent results in the outcomes assessed in this review and should be a first recommendation for patients suffering from elbow, knee, and/or shoulder pathology.