Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

The Clinical Outcome of Patellofemoral Arthroplasty vs Total Knee Arthroplasty in Patients Younger Than 55 Years.

BACKGROUND: Patellofemoral osteoarthritis affects 10% of patients older than 40 years and is commonly treated by patellofemoral joint arthroplasty (PFA) or a total knee arthroplasty (TKA). PFA is a more conservative approach with documented faster recovery. No study to date has compared both approaches with respect to patient-reported outcome measures in patients younger than 60 years. METHODS: A retrospective case-matched cohort based on age, sex, body mass index, and side of 23 PFAs (in 19 patients) operated on by 2 surgeons and of 23 TKAs (23 patients) operated on by 6 surgeons was included in the study. All patients were younger than 55 years and operated on between March 2010 and September 2015. The Western Ontario and McMaster Osteoarthritic Index, Knee injury and Osteoarthritis Outcome scores, Tegner, and University of California, Los Angeles activity scores were compared between preoperative and minimum 2-year postoperative timepoints between groups. RESULTS: TKA and PFA were comparable on all patient-reported outcome measures at minimum 2-year follow-up; however, PFA patients exhibited statistically significantly larger improvement between 1 year postoperative and 2 years postoperative timepoints (P < .05). All patients improved between preoperative and postoperative timepoints (P < .05). CONCLUSION: Although TKA performed better with respect to functional outcomes at the 1-year mark, at 2-year follow-up, PFA and TKA performed equally well. Our results allow us to conclude that in younger patients with isolated patellofemoral osteoarthritis who desire a more conservative, kinematic-preserving approach, PFA continues to be a practical treatment option yielding early outcomes that compare favorably with TKA.

Defining growth potential and barriers to same day discharge total knee arthroplasty.

BACKGROUND: Outpatient arthroplasty programs are becoming well established. Adverse event rates have been demonstrated to be no worse than inpatient arthroplasty in the literature for selected patients. The purpose of this study was to determine our rate of outpatient total knee arthroplasty (TKA), examine justification for exclusions, and estimate the proportion of TKAs that can occur safely on an outpatient basis. METHODS: Retrospective case series of 400 consecutive TKAs from Oct 2014 to Mar 2017. Patient demographics, allocation to outpatient surgery vs standard admission, and reason for exclusion from outpatient surgery were recorded. Ninety-day Emergency department (ED) visits, readmission rates, and length of stay (LOS) were compared between groups using independent sample t test and Chi-squared test. RESULTS: Outpatients were younger (p = 0.001), had lower BMI (p < 0.001), and ASA scores (p < 0.001) than inpatients. One hundred twenty-five (31%) TKAs were assigned to outpatient surgery and 123 achieved discharge on the same day. There was no difference in 90-day ED visits (p = 0.889) or readmission rates (p = 0.338) between groups. Reasons for exclusion from outpatient surgery included medical (absolute 43% and relative 31%), distance > one hour from hospital (18%), no help (7%), and other/unclear (10%). LOS was significantly longer for medical than non-medical exclusions (p < 0.001) and for the absolute compared to relative medical exclusions (p = 0.004). CONCLUSION: Outpatient TKA is safe in selected patients, and inclusion can likely be broadened by addressing modifiable exclusions and narrowing medical exclusions. We found that 55% of our TKA population could be appropriate for outpatient surgery.

Quality of Recovery, Postdischarge Hospital Utilization, and 2-Year Functional Outcomes After an Outpatient Total Knee Arthroplasty Program.

BACKGROUND: Outpatient total knee arthroplasty (TKA) has been made possible with advances in perioperative care and standardized clinical inpatient pathways. While many studies report on benefits of outpatient programs, none explore patient-reported outcome measures. As such, our goals were to compare the short-term quality of recovery; highlight postdischarge hospital resources utilization; and report on 2-year functional outcomes scores. METHODS: This was a prospective comparative cohort study of 43 inpatients (43 TKAs) and 43 outpatients (43 TKAs) operated on by a single surgeon between September 28, 2010 and May 5, 2015. All patients were given a diary to complete at 1, 3, 7, 14, and 28 days postoperatively; we collected 90-day complications, readmissions, and emergency department visits; Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores were completed preoperatively and 2 years postoperatively. SPSS (IBM, version 22.0) was used for all statistical analyses. RESULTS: Quality of recovery (QoR-9) was similar in the outpatient TKA group compared with the inpatient group. No statistically significant differences were observed for Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index subscores (P > .05). There was 1 readmission in both outpatient and inpatient groups. Six inpatients and 8 outpatients returned to the emergency department for any reason within 90 days, with no statistical significance observed between the 2 groups (P = .771). CONCLUSION: Outpatient TKA in selected patients produced similar short-term and 2-year patient-reported outcome measures and a comparable 90-day postdischarge hospital resource utilization when compared to an inpatient cohort, supporting further investigation into outpatient TKA.

Evaluation of a Patient Decision Aid for Unicompartmental or Total Knee Arthroplasty for Medial Knee Osteoarthritis.

BACKGROUND: Many patients with isolated medial compartment osteoarthritis are candidates for either unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). A novel patient decision aid (PDA) was developed to educate patients on both interventions and prepare them for making the decision with their surgeon. The study objective was to evaluate the acceptability and usefulness of a PDA for informing and helping patients reach a surgical preference without increasing decisional conflict. METHODS: A PDA was developed in accordance with the criteria listed by Ottawa Decision Support Framework and prospectively tested in UKA and TKA patients, who were mailed the PDAs to complete at home along with outcome measures before surgeon consultation. Of 50 patients who consented to participate, 45 patients (26 men, 19 women) used the PDA. Quantitative analysis of acceptability, decisional conflict, knowledge, and preferred surgical option was then performed. RESULTS: Mean patient age was 64.6 years (range, 50-80 years). Patients rated the PDA as acceptable: 84.4% indicated balanced presentation of information and 77.8% asserted that PDA helped them to make decisions between UKA and TKA. Mean knowledge score was 86.6% and total decisional conflict was 19.7 out of 100. Of 45, 33 stated a preferred option (24 UKA; 9 TKA; 12 unsure). CONCLUSION: Patients understood the majority of the benefits and risks for each surgical option without increasing decisional conflict. The decision aid for advanced medial compartment osteoarthritis is shown to be acceptable and useful for choosing between UKA and TKA.

Assessing functional recovery shortly after knee or hip arthroplasty: a comparison of the clinimetric properties of four tools.

BACKGROUND: Following hip or knee arthroplasty, it is clinically warranted to get patients functional as quickly as possible. However, valid tools to assess function shortly after knee or hip arthroplasty are lacking. The objective was to compare the clinimetric properties of four instruments to assess function shortly after arthroplasty. METHODS: One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively, 1 and 2 days postoperatively, and 2 and 6 weeks postoperatively with the Timed Up and Go (TUG), Iowa Level of Assistance Scale (ILAS), Postoperative Quality of Recovery Scale (PQRS), and Readiness for Hospital Discharge Scale (RHDS). Descriptive data, floor and ceiling effects, responsiveness, interpretation and construct validity were determined. RESULTS: Only the ILAS and RHDS support subscale demonstrated floor or ceiling effects. A large deterioration from preoperative to postoperative, followed by large improvements after surgery were seen in the TUG and ILAS scores. The RHDS personal status subscale and the PQRS pain and function dimensions demonstrated large improvements after surgery. Changes in the RHDS global scale and personal status subscale, PQRS pain dimension and TUG were significantly related to patient perceived improvement. Minimal important changes were obtained for the RHDS global (1.1/10) and personal status subscale (2.3/10), and the TUG (43.4 s at 6 weeks). For construct validity, the PQRS function dimension and RHDS were moderately related to the TUG or ILAS. The correlation between TUG and ILAS was high from preoperative to postoperative day 2, but substantially decreased at 2 and 6 weeks. CONCLUSIONS: The TUG and RHDS personal status subscale demonstrated the best clinimetric properties to assess function in the first 6 weeks after hip or knee arthroplasty.

The effect of medial release of the distal patellar tendon insertion on lateral patella translation and residual insertion strength: a cadaveric study.

Patellar tendon avulsion is a risk with difficult exposure in a stiff knee, patella baja or previous tibial osteotomy. We sought to define a safe amount of release of the patellar tendon insertion for such cases. Eleven pairs of fresh frozen cadaveric lower limb specimens were acquired and randomized to either intact or partial release of the distal tibial insertion. Partial release of the tibial insertion of the tendon increased lateral exposure a mean 29% ± 15% (P = 0.002) while reducing ultimate strength to a mean of 80% that of the intact contralateral tendon. Measured patella release increased lateral patella translation and can be performed without risk of catastrophic rupture with basic activities of daily living following TKA.

Intercondylar fibrotic lesion after retrograde intramedullary nailing of a femoral shaft fracture: a case report and review of the literature.

Retrograde intramedullary nailing is a largely successful technique for the treatment of femoral shaft fractures, although reports of knee pain after this procedure are not uncommon. Here we describe the case of a patient who developed a polyp-like fibrotic lesion of the intercondylar notch nearly 2 years after retrograde intramedullary nailing of a femoral shaft fracture as discovered by arthroscopic evaluation. This lesion caused pain and compromised our patient's function; however, both of these measures were subjectively improved after the debridement of the lesion. This case emphasizes the necessity of long-term follow-up and further investigation into the cause and significance of postoperative knee pain in hopes of continuing to improve patient outcomes.

Midterm Outcomes in Lateral Unicompartment Knee Replacement: The Effect of Patient Age and Bearing Choice.

Isolated lateral compartment knee osteoarthritis (OA) affects between 7 and 10% of patients with knee OA. Although lateral unicompartmental knee arthroplasty (UKA) is an accepted treatment to manage this condition, it is performed relatively infrequently. The aim of this study was to evaluate the mid-term survivorship, radiographic outcomes, and patient-reported outcome measures (PROMs). We performed a retrospective review of a prospectively maintained database of consecutive isolated lateral UKAs performed by a single surgeon at an academic institution between September 2007 and December 2015. Our primary outcome was failure defined as revision surgery to total knee arthroplasty (TKA). Secondary outcomes included any additional surgery for any other reason. Forty-nine consecutive patients (27 females) with median age of 54.7 years (45.2-82.2) met the inclusion criteria. The survival rate for the whole cohort was 86.1% (95% confidence interval [CI]: 73.2-99.0) at 10 years as defined by conversion to TKA. There were a total of four lateral UKAs (all mobile bearings) revised to TKAs. The entire cohort demonstrated statistically significant improvements from preoperative PROMs compared with the most recent postoperative PROMs including the Western Ontario and McMaster Universities Osteoarthritis Index, Knee injury and Osteoarthritis Outcome Score, and Tegner activity scale at a median 8.8 (1.7-12.2) years follow-up. Patients with mobile bearing underwent higher revision to TKA and reoperation for all indications compared with fixed-bearing lateral UKA. In this relatively young cohort, lateral UKA yielded acceptable long-term survival and satisfactory improvement in functional outcomes. Patients who had fixed-bearing implants had similar improvement and trended toward lower revision rates than those with mobile-bearing implants. Level III therapeutic: retrospective Study was performed.

Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study.

OBJECTIVE: To evaluate a surgical screening clinic for patients with knee osteoarthritis (OA) referred for total knee arthroplasty (TKA) and explore management before referral. DESIGN: Descriptive study using retrospective chart review. SETTING: Large Canadian teaching hospital. PARTICIPANTS: Patients with knee OA referred for TKA over a 1-year period. INTERVENTIONS: Patients underwent standardized assessment by physicians who practice sport medicine to determine eligibility for surgical consultation. MAIN OUTCOME MEASURES: Proportion of patients deemed eligible for surgical consultation and undergoing TKA, and conservative management options tried before clinic referral. RESULTS: Of the 327 patients, 172 (52.6%) were referred to the surgeon, of whom 76% underwent TKA. Options used before referral were medications (92.0%), injections (41.3%), and physiotherapy (34.9%). Patients referred to the surgeon, compared with those who were not, were more likely to have met all referral criteria (86.5% vs 33.3%, P < 0.001), tried 3 or more options (70.9% vs 49.7%, P < 0.01), used injections (58.7% vs 32.3%, P < 0.001), scored higher on the Hip-Knee Priority Tool (45 vs 24, P < 0.001), and had been referred by a physician who practices sport medicine (88.2% vs 46.2%, P < 0.001). CONCLUSIONS: Orthopedic surgical screening by trained physicians using standardized tools halved the number of surgical consultations. Few conservative management options were tried before referral, indicating the need to enhance presurgical care for patients with knee OA.

Validity of a short-term quality of life questionnaire in patients undergoing joint replacement: the Quality of Recovery-40.

One hundred thirty-two patients undergoing total hip or knee arthroplasty were evaluated before and after surgery with the Quality of Recovery-40 (QoR-40) and the Short Form 12 (SF-12) questionnaires seven times over a 4-month period, with the objective of comparing their psychometric properties. Physical dimensions of the QoR-40 and SF-12 were not related in the days after surgery but moderately related over the first month. Only the change in score for the physical independence dimension of the QoR-40 exceeded measurement error. Effect sizes were larger for the QoR-40 within the first month post-surgery and larger for the SF-12 past 1 month. Effect sizes were larger for the physical dimensions of both instruments compared to the psychological dimensions. Only the physical independence dimension of the QoR-40 appears useful to assess the quality of life in the first month following surgery.

Outpatient unicompartment knee arthroplasty with indwelling femoral nerve catheter.

Contemporary multimodal anesthesia regimens allow the performance of unicompartment knee arthroplasty (UKA) on an outpatient basis. Our initial pilot experience is presented using a continuous femoral nerve block as an adjunct for 24 patients classified as American Society of Anesthesiology class 1 (14 men, 10 women; median age, 56 years; range, 46-72 years). After minimally invasive UKA, patients documented their pain and oral medication use while at home for the first 5 days. Adverse events, medication adverse effects, and the amount of infused ropivacaine were recorded. Median pain scores for the first 3 days were 1, 2, and 2 (at rest) and 4, 5, and 3 (during physical therapy). Eighteen patients (75%) required less than 4 mg oral hydromorphone/d. Of the 18, 10 (42%) did not require supplemental oral opioids. The median catheter use was 3 days. Our results suggest that with careful patient selection and adequate teaching, continuous femoral nerve blocks may be used as part of a multimodal pain regimen to assist the delivery of outpatient UKA with high patient satisfaction.

Unicompartmental knee arthroplasties revised to total knee arthroplasties compared with primary total knee arthroplasties.

We studied the technical operative features and the subjective outcomes of 63 patients requiring a revision to a total knee arthroplasty (TKA) for failed Oxford medial unicompartmental knee arthroplasty. We compared this revision study group to a contemporary control cohort of 126 patients who underwent primary TKAs. The 2 groups from the same institution had a minimum follow-up of 2 years and were retrospectively matched 1:2 for age, sex, body mass index, and follow-up time. Length of stay and hemoglobin level drop were similar. Technically, the revision group required larger polyethylene inserts (P < .001) and longer tourniquet times (P < .001) with 15 of these patients needing augments, grafts, and/or stems. Subjectively, the revision group's mean total Western Ontario and McMaster Universities Arthritis Index score was 25.8 ± 20.2, thus less satisfactory compared with the control group (19.8 ± 15.3) at a mean follow-up of 3.1 years (P = .03). A revision unicompartmental knee arthroplasty to TKA is technically more difficult and functionally less satisfactory at last follow-up when compared with a primary TKA.

Evaluation of Safety and Medium-Term Functional Outcomes of a Medial Fixed-Bearing Unicompartmental Knee Arthroplasty with Ultra-Highly Cross-Linked Polyethylene.

The primary objective of this study was to evaluate the in vivo safety of a unicompartmental knee arthroplasty design with sequentially annealed cross-linked polyethylene by evaluating reoperation rate, in particular those related to excessive polyethylene wear or breakage. The secondary objective was to examine functional outcomes via standardized questionnaires. This was a 5-year institutional review board-approved prospective single-surgeon case series of the first 152 consecutive patients with symptomatic medial unicompartmental osteoarthritis implanted with a partial knee replacement between May 2010 and December 2014. Study participants were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthrtis Index (WOMAC) questionnaires at preoperation and 2 to 5 years postoperation. Major complications and all reoperations were recorded and we produced Kaplan-Meier survivorship curves with the end point of revision to TKA. Pre- and postoperative differences for KOOS and WOMAC were evaluated by paired t-tests. The median length of follow-up was 7.2 (0-9.72) years. Seven patients required revision surgery to TKA (4.9% of patients): four with progression of arthritis in other compartments, two for infection, and one for loosening of the femoral component and subsequent progression of pain. There were no failures of polyethylene. Survival of cohort was 99.3 and 97.9% at 2 and 5 years, respectively. Patients significantly improved (p-value < 0.001) between preoperative assessment and at 2 years, with no decline at 5 years postoperation. These preliminary midterm results with this fixed-bearing design and cross-linked polyethylene were encouraging with no catastrophic failures of polyethylene. Patient reported outcomes were significantly improved and revision rates were acceptable and lower than registry reported results.

Decision support needs of patients choosing between unicompartmental and total knee arthroplasty for advanced medial compartment osteoarthritis of the knee.

Patients with isolated medial knee osteoarthritis are often candidates for both unicompartmental knee arthroplasty and total knee arthroplasty and must choose between these 2 options. We interviewed 20 such patients to describe their decision support needs and 14 knee arthroplasty surgeons to describe their requirements in supporting patients' decision making. Patients and surgeons both desired active patient participation in the decision. Of 14 surgeons, 13 identified a knowledgeable patient as the most important factor in facilitating decision making, but many worried about confusing patients from information overload. Patients, on the other hand, demonstrated poor knowledge of the advantages and disadvantages of each surgical option, and 17 of 20 desired supplemental educational resources. Thus, most patients choosing between unicompartmental knee arthroplasty and total knee arthroplasty would appreciate and benefit from a decision support intervention.

Initial experience with the oxford unicompartmental knee arthroplasty.

Our initial experience with mobile bearing medial compartment unicompartmental arthroplasty (UKA) is presented to highlight lessons that have been learned to avoid short-term failures. Consecutive cases of the Oxford medial UKA performed between February 2001 and April 2006 were reviewed to derive those cases that were revised to total knee arthroplasty (TKA). There were 545 patients available with mean age and body mass index of 65.0 and 30.1, respectively. At final follow-up, 32 patients were revised for lateral compartment arthritis, aseptic component loosening, persisting medial or anterior pain and dislocated meniscal bearing. Revisions were performed with primary unconstrained TKA implants with no stems or wedges required. Our results seem to reflect those seen in registries confirming an earlier higher revision rate and highlight the technical issues of overstuffing the compartment, inadequate cementation technique, and strict adherence to patient selection.

Mid-Term Evaluation of the Unicompartmental Knee Arthroplasty in Patients with BMI of 40 or Greater.

Limited evidence is available on mid-term follow-up for patients with body mass index (BMI) ≥ 40 receiving a unicompartmental knee arthroplasty (UKA). The primary objective of this study was to investigate survival of the UKA in patients with BMI ≥ 40. Secondary objectives were to assess functional and patient reported outcome measures (PROMs). Survival analysis with endpoint revision of any component for any reason was conducted using Kaplan-Meier technique on 121 knees (103 patients) that underwent UKA with Oxford Phase 3 implant (Oxford Knee, Biomet, Swindon, United Kingdom) between September 2001 and March 2014 by seven surgeons. Survivorship differences were compared using Log Rank (Mantel-Cox) tests, and Cox Proportional Hazard Model was used to assess predictors of failure. Preoperative PROMs were compared at 2 and 5 years postoperatively using paired t-tests. Mean age of patients was 58 years (43-75), mean BMI 43 kg/m2 (40-51), and mean follow-up 7 years (2 months to 15 years). Survival rate for the whole cohort was 92% at 2 years and 86% at 5 years. Females had a significantly higher revision rate than males (p = 0.043). A total of 19 knees required revision (16 to TKA, 2 polyethylene liner exchanges, and 1 femoral component and liner revision). With respect to PROMs, there was a significant improvement at 2 and 5 years (p < 0.001) on 4 of 5 knee injury and osteoarthritis outcome score subscales. The mid-term survival rate for the Oxford UKA in patients with morbid obesity is similar to that of other nondesigner patient series with BMI ≥ 30, which provides further evidence for the safety of the implant in this patient population with significant improvements on PROMs at short and mid-term follow-up.

Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution.

One thousand one hundred ninety patients underwent knee arthroplasty between January 2004 and July 1, 2007, and received an indwelling continuous infusion femoral catheter for postoperative ropivicaine pump infusion. Catheters were placed using electrical stimulation guidance. For the initial 469 patients (group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the infusion was discontinued 12 hours after surgery. There were 9 femoral nerve palsies (2 in group 1, 7 in group 2) and 8 major falls (0.7%). The overall complication rate was 1.5%, and the risk of permanent nerve injury was 0.2%. Patients should be made aware of these complications as part of the usual informed consent process before using this technique for postoperative pain control after knee arthroplasty. We did not observe fewer falls when the continuous infusion was stopped 12 hours after surgery.

Functional outcome after proximal humeral fractures treated with hemiarthroplasty.

OBJECTIVE: To evaluate functional outcome after hemiarthroplasty for displaced proximal humeral fractures and to review whether prosthesis type, intraoperative technique or previous ipsilateral shoulder surgery could affect the outcome. METHODS: We reviewed the medical records and radiographs of patients who had undergone hemiarthroplasty for proximal humeral fractures between 1992 and 2000. We identified 45 patients, 39 with acute fractures and 6 with fracture-related complications. One surgeon performed 17 surgeries (38%), and the rest were carried out by 11 other orthopedic surgeons. Using the American Shoulder and Elbow Surgeons Evaluation Form and the Western Ontario Rotator Cuff Index, we evaluated patients who had been followed for at least 2 years for residual shoulder pain, range of motion, strength, stability and function. The senior authors reviewed the radiographs. RESULTS: The mean age of the patients at presentation was 70 (range 46-95) years. The mean active forward elevation was 87 degrees, abduction 63 degrees and external rotation 22 degrees; the mean internal rotation was to the L2 vertebra. Of the patients, 15% reported severe pain, and 25% were unable to sleep on the affected side. Patients with previous surgeries and those with intraoperative cuff tears were found to have more postoperative pain. CONCLUSION: We conclude that soft tissue status and operative technique play an important role in late postoperative pain and range of motion. Hemiarthroplasty after failed open reduction and internal fixation is associated with inferior results. We were unable to show a difference in long-term outcome related to the prosthesis type.