Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Knee Arthroplasty.

BACKGROUND: Frailty can predict adverse outcomes after various orthopaedic procedures, but is not well-studied in revision total knee arthroplasty (rTKA). We investigated the correlation between the Hospital Frailty Risk Score (HFRS) and post-rTKA outcomes. METHODS: Using the Nationwide Readmissions Database, we identified rTKA patients discharged from January 2017 to November 2019 for the most common diagnoses (mechanical loosening, infection, and instability). Using HFRS, we compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients with multivariate and binomial regressions. The 30-day complication and reoperation rates were compared using univariate analyses. We identified 25,177 mechanical loosening patients, 12,712 infection patients, and 9,458 instability patients. RESULTS: Frail patients had higher rates of 30-day readmission (7.8 versus 3.7% for loosening, 13.5 versus 8.1% for infection, 8.7 versus 3.9% for instability; P < .01), longer length of stay (4.1 versus 2.4 days for loosening, 8.1 versus 4.4 days for infection, 4.9 versus 2.4 days for instability; P < .01), and greater cost ($32,082 versus $27,582 for loosening, $32,898 versus $28,115 for infection, $29,790 versus $24,164 for instability; P < .01). Frail loosening patients had higher 30-day complication (6.8 versus 2.9%, P < .01) and reoperation rates (1.8 versus 1.2%, P = .01). Frail infection patients had higher 30-day complication rates (14.0 versus 8.3%, P < .01). Frail instability patients had higher 30-day complication (8.0 versus 3.5%, P < .01) and reoperation rates (3.2 versus 1.6%, P < .01). CONCLUSIONS: The HFRS may identify patients at risk for adverse events and increased costs after rTKA. Further research is needed to determine causation and mitigate complications and costs.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Total Hip Arthroplasty.

BACKGROUND: Frailty has been associated with poor outcomes and higher costs after primary total hip arthroplasty. However, frailty has not been studied in relation to outcomes after revision total hip arthroplasty (rTHA). This study examined the relationship between the Hospital Frailty Risk Score (HFRS), postoperative outcomes, and cost profiles following rTHA. METHODS: In this retrospective cohort study, we identified patients who underwent rTHA from January 2017 to November 2019 in the Nationwide Readmission Database. The 3 most frequently reported diagnosis codes for rTHA were then selected: dislocation; mechanical loosening; and infection. We calculated the HFRS for each patient to determine frailty status. We compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients, using multivariate logistic and negative binomial regressions to adjust for covariates. We identified 36,243 total patients who underwent rTHA. Overall, 15,448 patients had a revision for dislocation, 11,062 for mechanical loosening, and 9,733 for infection. RESULTS: Compared to nonfrail patients, frail patients had higher rates of 30-day readmission, longer length of stay, and higher hospitalization cost. Frail patients had significantly higher rates of 30-day complication and 30-day reoperation. CONCLUSIONS: Frailty, measured using HFRS, is associated with increased postoperative complications and costs after rTHA. The HFRS has the ability to efficiently identify frail patients at-risk for perioperative complications enabling care teams to better focus optimization interventions on this patient cohort.

Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty.

BACKGROUND: Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA. METHODS: Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests. RESULTS: Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01). CONCLUSIONS: Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA. TYPE OF STUDY: Level III retrospective cohort study.

Perioperative management of leg-length discrepancy in total hip arthroplasty: a review.

Leg-length discrepancy (LLD) presents a significant management challenge to orthopedic surgeons and remains a leading cause of patient dissatisfaction and litigation after total hip arthroplasty (THA). Over or under-lengthening of the operative extremity has been shown to have inferior outcomes, such as dislocation, exacerbation of back pain and sciatica, and general dissatisfaction postoperatively. The management of LLD in the setting of THA is multifactorial, and must be taken into consideration in the pre-operative, intra-operative, and post-operative settings. In our review, we aim to summarize the best available practices and techniques for minimizing LLD through each of these phases of care. Pre-operatively, we provide an overview of the appropriate radiographic studies to be obtained and their interpretation, as well as considerations to be made when templating. Intra-operatively, we discuss several techniques for the assessment of limb length in real time, and post-operatively, we discuss both operative and non-operative management of LLD. By providing a summary of the best available practices and strategies for mitigating the impact of a perceived LLD in the setting of THA, we hope to maximize the potential for an excellent surgical and clinical outcome.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis.

BACKGROUND: The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve. QUESTIONS/PURPOSES: We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice? METHODS: A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs. RESULTS: At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values. CONCLUSION: For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

No Benefit to Sensor-guided Balancing Compared With Freehand Balancing in TKA: A Randomized Controlled Trial.

BACKGROUND: Soft tissue balancing in TKA has traditionally relied on surgeons' subjective tactile feedback. Although sensor-guided balancing devices have been proposed to provide more objective feedback, it is unclear whether their use improves patient outcomes. QUESTIONS/PURPOSES: We conducted a randomized controlled trial (RCT) comparing freehand balancing with the use of a sensor-guided balancing device and evaluated (1) knee ROM, (2) patient-reported outcome measures (PROMs) (SF-12, WOMAC, and Knee Society Functional Scores [KSFS]), and (3) various surgical and hospital parameters (such as operative time, length of stay [LOS], and surgical complications) at a minimum of 2 years of follow-up. METHODS: A total of 152 patients scheduled for primary TKA were recruited and provided informed consent to participate in this this study. Of these, 22 patients were excluded preoperatively, intraoperatively, or postoperatively due to patient request, surgery cancellation, anatomical exclusion criteria determined during surgery, technical issues with the sensor device, or loss to follow-up. After the minimum 2-year follow-up was accounted for, there were 63 sensor-guided and 67 freehand patients, for a total of 130 patients undergoing primary TKA for osteoarthritis. The procedures were performed by one of three fellowship-trained arthroplasty surgeons (RPS, HJC, JAG) and were randomized to either soft tissue balancing via a freehand technique or with a sensor-guided balancing device at one institution from December 2017 to December 2018. There was no difference in the mean age (72 ± 8 years versus 70 ± 9 years, mean difference 2; p = 0.11), BMI (30 ± 6 kg/m 2 versus 29 ± 6 kg/m 2 , mean difference 1; p = 0.83), gender (79% women versus 70% women; p = 0.22), and American Society of Anesthesiology score (2 ± 1 versus 2 ± 1, mean difference 0; p = 0.92) between the sensor-guided and freehand groups, respectively. For both groups, soft tissue balancing was performed after all bony cuts were completed and trial components inserted, with the primary difference in technique being the ability to quantify the intercompartmental balance using the trial tibial insert embedded with a wireless sensor in the sensor-guided cohort. Implant manufacturers were not standardized. Primary outcomes were knee ROM and PROMs at 3 months, 1 year, and 2 years. Secondary outcomes included pain level evaluated by the VAS, opioid consumption, inpatient physical therapy performance, LOS, discharge disposition, surgical complications, and reoperations. RESULTS: There was no difference in the mean knee ROM at 3 months, 1 year, and 2 years postoperatively between the sensor-guided cohort (113° ± 11°, 119° ± 13°, and 116° ± 12°, respectively) and the freehand cohort (116° ± 13° [p = 0.36], 117° ± 13° [p = 0.41], and 117° ± 12° [p = 0.87], respectively). There was no difference in SF-12 physical, SF-12 mental, WOMAC pain, WOMAC stiffness, WOMAC function, and KSFS scores between the cohorts at 3 months, 1 year, and 2 years postoperatively. The mean operative time in the sensor-guided cohort was longer than that in the freehand cohort (107 ± 0.02 versus 84 ± 0.04 minutes, mean difference = 23 minutes; p = 0.008), but there were no differences in LOS, physical therapy performance, VAS pain scores, opioid consumption, discharge disposition, surgical complications, or percentages of patients in each group who underwent reoperation. CONCLUSION: This RCT demonstrated that at 2 years postoperatively, the use of a sensor-balancing device for soft tissue balancing in TKA did not confer any additional benefit in terms of knee ROM, PROMs, and clinical outcomes. Given the significantly increased operative time and costs associated with the use of a sensor-balancing device, we recommend against its routine use in clinical practice by experienced surgeons. LEVEL OF EVIDENCE: Level I, therapeutic study.

What's New in Pediatric Limb Lengthening and Deformity Correction?

Over the past 5 years, published literature regarding treatment of pediatric limb deformity and limb length discrepancy demonstrates much interest in better understanding, categorizing and treating these challenging problems. Many studies explore expanding and refining indications for traditional treatment methods like guided growth techniques. Other studies have evaluated the results of new techniques such as lengthening via mechanized intramedullary nails. Additionally, series comparing older and newer techniques such as lengthening with external devices versus mechanized nails are becoming increasingly available.

Robotic-assisted unicompartmental knee replacement offers no early advantage over conventional unicompartmental knee replacement.

PURPOSE: Unicompartmental knee arthroplasty (UKA) is effective for treating degenerative joint disease in a single compartment. Robotic-arm-assisted arthroplasty (RAA) has gained popularity and has theoretical benefits of improved outcomes over conventional (CONV) UKA due to the technical precision of bone preparation. This study compares the short-term clinical outcomes, including survivorship and patient-reported functional outcomes, for a series of medial UKAs performed with RAA and CONV. METHODS: One hundred seventy-six consecutive fixed-bearing medial UKAs were retrospectively identified with a minimum follow-up of 2 years. One hundred and eighteen CONV and 58 RAA were performed. Pre- and post-operative SF12, WOMAC, and KSS Functional Questionnaires were available for all patients. RESULTS: At 2 years, both groups improved in all functional outcomes, with no significant difference between the RAA and CONV cohorts. However, the RAA cohort had a significantly longer operative time (p < 0.001) and a higher early revision rate than the CONV group (7 [12.0%] vs. 7 [6.8%]; p < 0.05). CONCLUSIONS: These results demonstrate that at short-term follow-up of 2 years, RAA was not superior to CONV in terms of functional scores and instead was associated with greater operative time and cost and lower survivorship. Therefore, at this time usage of RAA in UKA is not recommended compared to conventional UKA. Longer term studies are necessary to draw conclusions about the overall outcomes of RAA compared to CONV. LEVEL OF EVIDENCE: III.

Preemptive Analgesia With Oxycodone Is Associated With More Pain Following Total Joint Arthroplasty.

BACKGROUND: Preemptive multimodal analgesia (PMA) is a commonly used technique to control pain following total joint arthroplasty. PMA protocols use multiple analgesics immediately preoperatively to prevent central sensitization and amplification of pain during surgery. While benefits of some individual components of a PMA protocol have been established, there are little data to support inclusion or exclusion of opioids in this context. METHODS: This is a retrospective cohort study of 550 patients undergoing elective, primary total joint arthroplasty at a single institution using a standardized preoperative perioperative protocol. Two hundred seventy-five patients received oxycodone in addition to a standard multimodal preoperative analgesia regimen just before surgery and were compared to a matched cohort of 275 patients who received the standard regimen alone. Outcome measures included inpatient visual analog scale pain scores, inpatient opioid consumption, length of stay, and ambulation distance with physical therapy. RESULTS: Patients who received opioids in preoperative holding reported significantly greater visual analog scale pain scores on postoperative day 1 (3.7 vs 3.1; P = .01), when compared to those who did not. These patients also walked shorter distances on postoperative day 0 (59.5' vs 125.7'; P < .001) and consumed greater morphine equivalents per hospital day over the course of their hospital stay (52.2 vs 37.2 mg; P < .001). These differences remained significant when stratified by procedure, total knee arthroplasty or total hip arthroplasty. Differences in pain and function between groups were more pronounced in patients undergoing total hip arthroplasty than those undergoing total knee arthroplasty. CONCLUSION: Total joint patients who were given preemptive opioids immediately before surgery experienced more pain, consumed more postoperative opioids, and exhibited impaired early function as compared to those who were not given preemptive opioids. Orthopedic surgeons should reconsider routine use of preemptive opioids in this context.

Transdermal Scopolamine as an Adjunct to Multimodal Pain Management in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Postoperative nausea and vomiting (PONV) after surgery degrades patient experience, tolerance of pain medication, rehabilitation progress, and functional outcomes. Given the importance of early rehabilitation following total joint arthroplasty (TJA), we asked whether transdermal scopolamine is effective in reducing rates of PONV and improving functional outcomes following TJA. METHODS: We retrospectively reviewed the charts of 1580 consecutive patients who underwent TJA between 2014 and 2017 and compared patients before the addition of the scopolamine patch (control group) to those after the addition (study group). Patients were given the scopolamine patch in the holding area unless contraindicated. A total of 495 patients were excluded. Charts were reviewed for PONV, demographic information, surgical time, length of stay, distance walked with physical therapy, and Visual Analog Scale pain scores. Student t-test was used to compare continuous data and chi-square was used for categorical variables. RESULTS: The incidence of PONV was significantly lower in the study group compared to the control group (14.4% vs 29.3%, P < .0001). Patients who were given scopolamine had lower Visual Analog Scale pain scores on postoperative days (POD) 0 through 2 (P < .01), were able to walk further distances on POD 0 through 3 (P < .001), and received fewer morphine equivalents on POD 1 and 2 (P < .001). Greater morphine equivalents were received by the study group on POD 0. CONCLUSION: Use of a scopolamine patch was associated with significant reduction in PONV and improvement in functional outcomes following TJA. These data support the use of transdermal scopolamine as part of a multimodal, perioperative pain protocol in patients undergoing TJA.

Hemiarthroplasty Conversion: A Comparison to Primary and Revision Total Hip Arthroplasty.

BACKGROUND: Arthroplasty is the standard of care for elderly patients with displaced femoral neck fractures, with viable options including hemiarthroplasty (HA) and total hip arthroplasty (THA). With time, HA may need to be converted to THA, but it is unclear whether this is more similar to primary or revision THA. We compare complication and revision rates between these groups within 90 days and 2 years postoperatively. METHODS: We retrospectively reviewed 3 cohorts of patients treated at our institution: primary, conversion, and revision THA. Outcomes studied included intraoperative data, postoperative complications, and revision rates. We analyzed the groups using both parametric (analysis of variance test) and nonparametric (chi-squared test) statistics. RESULTS: Operative time between primary THA (108.0 minutes), conversion HA (147.9 minutes), and revision THA (160.1 minutes) cohorts differed significantly (P = .011). Estimated blood loss was also different between primary THA (386 mL), conversion HA (587 mL), and revision THA cohorts (529 mL) (P = .011). At 2 years, major complication rates between primary THA (6.2%), conversion HA (11.7%), and revision THA (26.7%) cohorts also differed significantly (P = .003), as was the revision rate in the primary THA (4.6%), conversion HA (10.0%), and revision THA (18.3%) cohorts (P = .043). CONCLUSION: This is the first study to compare short-term and midterm complications between primary, conversion, and revision THA. We observed conversion HA had similar operative time and estimated blood loss to revision THA, which was significantly higher than primary THA. However, we found that conversion HA more closely resembled primary THA with respect to perioperative complications rates.

The Learning Curve by Operative Time for Soft Tissue Balancing in Total Knee Arthroplasty Using Electronic Sensor Technology.

BACKGROUND: Electronic sensor devices can provide an objective assessment of soft tissue balancing in total knee arthroplasty (TKA) which may potentially decrease postoperative pain. We aim to quantify the learning curve for operative time (OT) for this technology. METHODS: Consecutive TKA cases balanced with an electronic sensor balancing device by one senior surgeon from 2013 to 2017 were included in this study. The OT (in minutes) was analyzed using the cumulative sum analysis to evaluate the learning curve for this technology. Further analysis was done by splitting the 287 patients into 7 cohorts, 41 patients each. RESULTS: Two hundred eighty-seven patients balanced with sensor technology were available for analysis. The cumulative sum OT learning curve estimated that this technology's learning curve was 41 cases. This curve consisted of 2 phases: phase 1 which includes the first 41 cases and phase 2 which includes the remaining 246 patients. The mean OT for the first and last sensor-assisted cohorts was 120.4 and 108.9 minutes (P = .021). The mean OT for the first sensor-assisted cohort and the control cohort was 120.4 versus 109 minutes (P = .023). The mean OT for the last sensor-assisted cohort and the control cohort was 108.9 versus 109 minutes (P = .94). CONCLUSION: Our findings suggest that it takes approximately 41 cases of sensor-assisted TKA cases to achieve OTs identical to manually balanced TKA cases. This is a relatively shallow learning curve for the sensor technology, and allows arthroplasty surgeons to objectively achieve soft tissue balancing without adding OT to the surgery.

Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption.

BACKGROUND: Early ambulation with physical therapy (PT) following total knee arthroplasty (TKA) has demonstrated benefits in the literature. However, the impact of early PT on rehabilitation performance and opioid consumption has not been elucidated. We evaluate the effect of same-day PT on inhospital functional outcomes and opioid consumption. METHODS: We retrospectively identified 2 cohorts of primary TKA patients from July 2016 to December 2017: PT0 (n = 295) received PT on the day of surgery, and PT1 (n = 392) received PT on postoperative day (POD) 1. Outcomes studied included number of feet walked on POD0-3, visual analog scale pain scores, morphine equivalents (ME) consumed, length of stay, and discharge disposition. Analysis was conducted using the Student t-test and Fisher exact test. RESULTS: In comparison to the PT1 group, the PT0 group walked significantly more steps on POD1 (347.6 vs 167.4 ft, P < .0001), POD2 (342.1 vs 203.5 ft, P < .0001), and POD3 (190.3 vs 128.9 ft, P = .00028). There was no difference between the 2 groups for visual analog scale. The PT0 group also consumed significantly fewer total ME when compared to the PT1 group (149.0 vs 200.3 mg, P = .0002). The PT0 group had a significantly shorter length of stay when compared to the PT1 group (2.7 vs 3.2 days, P = .00075). More patients were discharged home in the PT0 group (81.7% vs 54.8%, P < .0001). CONCLUSION: We observed that initiation of PT on POD0 led to better PT performance, reduced ME during hospitalization, and more patients discharged home. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Should Cannabinoids Be Added to Multimodal Pain Regimens After Total Hip and Knee Arthroplasty?

BACKGROUND: This study investigated the effects of dronabinol on pain, nausea, and length of stay following total joint arthroplasty (TJA). METHODS: We retrospectively compared 81 consecutive primary TJA patients who received 5 mg of dronabinol twice daily in addition to a standard multimodal pain regimen with a matched cohort of 162 TJA patients who received only the standard regimen. A single surgeon performed all surgeries. Patient demographics, length of stay, opioid morphine equivalents (MEs) consumed, reports of nausea/vomiting, discharge destination, distance walked in physical therapy, and visual analog scale pain scores were collected for both groups. Student's t-tests as well as chi-square or Mann-Whitney U-tests were used for statistical comparisons. RESULTS: There were no significant differences between the 2 groups for age, gender, body mass index, American Society of Anesthesiologists score, anesthesia type, visual analog scale scores, distance walked with physical therapy, discharge disposition, or episodes of nausea/vomiting. The mean length of stay in the dronabinol group was significantly shorter at 2.3 ± 0.9 days versus 3.0 ± 1.2 days in the control group (P = .02). In the context of a shorter stay, the dronabinol group consumed significantly fewer total MEs (252.5 ± 131.5 vs 313.3 ± 185.4 mg, P = .0088). Although the dronabinol group consumed fewer MEs per day and per length of stay on average, neither of these achieved statistical significance. No side effects of dronabinol were reported. CONCLUSION: These findings suggest that further investigation into the role of cannabinoid medications for non-opioid pain control in the post-arthroplasty patient may hold merit.

Treatment of Periprosthetic Knee Infection With Concurrent Rotational Muscle Flap Coverage Is Associated With High Failure Rates.

BACKGROUND: Soft-tissue deficiency is a potentially devastating complication of the infected total knee arthroplasty (TKA). Rotational muscle flaps are commonly used to address these defects. However, reported success rates vary widely. METHODS: We reviewed 26 consecutive patients who underwent rotational muscle flap surgery for full-thickness anterior soft-tissue defect during treatment of an infected TKA. Twenty-four cases used a medial gastrocnemius rotational flap, 1 used a lateral gastrocnemius flap, and 1 used a rectus femoris-vastus intermedius flap. Implant survival, recurrence of infection, and limb survival were reported. Patient and procedural characteristics were tested for association with failure using χ2 and Student t-test. Kaplan-Meier analysis was used to estimate the failure-free survival function. RESULTS: Mean follow-up time was 3.3 years. Eighteen of 26 patients (69.2%) experienced recurrent infection requiring an average of 5.3 additional operations (range, 1-20). Five (19.2%) required arthrodesis while 6 (23.1%) eventually underwent above-the-knee amputation. Two patients (7.7%) died due to complications of revision surgery or persistent infection. Eleven patients (42.3%) were infection free with a retained prosthesis after treatment at a mean follow-up of 5.3 years (range, 0.7-18.0 years). CONCLUSION: Rotational muscle flap coverage of soft-tissue defects in the setting of the infected TKA remains a viable salvage option. However, despite adequate tissue coverage, many patients experience recurrent infection requiring additional surgical treatment. Patients and surgeons should be aware of the potential high failure rates observed when treating these complex problems.

The Use of Electronic Sensor Device to Augment Ligament Balancing Leads to a Lower Rate of Arthrofibrosis After Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a highly successful surgery shown to improve quality of life. One of the more common known complications of TKA is early arthrofibrosis requiring manipulation under anesthesia (MUA). This investigation evaluates the incidence of arthrofibrosis before and after the implementation of an electronic sensor device used to assist with ligament balancing. METHODS: Six hundred ninety TKAs performed without sensor use were compared to a cohort of 252 TKAs performed with sensor usage. RESULTS: Prior to usage, there was a 5% rate of MUA after TKA, while after implementation, the MUA rate went down to 1.6% (P = .004). Ligament balancing using sensor assistance led to a statistically significant decrease in MUA in this cohort of patients. An odds ratio analysis also demonstrated that non-sensor patients had a 3.2× higher likelihood of requiring MUA than the sensor patients. CONCLUSION: The use of an electronic sensor device during trialing of TKA with resultant improved ligamentous balancing led to a statistically significant reduction in the rate of MUA in this cohort of patients. This type of approach to ligamentous balancing may continue to show evidence of improved clinical outcomes.

The Effect of Periprosthetic Fractures Following Total Hip and Knee Arthroplasty on Long-Term Functional Outcomes and Quality of Life.

Background: Periprosthetic fractures (PPFs) after total joint arthroplasty (TJA) can be devastating, yet their long-term impact has not been well described. The aim of this study is to compare the long-term outcomes of patients who sustained a PPF about a TJA with those of patients who underwent an uncomplicated TJA. Methods: Patients who sustained a PPF after primary TJA between 2005 and 2014 were identified. Seventeen patients with a minimum 2-year follow-up (PPF cohort) were compared to a matched cohort of 67 patients who underwent uncomplicated TJA. Demographic data, comorbidities, surgical details, and complications were analyzed. Quality of life and functional outcomes were assessed with 12-Item Short Form Health Survey (SF-12), Western Ontario and McMasdter Universities Arthritis Index (WOMAC), and Knee Society Function Score. Results: The overall complication rate was 41.2% in the PPF group, including 3 additional fractures (17.6%), 2 wound infections (11.8%), one prosthetic joint infection (5.8%), and one painful patellar hardware necessitating removal (5.8%). At 2 years, both physical and mental components of the SF-12 were significantly lower for the PPF cohort vs control (SF-12-P, 28.7 ± 4.4 vs 40.8 ± 10.3, P < .001, SF-12-M, 36.7 ± 5.07 vs 55.0 ± 8.19, P < .0001). WOMAC pain and function scores were also significantly worse in the PPF cohort vs control at 2 years (WOMAC-pain, 38.8 ± 29.9 vs 87.4 ± 22.1; P < .0001, WOMAC-function, 40.7 ± 8.7 vs 76.1 ± 20.3; P < .0001). At 2 years, score improvements from prearthroplasty baseline were significantly greater in the control cohort vs PPF for SF-12-physical, WOMAC-pain, and WOMAC-function. Conclusions: Patients who sustained PPFs following TJA have poor long-term outcomes despite appropriate treatment. These results can help counsel patients and encourage heightened efforts to minimize the risk of PPF. Level of Evidence: Level III.

Computed Tomography Scan Versus Saline Load Test in the Detection of Traumatic Arthrotomies of the Ankle: A Cadaveric Study.

OBJECTIVE: To evaluate the sensitivity and ability of computed tomography (CT) scan for diagnosing traumatic ankle arthrotomies compared with that of the saline load test (SLT). METHODS: Eleven cadaveric ankles were included in this study. Before intervention, a CT scan was obtained to confirm the absence of intra-articular air. Arthrotomies were created at the anterolateral, posterolateral, anteromedial, and posteromedial aspects of the ankle under fluoroscopic visualization. A postarthrotomy and postrange of motion CT scan was obtained to evaluate for the presence of intra-articular air. Each ankle then underwent a SLT with 60 mL of saline, where volumes provoking extravasation were recorded. RESULTS: Of the 11 included ankles, intra-articular air was detected in all 11 ankles by CT scan. All 11 ankles also demonstrated extravasation of saline through the arthrotomy site during SLT. Thus, the sensitivity for both CT scan and SLT for detecting ankle traumatic arthrotomy was 100%. The mean volume of saline needed for extravasation was 7.7 mL, with a range of 3-22 mL and a SD of 5.4. CONCLUSIONS: Given that CT scan was equally as sensitive to the SLT, this study presents good evidence that CT scan may be used for the detection of ankle traumatic arthrotomies.

Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review.

¼: Obesity, defined as body mass index (BMI) ≥30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly. ¼: From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI ≥40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI ≥30) or morbidly obese (BMI ≥40). ¼: In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI ≥40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision. ¼: The current literature on the role that bariatric weight loss surgery before TJA has on improving surgical outcomes is split and referral to a bariatric surgeon should be a shared-decision between patient and surgeon on a case-by-case basis. ¼: Despite the increased risk profile of TJA in the morbidly obese cohort, these patients consistently show improvement in pain and physical function postoperatively that should be considered when deciding for or against surgery.

Computed Tomography Scan Versus Saline Load Test for Detection of Traumatic Shoulder Arthrotomy: A Cadaveric Study.

OBJECTIVES: Traumatic shoulder arthrotomy (TSA) is a rare injury that is commonly detected through saline load test (SLT). There are no studies that have studied the ability of computed tomography (CT) scan to detect a TSA. The purpose of this study is to determine the ability of CT scan to detect a TSA and compare it with the SLT. METHODS: Twelve cadaveric shoulders were included in the study. Before intervention, a CT scan was conducted to determine presence of intra-articular air. After confirmation that no air was present, an arthrotomy was made at the anterior or posterior portal site. A CT was obtained postarthrotomy to evaluate for intra-articular air. Each shoulder then underwent an SLT to assess the sensitivity of SLT and the volume needed for extravasation. RESULTS: Twelve shoulders were included after a pre-intervention CT scan. Six shoulders received an arthrotomy through the anterior portal and six shoulders received an arthrotomy through the posterior portal. After the arthrotomy, air was visualized on CT scan in 11 of the 12 shoulders (92%). All 12 shoulders demonstrated extravasation during SLT. The mean volume of saline needed for extravasation was 29 mL with an SD of 10 and range of 18-50 mL. CONCLUSIONS: CT scan is a sensitive modality (sensitivity of 92%) for detection of TSA. In comparison, SLT is more sensitive (sensitivity of 100%) and outperforms CT scan for the diagnosis of TSA in a cadaveric model. Further research is needed to solidify the role that CT imaging has in the diagnosis of TSAs.