Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success.

BACKGROUND: The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA). METHODS: There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours). RESULTS: In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer. CONCLUSIONS: Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Does Automated Impaction Improve Femoral Component Sizing and Alignment in Total Hip Arthroplasty?

BACKGROUND: While automated impaction can provide a more standardized process for femoral canal preparation, little is known regarding its effect on femoral component sizing and position. The purpose of our study was to directly compare femoral component canal fill ratio (CFR) and coronal alignment between primary total hip arthroplasty (THA) procedures performed with automated impaction versus manual mallet impaction. METHODS: A retrospective analysis was performed on 184 patients who underwent primary THA by a single arthroplasty surgeon between 2017 and 2021 with a modern cementless femoral component using either the direct anterior or posterolateral approach. The final cohort was divided into 2 groups based on impaction technique during broaching: automated (N = 122) or manual (N = 62). A propensity score match was used to match for age, body mass index, sex, high versus standard offset stem, and preoperative femoral bone quality. Radiographic review was performed to measure intramedullary prosthetic CFR and coronal alignment. RESULTS: The automated cohort trended toward the use of a larger stem (5.67 versus 4.82, P = .006) and had a larger CFR at all 4 levels within the proximal femur (P = .004). The automated cohort had a more valgus and reliable coronal alignment (-0.57 (SD 1.50) versus -0.03 (SD 2.17) degrees, P = .03) and significantly shorter operative time (mean 78 versus 90 minutes, P < .001). There were no intraoperative or postoperative periprosthetic fractures in either cohort. CONCLUSION: Automated impaction in primary THA is a safe technique for femoral preparation, which resulted in improved stem coronal alignment, optimized canal fill within the proximal femur, and reduced operative times.

Survivorship, Clinical and Radiographic Outcomes of a Novel Cementless Metal-Backed Patella Design.

BACKGROUND: Enhanced implant longevity through biological fixation is achievable using cementless total knee arthroplasty but concerns about patellar component failure have lingered because of prior experiences with older component designs. A new metal-backed patella (MBP) design was released which features a 3-dimensional printed porous titanium metal backing to improve biologic fixation potential and a unique compression molding technique to create a stronger interlock layer between the polyethylene and metal backing. Our study purpose was to determine the clinical and radiographic outcomes and survivorship of this novel cementless MBP. METHODS: Our institutional registry identified 388 cementless MBP with minimum 2-year and 80 with minimum 5-year follow-up. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores were used to evaluate clinical outcomes. Aseptic loosening noted on radiographs as well as revision for any reason were the end points used to determine survivorship. RESULTS: Improvement in the preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, VR/SF-12 physical health and mental health scores were all statistically significant at 2-year follow-up and the VR/SF-12 mental health score at 5-year follow-up. By radiologic criteria, biologic fixation of the patellar component was present in all except 1 case at 2 years (99.6%) and at 5 years (97.7%). Radiolucent lines were present in 15 cases (6.2%) at 2 years and in 6 cases (14%) at 5 years, but progressive increase in radiolucent lines was seen in only 4 cases. No component was revised for loosening; aseptic survivorship was 100%. CONCLUSION: This 3-dimensional printed cementless patellar component shows excellent survivorship at 2-year and 5-year follow-up. We are hopeful about the long-term durability of this implant.

Lateral Trochanteric Pain Following Primary Total Hip Arthroplasty: Incidence and Success of Nonoperative Treatment.

BACKGROUND: Our study aimed at quantifying the overall incidence of lateral trochanteric pain (LTP) following total hip arthroplasty (THA) and risk based on surgical approach. The success of conservative treatment and potential risk factors for failure of conservative treatment were evaluated. METHODS: This is a retrospective review of patients who underwent primary THA between 2010 and 2019 and had a postoperative diagnosis of ipsilateral LTP. Chart review revealed patient demographics/comorbidities, preoperative diagnosis, surgical approach, femoral components, and nonoperative treatment modalities. Radiographic analysis was performed to measure leg length discrepancy, femoral offset, and femoral head lateralization. RESULTS: The incidence of LTP following primary THA was 1.70% (573/33,761) with an average time to diagnosis of 27.3 months. The direct anterior approach demonstrated the highest risk and the direct lateral demonstrated the lowest risk for LTP (P < .001). Also, 82.4% (472/573) were diagnosed greater than 6 months postoperatively (P < .001). Of 573 patients, 95 (16.6%) were treated with physical therapy, home exercises, or oral medications with a success rate of 96.8% (92/95). Remaining 478 (83.4%) were treated with corticosteroid injection (CSI). And 89.5% (428/478) of the CSI cohort demonstrated clinical improvement with 3 or less CSIs. Risk factors for failure of conservative treatment were depression (P = .034), kidney disease (P = .040), and osteoporosis (P = .007). CONCLUSION: Postoperative LTP after THA is rare with an incidence of 1.70%. The direct anterior approach presented higher risk of LTP. Non-CSI modalities and CSIs were both successful treatment options. In patients with depression, kidney disease, and osteoporosis, conservative treatment may be less efficacious.

A Role for Modern Primary Cementless Femoral Stems in Revision Hip Arthroplasty.

BACKGROUND: In revision total hip arthroplasty (THA) cases with preserved femoral metaphyseal bone, tapered proximally porous-coated "primary" femoral stems may be an option. The objective of this study was to compare outcomes of patients with Paprosky I or II femoral bone loss undergoing revision THA with either a primary metaphyseal-engaging cementless stem or a revision diaphyseal-engaging stem. METHODS: This was a retrospective analysis of 70 patients with Paprosky I or II femoral bone loss who underwent femoral revision. 35 patients who were revised using a primary cementless femoral stem were compared with 35 patients who underwent femoral revision using a revision diaphyseal-engaging stem. The groups were similar regarding age, gender, body mass index, and American Society of Anesthesiologists. Clinical and radiographic outcomes and complications were compared over an average follow-up of 2.9 years (SD 1.4). RESULTS: Revision THA was most commonly performed for periprosthetic joint infection (N = 27, 38.6%). The groups were similar with regards to Paprosky femoral classification (P = .56), length of stay (P = .68), discharge disposition (P = .461), operative time (P = .20), and complications (P = .164). There were no significant differences between primary and revision femoral stem subsidence (0.12 vs. 0.75 mm, P = .18), leg length discrepancy (2.3 vs. 4.05 mm, P = .37), and Hip Disability and Osteoarthritis Outcome Score Jr (73.1 [SD 21.1] vs. 62.8 [SD 21.7], P = .088). No patient underwent additional revision surgery involving the femoral component. CONCLUSION: Use of modern primary cementless femoral stems is a viable option for revision hip arthroplasty in the setting of preserved proximal femoral metaphyseal bone. Outcomes are not inferior to those of revision stems and offer potential benefits.

Short-Term Follow-Up of Patellar Component Revision in Patients With Isolated Patellar Component Loosening.

BACKGROUND: The etiology of patellar component loosening can be multifactorial, including component malposition, trauma, infection, and poor implant design. These cases may be managed with isolated patellar component revision or simultaneous patellar component with femoral and/or tibial component revision. Isolated patellar revision in the setting of aseptic loosening historically has had limited success with high rates of repeat revision. METHODS: We performed a retrospective cohort study of 75 cases diagnosed with patellar component loosening that underwent revision. Patients were followed for a minimum of 2 years. Cases were categorized as either isolated patellar (IP) revision or patellar with femoral and/or tibial component (P + O) revisions. Survivorship and re-revision causes were compared between groups. Secondary outcomes included surgical time, estimated blood loss, range of motion, and length of stay. RESULTS: Fifty patients underwent IP revision, and 25 patients had P + O revision. Overall survivorship at the 2-year follow-up interval was 94.6%. Survivorship of IP revision undertaken for aseptic loosening was 94%. Survivorship of P + O revision was 96%. Eight percent of patients required reoperation from the P + O revision group, while 12% of patients in the IP revision group underwent a reoperation. Patients undergoing IP revision had better postoperative range of motion, lower surgical times, lower estimated blood loss, and decreased length of stay. CONCLUSION: IP revision demonstrates excellent survivorship and clinical outcomes comparable to P + O revision. When appropriate, IP revision should be considered as a potential treatment option. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty.

BACKGROUND: There is an association between intraoperative and postoperative femoral fractures and the direct anterior approach (DAA) to total hip arthroplasty (THA). The purpose of our study is to identify risk factors for Vancouver B fractures and to establish a predictable timeline for when these occur. METHODS: We retrospectively identified patients with Vancouver B periprosthetic femoral fractures (n = 49) after 11,509 elective primary cementless THA procedures through the DAA between 2012 and 2018 at a single institution. Fracture patients were matched to nonfracture patients (n = 267) by date of surgery and surgeon. Clinical and radiographic factors were collected for multivariable analysis to identify predictors of fracture. RESULTS: Periprosthetic Vancouver B femoral fracture incidence was 0.4%. 48 (98%) fractures were postoperative. Fractures occurred at an average of 44 days after surgery (range: 1 to 653 days) with >85% of fractures occurring in the first 6 weeks postoperatively. Significant variables predictive of fracture included >3 degrees valgus and >5 degrees varus coronal stem malalignment, Dorr B and C femoral geometry, lower canal flare index (2.75 vs 3.20), advanced age, increased comorbidities, greater stem canal fill, and right-sided procedures. CONCLUSION: Despite an overall low rate of Vancouver B perioperative periprosthetic femoral fractures, it is a devastating complication that typically presents within the first 6 weeks after DAA THA surgery. The risk is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures.

The Efficacy of Liposomal Bupivacaine Over Traditional Local Anesthetics in Periarticular Infiltration and Regional Anesthesia During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Since its Food and Drug Administration approval in 2011 as a local anesthetic for postsurgical analgesia, liposomal bupivacaine (LB) has been incorporated into the periarticular injection (PAI) of many knee surgeons. The slow release of this medication from vesicles should significantly extend the duration of its analgesic effect, but current evidence has not clearly demonstrated this benefit. METHODS: We systematically searched electronic databases including PubMed, MEDLINE, Cochrane Library, EMBASE, ScienceDirect, and Scopus, as well as the Journal of Arthroplasty web page for relevant articles. All calculations were made using Review Manager 5.3. RESULTS: We identified 42 studies that compared LB to an alternate analgesic modality. Seventeen of these studies were controlled trials that were included in meta-analysis. Significant differences were seen in pain scores with LB over a peripheral nerve block (mean difference = 0.45, P = .02) and LB over a traditional PAI (standard mean difference = -0.08, P = .004). CONCLUSION: While LB may offer a statistically significant benefit over a traditional PAI, the increase in pain control may not be clinically significant and it does not appear to offer a benefit in reducing opioid consumption. However, there is no standardization among current studies, as they vary greatly in design, infiltration technique, and outcome measurement, which precludes any reliable summarization of their results. Future independent studies using a standardized protocol are needed to provide clear unbiased evidence.

A Simple Protocol to Stratify Pulmonary Risk Reduces Complications After Total Joint Arthroplasty.

BACKGROUND: Pulmonary complications after total joint arthroplasty are a burden to patients and the healthcare system. The aim of this study is to demonstrate the effectiveness of a pulmonary screening questionnaire and intervention protocol developed at our institution to prevent pulmonary complications. METHODS: Between 2010 and 2015, 7658 consecutive total joint arthroplasty patients at our institution were reviewed. Based on our pre-operative pulmonary risk assessment tool, 1625 patients were flagged as high pulmonary risk. Patients were determined to be high risk if they were a current or former heavy smoker with an abnormal spirometry, had a positive obstructive sleep apnea screening, required continuous positive airway pressure/bi-level positive airway pressure use, had a history of significant pulmonary disease, had an oxygen saturation <90%, or had body mass index >40. A standardized monitoring protocol and interventions including smoking cessation, treatment and optimization of primary pulmonary conditions, peri-operative inhaler use, spinal anesthesia, aspiration precautions, elevated head of bed >20° resting and >45° while eating, maintaining oxygen saturation ≥92%, early use of incentive spirometer, avoidance of narcotics and early respiratory therapy consult were initiated for all high risk patients. RESULTS: Only 7 of 7658 (0.091%) patients suffered pulmonary complications after initiating our intervention protocol. These included 3 aspiration pneumonias, 1 asthma exacerbation, 1 chronic obstructive pulmonary disease exacerbation, 1 continuous positive airway pressure intolerance in a patient with obstructive sleep apnea, and 1 requirement of bi-level positive airway pressure. The pulmonary risk questionnaire accurately identified all patients who had pulmonary complications. The overall pulmonary complication rate at our institution decreased from 5.7% to 0.09% after implementing our screening questionnaire and intervention protocol (P < .0001). CONCLUSION: Our results demonstrate a more than 63-fold reduction in pulmonary complications at our institution. Our screening questionnaire and intervention protocol is an effective way of identifying and preventing pulmonary complications.

Primary Total Knee Arthroplasty Implants as Functional Prosthetic Spacers for Definitive Management of Periprosthetic Joint Infection: A Multicenter Study.

BACKGROUND: There are limited data on the utility of a standard primary total knee arthroplasty (TKA) femoral component with an all polyethylene tibia as a functional prosthetic spacer in place of a conventional all cement spacer for the management of periprosthetic joint infection (PJI). The aim of this multicenter study was to retrospectively review (1) ultimate treatment success; (2) reimplantation rates; (3) reoperation rates; and (4) change in knee range of motion in patients managed with functional prosthetic spacers following TKA PJI. METHODS: A retrospective review was performed for patients at 2 tertiary care centers who underwent a functional prosthetic spacer implantation as part of a functional single-stage (n = 57) or all cement spacer conventional two-stage (n = 137) revision arthroplasty protocol over a 5-year period. Outcomes including reinfection, reimplantation, and reoperation rates, success rate as defined by the Delphi criteria, and final range of motion were compared between the 2 cohorts at a minimum of 2-year follow-up. RESULTS: There was no significant difference in reinfection (14.0 vs 24.1%), reoperation (19.3 vs 27.7%), or success rates (78.9 vs 70.8%; P > .05 for all) between the one-stage and two-stage revision TKA cohorts. Mean final total arc of motion was also similar between the 2 groups (105.8 vs 101.8 degrees, respectively). CONCLUSION: Functional prosthetic spacers offer the advantage of a single procedure with decreased overall hospitalization and improved cost-effectiveness with analogous success rates (78.9%) compared with two-stage exchange (70.8%) at mid-term follow-up. Although long-term data are required to determine its longevity and efficacy, the outcomes in this study are encouraging. LEVEL OF EVIDENCE: 3.

A Proactive Approach to High Risk Delirium Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Delirium is a common complication among elderly patients undergoing total joint arthroplasty (TJA). Its incidence has been reported from 4% to 53%. The Centers for Medicare and Medicaid Services consider delirium following TJA a "never-event." The purpose of this study is to evaluate a simple perioperative protocol used to identify delirium risk patients and prevent its incidence following TJA. METHODS: Our group developed a protocol to identify and prevent delirium in patients undergoing TJA. All patients were screened and scored in the preoperative assessment, on criteria such as age, history of forgetfulness, history of agitation or visual hallucinations, history of falls, history of postoperative confusion, and inability to perform higher brain functions. Patients were scored on performance in a simple mental examination. The patients were classified as low, medium, or high risk. Patients who were identified as high risk were enrolled in a delirium avoidance protocol that minimized narcotics and emphasized nursing involvement and fluids administration. RESULTS: Five of 7659 (0.065%) consecutive TJA patients from 2010 to 2015 developed delirium. A total of 422 patients were identified as high risk. All 5 patients who suffered delirium were within the high risk group. No low or medium risk patients suffered a delirium complication. Three (0.039%) patients suffered drug-induced delirium, 1 (0.013%) had delirium related to alcohol withdrawal, and 1 (0.013%) had delirium after a systemic infection. CONCLUSION: This protocol is effective in identifying patients at high delirium risk and diminishing the incidence of this complication by utilizing a simple screening tool and perioperative protocol.

When Does the Knee Feel Normal Again: A Cross-Sectional Study Assessing the Forgotten Joint Score in Patients After Total Knee Arthroplasty.

BACKGROUND: The forgotten joint score (FJS) is a recent scoring system that assesses how natural the prosthesis feels after total joint arthroplasty. Although the FJS has been extensively applied in populations with total hip prosthetics, less is known about the patients undergoing total knee arthroplasty (TKA). The purpose of this study is to investigate the temporal relationship between TKA and the FJS. METHODS: We evaluated 566 patients after TKA using the FJS questionnaire. Scores were calculated at the follow-up intervals of 1 (n = 79), 6 (n = 78), 12 (n = 81), 24 (n = 100), 36 (n = 76), 48 (n = 75), and 60 (n = 77) months. The scores ranged from 0-100, with a higher score indicating a more natural or "forgotten" joint. RESULTS: Postoperative FJS averages were 39.3 ± 27.4 at 1 month, 59.4 ± 28.3 at 6 months, 72.5 ± 24.2 at 1 year, 76.4 ± 23.4 at 2 years, 75.1 ± 24.2 at 3 years, 68.6 ± 28.7 at 4 years, and 64.4 ± 29.0 at 5 years. The average score at 1 month was significantly lower than the average scores at all other intervals. The average score at 6 months was significantly lower than the average scores at 12, 24, and 36 months. The average score at 60 months was significantly lower than the average score at 24 months. CONCLUSION: Based on the findings of this study, patients can expect marked improvement in the natural feel of the prosthesis during the first year after TKA, slight continued improvement at 2 and 3 years, and a decline after 4 years.

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia.

BACKGROUND: The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia. METHODS: Consecutive patients who underwent a primary THA without preoperative catheterization under spinal anesthesia were identified in a prospectively collected institutional patient database. All patients were monitored postoperatively for urinary retention on the basis of symptoms and the use of bladder ultrasound scans performed by a hospital technician. If necessary, straight catheterization was performed up to 2 times prior to indwelling catheter insertion. RESULTS: One hundred eighty patients were included in the study. Six patients who required indwelling catheterization for intraoperative monitoring were excluded. Seventy-six patients experienced POUR and required straight catheterization. Fourteen patients ultimately required indwelling catheterization. One patient who was not catheterized developed a urinary tract infection versus none of the patients who were catheterized. POUR was significantly associated with intraoperative fluid volume and a history of urinary retention (P = .018 and .023, respectively). Intraoperative fluid volumes of 2025, 2325, 2875, and 3800 mL were associated with a specificity for POUR of 60%, 82.7%, 94.9%, and 98%, respectively. No significant associations were found among catheterization and gender, body mass index, American Society of Anesthesiologists class, history of polyuria, history of incontinence, postoperative oral narcotics use, or surgical duration. CONCLUSION: Patients with a history of prior urinary retention and those who receive high volumes of intraoperative fluid volume are at higher risk for POUR following THA performed under spinal anesthesia.

Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?

BACKGROUND: Periprosthetic joint infection (PJI) is an important cause of failure in total knee arthroplasty. Irrigation and debridement including liner exchange (I&D/L) success rates have varied for acute PJI. The purpose of this study is to present results of a specific protocol for I&D/L with retention of total knee arthroplasty components. METHODS: Sixty-seven consecutive I&D/L patients were retrospectively evaluated. Inclusion criteria for I&D/L were as follows: fewer than 3 weeks of symptoms, no immunologic compromise, intact soft tissue sleeve, and well-fixed components. I&D/L consisted of extensive synovectomy; irrigation with 3 L each of betadine, Dakin's, bacitracin, and normal saline solutions; and exchange of the polyethylene component. Postoperatively, all patients were treated with intravenous antibiotics. Infection was considered eradicated if the wound healed without persistent drainage, there was no residual pain or evidence of infection. RESULTS: Forty-six patients (68.66%) had successful infection eradication regardless of bacterial strain. Those with methicillin-resistant Staphylococcus aureus (MRSA) had an 80% failure rate and those with Pseudomonas aeruginosa had a 66.67% failure rate. The success rate for bacteria other than MRSA and Pseudomonas was 85.25%. CONCLUSION: Our protocol for I&D/L was successful in the majority of patients who met strict criteria. We recommend that PJI patients with MRSA or P aeruginosa not undergo I&D/L and be treated with 2-stage revision. For nearly all other patients, our protocol avoids the cost and patient morbidity of a 2-stage revision.

Complications and Mortality in Chronic Renal Failure Patients Undergoing Total Joint Arthroplasty: A Comparison Between Dialysis and Renal Transplant Patients.

BACKGROUND: In total joint arthroplasty (TJA) literature, there is a paucity of large cohort studies comparing chronic kidney disease (CKD) and end-stage renal disease (ESRD) vs non-CKD/ESRD patients. Thus, the purposes of this study were (1) to identify inhospital complications and mortality in CKD/ESRD and non-CKD/ESRD patients and (2) compare inhospital complications and mortality between dialysis and renal transplantation patients undergoing TJA. METHODS: We queried the Nationwide Inpatient Sample database for patients with and without diagnosis of CKD/ESRD and those with a renal transplant or on dialysis undergoing primary or revision total knee or hip arthroplasty from 2007 to 2011. Patient comorbidities were identified using the Elixhauser comorbidity index. International Classification of Diseases, Ninth Revision, codes were used to identify postoperative surgical site infections (SSIs), wound complications, deep vein thrombosis, and transfusions. RESULTS: Chronic kidney disease/ESRD was associated with greater risk of SSIs (odds ratio [OR], 1.4; P<.001), wound complications (OR, 1.1; P=.01), transfusions (OR, 1.6; P<.001), deep vein thrombosis (OR, 1.4; P=.03), and mortality (OR, 2.1; P<.001) than non-CKD/ESRD patients. Dialysis patients had higher rates of SSI, wound complications, transfusions, and mortality compared to renal transplant patients. CONCLUSION: Chronic kidney disease/ESRD patients had a greater risk of SSIs and wound complications compared to those without renal disease, and the risk of these complications was even greater in CKD/ESRD patients receiving dialysis. These findings emphasize the importance of counseling CKD patients about higher potential complications after TJA, and dialysis patients may be encouraged to undergo renal transplantation before TJA.

Prospective Evaluation of Sleep Disturbances After Total Knee Arthroplasty.

Sleep disturbance after total knee arthroplasty (TKA) has not been studied 6 months after surgery. A prospective study was conducted on 34 primary, unilateral TKA patients preoperatively until 6 months postoperatively. Sleep quality was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. Pain was measured on a visual analog scale. Sleep quality worsened from baseline during the first 6 weeks postoperatively (P = .03), but improved at 3 and 6 months (P = .003). Pain scores decreased from baseline over all time points, and there was no correlation between sleep quality and pain. The Epworth Sleepiness Scale did not change over time. This study can be used to counsel TKA patients to expect initial sleep disturbances that improve by 3 months.

Coronary revascularization and adverse events in joint arthroplasty.

BACKGROUND: There is a paucity of literature about outcome of total joint arthroplasty in patients with the history of angioplasty and/or stent or coronary artery bypass graft (CABG). The present study aimed to evaluate perioperative complications and mortality in these patients. METHODS: We used the Nationwide Inpatient Sample data from 2002-2011. Using the Ninth Revision of the International Classification of Disease, Clinical Modification codes for disorders and procedures, we identified patients with a history of coronary revascularization (angioplasty and/or stent or CABG) and compared the inhospital adverse events in these patients with patients without a history of coronary revascularization. RESULTS: Cardiac complications occurred in 1.06% patients with a history of CABG; 0.95% of patients with a coronary angioplasty and/or stent and 0.82% of the control patients. In the multivariate analysis, neither the history of CABG (P = 0.07) nor the history of angioplasty and/or stenting (P = 0.86) was associated with a higher risk of cardiac complications. However, myocardial infarction occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio, 1.24, P = 0.001) and coronary angioplasty and/or stenting (0.67%, odds ratio, 1.96, P < 0.001) compared with that in the controls (0.27%). History of coronary revascularization did not increase the risk of respiratory, renal, and wound complications, surgical site infection, and mortality. CONCLUSIONS: Based on the findings of this study, it appears that there is no increased risk of inhospital mortality and complications (except for myocardial infarction) in patients with a history of coronary artery revascularization undergoing total joint arthroplasty. We also found perioperative cardiac arrhythmia, particularly atrial fibrillation, to be an independent predictor of inhospital adverse events.

Total joint arthroplasty in transplant recipients: in-hospital adverse outcomes.

This study aims to determine in-hospital complications and mortality in transplant recipients following total joint arthroplasty. The Nationwide Inpatient Sample database was queried for patients with history of transplant and joint arthroplasty (primary or revision) from 1993 to 2011. Kidney transplant increased risk of surgical site infection (SSI) and wound infections (OR=2.03), systemic infection (OR=2.85), deep venous thrombosis (OR=2.07), acute renal failure (ARF) (OR=3.48), respiratory (OR=1.34), and cardiac (OR=1.21) complications. Liver transplant was associated with SSI/wound infections (OR=2.32), respiratory complications (OR=1.68), cardiac complications (OR=1.34), and ARF (OR=4.48). Other transplants grouped together were associated with wound complications (OR=2.13), respiratory complications (OR=2.06), and ARF (OR=4.42). Our study suggests these patients may be at increased risk of in-hospital complications, particularly ARF in renal and liver transplant patients.

Extensor mechanism reconstruction with achilles tendon allograft in TKA: results of an abbreviate rehabilitation protocol.

Various treatment alternatives address extensor mechanism failure after total knee arthroplasty. We present the results of a protocol utilizing Achilles tendon allograft followed by an abbreviated immobilization program to treat extensor mechanism disruptions after TKA in 29 knees (27 patients). Failed reconstruction was defined as mechanical allograft failure requiring re-intervention, extension lag >30°, recurrent falls, regression to a lower ambulatory status, and revision due to infection. With mean follow-up of 3.5 years, seventeen cases (58.6%) had satisfactory results, eleven cases (37.9%) were considered failures, and one case was lost to follow-up. Among failures, eight (27.5%) underwent reoperation with four (13.8%) due to late infections. Our observational data suggest that 1) a shortened immobilization protocol yields less favorable results than expected, and 2) continuous monitoring of patients who had allograft reconstruction for possible development of late infection is recommended.

Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail.

BACKGROUND: The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN). MATERIALS AND METHODS: The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group. RESULTS: There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649). CONCLUSION: Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care. LEVEL OF EVIDENCE: Level III, therapeutic study.