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BACKGROUND: There is a paucity of evidence on outcomes following total hip arthroplasty (THA) in patients who have symptomatic degenerative labral tears and mild to moderate osteoarthritis. The purpose of this study was to determine if outcomes of primary THA in the setting of painful, symptomatic labral tear, and mild to moderate arthritic changes (MMOA) were comparable to outcomes of primary THA performed for severe arthritic changes (AOA). Primary outcomes were patient-reported outcomes (PRO) scores. Secondary outcomes included length of stay (LOS) and perioperative complications. METHODS: This was a retrospective investigation of all THAs between January 2018 and July 2022. There were 111 patients who had THA due to failure of non-operative treatment of a degenerative labral tear without advanced arthritic changes (MMOA cohort, Kellgren-Lawrence (KL) Grades 1 to 3). These patients were matched to 111 patients who underwent THA for advanced OA (AOA cohort, KL Grade 4). Patient-reported outcomes (PROs) included the Western Ontario McMaster Universities Arthritis Index (WOMAC). The average age for the labral tear cohort was 59 years, with 50.6% women, compared to 70 years (P < 0.001), and 49.4% women (P = 0.93) in the advanced OA cohort. RESULTS: There were no differences in preoperative PROs, complications, or length of stay (LOS) between groups. When looking at postoperative PROs between cohorts, the labral tear cohort had less improvement in WOMAC-S (24.3 versus 34.0, P = 0.005) and WOMAC-F (26.3 versus 36.0, P = 0.005) at 12 months and greater improvement in WOMAC-P at 12 months (38.3 versus 34.7, P = 0.04). The SF12-P scores were significantly higher among the labral tear cohort compared to the AOA cohort at 12 months (48.5 versus 47.8, P < 0.001). The SF12-M scores were significantly higher in the AOA cohort compared to the labral tear cohort at 3 months (47.1 versus 47.4, P = 0.02) and 12 months (46.7 versus 47.6, P < 0.001). In the multivariate analysis, the change in WOMAC-P at 12 months was significantly better for labral tear patients (OR [odds ratio] 7.5 versus, P = 0.008, CI (confidence interval) [6.85 to 8.14]). CONCLUSION: Our study showed that patients who have symptomatic degenerative labral tears with mild to moderate arthritic changes have comparable outcomes to patients who have advanced OA following primary THA. Given suboptimal outcomes with hip arthroscopy for labral tear in the setting of early arthritis, primary THA can be a reasonable treatment modality for patients failing non-operative treatments.
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Background: The anterior-based muscle-sparing (ABMS) approach, using the intramuscular interval between the tensor fascia lata and gluteus medius, is an increasingly popular total hip arthroplasty (THA) approach. Its incidence of lateral femoral cutaneous nerve (LFCN) numbness has not been defined. The incidence of LFCN symptoms in direct anterior THA ranges from 7%-32% at 1-year follow-up. The purpose of this study is to determine the incidence of LFCN symptoms in patients who underwent ABMS THA at 1-year follow-up. Methods: This was a single-center, multisurgeon retrospective study of ABMS THAs with minimum 1-year follow-up data between January 2014 and September 2021. Eight hundred sixty-nine THAs were included. Mean age of the patients was 67.2 years, with 43.4% male and 56.5% female. Mean body mass index was 26.8, and mean American Society of Anesthesiologists was 2.3. Statistical analysis included chi-square tests, 2-sample t-test, and binomial logistic regression. A P-value of .05 was considered statistically significant for all tests. Results: Nine patients (1%) reported LFCN-associated symptoms at 1-year follow-up. The most common complaint was numbness (n = 5, 55.6%), followed by diminished sensation (n = 2, 22.2%), burning (n = 1, 11.1%), and generalized pain (11.1%). There was no difference in age, sex, body mass index, or American Society of Anesthesiologists between the group that experienced symptoms and the group that did not (P = 1.00, P = .34, P = .74, P = .80). Conclusions: The incidence of LFCN dysfunction is 1% at 1 year after surgery with the ABMS approach. Additional studies may elucidate all risks and benefits of the ABMS approach with respect to LFCN injuries.
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BACKGROUND: One major goal of total knee arthroplasty (TKA) is to achieve balanced medial and lateral gaps in flexion and extension. While bone resections are planned by the surgeon, soft tissue laxity is largely intrinsic and patient-specific in the absence of additional soft tissue releases. We sought to determine the variability in soft tissue laxity in patients undergoing TKA. METHODS: We retrospectively reviewed 113 patients undergoing TKA. Data on preoperative knee deformity were collected. Data from a dynamic intraoperative stress examination were collected by a robotic tracking system to quantify maximal medial and lateral opening in flexion (85-95 degrees) and extension (-5-20 degrees). T-tests were used to assess the differences between continuous variables. RESULTS: A valgus stress opened the medial compartment a mean of 4.3 ± 2.3 mm (0.0-12.4 mm) in extension and 4.6 ± 2.3 mm (0.0-12.9 mm) in flexion. A varus stress opened the lateral compartment a mean of 5.4 ± 2.4 mm (0.3-12.6 mm) in extension and 6.2 ± 2.5 mm (0.0-13.4 mm) in flexion. The medial compartment of varus knees opened significantly more in response to valgus stress than valgus knees in both extension (5.2 mm vs. 2.6 mm; P < 0.0001) and flexion (5.4 mm vs 3.3 mm; P < 0.0001). The lateral compartment of valgus knees opened significantly more in response to varus stress than varus knees in both extension (6.7 mm vs. 4.8 mm; P < 0.0001) and flexion (7.4 mm vs. 5.8 mm; P = 0.0003). CONCLUSIONS: Soft tissue laxity is highly variable in patients undergoing TKA, contributing anywhere from 0-13 mm to the post-resection gap. Only a small part of this variability is predictable by preoperative deformity. These findings have implications for either measured-resection or gap-balancing techniques. LEVEL OF EVIDENCE: Level III.
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OBJECTIVE: Surgical site complications (SSCs) are the leading cause of unplanned emergency department visits and readmissions following total joint arthroplasty (TJA). The use of closed-incision negative pressure therapy (ciNPT) has shown promise in reducing SSC occurrence. However, no study has evaluated the cost-effectiveness of ciNPT in primary TJA. The purpose of this study was to calculate the break-even absolute risk reduction (ARR) of SSCs, the break-even treatment cost of SSCs, and the break-even cost-of-use for ciNPT, based on existing literature to assess the cost-effectiveness of ciNPT in primary TJA. METHOD: Relevant values for ARR, infection treatment cost and intervention cost were obtained via literature review. A break-even analysis was conducted to investigate the cost-effectiveness of ciNPT use in primary TJA, as well as to derive the ARR, infection treatment cost (Ct) and intervention protocol cost (Cp) values at which ciNPT use becomes cost-effective. RESULTS: The values derived from the literature review were as follows: Cp=$160.76 USD; Ct=$5348.78 USD; ARR=0.0375. The break-even ARR was calculated to be 3.0%, the break-even Cp was calculated to be $200.58 USD, and the break-even Ct was calculated to be $4286.93 USD. The ARR of ciNPT use was greater than the calculated break-even ARR. CONCLUSION: This analysis demonstrated that ciNPT use in primary TJA was cost-effective. By examining the difference between the calculated break-even Cp and the Cp reported in the literature, the cost saved per patient treated with ciNPT can be calculated to be $39.82 USD.
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Análise Custo-Benefício , Tratamento de Ferimentos com Pressão Negativa , Infecção da Ferida Cirúrgica , Humanos , Tratamento de Ferimentos com Pressão Negativa/economia , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/prevenção & controle , Artroplastia de Substituição/economiaRESUMO
Background: Robotic-assisted total knee arthroplasty (RA-TKA) allows surgeons to perform intraoperative soft tissue laxity assessments prior to bone resections and is used to alter resections to achieve gap balance. This study compared 2 techniques for flexion gap laxity assessment during RA-TKA. Methods: A prospective study of 50 primary RA-TKAs performed by a single surgeon was conducted between February and October 2023. Following full exposure, anterior tibial dislocation, and osteophyte removal, maximal medial and lateral compartment flexion laxity was quantified to the nearest 0.5 mm by the robotic system using a dynamic, surgeon-applied stress (SURGEON). This data was used to plan a balanced flexion gap by adjusting the femoral component size, rotation, and anterior-posterior translation. Flexion laxity was quantified again after distal femoral and proximal tibial resections using a ligament tensor instrument (TENSOR). These new data were used to plan for the same desired flexion gap using the same variables. Paired-samples t-tests and a simple linear regression were used for analysis. Results: Both methods produced near-identical recommendations for femoral component sizing (mean deviation 0.06 sizes, range -1 to +1 size; P = .569), rotation (deviation mean 1.0°, range -3.0° to +3.0°; P = .741), and anterior-posterior translation (deviation mean 0.13 mm, range -0.5 to +0.5 mm, P = .785). SURGEON femoral component rotation predicted TENSOR rotation (R2 = 0.157; 95% confidence interval = 0.124, 0.633; P = .004). Conclusions: Assessing flexion laxity with a surgeon-applied stress vs a ligament tensor produced near-identical laxity data in RA-TKA, suggesting surgeons may comfortably choose either technique as a reliable method. Level of Evidence: Level III.
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INTRODUCTION: Accurate positioning of components in total knee arthroplasty (TKA) is essential to a satisfactory outcome. Significant malrotation may lead to chronic pain, stiffness, and dysfunction. This study aims to quantify improvements in functional outcomes following revision surgery for malrotation of either one or both components in TKA versus revision for aseptic loosening. METHODS: This was a retrospective review of TKAs that matched and compared the two-year functional outcomes of the malrotation group to a functionally similar aseptic loosening group. Functional outcomes were compared between groups using Short Form (SF-12), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Knee Society Functional Score (KSFS). Student t-tests and chi-squared or Fisher's tests were used for statistical analysis. RESULTS: Of the patients revised, 24 had malrotation and 57 had aseptic loosening. A total of 16 femoral and 17 tibial components were revised for malrotation. All 16 femoral components were internally malrotated (mean -4.8 ± 4.1 degrees; range, -0.5 to -16.6). Of the tibial components, 15 were internally malrotated, (mean -9.5 ± 6.6 degrees; range, -2.2 to -23.5) and 2 were externally malrotated (mean 4.6 ± 2.1 degrees; range, 3.1 to 6.0). All functional outcome measures significantly improved comparably within both groups preoperatively to 24 months postoperatively. At 24 months, functional outcome measures were comparable between the groups and WOMAC function scores were significantly higher in the malrotation group. CONCLUSION: Revision TKA for malrotation can yield clinically and statistically significant functional improvements, similar in magnitude to those seen following revision TKA for aseptic loosening. LEVEL OF EVIDENCE: Level III.
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Artroplastia do Joelho , Prótese do Joelho , Falha de Prótese , Reoperação , Humanos , Artroplastia do Joelho/métodos , Estudos Retrospectivos , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Amplitude de Movimento Articular/fisiologia , Osteoartrite do Joelho/cirurgia , Resultado do Tratamento , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologiaRESUMO
BACKGROUND: Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems. METHODS: An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator. RESULTS: Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B. CONCLUSIONS: We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal. LEVEL OF EVIDENCE: Level III.
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Background: Initial stability of cementless stems is important to minimize the risk of subsidence, pain, and periprosthetic fracture after total hip arthroplasty (THA). Collared stems improve initial component stability when contacting the femoral calcar. Direct contact is not always achieved, and collared stem performance has not been studied in this context. We hypothesized that collared stems achieving direct contact would demonstrate reduced subsidence. Methods: A single-surgeon retrospective study of 482 consecutive primary THAs implanted between February 2020 and May 2023 using collared cementless stems was performed. The 2 cohorts included stems with initial collar-calcar contact vs stems without. Subsidence was evaluated by comparing intraoperative fluoroscopy to postoperative 8-week radiographs. Binary logistic regression identified independent risk factors for subsidence. Chi-square tests were used for categorical variables and t-tests for continuous variables. Results: Of stems, 63.9% achieved initial collar-calcar contact, while 36.1% did not. The rate (1.3% vs 19.0%; P < .001) and magnitude (0.02 mm, range 0-3 mm vs 0.35 mm, range 0-3 mm; P < .001) of subsidence were significantly higher among stems without initial contact. Stems without initial collar-calcar contact (P < .001) and male gender (P = .007) were independent risk factors for subsidence. Two patients with initial contact had nondisplaced calcar cracks and <3 mm of subsidence at 4 weeks, which healed with protected weight-bearing. Stem survivorship was 100% in both groups, with all achieving osteointegration and none needing revision. Conclusions: Excellent performance of collared cementless stems was observed at 8 weeks after primary THA. Initial collar-calcar contact lowered the risk and magnitude of minor subsidence but did not affect survivorship or fracture risk. Level of Evidence: Level III.
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BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE: Level III.
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Perennial bioenergy crops are a key tool in decarbonizing global energy systems, but to ensure the efficient use of land resources, it is essential that yields and crop longevity are maximized. Remedial shallow surface tillage is being explored in commercial Miscanthus plantations as an approach to reinvigorate older crops and to rectify poor establishment, improving yields. There are posited links, however, between tillage and losses in soil carbon (C) via increased ecosystem C fluxes to the atmosphere. As Miscanthus is utilized as an energy crop, changes in field C fluxes need to be assessed as part of the C balance of the crop. Here, for the first time, we quantify the C impacts of remedial tillage at a mature commercial Miscanthus plantation in Lincolnshire, United Kingdom. Net ecosystem C production based on eddy covariance flux observations and exported yield totalled 12.16 Mg C ha-1 over the 4.6 year period after tillage, showing the site functioned as a net sink for atmospheric carbon dioxide (CO2). There was no indication of negative tillage induced impacts on soil C stocks, with no difference 3 years post tillage in the surface (0-30 cm) or deep (0-70 cm) soil C stocks between the tilled Miscanthus field and an adjacent paired untilled Miscanthus field. Comparison to historic samples showed surface soil C stocks increased by 11.16 ± 3.91 Mg C ha-1 between pre (October 2011) and post tillage sampling (November 2016). Within the period of the study, however, the tillage did not result in the increased yields necessary to "pay back" the tillage induced yield loss. Rather the crop was effectively re-established, with progressive yield increases over the study period, mirroring expectations of newly planted sites. The overall impacts of remedial tillage will depend therefore, on the longer-term impacts on crop longevity and yields.
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BACKGROUND: Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA. METHODS: PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA. RESULT: Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed. CONCLUSIONS: Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.
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BACKGROUND: The complexity of health care delivery systems presents a unique challenge for the perioperative space. In the area of arthroplasty procedures, the shift of complex patients into ambulatory surgery centers and reimbursement that is no longer commensurate with the inflated costs of performing these procedures have created difficulties for hospitals and physicians alike. Thus, there is a critical need to optimize perioperative workflows while maintaining high-quality care provision. METHODS: Our institution implemented the Comprehensive Unit-based Safety Program (CUSP) to improve the quality and efficiency of total knee and hip arthroplasties (TKAs and THAs). This initiative involved extensive collaboration with clinical and administrative teams, as well as 5 intervention-driven workgroups. First-case on-time start rates and duration of first-case delays, case length, anesthesia preparation, in-room patient preparation, operation, patient exit, and room turnover after CUSP implementation were analyzed using independent samples median testing, Mann-Whitney U testing, and a percentage-point difference calculation. RESULTS: After CUSP arthroplasty implementation, first-case on-time start rates increased from 43 to 81%. Statistically significant decreases were observed in median times for first-case delays, case length, in-room patient preparation, operation, patient exit, and room turnover for TKAs and THAs, but not anesthesia preparation. CONCLUSIONS: The implementation of CUSP arthroplasty for TKAs and THAs resulted in significant improvements in nearly all efficiency metrics, as well as preventions of patient safety missteps. These results exemplify the versatility of CUSP as a quality improvement method that can maintain patient safety and perioperative efficiency in the arthroplasty service of a large-scale medical center. LEVEL OF EVIDENCE: III.
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Artroplastia de Quadril , Artroplastia do Joelho , Segurança do Paciente , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , IdosoRESUMO
BACKGROUND: In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS: We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS: We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION: In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
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Estimulantes do Sistema Nervoso Central , Overdose de Drogas , Metanfetamina , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Masculino , Estados Unidos/epidemiologia , Adulto , Feminino , Analgésicos Opioides/uso terapêutico , Motivação , Tolerância a Medicamentos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Overdose de Drogas/epidemiologiaRESUMO
Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA.We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or chi-square tests as appropriate. For each preoperative factor, we obtained an odds ratio (OR) for MUA risk using multivariate logistic regression.Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (OR: 2.727, p = 0.047) and diagnosed hypertension (OR: 4.764, p = 0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative ROM, the higher likelihood needed of MUA (OR: 1.031, p = 0.034).Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.Level III of evidence was present.
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Artroplastia do Joelho , Amplitude de Movimento Articular , Humanos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Fatores de Risco , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologia , AnestesiaRESUMO
BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.
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Artroplastia de Quadril , Falha de Prótese , Reoperação , Humanos , Artroplastia de Quadril/métodos , Reoperação/estatística & dados numéricos , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Idoso , Adulto , Prótese de Quadril , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Maximizing operative room (OR) efficiency is important for hospital efficiency, patient care, and positive surgeon and staff morale. Reducing turnover time (TOT) has become a popular focus to improve OR efficiency. The present study evaluated if TOT is influenced by changing case type, implant vendor, and/or laterality. METHODS: In total, 444 turnovers from January to July 2023 were retrospectively analyzed. All turnovers were same-surgeon turnovers between primary arthroplasty cases in dedicated, overlapping rooms. Single linear regression models tested the predictability of TOT based on case type, vendor, and laterality. A multivariate multiple regression and 1-way Analyses of Variance analyzed variables against each other. Independent sample t-tests evaluated TOTs when all variables were the same or different. RESULTS: Changing versus keeping the same case type increased TOT by 2.4 minutes (95% confidence interval [CI] = 0.7, 4.0; P = .004). Changing vendors increased TOT by 2.9 minutes (95% CI = 1.1, 4.7; P = .002). Laterality did not affect TOT, with a change of 0.9 minutes (95% CI = -0.6, 2.5; P = .229). Vendor (P = .030) independently predicted TOT when analyzed as a covariate with case type (P = .410). The TOT with same case type and vendor (mean 38.2 minutes; range, 22 to 62) was less than that of different case types and vendors (mean 41.4 minutes; range, 26 to 73) (P = .017). Mean TOT differed by 5.5 minutes when keeping all variables the same versus all different (P = .018). CONCLUSIONS: Maintaining a consistent case type, vendor, and laterality had a synergistic effect in reducing TOT in arthroplasty ORs with the same primary surgeon running 2 overlapping rooms. Changing vendor representatives was found to independently predict TOT increases, which is likely attributed to a disruption in workflow and collaboration of the multidisciplinary OR team. LEVEL OF EVIDENCE: Level III.
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Salas Cirúrgicas , Humanos , Estudos Retrospectivos , Salas Cirúrgicas/organização & administração , Eficiência Organizacional , Agendamento de Consultas , Masculino , Feminino , Artroplastia de Substituição/estatística & dados numéricos , Artroplastia de QuadrilRESUMO
INTRODUCTION: The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD. METHODS: Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD. RESULTS: Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate. DISCUSSION: Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.
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Artroplastia de Quadril , Artroplastia do Joelho , Alta do Paciente , Humanos , Tempo de Internação , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: The lesser trochanter (LT) profile is an often-used marker for proximal femoral rotation, particularly during the operative fixation of femoral fractures. Previous studies have come to conflicting conclusions about its reliability for this purpose. METHODS: The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,722 computed tomographic (CT) scans of whole femora. Each femur was taken through an 80° rotational arc in 2.5° increments, and the LT profile was constructed for each position. These 56,826 LT profile measurements were then correlated with the femoral rotation. RESULTS: Across the arc of motion studied, the LT correlated weakly with proximal femoral rotation (R 2 = 0.32). There was a 35° arc, between 10° and 45° relative external rotation of the proximal femur, within which the LT profile only changed by 1 mm. The mean overall femoral anteversion was 21.2°, and women tended to have more femoral anteversion (23.9°) than men (19.2°). On average, men had a 1.6-mm more prominent LT than women. Side-to-side differences in femoral anteversion as well as LT position and size were not significant or were clinically unimportant. CONCLUSIONS: A large-scale, CT-based study shows that the LT profile is a less reliable marker of proximal femoral rotation than previously thought. This is true particularly if there is relative external rotation of the proximal femur, where the proximal femur can undergo up to 35° of rotation before 1 mm of change in the LT profile occurs. Care must be taken to check other markers of rotation such as by clinical examination during fixation of femoral fractures and not rely solely on the LT profile. CLINICAL RELEVANCE: In the largest study of its kind, this CT-based study of 56,826 LT profile measurements found that when the proximal femur is externally rotated, the LT profile becomes an unreliable marker of rotation, which can lead to excessive internal rotation of the distal fracture fragment. The LT profile should be used with caution, and confirmation of rotation by other means is recommended.
Assuntos
Fraturas do Fêmur , Fêmur , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Fêmur/diagnóstico por imagem , Rotação , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Pessoa de Meia-Idade , Idoso , Reprodutibilidade dos Testes , Adulto , Amplitude de Movimento Articular/fisiologia , Idoso de 80 Anos ou maisRESUMO
While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.
RESUMO
INTRODUCTION: Radiolucent lines occasionally develop around the proximal aspect of fully hydroxyapatite (HA)-coated tapered femoral stems after total hip arthroplasty (THA). It was hypothesised that distal wedging of stems may predispose to proximal radiolucent line formation, which may negatively impact clinical outcome. METHODS: All primary THA performed with a collarless fully HA-coated stem that had a minimum of 1 year of radiographic follow-up were identified in a surgical database (n = 244). Radiographic measures of proximal femoral morphology and femoral canal fill at the middle and distal thirds of the stem were analysed for association with the presence of proximal radiolucent lines. Linear regression was used to explore any association between radiolucent lines and patient reported outcome measures (PROMs), available in 61% of patients. RESULTS: Proximal radiolucent lines developed in 31 cases (12.7%) at final follow-up. Dorr A femoral morphology and increased canal-fill at the distal â of the stem correlated with the development of radiolucent lines (p < 0.001). No correlation was observed between pain or PROMs and the presence of proximal radiolucent lines. DISCUSSION: We observed an unexpectedly high incidence of proximal femoral radiolucent lines about collarless fully HA coated stems. Distal-only implant wedging in Dorr A bone may compromise proximal fixation. Although this finding did not correlate with short-term outcomes, the long-term clinical impact requires further study.