Reoperation Rates Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Posttraumatic Indications.

AIMS: This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database. METHODS: A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge. RESULTS: A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all Ps < .05). CONCLUSION: Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

Local and Systemic Complications of Knee and Hip Arthroscopy: A Matched-Cohort Study.

Background: Surgeons are familiar with the complication rates and risks of knee arthroscopy, but comparative data between hip arthroscopy and knee arthroscopy are lacking. Purpose: To compare complications in knee arthroscopy, the most common arthroscopic procedure, with those in hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective matched-cohort study analyzing patients who received a primary hip or knee arthroscopy was performed using the PearlDiver database. A total of 19,735 patients were identified for each cohort. Systemic complications and readmissions were assessed at 3 months postoperatively. Local complications and reoperations were assessed at 6 months, 12 months, and 24 months postoperatively. All categorical variables were compared using chi-square analysis. Results: Hip arthroscopy had significantly higher rates of nerve injury, stiffness, heterotopic ossification, and avascular necrosis (all P < .001) than knee arthroscopy at all observed time periods postoperatively. Hip arthroscopy also had a greater rate of all local joint complications than knee arthroscopy (16.79% vs 11.80%; P < .001). Knee arthroscopy was found to have higher incidences of deep vein thrombosis (0.98% vs 0.66%; P < .001) and myocardial infarction (0.06% vs 0.00%; P < .001) as well as a higher overall systemic complication rate (3.93% vs 3.44%; P = .013). Hip arthroscopy was found to have higher rates of subsequent arthroscopy, arthroplasty, and overall reoperation when compared with knee arthroscopy (11.99% vs 14.99%; P < .001) at all time periods up to 24 months postoperatively. Conclusion: Although the systemic complication rate was higher in knee arthroscopy, local joint complications, reoperation, and total complication rates were higher for hip arthroscopy. Surgeons should be aware of these potential differences to best discuss and mitigate risks with this expanding patient population.

Similar Complication Rates for Humeral Shaft Fractures Treated With Humeral Nails Versus Open Reduction and Internal Fixation With Plating.

Humeral shaft fractures account for an estimated 3% of all adult fractures. When operative treatment is indicated, intramedullary (IM) nailing and open reduction and internal fixation with plating are the 2 most common techniques. Early IM nails were associated with poor outcomes, but with advancements in nail design, patient outcomes have been improving with this technique. This study used a nationwide database to quantify and compare the rates of postoperative complications between IM nails and plating for humeral shaft fractures in a national population. An administrative database was queried from the beginning of 2010 to the second quarter of 2017 for patients undergoing IM nailing vs open reduction and internal fixation with a plate for humeral shaft fractures. Systemic complications, fracture complications, and mean prescribed morphine milligram equivalents were collected and compared with statistical analysis. The overall rate of complications was high for both IM nailing (30.8%) and plating (34.2%). Patients were at greater risk for radial nerve palsy and infection at 90 days, 6 months, and 1 year if they received plate fixation (P<.05). The plate cohort had a lower risk of rotator cuff repair for all periods (P<.05). Patients in the IM nail cohort had higher rates of hardware removal for all periods (P<.05). Both IM nails and plates have overall similar rates of complications, and either can be used for humeral shaft fractures, based on surgeon preference, skill, and consideration of minor differences in complications between these 2 treatments. [Orthopedics. 2022;45(3):156-162.].

Addition of the Sartorius Tendon Improves Biomechanics of a Four-Strand Hamstring Anterior Cruciate Ligament Autograft.

PURPOSE: The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties. METHODS: Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A P < .05 was considered statistically significant. RESULTS: The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft. CONCLUSIONS: The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation. CLINICAL RELEVANCE: The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

Midterm Safety of Carbon Dioxide Insufflation of the Knee During Arthroscopic Cartilage-Based Procedures.

BACKGROUND: When compared with fluid arthroscopy, carbon dioxide (CO2) insufflation offers an increased scope of view and a more natural-appearing joint cavity, and it eliminates floating debris that may obscure the surgeon's view. Despite the advantages of CO2 insufflation during knee arthroscopy and no reported cases of air emboli, the technique is not widely used because of concerns of hematogenous gas leakage and a lack of case series demonstrating safety. PURPOSE/HYPOTHESIS: To investigate the safety profile of CO2 insufflation during arthroscopic osteochondral allograft transplantation of the knee and report the midterm clinical outcomes using this technique. We hypothesized that patients undergoing CO2 insufflation of the knee joint would have minimal systemic complications, allowing arthroscopic cartilage work in a dry field. STUDY DESIGN: Case series; level of evidence, 4. METHODS: A retrospective chart review was performed of electronic medical records for patients who underwent arthroscopic osteochondral allograft transplantation of the knee with the use of CO2 insufflation. Included were patients aged 18 to 65 years who underwent knee arthroscopy with CO2 insufflation from January 1, 2015, to January 1, 2021, and who had a minimum follow-up of 24 months. All procedures were performed by a single, fellowship-trained and board-certified sports medicine surgeon. The patients' electronic medical records were reviewed in their entirety for relevant demographic and clinical outcomes. RESULTS: We evaluated 27 patients (14 women and 13 men) with a mean age of 38 and a mean follow-up of 39.2 months. CO2 insufflation was used in 100% of cases during the placement of the osteochondral allograft. None of the patients sustained any systemic complications, including signs or symptoms of gas embolism or persistent subcutaneous emphysema. CONCLUSION: The results of this case series suggest CO2 insufflation during knee arthroscopy can be performed safely with minimal systemic complications and provide an alternative environment for treating osteochondral defects requiring a dry field in the knee.

Instability After Total Hip Arthroplasty and the Role of Advanced and Robotic Technology.

Instability remains the leading cause of reoperation following total hip arthroplasty (THA). In this article, the risk factors for instability after THA are reviewed, including patient-related characteristics, surgical techniques, positioning of implants, and the role of advanced technology and robotics as a platform that may reduce the incidence of instability.

Use of Simple Geometry to Predict Changes in Coronal and Sagittal Alignments Using an Extramedullary Tibial Cutting Guide During Total Knee Arthroplasty.

During total knee arthroplasty, balancing is necessary for long-term stability and longevity of implants as improper balancing leads to abnormal surface strain. A routine practice among surgeons is to add more posterior slope to the proximal tibia to provide an increase in the flexion gap to balance the knee throughout the entire range of motion, particularly when doing cruciate-retaining knees. The aim of this technique guide is to provide a simple estimate of the posterior slope added or subtracted when cutting the proximal tibia using a standard extramedullary guide.  It can also be applied to predict the amount of coronal change instituted using a standard extramedullary drop guide. Using a few basic calculations with a sine equation, a surgeon can accurately predict the amount of change in the slope applied when cutting the proximal tibia. This can be done to control the degree of slope added to the anterior-posterior direction and can be used to predict coronal alignment changes as well. This technique can be applied to any length extramedullary guide and applied across all companies to provide surgeons with an exact degree change in the tibial slope and coronal alignment with simple calculations.

Patients with Dupuytren's Contracture, Ledderhose Disease, and Peyronie's Disease are at higher risk of arthrofibrosis following total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a successful treatment for patients with late stage osteoarthritis, yet arthrofibrosis remains a consistent cause of TKA failure. Dupuytren's, Ledderhose and Peyronie's Diseases are related conditions of increased fibroblast proliferation. The aim of this study was to identify whether an association exists between these conditions and arthrofibrosis following TKA. METHODS: Patient records were queried from 2010 to 2016 using an administrative claims database to compare the rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with independent chart diagnoses of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases versus those without. Complications were queried and compared using multivariate logistic regression. RESULTS: Patients with Dupuytren's (n = 5,232) and Ledderhose (n = 50,716) had a significantly higher rate of ankylosis following TKA: 30-days (OR, 1.54; OR, 1.23), 90-days (OR, 1.20; OR, 1.24), 6-months (OR, 1.23; OR, 1.23), and 1-year (OR, 1.28; OR, 1.23), while patients with Peyronie's (n = 1,186) had a higher rate of diagnosis at 6-months (OR, 1.37) and 1-year (OR, 1.35). Patients with diagnoses of any of the fibroproliferative diseases had a statistically higher risk of MUA at 90-days, 6-month, and 1-year following primary TKA. These cohorts did not have a significantly higher rate of revision TKA. CONCLUSION: There is an increased odds risk of arthrofibrosis and MUA in patients who have undergone TKA and have a diagnosis of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases. Improvements to frequency and application of post-operative treatment should be considered in these cohorts to improve outcomes.

Variability of Cutting and Thermal Dynamics Between New and Used Acetabular Reamers During Total Hip Arthroplasty.

BACKGROUND: Aseptic loosening of the acetabular component remains one of the leading causes of early failure of total hip arthroplasty. Poor apposition of bone onto the implant surface can be due to inaccurate reaming and osteonecrosis of the acetabular bone due to the heat generated while reaming. METHODS: New and used acetabular reamers were tested on an MTS system using a clinically relevant force of 87.6 N. A thermal profile and depth achieved by the reamers were analyzed and compared between the 2 cohorts. Heat generated and force required for the community used reamers to achieve the same depth as the new reamers were subsequently analyzed. RESULTS: The new reamers achieved a depth 3.4 mm deeper than the community reamers (P < .001). The new reamers generated 4.1°C less heat than the community reamers (P = .007) under the same force and time. When programmed to ream to the average depth of the new reamers, the community reamers generated 16.8°C more heat (P = .002) and required forces 95-318% greater than the 87.6 N force used by the new reamers. CONCLUSIONS: Community use of reamers will cause variations in depth of penetration and increased temperatures at a clinically generated force vs new reamers. When community reamers were forced to the same depths the new reamers achieved, a significantly greater amount of heat was generated, and an increased amount of time was needed, both of which are known risk factors for osteonecrosis.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk.

BACKGROUND: Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without. METHODS: Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant. RESULTS: Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9). CONCLUSION: Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Complication rates of bilateral total hip versus unilateral total hip arthroplasty are similar.

OBJECTIVE: Utilize a nationwide database to identify and compare the differences between patient demographics and clinical outcomes for patients undergoing simultaneous bilateral total hip arthroplasty (THA) and unilateral THA. METHODS: A nationwide administrative claims database was utilized; In-hospital, 90-day, and 1-year post-discharge rates of local and systemic complications were collected and compared with multivariate logistic regression. RESULTS: Incidence of prosthetic joint infection was significantly lower in the bilateral cohort. Length of stay was significantly shorter in the unilateral THA cohort. CONCLUSION: Surgeons should consider simultaneous bilateral THA a safe and effective procedure for low risk patients with appropriate comorbidities.

Robotic Total Knee Arthroplasty vs Conventional Total Knee Arthroplasty: A Nationwide Database Study.

BACKGROUND: As robot-assisted equipment is continuously being used in orthopaedic surgery, the past few decades have seen an increase in the usage of robotics for total knee arthroplasty (TKA). Thus, the purpose of the present study is to investigate the differences between robotic TKA and nonrobotic TKA on perioperative and postoperative complications and opioid consumption. METHODS: An administrative database was queried from 2010 to Q2 of 2017 for primary TKAs performed via robot-assisted surgery vs non-robot-assisted surgery. Systemic and joint complications and average morphine milligram equivalents were collected and compared with statistical analysis. RESULTS: Patients in the nonrobotic TKA cohort had higher levels of prosthetic revision at 1-year after discharge (P < .05) and higher levels of manipulation under anesthesia at 90 days and 1-year after discharge (P < .05). Furthermore, those in the nonrobotic TKA cohort had increased occurrences of deep vein thrombosis, altered mental status, pulmonary embolism, anemia, acute renal failure, cerebrovascular event, pneumonia, respiratory failure, and urinary tract infection during the inpatient hospital stay (all P < .05) and at 90 days after discharge (all P < .05). All of these categories remained statistically increased at the 90-days postdischarge date, except pneumonia and stroke. Patients in the nonrobotic TKA cohort had higher levels of average morphine milligram equivalents consumption at all time periods measured (P < .001). CONCLUSIONS: In the present study, the use of robotics for TKA found lower revision rates, lower incidences of manipulation under anesthesia, decreased occurrence of systemic complications, and lower opiate consumption for postoperative pain management. Future studies should look to further examine the long-term outcomes for patients undergoing robot-assisted TKA. LEVEL OF EVIDENCE: Level III.

The Impact of Femoral Nerve Anesthesia on Short-Term Clinical Outcomes and Opioid Claims After Total Knee Arthroplasty.

BACKGROUND: The impact of femoral nerve blocks (FNBs) during primary total knee arthroplasty (TKA) on clinical outcomes and pain management remains unclear. The present research investigates the impact that continuous and single-shot FNBs during TKA have on postoperative opioid claims and short-term clinical outcomes. METHODS: An administrative claims database was queried to identify patients who underwent primary TKA with a continuous FNB, single-shot FNB, or no FNB. More than 300,000 patients were analyzed from the database. Rates of opioid claims were compared via achi-square analysis. Incidence of postoperative complications was compared with multivariable logistic regression. RESULTS: Patients receiving a FNB had a significantly higher risk of falls both at 6 months (odds ratio [OR], 1.30) and 1 year postoperatively (OR, 1.25), as well as readmissions within 90 days (OR, 1.18) compared with patients without FNBs. The FNB cohort exhibited a higher risk of deep vein thrombosis (OR, 1.57), myocardial infarction (OR, 1.79), and cerebrovascular accident (OR, 1.20) during the inpatient stay. Relative to single-shot FNBs, continuous FNBs were associated with a higher risk of readmissions within 90 days and systemic complications, although the risk varied by age, sex, and Charlson Comorbidity Index score. More patients without FNBs filed opioid claims within 1 year postoperatively, but the average total morphine milligram equivalents prescribed was comparable to patients who received FNBs. CONCLUSIONS: FNBs during TKA place patients at a significantly higher risk of falls, readmissions, and systemic complications in the short term. The risk of readmission and systemic complications was higher for continuous FNBs. More patients without FNBs filed opioid claims postoperatively than patients who received FNBs.