The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database.

Background: There is debate regarding the efficacy of intra-articular (IA) hyaluronic acid (HA) injections for the management of knee osteoarthritis (OA). This study aimed to determine if IA HA utilization and payer coverage of viscosupplementation affected the prevalence of total knee arthroplasty (TKA) procedures and the age of TKA patients. Methods: We performed a retrospective analysis from 2014 to 2020 using a large national commercial claims data set. We analyzed the number of TKA procedures and the age of the patients in states that covered IA HA vs those with limited coverage. Mixed random effects and slopes models were used to identify the impact of the IA HA injections. Results: Of 7,335,301 patients with knee OA, 440,606 (6.0%) received a TKA procedure at an average age of 59 years. The rate of TKA procedures increased by 0.56% per year (95% confidence interval [CI] 0.46-0.66; P < .001). Payer coverage of IA HA injections had no effect on TKA prevalence (P = .926). The age of surgical patients increased yearly by 0.15 years (95% CI 0.12-0.18; P < .001), regardless of IA HA injections (P = .990). After controlling for demographics and comorbidities, patients that received an IA HA injection had a higher probability of receiving a subsequent TKA (odds ratio = 2.83; 95% CI 2.80-2.87; P < .001); this finding was conditional of patients' age at the first diagnosis of knee OA. Conclusions: Additional clinical trials should be employed to identify the role of HA injections in the treatment armamentarium for knee OA.

Do Patient Engagement Platforms in Total Joint Arthroplasty Improve Patient-Reported Outcomes?

BACKGROUND: Web-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs). METHODS: We performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized. RESULTS: Of the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P < .001, P < .003), had higher body mass index (P = .024, P = .011), and had a higher household income (P < .001, P < .001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013). CONCLUSION: There is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients.

Dental Screening in Elective Total Joint Arthroplasty: Risk Factors for Failure.

BACKGROUND: Active dental infection at the time of total joint arthroplasty (TJA) or in the acute postoperative period following TJA is thought to increase the risk of periprosthetic joint infection (PJI). Many surgeons recommend preoperative dental screening. This study aimed to identify how many elective TJA patients failed preoperative dental screening and what patient risk factors were associated with failure. METHODS: A consecutive series of elective, primary TJA was reviewed from 8/1/2016 to 8/1/2017. We studied 511 operations in 511 patients. All patients were referred for preoperative dental screening per protocol. Dental screening failure was defined as required dental intervention by the dentist. Screening failure rate was calculated for and logistic regression was used to evaluate the relationship between odds of screening failure and patient demographic data. RESULTS: In 94 of the 511 total cases (18.5%), patients failed dental screening and required dental procedures prior to TJA. Reasons for failure included tooth extractions, root canals, abscess drainage, and carious lesions requiring filling. Patient characteristics associated with failed dental screening included male gender (odds ratio 1.56, 95% confidence interval 1.0006-2.468, P = .047) and current smoker (odds ratio 3.6, 95% confidence interval 1.650-7.927, P = .001). CONCLUSION: Universal dental screening prior to primary TJA resulted in 18.5% of patients needing an invasive dental intervention. Universal dental screening results in extra cost and time for patients and providers. Although male gender and active smoking were associated with increased odds of requiring an invasive dental procedure, more work is needed to develop targeted screening to improve perioperative workflow and limit unnecessary dental evaluations for patients.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Intraoperative Point of View Video Capture and Surgical Segmentation in Carpal Tunnel Release: A Feasibility Analysis.

OBJECTIVE: The purpose of this study was to (1) examine the feasibility of intraoperative point of view video while performing open and endoscopic carpal tunnel release (CTR), (2) define surgical segments of CTR, and (3) describe the duration of various surgical steps of open versus endoscopic CTR in a teaching setting. DESIGN: Fellowship trained hand surgeons reached consensus on surgical segments for CTR. Adult patients 18 and older previously indicated for CTR in clinic were eligible. Head-mounted point-of-view cameras were worn during endoscopic and open CTR by resident surgeons. Video was reviewed to determine segment duration. Independent sample t tests were used for comparison of duration by technique with statistical significance set as p < 0.05. SETTING: University of Iowa Hospitals and Clinics; 200 Hawkins Dr, Iowa City, IA 52242; Tertiary Academic Medical Center. PARTICIPANTS: Orthopedic Surgery Residents and Orthopedic Surgery Faculty. RESULTS: Surgical segments were defined as incision, dissection of superficial soft tissue structures, transection of the carpal ligament, and surgical incision closure. Twelve of 14 video capture events yielded data. In the teaching setting, the average duration of endoscopic CTR was 609.5 seconds (±111.07) versus 547.75 seconds (±82.06) for open with p value = 0.406. No surgical segments were significantly different. Transition time from dissection to ligament transection differed significantly (p = 0.004) between endoscopic (46.88 seconds ± 19.19) and open (9.0 seconds ± 7.90) CTR. Transition time between ligament transection and closure was significantly different (p = 0.029) among endoscopic (50.5 seconds ± 15.0) and open (26.25 seconds ± 2.99) CTR. CONCLUSIONS: Point-of-view video capture is feasible for the capture of video during a common hand surgery procedure. A method for managing device battery power is necessary for future applications. CTR can be defined as, and described in, individual procedure segments potentially useful for surgical education as well as efficiency improvements. Identification of surgical segments may aid the development of better objective tools for the assessment of surgeon skill and competency for common orthopedic procedures.

Restrictive Opioid Prescribing Protocols Following Total Hip Arthroplasty and Total Knee Arthroplasty Are Safe and Effective.

BACKGROUND: Orthopedic surgeons may overprescribe opioids postoperatively. Literature examining opioid prescribing guidelines following total joint arthroplasty (TJA) is limited. METHODS: Retrospective review was conducted of primary TJAs from June 2017 to February 2018, with 3-month follow-up. Patients were divided into those who underwent surgery before (historical cohort) and after (restrictive cohort) implementation of a strict postoperative opioid prescribing protocol. RESULTS: Three hundred ninety-nine total patients were included (282 in historical cohort, 117 in restrictive cohort). There was no significant difference in preoperative, perioperative, and postoperative inpatient opioid use. Historical cohort was given significantly larger initial prescriptions, received significantly more refills, and received significantly greater total quantity of opioids per patient. There were significantly fewer call-ins in the restrictive cohort. Clinical outcomes were not significantly different. CONCLUSION: Drastic reductions in opioid prescriptions following TJA are possible without an increase in refills, call-ins, or adverse clinical effects.

Acute Periacetabular Osteotomy for Recurrent Posttraumatic Dislocation of the Hip: A Case Report.

CASE: A 23-year-old woman with injury-induced acetabular dysplasia developed subacute recurrent dislocation of the right hip following closed reduction of a traumatic dislocation. The initial dislocation had been associated with small posterior wall and femoral head fractures. The recurrent dislocation was addressed with an acute periacetabular osteotomy (PAO) for hip stabilization and femoral head fragment excision. CONCLUSION: An acute PAO is an unusual yet viable treatment strategy for addressing recurrent dislocation following traumatic fracture-dislocation in patients with posterior wall deficiency and injury-induced hip dysplasia. In the patient described herein, the procedure resulted in early stability, but she developed posttraumatic osteoarthritis at 1 year and 4 months after the injury.

Popliteal (Baker's) Cysts in the Setting of Primary Knee Arthroplasty.

BACKGROUND: Popliteal (Baker's) Cysts are rare complications of knee arthroplasty. Enlargement, irritation, or rupture of the cyst can lead to significant pain, tightness, and tenderness. The literature regarding popliteal cysts occurring following knee arthroplasty is limited and does not report prevalence, natural history, and treatment of popliteal cyst in the setting of knee arthroplasty. METHODS: Following Institutional Review Board approval, 2,025 primary total and partial knee arthroplasties by four surgeons at one institution from 2011-2016 were reviewed for occurrence of popliteal cysts. Twelve cases occurring after arthroplasty were identified, including four unicompartmental knee arthroplasties and eight total knee arthroplasties. Demographic data were evaluated and symptoms, time of onset following arthroplasty, attempted treatment strategies, and success or failure of attempted treatments or interventions were recorded. RESULTS: The mean age of patients that presented with a popliteal cyst was 63.6 years old (range = 45 - 78 years). There were 5 males and 7 females. The mean BMI was 26.32 (range = 19.0 - 35.0). In 2,205 primary knee arthroplasties performed from 2011-2016 (including 175 partial and 1850 total), the prevalence of popliteal cysts following surgery was 0.6% (n=12). All popliteal cysts were discovered between six weeks and two years following surgery, with the majority occurring during the first year. Twenty-five percent (3/12) of patients presented with minimal symptoms. These were managed expectantly. Seventy-five percent (9/12) were symptomatic. One patient had only a diagnostic ultrasound, two patients underwent ultrasound-guided aspiration and steroid injection, three underwent simple aspiration. Two underwent surgical excision. One cyst ruptured. All cases went on to symptomatic resolution. There was no association with diabetes, smoking, or body mass index. A disproportionately high number (25% or 4/12) occurred in partial knee arthroplasty. CONCLUSION: While popliteal cysts following primary total knee arthroplasty are rare, they can become a persistent and even disabling problem for arthroplasty patients. Given the lack of formalized recommendations in the existing literature, we propose a treatment algorithm that has been successful in our clinic, including observation initially, ultrasound-guided injection/aspiration if symptomatic, and surgical excision as a last resort. LEVEL OF EVIDENCE: Level IV.

Use of 2-Octyl Cyanoacrylate Adhesive and Polyester Mesh for Wound Closure in Primary Knee Arthroplasty.

Wound closure in primary knee arthroplasty is important both for surgical success, by minimizing the risk of wound complications and infection, and for patient satisfaction with wound care and cosmesis. This article reports the use of a topical self-adhering, pressure-sensitive polyester mesh combined with 2-octyl cyanoacrylate adhesive for final skin closure of primary knee arthroplasty without external staples or sutures. During a 2.5-year period, 360 consecutive primary knee arthroplasty procedures (321 total knee arthroplasty procedures and 39 partial knee arthroplasty procedures) performed by 1 surgeon at 1 institution were reviewed. For all primary arthroplasty procedures, closure was performed with a standardized method. Final skin closure was performed with 2-octyl cyanoacrylate adhesive and polyester mesh. Patients returned at 6 weeks and 1 year postoperatively. The study found a 0.8% rate of superficial wound complications, no cases of dehiscence, no wound complications requiring operative irrigation and debridement, and no prosthetic joint infections. One patient had a reaction consistent with previously reported localized contact dermatitis that was believed to be related to the 2-octyl cyanoacrylate adhesive. In 2 cases, treatment with cephalexin was required, in 1 case for 2 small suture abscesses and in the other case for periincisional cellulitis. All wound complications resolved by 6 weeks. The results showed that 2-octyl cyanoacrylate adhesive and polyester mesh can be used successfully in the setting of primary knee arthroplasty for closure of high-tension knee arthroplasty wounds. This series found a 0.8% rate of superficial wound complications, no cases of dehiscence, and no infections. [Orthopedics. 2017; 40(5):e784-e787.].

Imaging Pediatric Spondylolysis: A Systematic Review.

STUDY DESIGN: A systematic review. OBJECTIVE: The aim of this study was to provide an evidence-based recommendation for when and how to employ imaging studies when diagnosing back pain thought to be caused by spondylolysis in pediatric patients. SUMMARY OF BACKGROUND DATA: Spondylolysis is a common structural cause of back pain in pediatric patients. The radiologic methods and algorithms used to diagnose spondylolysis are inconsistent among practitioners. METHODS: A literature review was performed in PubMed and Cochrane databases using the search terms "spondylolysis," "pediatric," "adolescent," "juvenile," "young," "lumbar," "MRI," "bone scan," "CT," and "SPECT." After inclusion criteria were applied, 13 articles pertaining to diagnostic imaging of pediatric spondylolysis were analyzed. RESULTS: Ten papers included sensitivity calculations for comparing imaging performance. The average sensitivity of magnetic resonance imaging (MRI) with computed tomography (CT) as the standard of reference was 81.4%. When compared with single-photon emission CT (SPECT), the average sensitivity of CT was 85% and the sensitivity of MRI was 80%. Thirteen studies made a recommendation as to how best to perform diagnostic imaging of patients with clinically suspected spondylolysis. When compared with two-view plain films, bone scans had seven to nine times the effective radiation dose, while four-view plain films and CT were approximately double. Of the diagnostic methods examined, MRI was the most expensive followed by CT, bone scan, four-view plain films, and two-view plain films. CONCLUSION: Due to their efficacy, low cost, and low radiation exposure, we find two-view plain films to be the best initial study. With unusual presentations or refractory courses, practitioners should pursue advanced imaging. MRI should be used in early diagnosis and CT in more persistent courses. However, the lack of rigorous studies makes it difficult to formulate concrete recommendations. LEVEL OF EVIDENCE: 3.