Salvage of Chronic Syndesmosis Instability: A Retrospective Review With Mid-Term Follow-Up.

Malreduced syndesmotic injuries lead to poor outcomes. No consensus exists regarding preferred surgical treatment. This study aims to assess clinical and radiographic outcomes in patients undergoing distal tibiofibular arthrodesis or stabilization. Retrospective review identified patients undergoing distal tibiofibular arthrodesis or stabilization between 2003 and 2019. Surgical factors, revision surgeries, and American Orthopedic Foot and Ankle Score ankle-hindfoot scores were collected. Radiographs were independently evaluated by 4 surgeons. Seventy patients were included. Mean American Orthopedic Foot and Ankle Score scores (n = 33) improved from 48 ± 16 preoperatively to 85 ± 14 (p < .001) at a median follow-up of 31.1 months. Mean Kellgren scores (n = 47) increased from 2.1 ± 1 to 2.5 ± 1 (p < .001) and the mean medial clear space decreased from 3.2 mm ± 0.8 mm to 2.8 mm ± 0.8 mm (p <.001) with no differences between the arthrodesis and stabilization groups. Zero patients progressed to arthroplasty or fusion. Patients demonstrated significant functional improvement after distal tibiofibular arthrodesis and stabilization. Progression of arthritis, while statistically significant, was not clinically significant.

Reverse coronal deformity: use of robotic total knee arthroplasty for identification and correction.

BACKGROUND: Despite continued advances in techniques and implant designs, a population of patients who are dissatisfied after total knee arthroplasty (TKA) remains. During robotic-assisted arthroplasty, real-time intraoperative assessment of patient knee alignment is performed. Here, we assess the prevalence of an under-appreciated deformity, reverse coronal deformity (RCD), and the benefits of utilizing robotic-assisted knee arthroplasty to help correct this dynamic deformity. METHODS: A retrospective study evaluating patients undergoing robotic-assisted cruciate-retaining TKA was performed. Intraoperative measurements were obtained using tibial and femoral arrays to assess coronal plane deformity at full extension and at 90° flexion. RCD was defined as ≥ 2° varus in knee extension that reversed to ≥ 2° valgus in flexion, or vice-versa. Coronal plane deformity was then reassessed after robotic-assisted bony resection and implant placement. RESULTS: Of 204 patients that underwent TKA, 16 patients (7.8%) were found to have RCD, with 14 patients (87.5%) transitioning from varus in extension to valgus in flexion. The average coronal deformity was 7.75°, with a maximum of 12°. These improved to an average coronal change of 0.93° post-TKA. Final medial and lateral gaps were all balanced to within 1° in extension and flexion. Another 34 patients (16.7%) had ≥ 5° change in coronal plane deformity from extension to flexion (average 6.39°), however, did not experience a reversal of their coronal deformity. Outcomes were assessed with KOOS Jr. scores postoperatively. CONCLUSION: Computer and robotic assistance were utilized to demonstrate the prevalence of RCD. We also demonstrated accurate identification and successfully balancing of RCD utilizing robotic-assisted TKA. An increased awareness of these dynamic deformities could aid surgeons in proper gap balancing even in the absence of navigation and robotic-assisted surgery.

National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair.

PURPOSE: The goal of this study was to investigate trends in the United States for arthroscopic subacromial decompression (aSAD) and open SAD (oSAD) with and without rotator cuff repair (RCR) between 2010 and 2018. METHODS: The PearlDiver Mariner claims database was queried using CPT codes for open and arthroscopic subacromial decompression and rotator cuff repair. Patient cohorts were developed for those undergoing aSAD or oSAD between 2010 and 2018, then segmented by whether RCR was performed simultaneously. Annual incidence was analyzed, as were associated diagnosis codes, and concomitant shoulder-associated procedures performed on the same day. RESULTS: The PearlDiver Mariner dataset from 2010 to 2018 included 186,932 patients that underwent aSAD, while 9,263 patients underwent oSAD. The total incidence of aSAD declined from 118.0 to 71.3 per 100,000 (39.6% decrease) (P < .001). This change was due primarily to a decreasing incidence of aSAD performed without RCR, which declined from 66.3 to 25.5 per 100,000 (61.5% decrease) (P < .001). During the same period, the incidence of aSAD combined with RCR remained relatively stable, from 51.7 to 45.8 per 100,000 (11.5% decrease) (P = .27). The overall incidence of oSAD declined from 7.1 to 2.2 per 100,000 (68.1% decrease) (P < .001). CONCLUSIONS: The overall rate of aSAD has declined in recent years, primarily due to a large decrease in the incidence of aSAD without RCR as an isolated treatment for rotator cuff disorders. CLINICAL RELEVANCE: Prior studies have demonstrated a rising incidence of SAD; however, high-level clinical evidence and clinical practice guidelines have challenged its efficacy. It is important for orthopaedic surgeons to understand evolving national trends in management among their peers.

Are Comorbidities Affecting Rotator Cuff Repair Outcomes? A Retrospective Review of Postoperative Costs and complications.

Our study examines the effect of comorbidities on rotator cuff repair (RCR) postoperative costs and complication rates. A retrospective review of patients receiving RCRs from 2008-2016 using the PearlDiver database was performed. We evaluated the effect of major comorbidities on postoperative costs and complications within one year of surgery. In total, 8,747 patients underwent RCR. Patients with no comorbidities had a 6-month and 12-month postoperative cost of $3,534 and $3,853, respectively. Patients with one comorbidity had 6-month postoperative costs ranging from $2,623 to $3,466 and 1-year postoperative costs ranging from $2,992 to $5,906. Patients with 3+ comorbidities receiving arthroscopic RCR had the highest complication rates at 1-, 3- and 6-month intervals (11.8%, 19.7% and 26.8%, respectively) compared to those with no comorbidities (8.1% [p = 0.139], 12.7% [p = 0.022] and 15.9% [p = 0.001], respectively). Patients with isolated comorbidities likely require similar healthcare utilization to those without, but patients with 3+ comorbidities risk greater complications and higher post-operative costs. (Journal of Surgical Orthopaedic Advances 30(1):024-029, 2021).

Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist?

BACKGROUND: While there are many possible complications associated with total joint arthroplasty (TJA), venous thromboembolism (VTE) is both frequent and potentially severe. Despite this importance, there are inconsistent recommendations for prophylaxis based on patient risk factors. METHODS: A predictive model was constructed to compare low-molecular-weight heparin(LMWH) and aspirin (ASA) for prevention of VTE-associated complications following TJA.The model used risks from prior prophylaxis studies to estimate the risk of developing a symptomatic deep vein thrombosis, pulmonary embolism, thrombocytopenia, and operative or nonoperative site bleeding. We also evaluated the progression to 4 possible final health states: postphlebitis syndrome, intracranial hemorrhage, death, or baseline health. Within published ranges, we selected assumptions that were favorable to LMWH such that these analyses represent a best case scenario for LMWH or an alternative more aggressive low-molecular-weight heparin alternative (LMWHA). Events and outcomes were assigned quality-adjusted life-year (QALY) losses according to prior studies to determine the effect on patients' outcomes for ASA and LMWHA prophylaxis. RESULTS: Assessing VTE risk populations from 0.2% to 2% with life expectancies ranging from 5 to 40 years postoperatively, patients with a risk ratio less than 3.7 showed increased expected QALY with ASA compared to LMWHA. For patients with a baseline VTE risk of 1% and a 15 year life expectancy, a risk ratio of 13.4 was needed to identify patients that would benefit from LMWHA. With life expectancy increased to 30 years, the risk ratio needed to idetify these patients was 7.4. CONCLUSION: Patients undergoing TJA should receive ASA chemoprophylaxis in nearly all situations, unless the patient has a significantly increased VTE risk compared to the baseline population and a long life expectancy.

Wettability-Independent Droplet Transport by Bendotaxis.

We demonstrate "bendotaxis," a novel mechanism for droplet self-transport at small scales. A combination of bending and capillarity in a thin channel causes a pressure gradient that, in turn, results in the spontaneous movement of a liquid droplet. Surprisingly, the direction of this motion is always the same, regardless of the wettability of the channel. We use a combination of experiments at a macroscopic scale and a simple mathematical model to study this motion, focusing in particular on the timescale associated with the motion. We suggest that bendotaxis may be a useful means of transporting droplets in technological applications, e.g., in developing self-cleaning surfaces, and discuss the implications of our results for such applications.

Preoperative Interventions and Charges in the 2-Year Period Before Unicompartmental Knee Arthroplasty: What Happens Before Surgery.

BACKGROUND: This study investigated preoperative interventions and their costs in the 2-year period before a patient undergoing a unicompartmental knee arthroplasty (UKA). METHODS: A retrospective cohort analysis of patients undergoing UKA between 2009 and 2011 was conducted using the PearlDiver Patient Record Database to track inpatient and outpatient billing records. RESULTS: One thousand eight hundred forty-one patients from Medicare and 4704 patients from United Healthcare underwent UKA between 2009 and 2011. In the 2 years before UKA, the per patient average charge was $3919.96 for Medicare patients and $5219.14 for United Healthcare patients, with 21.7% of Medicare-associated charges and 28.2% of United Healthcare-associated charges occurring within 3 months of surgery. In the 2-year period before surgery, 65.5% of Medicare patients and 53.6% of United Healthcare patients received an intra-articular injection, with 29.1% (Medicare) and 46.0% (United Healthcare) of these injections occurring within 3 months of surgery. In addition, 15.1% of Medicare patients and 20.7% of United Healthcare patients underwent an arthroscopy, with between 32.4% and 43.8% of these occurring in the final 6 months before UKA. CONCLUSION: Preoperative interventions (ie, imaging, procedures, physical therapy, and injections) occur at a high frequency in close proximity to UKA resulting in substantial costs. The development of algorithms to guide management of these patients is critical in reducing costs before UKA.

Preoperative Interventions and Charges Before Total Knee Arthroplasty.

BACKGROUND: The cost effectiveness of total knee arthroplasty (TKA) has been well established, but little data exist regarding preoperative interventions and their costs. The purpose of this study was to examine preoperative interventions and their associated charges within the 2-year period before TKA. METHODS: A retrospective cohort analysis of patients undergoing TKA between 2007 and 2011 was conducted using the PearlDiver Patient Record Database. Patients' inpatient and outpatient billing records were tracked over the 2-year period before receiving a TKA. RESULTS: A total of 35,596 patients from Medicare and 47,064 from United Healthcare underwent TKA from 2009 to 2011. In the 2-year period before TKA, the per patient average charge was $3545.82 for Medicare and $3281.57 for United Healthcare. In the 2-year period before TKA, 21.4% (Medicare) and 23.3% (United Healthcare) of all patients received a magnetic resonance imaging, with between 31.9% (Medicare) and 45.6% (United Healthcare) of these occurring within 3 months of surgery (P < .05). During this same period, 49.4% (Medicare) and 63.2% (United Healthcare) of all patients received an intra-articular injection, with between 29.4% (Medicare) and 44.8% (United Healthcare) of these occurring within 3 months of surgery (P < .05). CONCLUSION: Interventions and costs before TKA occur largely within 6 months preoperatively, with a substantial portion occurring within 3 months. These interventions may not be clinically or cost effective for certain patients, such as those with moderate-to-severe osteoarthritis. Foregoing these interventions and opting to perform TKA earlier may reduce costs and prevent unnecessary tests and procedures.

Distinguishing Periprosthetic Crystalline Arthropathy from Infection in Total Knee Arthroplasty: A Systematic Review.

Distinguishing periprosthetic crystalline arthropathy from periprosthetic joint infection (PJI) remains a diagnostic challenge as both symptom presentation and diagnostic tests overlap. Accurate differentiation is important as treatment plans vary significantly. We sought to systematically review all cases of total knee arthroplasty (TKA) periprosthetic crystalline arthropathy reported in the literature and summarize clinical, diagnostic, and operative findings in the context of guidelines for diagnosing PJI. The goal of this systematic review is to determine the amount of diagnostic overlap and to identify best practices for differentiating between these two diagnoses. MEDLINE and Google Scholar were searched to identify cases of crystalline arthropathy following TKA. Case reports were reviewed for patient characteristics, clinical symptoms, physical exam, laboratory results, and treatment outcomes. These findings were summarized across patients and dichotomized based on current thresholds for diagnosing PJI according to Musculoskeletal Infection Society criteria. Twenty-six articles were identified which included 42 cases of periprosthetic crystalline arthropathy (17 gout, 16 pseudogout, one both, and eight not specified). Of these cases, 25 presented over 1 year after their index arthroplasty and 15 had no prior history of crystalline arthropathy. Only six cases had a superimposed infection based on aspiration or intraoperative cultures. For cases without a culture-positive infection, several diagnostic tests overlap with PJI thresholds: 95% of patients had C-reactive protein greater than 1 mg/dL, 76% had an erythrocyte sedimentation rate greater than 30 mm/hour, 91% had a synovial white blood cell greater than 3,000 cells, and 76% had a synovial polymorphonuclear cells percent greater than 80%. Patients without co-infection were managed with non-steroidal anti-inflammatory drugs, colchicine, allopurinol, steroids, or a combination of these treatments and most had complete resolution of symptoms within 1 week. Commonly used markers of PJI fail to reliably distinguish periprosthetic crystalline arthropathy from infection. Though clinical judgement and consideration of the implications of delayed treatment for acute PJI remain paramount, in the setting of synovial crystals, surgeons may wish to consider this alternate etiology as the source of the patient's clinical symptoms.

Transitioning a Practice to Robotic Total Knee Arthroplasty Is Correlated with Favorable Short-Term Clinical Outcomes-A Single Surgeon Experience.

BACKGROUND: This study sought to evaluate the patient experience and short-term clinical outcomes associated with the hospital stay of patients who underwent robotic arm-assisted total knee arthroplasty (TKA). These results were compared with a cohort of patients who underwent TKA without robotic assistance performed by the same surgeon prior to the introduction of this technology. MATERIALS AND METHODS: A cohort of consecutive patients undergoing primary TKA for the diagnosis of osteoarthritis by a single fellowship trained orthopaedic surgeon over a 39-month period was identified. Patients who underwent TKA during the year that this surgeon transitioned his entire knee arthroplasty practice to robotic assistance were excluded to eliminate selection bias and control for the learning curve. All patients received the same prosthesis and postoperative pain protocol. Patients that required intubation for failed spinal anesthetic were excluded. A final population of 492 TKAs was identified. Of these, 290 underwent TKA without robotic assistance and 202 underwent robotic arm-assisted TKA. Patient demographic characteristics and short-term clinical data were analyzed. RESULTS: Robotic arm-assisted TKA was associated with shorter length of stay (2.3 vs. 2.6 days, p < 0.001), a 50% reduction in morphine milligram equivalent utilization (from 214 to 103, p < 0.001), and a mean increase in procedure time of 9.3 minutes (p < 0.001). There was one superficial infection in the nonrobotic cohort and there were no deep postoperative infections in either cohort. There were no manipulations under anesthesia in the robotic cohort while there were six in the nonrobotic cohort. Additionally, there were no significant differences in emergency department visits, readmissions, or return to the operating room. CONCLUSION: This analysis corroborates existing literature suggesting that robotic arm-assisted TKA can be correlated with improved short-term clinical outcomes. This study reports on a single surgeon's experience with regard to analgesic requirements, length of stay, pain scores, and procedure time following a complete transition to robotic arm-assisted TKA. These results underscore the importance of continued evaluation of clinical outcomes as robotic arthroplasty technology continues to grow.

Are Oblique Views Necessary? A Review of the Clinical Value of Oblique Knee Radiographs in the Acute Setting.

INTRODUCTION: The purpose of this study was to assess the added clinical value of oblique knee radiographs four-view (4V) compared to orthogonal anteroposterior (AP) and lateral radiographs in a two-view (2V) series. METHODS: We obtained 200 adult, 4V knee radiographs in 200 patients in the ED and randomly divided them into two groups with 100 series in each group. Ten reviewers - three musculoskeletal radiologists and seven orthopedic surgeons - performed radiograph analyses. These reviewers were randomly divided evenly into group one and group two. Reviewers were blinded to patient data and first reviewed 2V radiographs (AP/lateral) only, and then reviewed 4V radiographs, including AP/lateral, and two additional oblique views for the same patients at least four weeks later. Acute pathology identification and the need for further imaging was assessed for all reviewers, and clinical decision-making (operative vs nonoperative treatment, need for admission, need for additional imaging) was assessed only by the seven orthopaedic surgeon reviewers. RESULTS: Mean sensitivity for pathology identification was 79% with 2V and 81% with 4V (P =0.25). Intra-observer kappa value was 0.81 (range 0.54-1.00). Additional oblique radiographs led orthopaedic reviewers to change their treatment recommendations in 62/329 patients (18.84%) (P <0.001). Eight of 329 radiographic series were identified as "critical misses." (2.43%) (P =0.004), when pathology was reported as normal or reviewers recommended nonoperative treatment on 2V radiographs but changed their recommendation to operative management after the addition of oblique radiographs. The number needed to treat (NNT) for any treatment change and for "critical misses" was 83 and 643, respectively. CONCLUSION: Although the addition of oblique radiographs may improve a clinician's ability to identify subtle pathologic findings not identified on 2V, it rarely leads to significant changes in treatment recommendations. Given the high NNT, limiting the usage of these oblique radiographs in the general patient population may reduce costs without significantly affecting patient care.

Ice front retreat reconfigures meltwater-driven gyres modulating ocean heat delivery to an Antarctic ice shelf.

Pine Island Ice Shelf (PIIS) buttresses the Pine Island Glacier, the key contributor to sea-level rise. PIIS has thinned owing to ocean-driven melting, and its calving front has retreated, leading to buttressing loss. PIIS melting depends primarily on the thermocline variability in its front. Furthermore, local ocean circulation shifts adjust heat transport within Pine Island Bay (PIB), yet oceanic processes underlying the ice front retreat remain unclear. Here, we report a PIB double-gyre that moves with the PIIS calving front and hypothesise that it controls ocean heat input towards PIIS. Glacial melt generates cyclonic and anticyclonic gyres near and off PIIS, and meltwater outflows converge into the anticyclonic gyre with a deep-convex-downward thermocline. The double-gyre migrated eastward as the calving front retreated, placing the anticyclonic gyre over a shallow seafloor ridge, reducing the ocean heat input towards PIIS. Reconfigurations of meltwater-driven gyres associated with moving ice boundaries might be crucial in modulating ocean heat delivery to glacial ice.

Gout in primary total knee arthroplasty: Prevalent but not independently associated with complications.

BACKGROUND: Gout is a common synovial pathology, but its prevalence in patients undergoing total knee arthroplasty (TKA) and potential association with complications such as periprosthetic infection (PJI) and revision are unknown. METHODS: Medicare data from 2009 to 2013 was retrospectively reviewed using PearlDiver. All patients 65 years of age or older and undergoing primary TKA with at least 3 years of pre-TKA records were included. The prevalence of gout was based on ICD-9 codes. Univariable associations of gout with PJI and revision at 1 year were assessed using odds ratios with 95% confidence intrervals (C.I.). To control for potential confounding, patients with a history of gout were matched on age, gender, smoking history, and Elixhauser Comorbidity Index (ECI) to patients without gout and associations reassessed. RESULTS: The prevalence of gout in Medicare patients undergoing primary TKA was 5.7%. On univariable analysis, patients with a history of gout were more likely to develop PJI (O.R., 1.58; 95% C.I., 1.45-1.72) and undergo revision (O.R., 1.33; 95% C.I., 1.25-1.41) at 1 year. After matching for confounders, a history of gout was no longer associated with developing PJI (O.R., 0.98; 95% C.I., 0.90-1.06) or undergoing revision (O.R., 0.94; 95% C.I., 0.89-1.00) at 1 year. CONCLUSIONS: Gout is a relatively common pathology in patients undergoing TKA. While gout is associated with increased complications, this appears to be driven by confounding through its association with other medical comorbidities. Gout does not appear to be an independent risk factor for complications following TKA.

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.