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

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

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

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

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

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

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

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

Does Physical Activity Level Influence Total Hip Arthroplasty Expectations, Satisfaction, and Outcomes?

BACKGROUND: Total hip arthroplasty (THA) patients expect pain relief and functional improvement, including return to physical activity. Our objective was to determine the impact of patients' physical activity level on preoperative expectations and postoperative satisfaction and clinical outcomes in patients undergoing THA. METHODS: Using an institutional registry of patients undergoing THA between 2007 and 2012, we retrospectively identified patients who underwent unilateral primary THA for osteoarthritis and completed a preoperative Lower Extremity Activity Scale, Hospital for Special Surgery Hip Replacement Expectations Survey, and Hip disability and Osteoarthritis Outcome Score in addition to two-year HOOS and satisfaction evaluations. Active patients (n = 1053) were matched to inactive patients (n = 1053) by age, sex, body mass index, and comorbidities. The cohorts were compared with regard to the association of expectations with Hip disability and Osteoarthritis Outcome Score and satisfaction, the change in Lower Extremity Activity Scale level from baseline to 2 years, complications, and revision surgical procedures. RESULTS: Significantly more active patients (74%) expected to be "back to normal" regarding ability to exercise and participate in sports compared with inactive patients (64%, P < .001). Overall satisfaction was similar. Higher expectations with regard to exercise and sports were associated with higher HOOS sports and recreation subdomain scores in active patients. The inactive patient group improved on baseline activity level at 2 years while the active group did not. CONCLUSION: At 2 years after THA, active and inactive patients were similarly satisfied and achieved comparable outcomes. Inactive patients showed a greater improvement in physical activity level from preoperative baseline than active patients. Complications and revision rates were similar. LEVEL OF EVIDENCE: III.

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

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

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

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

Total Hip Arthroplasty and the Medicare Inpatient-Only List: An Analysis of Complications in Medicare-Aged Patients Undergoing Outpatient Surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services has solicited public comments for the 2019 Proposed Rule to remove total hip arthroplasty (THA) from the inpatient-only list. Concerns exist regarding the safety of discharging higher risk Medicare patients as an outpatient and whether hospitals may still be reimbursed for an inpatient procedure. The purpose of this study is to determine whether Medicare-aged patients undergoing outpatient THA have higher complication rates than patients who underwent inpatient THA. We also sought to identify characteristics of Medicare-aged patients that are associated with increased risk of complications or longer stay following short-stay THA. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients over age 65 who underwent primary THA between 2015 and 2016. We compared demographics, comorbidities, and 30-day complication, reoperation, and readmission rates among outpatient, short-stay, and inpatient groups. A multivariate regression analysis identified patients who are at an increased risk for complications and a longer inpatient stay following short-stay THA. RESULTS: Of the 34,416 Medicare-aged patients who underwent THA, 310 (1%) were discharged on postoperative day 0, 5698 (16.5%) on postoperative day 1, and 28,408 (82.5%) were inpatients. The outpatient and short-stay patients had lower 30-day complication and readmission rates than the inpatient group. Independent risk factors for developing a complication or requiring an inpatient stay included general anesthesia, body mass index >35 kg/m2, diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, malnutrition, female gender, age >75 years, minority ethnicity, and an American Society of Anesthesiologists score of 4 (all P < .05). CONCLUSION: Outpatient and short-stay THA appears to be safe in a small subset of Medicare-aged patients. Centers for Medicare and Medicaid Services should allow surgeons flexibility in determining admission status based on each patient's risk profile.

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

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

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

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

In-Hospital Morbidity and Postoperative Revisions After Direct Anterior vs Posterior Total Hip Arthroplasty.

BACKGROUND: The direct anterior approach (DAA) offers the potential for less soft tissue insult, improved early recovery, and reduced dislocation rates. However, complications are associated with the DAA, particularly during the learning curve. We compare the DAA learning curve experience with the posterior approach regarding in-hospital complications and revision rate. METHODS: We evaluated systemic and local in-hospital complications associated with primary unilateral cementless THAs from January 1, 2010 to December 31, 2012 in 4249 patients through a posterior approach and 289 patients through a DAA. All procedures were performed consecutively by high-volume surgeons who use a single approach in a nonselective manner. The DAA was performed by surgeon transitioning from the posterior approach, thus incorporating the learning curve. Demographics were comparable. Revision procedures were captured through a minimum 4-year follow-up. Analyses compared complication and revision rates. RESULTS: The DAA group demonstrated shorter length of stay, procedure time, lower blood transfusion rate, and increased discharge to home rate. Local and major systemic in-hospital complications were rare and comparable between groups. The minor systemic complication rate was significantly greater for the posterior group (10.9% posterior vs 6.2% DAA, P < .05). Revision rate was significantly greater for the posterior group (2.7% posterior vs 0.7% DAA, P < .032). The incidence of revision for dislocation was 1.5% for the posterior approach vs 0.4% for the DAA. CONCLUSION: There was an increased rate of in-hospital minor systemic complications and overall revision, predominantly due to instability, after THA by the posterior approach, in comparison with the DAA.

Profile of Current Opinion on Arthroscopic Acromioplasty: A Video Survey Study.

PURPOSE: To provide a baseline profile of current opinion on use of arthroscopic acromioplasty and evaluate the consistency of surgical decision making on whether or not to perform acromioplasty across different surgeon practices. METHODS: Twenty-two fellowship-trained orthopaedic shoulder surgeons from the Association of Clinical Elbow and Shoulder Surgeons completed an Internet-based survey on practices associated with acromioplasty, including questions related to 15 arthroscopic videos. Based on video cases, interobserver and intraobserver agreement regarding clinically based decisions related to acromioplasty were assessed. RESULTS: Acromioplasty was uncommonly performed in isolation among this group and was most commonly performed in conjunction with repair of full-thickness rotator cuff tears. Nineteen of 22 (86%) surgeons favored an arthroscopic approach for acromioplasty. Depth of bony resection was determined most commonly based on clinical judgment and experience (68%). The video portion of the survey revealed slight interobserver agreement for classification of acromion morphology (κ = 0.099), need for acromioplasty (κ = 0.020), and adequacy of decompression (κ = 0.1). In contrast, there was fair intraobserver reliability regarding acromion morphology (κ = 0.370) and decision whether to perform acromioplasty in a given case (κ = 0.348) whereas there was moderate intraobserver reliability in the presence of a reparable rotator cuff tear (κ = 0.507) and assessment of the adequacy of decompression (κ = 0.453). CONCLUSIONS: Although surgeons had similarities regarding principles of acromioplasty, including indications, surgical approach, and technique, there was lack of consensus when surgeons reviewed the video of clinical cases. Although surgeons may have similar goals in terms of treatment of pathology related to subacromial impingement, individual surgeon thresholds for the need and adequacy of decompression are varied and are not standardized. LEVEL OF EVIDENCE: Level V, expert opinion.

Can We Reduce the Utilization of Home-Visiting Nurse Services After Primary Total Joint Arthroplasty?

BACKGROUND: Home-visiting nurse services (HVNSs) after total joint arthroplasty (TJA) are touted as advantageous compared with inpatient rehabilitation. No study has established the utility of HVNSs compared with discharge home without services. METHODS: A retrospective single-surgeon consecutive series of 509 primary TJA patients compared discharge disposition, length of stay, complications, and patient satisfaction between 2 cohorts. The cohorts were defined by the elimination of routine HVNSs. RESULTS: Surprisingly, without routine HVNSs, more patients were discharged home (95% vs 88.3% with routine HVNSs) and mean length of stay significantly decreased. Complication rate was similar (2.9% vs 3.9% with routine HVNSs). Patient satisfaction remained favorable. We estimated that eliminating HVNSs avoids excess costs of $1177 per hip and $1647 per knee arthroplasty. CONCLUSIONS: With dramatically diminished HVNS utilization after primary TJA, there was an associated decrease in length of stay and no increase in complication rate suggesting no compromise of patient care with significant cost savings.

Preoperative Mapping in Unicompartmental Knee Arthroplasty Using Computed Tomography Scans Is Associated with Radiation Exposure and Carries High Cost.

Robotic-assisted knee arthroplasty with some systems requires the use of computed tomography (CT) scans. The associated radiation dose has not been studied. The effective dose (ED, mSv) of radiation was calculated for 236 preoperative CT scans used for planning of robotic assisted surgery. The mean ED was 4.8±3.0 mSv. There was a 3-fold difference in ED between institutions. One or more additional CT scans were obtained in 25% of patients, amounting to a cumulative ED per patient up to 103 mSv. Preoperative CT is a disadvantage of some robotic-assisted knee arthroplasty systems due to additional cost and radiation exposure. Newer image-free robotic technologies are an alternative to CT-dependent surgery if accuracy and safety are not compromised.

Intraoperative Proximal Femoral Fracture in Primary Cementless Total Hip Arthroplasty.

Intraoperative proximal femoral fracture is a complication of primary cementless total hip arthroplasty (THA) at rates of 2.95-27.8%. A retrospective review of 2423 consecutive primary cementless THA cases identified 102 hips (96 patients) with fracture. Multivariate analysis compared fracture incidences between implants, Accolade (Stryker Orthopaedics) and Tri-Lock (DePuy Orthopaedics, Inc.), and evaluated potential risk factors using a randomized control group of 1150 cases without fracture. The fracture incidence was 4.4% (102/2423), 3.7% (36/1019) using Accolade and 4.9% using Tri-Lock (66/1404) (P=0.18). Female gender (OR=1.96; 95% CI 1.19-3.23; P=0.008) and smaller stem size (OR=1.64; 95% CI 1.04-2.63; P=0.03) predicted increased odds of fracture. No revisions of the femoral component were required in the fracture cohort.

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series.

Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following TKA.

Impact of COVID-19 on Pulmonary Embolism Rates in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the incidence and severity of pulmonary embolism (PE) in patients undergoing total hip and knee arthroplasties after the onset of the coronavirus disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: Patients who underwent a total hip arthroplasty or a total knee arthroplasty between 2017 and 2022 and had a PE within 90 days postoperatively were included. Demographics, medical history, procedural information, and PE outcomes were collected and evaluated. RESULTS: There were 5933 procedures and 17 PE events (0.27%) before COVID-19 compared with 3273 procedures and 16 PE events (0.49%) after COVID-19 (P=.12). There was an increase in intensive care unit admission after COVID-19 (44% vs 0%, P<.05). CONCLUSION: This study showed a trend toward an increased incidence of PE events in the post-COVID-19 cohort and a statistically significant increase in the severity. [Orthopedics. 202x;4x(x):xx-xx.].