Evaluating left atrial strain and left ventricular diastolic strain rate as markers for diastolic dysfunction in patients with mitral annular calcification.

BACKGROUND: Mitral annular calcification (MAC) poses many challenges to the evaluation of diastolic function using standard echocardiography. Left atrial (LA) strain and left ventricular early diastolic strain rate (DSr) measured by speckle-tracking echocardiography (STE) are emerging techniques in the noninvasive evaluation of diastolic function. We aim to evaluate the utility of LA strain and early DSr in predicting elevated left ventricular filling pressures (LVFP) in patients with MAC and compare their effectiveness to ratio of mitral inflow velocity in early and late diastole (E/A). METHODS: We included adult patients with MAC who presented between January 1 and December 31, 2014 and received a transthoracic echocardiogram (TTE) and cardiac catheterization with measurement of LVFP within a 24-h period. We used Spearman's rank correlation coefficient to assess associations of LA reservoir strain and average early DSr with LVFP. Receiver operating characteristic (ROC) curves were computed to assess the effectiveness of LA strain and DSr in discriminating elevated LVFP as a dichotomized variable and to compare their effectiveness with E/A ratio categorized according to grade of diastolic dysfunction. RESULTS: Fifty-five patients were included. LA reservoir strain demonstrated poor correlation with LVFP (Spearman's rho = 0.03, p = 0.81) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.54, 95% CI 0.38-0.69). Categorical E/A ratio alone also demonstrated poor discriminatory ability (AUC = 0.53, 95% CI 0.39-0.67), and addition of LA reservoir strain did not significantly improve effectiveness (AUC = 0.58, 95% CI 0.42-0.74, p = 0.56). Average early DSr also demonstrated poor correlation with LVFP (Spearman's rho = -0.19, p = 0.16) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.59, 95% CI 0.44-0.75). Addition of average early DSr to categorical E/A ratio failed to improve effectiveness (AUC = 0.62, 95% CI 0.46-0.77 vs. AUC = 0.54, 95% CI 0.39-0.69, p = 0.38). CONCLUSIONS: In our sample, LA reservoir strain and DSr do not accurately predict diastolic filling pressure. Further research is required before LA strain and early DSr can be routinely used in clinical practice to assess filling pressure in patients with MAC.

Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty.

Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.

Wrist Arthrotomy Saline Load Test.

BACKGROUND: Failure to recognize a potential wrist arthrotomy may lead to missed septic arthritis and devastating sequelae. The saline load test is routinely used to recognize traumatic arthrotomies of other joints; however, there are limited data optimizing this test for the wrist. The purpose of this study was to investigate and perform saline load testing to identify traumatic arthrotomies of the wrist. METHODS: This was a cadaveric study of 15 wrists. Traumatic arthrotomies were created using a blunt trocar through the 3-4 portal. A 3-mL syringe with 0.1 mL markings was used to inject methylene blue dyed saline into the wrist through the 1-2 portal. Once extravasation was visible from the atherectomized site, the volume was recorded. RESULTS: The mean (range) volume injected to identify the arthrotomy of all wrists was 1.22 mL (range, 0.1-3.1 mL). Multivariate regression demonstrated that cadaver age, laterality, and extension range of motion were not significantly associated with the injected saline volume at extravasation (P > .05, each). Greater joint range of motion was independently associated with higher saline volume load for extravasation (odds ratio: 1.049; 95% confidence interval: 1.024-1.075; P = .003). CONCLUSIONS: We found that 2.68 and 3.02 mL of methylene blue dyed saline offered 95% and 99% sensitivity, respectively, for diagnosing traumatic wrist arthrotomy. The maximum volume of saline needed to recognize an arthrotomy was 3.1 mL. We recommend this be the minimum volume used to evaluate a traumatic wrist arthrotomy.

Clinical and radiographic outcomes following anatomic total shoulder arthroplasty utilizing an inset glenoid component at 2-year minimum follow-up: a dual center study.

BACKGROUND: Anatomic total shoulder arthroplasty (aTSA) is a successful and reproducible treatment for patients with painful glenohumeral arthritis. However, long-term outcomes using traditional onlay glenoid components have been tempered by glenoid loosening. Inset components have been proposed to minimize glenoid loosening by reducing edge-loading and opposite-edge lift-off forces with humeral translation. Successful short- and long-term outcomes have been reported while using inset glenoid implants. The current study is the largest study presenting a minimum of 2-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI, USA). METHODS: A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by 2 fellowship-trained shoulder surgeons at 2 separate institutions from August, 2016, to August, 2019, was performed. Minimum follow-up was 2 years. Range of motion (ROM), visual analog scale (VAS) pain scores, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores were obtained. Radiographic outcomes, including central peg lucency and glenoid loosening, were assessed by 3 independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up. RESULTS: Seventy-five shoulders were included for the final analysis. The mean age of the entire cohort was 64 (±11.4) years. Twenty-one (28%) glenoids were type A1, 10 (13.3%) were type A2, 13 (17.3%) were type B1, 22 (29.3%) were type B2, 6 (8%) were type B3, and 3 (4%) were type D. At a minimum follow-up of 24 months (mean: 28.7 months), a significant improvement in ROM in all planes was observed. Significant improvements in VAS (5.1-0.9, P < .001), SANE (39.5-91.2, P < .001), and ASES (43.7-86.6, P < .001) scores were observed. There were 4 (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) case of glenoid loosening. No revisions were performed for glenoid loosening. CONCLUSION: At a minimum of 2 years postoperatively, there were significant improvements in ROM, VAS, SANE, and ASES scores with very low rates of central peg lucency and glenoid loosening in patients undergoing aTSA with an inset glenoid component. Further work is needed to determine the long-term benefit of this novel implant.

The Association of International Normalized Ratio with Postoperative Complications in Revision Total Knee Arthroplasty.

The purpose of this study was to examine the relationship between elevated preoperative international normalized ratio (INR) and (1) mortality, (2) postoperative bleeding, and (3) other postoperative complications in a national cohort of patients who underwent revision total knee arthroplasty (rTKA). The American College of Surgeons National Surgical Quality Improvement Program was queried for rTKA procedures conducted between 2006 and 2017. Cohorts were based on INR ranges: <1, 1 < INR ≤ 1.25, 1.25 < INR ≤ 1.5, and >1.5. Univariate/multivariate statistics were calculated to analyze associations between INR value and designated covariates. These statistics were additionally applied to optimal cutoff values of INR calculated using a receiver operating characteristics curve. The final cohort consisted of 1,676 patients. Progressively higher INR values were associated with an increased risk of mortality within 30 days (p < 0.006), bleeding requiring transfusion (p < 0.001), sepsis (p < 0.001), return to the operating room (Odds Ratio [OR], p = 0.011), reintubation (p < 0.001), pneumonia (p < 0.001), failure to wean from mechanical ventilation ≤48 hours (p < 0.001), acute renal failure (p = 0.001), and hospital length of stay (LOS). Statistically significant associations were similarly seen when calculated optimal INR values were used. Optimal INR turn point was found to be associated with a significant increased risk of long LOS (optimal INR = 1.03, OR: 1.7, 95% confidence interval [CI]: 1.33-2.18; p < 0.001) and a significant decreased risk of bleeding requiring transfusion (INR = 1.005, OR: 0.732, 95% CI: 0.681-0.786; p < 0.001). High preoperative INR values were independently and significantly associated with an increased risk of multiple postoperative complications. Current guidelines for INR <1.5 should be reassessed for patients undergoing rTKA.

The value of artificial neural networks for predicting length of stay, discharge disposition, and inpatient costs after anatomic and reverse shoulder arthroplasty.

HYPOTHESIS/PURPOSE: The objective is to develop and validate an artificial intelligence model, specifically an artificial neural network (ANN), to predict length of stay (LOS), discharge disposition, and inpatient charges for primary anatomic total (aTSA), reverse total (rTSA), and hemi- (HSA) shoulder arthroplasty to establish internal validity in predicting patient-specific value metrics. METHODS: Using data from the National Inpatient Sample between 2003 and 2014, 4 different ANN models to predict LOS, discharge disposition, and inpatient costs using 39 preoperative variables were developed based on diagnosis and arthroplasty type: primary chronic/degenerative aTSA, primary chronic/degenerative rTSA, primary traumatic/acute rTSA, and primary acute/traumatic HSA. Models were also combined into diagnosis type only. Outcome metrics included accuracy and area under the curve (AUC) for a receiver operating characteristic curve. RESULTS: A total of 111,147 patients undergoing primary shoulder replacement were included. The machine learning algorithm predicting the overall chronic/degenerative conditions model (aTSA, rTSA) achieved accuracies of 76.5%, 91.8%, and 73.1% for total cost, LOS, and disposition, respectively; AUCs were 0.75, 0.89, and 0.77 for total cost, LOS, and disposition, respectively. The overall acute/traumatic conditions model (rTSA, HSA) had accuracies of 70.3%, 79.1%, and 72.0% and AUCs of 0.72, 0.78, and 0.79 for total cost, LOS, and discharge disposition, respectively. CONCLUSION: Our ANN demonstrated fair to good accuracy and reliability for predicting inpatient cost, LOS, and discharge disposition in shoulder arthroplasty for both chronic/degenerative and acute/traumatic conditions. Machine learning has the potential to preoperatively predict costs, LOS, and disposition using patient-specific data for expectation management between health care providers, patients, and payers.

A Case Series of Successful Repair of Articular Cartilage Fragments in the Knee.

BACKGROUND: It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture. PURPOSE: To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively. RESULTS: At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports. CONCLUSION: The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee.

The Effect of Body Mass Index on 30-day Complications After Revision Total Hip and Knee Arthroplasty.

BACKGROUND: We aimed to explore the effect of body mass index (BMI) on 30-day complications after aseptic revision total knee arthroplasty (rTKA) and aseptic revision total hip arthroplasty (rTHA), considering BMI as both a categorical and continuous variable. METHODS: A total of 18,866 patients (9093 rTHA and 9773 rTKA) patients were included for analysis using the American College of Surgeons National Surgical Quality Improvement Project database. Thirty-day rates of readmissions, reoperations, and major and minor complications were compared between different weight categories (overweight: BMI >25 and ≤30 kg/m2; obese: BMI >30 and ≤40 kg/m2; morbidly obese: BMI >40 kg/m2) and the normal weight category (BMI >18.5 and ≤25 kg/m2) using multivariate regression models. Spline regression models were created to study BMI as a continuous variable. RESULTS: Both readmission rates and reoperation rates increased for rTKA as BMI increased (P < .005). There was a linear relationship between BMI and readmission rates for rTKA. Morbid obesity was associated with an increased reoperation rate for rTHA on univariate analysis (P = .022); however, multivariate analysis showed no statistically significant increase in readmission or reoperation rates as BMI increased for rTHA. CONCLUSIONS: The relationship between BMI and complications after revision total joint arthroplasty is a J-shaped curve with the lowest rates of complications occurring around a BMI of 30 kg/m2. The relationship between BMI and perioperative complications is stronger for revision TKA as opposed to revision THA.

Gap-Balancing versus Measured Resection Technique in Total Knee Arthroplasty: A Comparison Study.

Proper femoral component alignment in the axial plane during total knee arthroplasty (TKA) depends on accurate bone cuts and soft tissue balancing. Two methods that are used to achieve this are "measured resection" and "gap balancing." However, a controversy exists as to which method is more accurate and leads to better outcomes. Therefore, the purpose of this study was to evaluate: (1) implant survivorship, (2) patient outcomes, (3) complications, and (4) radiographic analysis comparing patients who underwent TKA with either gap-balancing or measured resection techniques. A total of 214 consecutive patients (221 knees) underwent primary TKA by a single surgeon between 2011 and 2012. Component alignment was achieved by using measured resection in 116 knees and gap balancing was used in 105 knees. The patients had a mean age of 66 years (range, 44-86 years) and a mean body mass index of 32 kg/m2 (range, 22-52 kg/m2). Patient range-of-motion (ROM) and Knee Society (KS) function and pain scores, and radiographic assessment, were assessed preoperatively and postoperatively at ∼6 weeks, 3 months, 1 year, and then annually. The mean follow-up time was 3 years. A Kaplan-Meier's analysis was performed to calculate the survivorship. The aseptic survivorship was 98% in both the measured resection and gap-balancing groups. The mean ROM was not significantly different between the measured resection and gap-balancing groups (123 vs. 123 degrees, p = 0.990). There were no significant differences between the two groups in terms of the KS function scores (86 vs. 85 points, p = 0.829) or the KS pain scores (93 vs. 92 points, p = 0.425). Otherwise, the radiographic evaluation at latest follow-up did not demonstrate any evidence of progressive radiolucencies or loosening, of any prosthesis. The results of this study found that at a mean follow-up of 3 years, both the measured resection and gap-balancing techniques achieved excellent survivorship and postoperative outcomes. This demonstrates that both methods can be used to achieve accurate femoral component alignment with similar short-term outcomes.

Comparing ε-Aminocaproic Acid and Tranexamic Acid in Reducing Postoperative Transfusions in Total Knee Arthroplasty.

Multiple studies have shown tranexamic acid (TXA) to reduce blood loss and transfusion rates in patients undergoing total knee arthroplasty (TKA). Accordingly, TXA has become a routine blood conservation agent for TKA. In contrast, ε-aminocaproic acid (EACA), a similar acting antifibrinolytic to TXA, has been less frequently used. This study evaluated whether EACA is as efficacious as TXA in reducing postoperative blood transfusion rates and compared the cost per surgery between agents. A multicenter retrospective chart review of elective unilateral TKA from April 2012 through December 2014 was performed. Five hospitals within a health care system participated. Data collected included age, gender, severity of illness score, use of antifibrinolytic and dose, red blood cell (RBC) transfusions and the number of units, and preadmission and discharge hemoglobin (Hb). Dosing of the antifibrinolytic differed based on the agent used, 5 or 10 g (based on weight) for EACA versus 1 g for TXA. The institutional acquisition cost of each antifibrinolytic was obtained and averaged over the study period. Of 2,922 primary unilateral TKA cases, 820 patients received EACA, 610 patients received TXA, and 1,492 patients received no antifibrinolytic (control group). Compared with the control group both EACA and TXA groups had significantly fewer patients transfused (EACA 2.8% [p < 0.0001], TXA 3.2% [p < 0.0001] vs. control 10.8%) and lower mean RBC units transfused per patient (EACA 0.05 units/patient [pt] [p < 0.0001], TXA 0.05 units/pt [p < 0.0001] vs. control 0.19 units/pt]. There was no difference in mean RBC units transfused per patient, percentage of patients transfused, and discharge Hb levels between the EACA and TXA groups (p = 0.822, 0.236, and 0.322, respectively). Medication acquisition cost for EACA averaged $2.23 per surgery compared with TXA at $39.58 per surgery. Administration of EACA or TXA significantly decreased postoperative transfusion rates compared with no antifibrinolytic therapy. Utilization of EACA for unilateral TKA proved to be comparable to TXA in all studied aspects at a lower cost. The level of evidence for the study is Level 3.

Total knee arthroplasty fibrosis following arthroscopic intervention.

BACKGROUND: Although arthroscopy is generally considered to be a relatively benign procedure with limited trauma to periarticular soft tissues, post-arthroscopic bleeding as well as osmolality differences between the normal saline used to irrigate and the native synovial fluid (282 vs. 420 mOs) can lead to capsular reactions. Therefore, the purpose of this study was to evaluate whether capsular reaction occurred after knee arthroscopy, by comparing a matched cohort of patients who either did or did not undergo prior arthroscopic surgery. Specifically, we compared histological features such as: (I) synovial thickness; (II) cellularity; and (III) the amount of fibrous tissue for each cohort. METHODS: Prior to their total knee arthroplasty (TKA), 40 consecutive patients who had previously undergone arthroscopy were matched to 40 consecutive patients who had not. During each patient's TKA, a biopsy of the capsule and fat pad was taken and formalin sections were sent to pathology to assess for synovial thickness, cellularity, and the amount of fibrous tissue. The pathologist was blinded to the groupings. Findings for all histologic features were classified as equivocal, slight to moderate, and moderate to severe. RESULTS: There were a significantly higher proportion of patients who had increased synovial thickness in the prior arthroscopy group as compared to the no-prior arthroscopy group (97.5% vs. 0%, P<0.001). Additionally, there were a significantly higher proportion of patients who had increased cellularity in the prior arthroscopy group as compared to the no-prior arthroscopy group (60.0% vs. 0%, P<0.001). There were also a significantly higher proportion of patients who had increased fibrous tissue in the prior arthroscopy group as compared to the no-prior arthroscopy group (95% vs. 62.5%, P<0.001). CONCLUSIONS: Arthroscopic surgery may have long-term effects on capsular tissue as surgical observations of patients with prior arthroscopic surgery from this study found that the capsule is thicker and denser. Histologic assessment confirms there may be increased synovial thickness, increased cellularity, as well as thickening of fibrous tissue. This preliminary study and further evaluation are required. This suggests that arthroscopic surgery may have long-lasting effects on periarticular tissue especially the capsular tissue which may have implications for pain and functional recovery.

Using Aminocaproic Acid to Reduce Blood Loss After Primary Unilateral Total Knee Arthroplasty.

xtensive blood loss after total knee arthroplasty (TKA) is common, and affected patients often require blood transfusions. Studies suggest that antifibrinolytic agents such as aminocaproic acid (ACA) reduce blood loss and blood transfusion rates in patients undergoing TKA. We conducted a study to evaluate whether a single intravenous 10-g dose of ACA given during primary unilateral TKA would decrease perioperative blood loss, raise postoperative hemoglobin levels, and reduce postoperative blood transfusion rates. We retrospectively reviewed the charts of 50 comparable cemented primary unilateral TKAs. Twenty-five patients had been given a single intraoperative 10-g dose of ACA (antifibrinolytic group), and the other 25 had not been given ACA (control group). Postoperative drain output was decreased significantly (P < .0001) in the antifibrinolytic group (155 mL) compared with the control group (410 mL), as was the number of units of blood transfused after surgery (antifibrinolytic group, 0 units; control group, 10 units; P < .002). There were no adverse events in the antifibrinolytic group. In TKA, perioperative blood loss and blood transfusion rates were reduced significantly in patients given a single intraoperative intravenous 10-g dose of ACA compared with patients not given antifibrinolytics. The positive effects of ACA were obtained without adverse events or complications.

Comparison of ε-Aminocaproic Acid and Tranexamic Acid in Reducing Postoperative Transfusions in Total Hip Arthroplasty.

BACKGROUND: Use of antifibrinolytic agents in total hip arthroplasty (THA) is well supported; however, most studies used tranexamic acid (TXA), whereas few used ε-aminocaproic acid (EACA), a similar antifibrinolytic. This study compares the efficacy and cost per surgery of intraoperative infusion of EACA and TXA in reducing postoperative blood transfusion rates in THA. METHODS: Retrospective chart review of 1799 primary unilateral THA cases from April 2012 through December 2014 at 5 hospitals within our health care network. RESULTS: In our cohort, 711 received EACA, 445 received TXA, and 643 (control group) received no antifibrinolytic. Both antifibrinolytic groups had significantly fewer patients receiving red blood cell (RBC) transfusions when compared with control group (EACA 6.8% [P < .0001], TXA 9.7% [P < .0001] vs control group 24.7%). Average number of RBC units per patient were similar for EACA and TXA (0.11 units/patient and 0.15 units/patient, respectively), and both were significantly lower than the control group (0.48 units/patient, P < .0001). No significant difference was noted in mean RBC units per patient and percentage of patients transfused between EACA and TXA groups (P = .144, P = .074). Logistic regression showed no difference between EACA and TXA when adjusting for age, gender, higher severity of illness levels, admission hemoglobin, performing surgeon, and hospital. Medication acquisition cost for EACA averaged $2.70 per surgery compared with TXA at $39.58 per surgery. CONCLUSION: Intraoperative antifibrinolytic use significantly decreases need for postoperative blood transfusions. At our institution, EACA is comparable to TXA in THA for reducing transfusion rates while at a lower cost per surgery.