Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty.

BACKGROUND: The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA. METHODS: Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA. RESULTS: In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all). CONCLUSION: Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Innovation and Entrepreneurship: Perspectives From Orthopedic Surgery.

Orthopedic surgeons are tasked with treating complex patients while employing critical surgical skills, clinical knowledge, and new technologies. The constant inundation of information, coupled with hours in the hospital setting, provides unique perspectives on various aspects of how health care is delivered, thereby creating a milieu ripe for innovation. The rigors of an orthopedic career make it challenging for physicians to translate an idea into a great product. Through the authors' experiences at a tertiary orthopedic practice, they review the process of taking an idea from concept to fruition. [Orthopedics. 2018; 41(3):135-140.].

The James A. Rand Young Investigator's Award: A Randomized Controlled Trial of Oral and Intravenous Tranexamic Acid in Total Knee Arthroplasty: The Same Efficacy at Lower Cost?

BACKGROUND: Tranexamic acid (TXA) is a synthetic antifibrinolytic agent successfully used intravenously (IV) to reduce blood loss after total knee arthroplasty (TKA). An oral formulation of the medication is available, at a fraction of the cost of the IV preparation. The purpose of this randomized controlled trial is to determine if oral TXA is equivalent to IV TXA in reducing blood loss in TKA. METHODS: In this double-blinded, placebo-controlled trial, patients undergoing primary TKA were randomized to receive 1.95g of TXA orally 2 hours preoperatively or 1g IV bolus before wound closure. The primary outcome was reduction of hemoglobin. Power analysis determined that 30 patients were required in each group. Equivalence analysis was performed with pooled and Satterthwaite t tests with a P-value of <.05 suggesting equivalence between treatments. RESULTS: Thirty-four patients received oral TXA and 37 patients received IV TXA. There was no difference in the mean reduction of hemoglobin between oral and IV groups (3.45g/dL vs 3.31g/dL, respectively; P = .001, equivalence), and total blood loss was equivalent at 1281 mL vs 1231 mL, respectively (P = .02, equivalence). One patient in each group was transfused. CONCLUSION: Oral TXA provides equivalent reductions in blood loss, at a cost of $14 compared with $47-$108 depending on the IV formulation selected. As approximately 700,000 primary TKA are performed in the United States annually, a switch to oral TXA could yield total cost savings of between $23 million and $67 million dollars per year for our health care system.

Total joint arthroplasty cost savings with a rapid recovery protocol in a military medical center.

The reported short-term benefits of rapid recovery protocols for total joint arthroplasty primarily come from specialized centers of excellence. The feasibility of achieving similar benefits at a military health care facility has not been reported. The authors hypothesized that application of such a protocol in this setting would decrease hospital stay and costs. A retrospective study was conducted comparing 85 hip and knee replacements by one surgeon using conventional protocol to 90 cases by a second surgeon using a rapid recovery protocol in the same hospital. Outcome measures included operative time, length of hospital stay, pain at discharge, use of inpatient rehabilitation facilities, complications requiring readmission, and inpatient admission costs. The results showed decreased length of stay by 2.9 days (p < 0.001) in the rapid recovery group, resulting in average cost savings of $1,511 (p < 0.001) with shorter operative time, equivalent pain at discharge, and fewer discharges to rehabilitation facilities. This feasibility study shows promising results, but prospective randomized trials are necessary to draw firm conclusions on the superiority of a rapid recovery protocol for total hip and knee arthroplasty in a military medical system.