Intra-articular Injections of the Hip and Knee With Triamcinolone vs Ketorolac: A Randomized Controlled Trial.

BACKGROUND: Clinicians commonly utilize intra-articular injections to treat symptomatic primary arthritis. Steroid injections are common yet have immune-modulating effects and can alter gene expression which may delay definitive arthroplasty and further damage cartilage. Nonsteroidal anti-inflammatory injections may offer a safer profile due to their differing mechanism of action; however, there is a relative dearth of information regarding their efficacy. This noninferiority study compares the effectiveness of triamcinolone vs ketorolac in treating symptoms of moderate to advanced primary osteoarthritis of the hip and knee. METHODS: In total, 110 patients (52 hips and 58 knees) with moderate to severe radiographic primary osteoarthritis of the hip or knee were randomized in a double-blinded study to receive an ultrasound-guided intra-articular injection of ketorolac or triamcinolone. Patient-reported outcome measures were collected pre-injection and at 1 week, 1 month, and 3 months. RESULTS: For hips and knees, intra-articular injections with either ketorolac or triamcinolone led to statistically significant improvements in patient-reported outcome measures. The treatment effect size was largest at 1 week and decreased over time. Primary analysis of variance comparisons revealed no significant differences between ketorolac and triamcinolone. For knee injections, post hoc secondary analysis suggests slight added durability in the triamcinolone group. Adverse effects were minimal with both interventions. CONCLUSION: Intra-articular ketorolac injections provide comparable improvement to triamcinolone for primary hip and knee osteoarthritis. Ketorolac is an additional low-cost option for conservative management of primary osteoarthritis, and due to its differing mechanism of action, it may not propagate additional cartilage damage or preclude from early surgical intervention if unsuccessful. TRIAL REGISTRATION NUMBER: NCT04441112.

Patient and Perioperative Variables Affecting 30-Day Readmission for Surgical Complications After Hip and Knee Arthroplasties: A Matched Cohort Study.

BACKGROUND: Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital. METHODS: Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission. RESULTS: Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 [1.4-8.5]; P < .01). CONCLUSION: Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.

Does Achieving High Flexion Increase Polyethylene Damage in Posterior-Stabilized Knees? A Retrieval Study.

BACKGROUND: Increased range of motion to higher degrees of flexion following total knee arthroplasty has been postulated to increase implant damage and revision rates, even in designs modified to accommodate high flexion. METHODS: We examined posterior-stabilized and high-flexion retrieved tibial inserts to look for differences in polyethylene surface damage with light microscopy and 3D deviation with laser scanning between inserts from patients who achieved a high degree of flexion (≥120° postoperatively) and inserts from patients who did not reach a high degree of flexion. RESULTS: No differences were found in damage scores on the articular and backside surfaces, except for abrasion in the posterior articular regions, or in 3D deviations between patients who reached a high degree of flexion and patients who did not. These results were independent of the reason for revision. CONCLUSION: In our series, reaching a high degree of flexion did not influence surface damage or 3D deviation of the polyethylene inserts.

What is the best material for molding casts in children?

BACKGROUND: Casts are used to treat clubfeet, developmental dysplasia of the hip (DDH), forearm fractures, and femur fractures. The ability of a cast to maintain a desired shape is termed moldability. Clinicians use plaster, fiberglass, and soft casts. To our knowledge the biomechanical molding characteristics of these 3 materials have never been reported. We hypothesized that moldability of plaster would be better than fiberglass and fiberglass would be better than soft cast. METHODS: We compared 12.7 cm wide casts of plaster, fiberglass, and soft cast. Casts were 5 layers thick, prepared in 40°C water, and placed over 2 layers of cotton padding on 5.1 cm and 15.2 cm diameter foam cylinders. A loading device simulated loads applied by clinicians when molding casts for 4 conditions: clubfoot (thumb-shaped 50 N load on 5.1 cm model), DDH (thumb-shaped 100 N load on 15.2 cm model), forearm fracture (palm-shaped 50 N load on 5.1 cm model), and femur fracture (palm-shaped 100 N load on 15.2 cm model). The loading device applied molding for 7 minutes. Five casts of each material were made for each model. Casts were removed, photographed, and the area of maximal deformation was compared with an unmolded cast. A large area of maximal deformation meant that the deformation was spread out over a large area, less precise molding. RESULTS: In the clubfoot model, plaster was more precise than fiberglass (P=0.002) and soft cast (P<0.0001). In the DDH model, plaster was more precise than fiberglass (P<0.0001) and soft cast (P<0.0001) and fiberglass was more precise than soft cast (P<0.0001).In the femur fracture model, plaster was more precise than fiberglass (P=0.001) and soft cast (P=0.001). CONCLUSIONS: The moldability of plaster is better than fiberglass and soft cast and fiberglass is better than soft cast. CLINICAL RELEVANCE: If precise molding is required, plaster has the best moldability. In cases not requiring precise molding, fiberglass and soft cast are lightweight, waterproof, and available in child-friendly colors.