The quality of immediate postoperative radiographs, performed after total hip replacement in the operating room versus in the post-anesthesia care unit: is there a difference?

INTRODUCTION: Currently, there are no clear guidelines regarding the optimal settings for immediate postoperative imaging following total hip arthroplasty (THA). Authors' primary aim was to determine the preferred setting for postoperative radiographs by comparing a technical quality of imaging performed in postanesthesia care unit (PACU) versus operating room (OR). MATERIALS AND METHODS: Our study is a retrospective comparison of quality of postoperative radiographs following THAs, performed in PACU versus OR. The evaluated factors included a technical quality (penetration, collimation and presence of foreign bodies), proper patient positioning, and clinical significance of the imaging expressed in number of decisions to perform immediate revision surgery that were based on postoperative imaging. RESULTS: 267 radiographs of patients who underwent primary unilateral THA were evaluated (139 performed in PACU and 128 in OR). In terms of technical quality, PACU radiographs were characterized by better penetration (69.1% vs 27.3%, p < 0.001) and less foreign bodies in the field (95.7% vs 83.6%, p < 0.001), but less adequate collimation (41.7% vs 79.7%, p < 0.001). There was a significant difference in the number of radiographs obtained without any noteworthy technical errors - 24 (17.3%) in PACU group vs 10 (7.8%) in OR group. CONCLUSION: Postoperative X-rays performed in the PACU were characterized by better technical quality compared to postoperative radiographs performed in OR. We, therefore, suggest to perform immediate postoperative evaluation in PACU to provide baseline radiographs of higher quality for future follow-up.

Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty when compared with severe osteoarthritis: a systematic review and meta-analysis.

PURPOSE: The association between severity of radiographic osteoarthritis with patient pain, function, and satisfaction following total knee arthroplasty has been disputed. The discrepancies in current literature prompt us to further examine this association in a systematic review and meta-analysis. METHODS: The OVID-Medline, Embase, and Web of Science databases were searched from their inception up to Mar 2020. The main independent variable was osteoarthritis severity as defined by preoperative radiographs. The outcomes measured were pain, function and satisfaction following total knee arthroplasty. A minimum of three studies assessing the same patient-reported outcome measures were included in the meta-analysis, as well as those separating patients by chronic pain or dissatisfaction. RESULTS: 29 studies were included in this study. Significant heterogeneity was seen between radiographic evaluation and reported outcomes. Patients with only mild radiographic osteoarthritis were more likely to suffer from chronic pain (odds ratio = 2.45, 95% CI = 1.80-3.34, p < 0.001) and dissatisfaction (odds ratio = 2.43, 95% CI = 1.79-3.31, p < 0.001) compared to patients with severe osteoarthritis. A significant association was found between mild radiographic severity and lower total Western Ontario and McMaster Universities Osteoarthritis scores (95% CI = - 0.37-0.06, p = 0.006) as well as Knee Society Scores (CI: - 0.54-0.16, p < 0.001). CONCLUSION: Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. They are also at risk for chronic pain and dissatisfaction and should be consulted about this risk prior to surgery. LEVEL OF EVIDENCE: III.

Lateral Column Lengthening for Flexible Flat Foot: Was It Short to Begin With?

BACKGROUND: Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column. OBJECTIVES: To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter. METHODS: The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio. RESULTS: All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not. CONCLUSIONS: Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter.

Biocompatibility of a Marine Collagen-Based Scaffold In Vitro and In Vivo.

Scaffold material is essential in providing mechanical support to tissue, allowing stem cells to improve their function in the healing and repair of trauma sites and tissue regeneration. The scaffold aids cell organization in the damaged tissue. It serves and allows bio mimicking the mechanical and biological properties of the target tissue and facilitates cell proliferation and differentiation at the regeneration site. In this study, the developed and assayed bio-composite made of unique collagen fibers and alginate hydrogel supports the function of cells around the implanted material. We used an in vivo rat model to study the scaffold effects when transplanted subcutaneously and as an augment for tendon repair. Animals' well-being was measured by their weight and daily activity post scaffold transplantation during their recovery. At the end of the experiment, the bio-composite was histologically examined, and the surrounding tissues around the implant were evaluated for inflammation reaction and scarring tissue. In the histology, the formation of granulation tissue and fibroblasts that were part of the inclusion process of the implanted material were noted. At the transplanted sites, inflammatory cells, such as plasma cells, macrophages, and giant cells, were also observed as expected at this time point post transplantation. This study demonstrated not only the collagen-alginate device biocompatibility, with no cytotoxic effects on the analyzed rats, but also that the 3D structure enables cell migration and new blood vessel formation needed for tissue repair. Overall, the results of the current study proved for the first time that the implantable scaffold for long-term confirms the well-being of these rats and is correspondence to biocompatibility ISO standards and can be further developed for medical devices application.

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury.

PURPOSE: To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions. METHODS: The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated. RESULTS: At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears. CONCLUSIONS: During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury. STUDY DESIGN: Case series; Level of evidence, 4.

Tranexamic Acid Can Be Administered to Arthroplasty Patients Who Receive Aspirin for Venous Thromboembolic Prophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is not uncommon after total joint arthroplasty (TJA). Various prophylactic agents have been used to minimize this complication after TJA. Numerous studies have demonstrated that acetylsalicylic acid (ASA) has equivalent efficacy to other agents in preventing VTE after TJA. However, some have expressed theoretical concern that ASA may not be an adequate VTE prophylaxis in TJA patients receiving tranexamic acid (TA), which is an antifibrinolytic agent. The purpose of the study was to assess the safety and efficacy of administering systemic TA in TJA patients who also received ASA for VTE prophylaxis. METHODS: A retrospective study was conducted on 2835 consecutive patients (1678 receiving TA and 1157 not receiving TA) who underwent primary or revision TJA between January 2013 and June 2014 and also received aspirin for VTE prophylaxis. The incidence of symptomatic deep vein thrombosis and pulmonary embolism was evaluated. RESULTS: Blood loss and transfusion rates were significantly lower in the TA group compared to the non-TA group (P < .0001, P = .017, respectively). The incidence of VTE, bleeding events, and wound complications was similar (P > .05) between the groups. CONCLUSION: In patients undergoing TJA who receive ASA for VTE prophylaxis, TA reduces bleeding and transfusions without increasing the incidence of subsequent VTE.

The Sphygmomanometer Pain Test: A Simple Method for Identifying Patients at Risk of Excessive Pain after Total knee Arthroplasty.

BACKGROUND: Despite the overall success of total knee arthroplasty (TKA), a relatively large proportion of patients remain dissatisfied with the outcome. We hypothesized that patients with a lower threshold for pain were more likely to have worse outcomes after TKA. METHODS: Forty-eight consecutive patients with primary knee osteoarthritis graded a standardized painful stimulus caused by inflating a sphygmomanometer placed on the forearm, on a visual analog scale (VAS) scale before their TKA. We compared the VAS scores to patients' Knee Society scores and Knee Society function scores 2 years after TKA. RESULTS: Patients with a severe VAS score (>74 mm) had significantly worse Knee Society scores compared to patients with mild (0-44 mm) and moderate (45-74 mm) VAS scores (55 ± 20.5 vs 81.5 ± 11.1 and 84.8 ± 13, respectively, P = .04) and worse Knee Society Function scores (34 ± 20.7 vs 75.2 ± 17.3 and 77 ± 17.4, respectively, P = .027) at 2 years after TKA. CONCLUSIONS: Patients with a lower threshold for pain, as determined by a standardized painful stimulus, are more likely to have lower Knee Society pain and function scores after TKA.

Aspirin Can Be Used as Prophylaxis for Prevention of Venous Thromboembolism After Revision Hip and Knee Arthroplasty.

BACKGROUND: The optimal prophylaxis for prevention of venous thromboembolic events (VTEs) after revision total joint arthroplasty (TJA) remains unknown. The objective of this study was to evaluate whether aspirin, known to be effective for prevention of VTEs after primary arthroplasty, is also effective after revision TJA. METHODS: We studied 2997 consecutive patients who underwent revision TJA between 2005 and 2013 and were treated with intermittent pneumatic compression devices and either aspirin (534 patients) or warfarin (2463 patients) for VTE prophylaxis. Pertinent data including the incidence of symptomatic VTEs, bleeding events, infection, and mortality were retrieved from our prospectively collected database. RESULTS: The incidence of symptomatic VTEs was significantly higher in the warfarin group at 1.75% (43 of 2463) compared with 0.56% (3 of 534) in the aspirin group (odds ratio: 3.2; 95% CI: 1.03-16.3; P = .03). There was a higher rate of bleeding events with administration of warfarin (1.5%) compared with aspirin (0.4%; P = .02; odds ratio: 4.1; 95% CI: 1.2-34.0). The rate of surgical site infection was similar between the aspirin group and the warfarin group (1.61% and 1.70%, respectively). CONCLUSION: Administration of aspirin as prophylaxis against VTEs after revision arthroplasty may be a viable option as it appears to be more effective than warfarin in prevention of symptomatic VTEs and is associated with a lower rate of complications.

Periprosthetic joint infection: the algorithmic approach and emerging evidence.

Periprosthetic joint infections (PJIs) continue to affect patients, result in accelerated mortality, and consume approximately $1 billion of annual healthcare resources. The future of otherwise successful total joint arthroplasties can be jeopardized by PJI. In recent years, the issue of hospital-acquired infections has gained increasing attention in the United States and the rest of the world, and numerous efforts are being made to address this problem. The orthopaedic community continues to partner with societies, professional organizations, and industry to address this challenge. Recently, an international group of more than 300 surgical experts produced a 350-page document that outlines some of the best practices and identifies the evidence gap related to the management of PJIs. The document, using an algorithmic approach, outlines effective strategies for the prevention, diagnosis, and surgical management of PJIs. It is anticipated that the application of this algorithmic approach will lead to a reduction in the incidence of PJIs, will allow clinicians to diagnose PJI effectively and expeditiously, and will improve the outcome of patients affected by PJIs.

Tourniquet Release Prior to Dressing Application Reduces Blistering Following Total Knee Arthroplasty.

Skin blisters occur in up to 20% of patients after total knee arthroplasty (TKA). Tourniquet release results in a limb volume increase of 10%. We hypothesized that releasing tourniquet before application of circumferential dressing will decrease blister formation. A prospective study was conducted on 135 consecutive primary TKAs. The tourniquet was released immediately after wound closure to allow for re-perfusion and then a dressing was applied. These patients were compared to a historical cohort of 200 primary TKAs, where the tourniquet was released after application of dressing. There was a significant difference in the incidence of blisters between the two groups [Late 7.5% (15/200) vs early release 2.2% (3/135) P=0.028]. Releasing the tourniquet prior to dressing application has reduced the incidence of blistering following TKA.

Adverse clinical outcomes in a primary modular neck/stem system.

We report our experience with 215 recalled neck modular stems due to corrosion. Among the 195 hips with 2 years follow-up, 56% had no clinical symptoms, 26% had groin pain (typical of corrosion), and 17% had other symptoms. Cobalt levels were comparable between asymptomatic (3.4 µg/L, range 0.7-7.3 µg/L) and symptomatic patients (4.0 µg/L range 0-13.2 µg/L). Abnormal imaging findings were seen in 46% of symptomatic and 11% of asymptomatic hips (P=0.001). Twenty-six hips (13%) have either undergone revision surgery or have been scheduled. Evidence of corrosion was seen at revision surgery in all patients. Despite modest elevations in serum cobalt levels, abnormal imaging studies were seen in 36%, clinical symptoms were seen in 44%, and revision for corrosion was undertaken or scheduled in 13% of the hips.

Reversed assembly of total hip arthroplasty components: a surgical tip to facilitate implant reduction during minimally invasive surgery.

Total hip arthroplasty (THA) using minimally invasive surgery (MIS) can result in soft tissue damage during the trial reduction and actual implantation. We present a surgical technique that reduces soft tissue trauma and facilitates implant reduction while protecting the prosthetic head from scratching during MIS THA. Primary THA using MIS was performed in 16 hips through a transgluteul direct lateral approach. Average follow-up was 54 months (range 52-58 months). At latest follow-up there was no evidence for component dissociation or loosening in any of the patients. Reverse assembly of THA components is a viable option, which may facilitate MIS THA and decrease soft tissue trauma.

Locking versus standard screw fixation for acetabular cups: is there a difference?

INTRODUCTION: Total hip replacement has been established as a valid treatment option for displaced subcapital fractures. However, insufficient primary fixation may be the reason for early loosening in these osteoporotic patients. Primary fixation of the cup is usually achieved by press-fit fixation that can be enhanced using screws. Locking the screws into their respective cups may seem to improve the primary fixation of the construct, as locked plates proved superior fixation for osteoporotic fractures. METHODS: The study consisted of three groups: in each group, three cups were fixed into blocks of foam bone using press-fit technique. In the first group, no additional screws were used, in the second group two standard screws were inserted, while in the third group two acetabular screws were cemented into the cup to simulate locked screw fixation. Load was applied onto the rim of the acetabular component to cause shearing between the cup and the block. Cup fixation was examined by a loading machine that acquired load versus displacement. The stiffness (load vs. displacement) was calculated. RESULTS: Screws, either locked or non-locked, enhanced cup fixation by 26 % (p value <0.01). No significant changes were found between the locking and non-locking screws groups. DISCUSSION: These experimental results indicate that acetabular screws enhance primary cup fixation. This may become significant in conditions where the acetabular bone stock is suboptimal, such as when performing total hip arthroplasty after displaced subcapital fractures. However, there is no superiority for locked screws over standard screw fixation.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty.

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function. METHODS: A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB. RESULTS: Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups. CONCLUSIONS: Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA. TRIAL REGISTRATION: The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711. LEVEL OF EVIDENCE: level I randomized controlled trial.

Septic arthritis of the knee following intraarticular injections in elderly patients: report of six patients.

BACKGROUND: Intraarticular injections for the local treatment of osteoarthritis are widely used in the office or hospital setting. Septic arthritis is a potential catastrophic complication of intraarticular injection, as bacterial arthritis of any cause is associated with up to 15% mortality and residual impairment of joint function in up to 50% of survivors. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered. OBJECTIVES: To report our experience with the clinical presentation, diagnosis and treatment of knee septic arthritis following intraarticular injections. METHODS: We followed six patients who were admitted to the hospital and underwent surgery for the treatment of pyogenic arthritis following injection to the knee joint in outpatient clinics. RESULTS: All but one patient were over 70 years old with comorbidities. Three patients were injected with steroid preparations and three with hyaluronic acid several days before admission. In all six patients the infection was treated surgically and three of them had undergone more than one operation during their hospitalization. Four of the six patients were treated by means of an open arthrotomy and synovectomy, and the other two were treated successfully with arthroscopic lavage and synovectomy. One patient underwent an above-knee amputation due to septic shock and died after several days. CONCLUSIONS: Despite the rarity of this complication, surgeons must be aware of the possibility of pyogenic arthritis when administering injections, especially in elderly patients with serious underlying medical conditions.

Ankle tourniquet pain control in forefoot surgery: a randomized study.

BACKGROUND: Forefoot surgery is often performed under regional anesthesia in awake patients, using tourniquet or Esmarch bandage to obtain a bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under ankle block anesthesia. MATERIALS AND METHODS: We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive either subcutaneous local anesthetic mixture under the tourniquet or no additional anesthetic. We checked for local tourniquet pain score (VAS 0 to 100) and skin condition during and after the procedure. RESULTS: The tourniquet was quite tolerable in both groups, with an average VAS score of 7 to 21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender was found. CONCLUSION: An ankle tourniquet was well-tolerated by patients without need for local anesthetic beneath the cuff.