Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities.

BACKGROUND: Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS: We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS: Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS: In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.

Scheduling and Vendor Consistency Improves Turnover Time Efficiency in Total Joint Arthroplasty.

BACKGROUND: Maximizing operative room (OR) efficiency is important for hospital efficiency, patient care, and positive surgeon and staff morale. Reducing turnover time (TOT) has become a popular focus to improve OR efficiency. The present study evaluated if TOT is influenced by changing case type, implant vendor, and/or laterality. METHODS: In total, 444 turnovers from January to July 2023 were retrospectively analyzed. All turnovers were same-surgeon turnovers between primary arthroplasty cases in dedicated, overlapping rooms. Single linear regression models tested the predictability of TOT based on case type, vendor, and laterality. A multivariate multiple regression and 1-way Analyses of Variance analyzed variables against each other. Independent sample t-tests evaluated TOTs when all variables were the same or different. RESULTS: Changing versus keeping the same case type increased TOT by 2.4 minutes (95% confidence interval [CI] = 0.7, 4.0; P = .004). Changing vendors increased TOT by 2.9 minutes (95% CI = 1.1, 4.7; P = .002). Laterality did not affect TOT, with a change of 0.9 minutes (95% CI = -0.6, 2.5; P = .229). Vendor (P = .030) independently predicted TOT when analyzed as a covariate with case type (P = .410). The TOT with same case type and vendor (mean 38.2 minutes; range, 22 to 62) was less than that of different case types and vendors (mean 41.4 minutes; range, 26 to 73) (P = .017). Mean TOT differed by 5.5 minutes when keeping all variables the same versus all different (P = .018). CONCLUSIONS: Maintaining a consistent case type, vendor, and laterality had a synergistic effect in reducing TOT in arthroplasty ORs with the same primary surgeon running 2 overlapping rooms. Changing vendor representatives was found to independently predict TOT increases, which is likely attributed to a disruption in workflow and collaboration of the multidisciplinary OR team. LEVEL OF EVIDENCE: Level III.

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications.

BACKGROUND: Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems. METHODS: An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator. RESULTS: Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B. CONCLUSIONS: We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal. LEVEL OF EVIDENCE: Level III.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision.

BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Collateral Ligament Tension and Balance Alone Does Not Ensure Improved Outcome After Total Knee Arthroplasty.

BACKGROUND: It is hypothesized that suboptimal soft tissue and collateral ligament balance is a cause of patient dissatisfaction following total knee arthroplasty (TKA). This analysis examined the association between compartment pressures during TKA and patient-reported outcome measurements (PROMs). METHODS: This single-institution, retrospective cohort study of prospectively collected compartment pressure data measured during TKA comprised 145 patients who underwent surgery between 2015 and 2021 and completed 1-year follow-up PROMs. The primary outcome included pressures, in pounds (lbs), of the medial and lateral compartments in extension (5°), mid-flexion (45°), and flexion (90°), and associated PROMs. The difference been the 1-year and preoperative PROMs was used to separate the top 25% from the bottom 75% performers. Pressures were compared using Student's T-tests and multivariate linear regressions, while controlling for preoperative deformity. A subgroup analysis of the most popular implant was performed. RESULTS: Higher medial compartment pressures were seen in our total cohort (Knee Society Score (KSS) mid-flexion 24 versus 18 lbs, P = .03, flexion 24 versus 17 lbs P = .01) and within our subgroup analysis (Short form- Mental (SF-M) extension 32 versus 21 lbs P = .01, KSS mid-flexion 27 versus 16 lbs P = .005, extension 31 versus 20 lbs P = .003). This trend persisted in the subgroup analysis when controlling for preoperative deformity (KSS extension +16.22 lbs P ≤ .001, mid-flexion +17.6 lbs. P = .001, and flexion +9.2 lbs, P = .005). CONCLUSION: Several groups demonstrated higher medial versus lateral pressures. However, this pattern was not consistent across PROMs, suggesting that compartment pressures at the time of TKA are an important factor but not the sole predictor of patient satisfaction.

Imageless robotic-assisted total knee arthroplasty leads to similar 24-month WOMAC scores as compared to conventional total knee arthroplasty: a retrospective cohort study.

PURPOSE: Robotic-assisted total knee arthroplasty (RA-TKA) was introduced to improve limb alignment, component positioning, soft-tissue balance and to minimize surgical outliers. This study investigates perioperative outcomes, complications, and early patient-reported outcome measures (PROMs) of one imageless RA-TKA system compared to conventional method TKA (CM-TKA) at 24-month follow-up. METHODS: This multi-surgeon retrospective cohort analysis compared 111 imageless RA-TKA patients to 110 CM-TKA patients (n = 221). Basic demographic information, intraoperative and postoperative data, and PROMs, including the functional score of the Knee Society Score (KSS-FS), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form 12 Mental and Physical scores (SF-12M and P), were collected and recorded preoperatively, at 3-, 12- and 24-months postoperatively. Range of motion (ROM), estimated blood loss (EBL), surgical duration, and complications were also collected. RESULTS: There were no baseline patient demographic differences between groups. EBL (240 vs. 190 mL, p < 0.001) and surgical duration (123 vs. 107 min, p < 0.001) were significantly greater in RA-TKA. There were no significant differences in postoperative complications, ROM, length of stay (LOS), and PROMs between cohorts at 3-, 12-, 24-months postoperatively. CONCLUSIONS: Imageless RA-TKA is associated with greater EBL and surgical duration compared to CM-TKA. However, at 24-month follow-up, there were no significant differences in ROM, LOS, complications and PROMs between cohorts. Imageless robotic surgery leads to similar 24-month clinical outcomes as compared to CM-TKA. LEVEL OF EVIDENCE: III.

Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty.

BACKGROUND: The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA. METHODS: This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m2, diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications. RESULTS: One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ2 = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ2 = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI. CONCLUSION: Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

Risks and Complications After Arthroplasty for Pathological or Impending Pathological Fracture of the Hip.

BACKGROUND: Treatment options for metastatic osseous lesions of the proximal femur include hemiarthroplasty (HA) or total hip arthroplasty (THA) depending on lesion characteristics and patient demographics. Studies assessing short-term outcomes after HA/THA in this patient population are limited. Therefore, the purpose of this present study was to identify short-term rates of morbidity and mortality after HA/THA for pathological proximal femur fractures, as well as readmission and reoperation rates and reasons. METHODS: This study utilized a large, prospectively collected registry to identify patients who underwent HA/THA between 2011 and 2018. Patients were stratified by indication for surgery, including pathological fracture, nonpathological fracture, and osteoarthritis. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis. RESULTS: In total, 883 patients undergoing HA/THA for a pathological fracture were identified. Relative to an osteoarthritis cohort, these patients tended to be older, had a lower body mass index, and had significantly more preoperative comorbidities. These patients had high rates of total complications (13.93%), including thirty-day mortality (3.29%), unplanned return to the operating room (4.98%), and pulmonary complications (3.85%). Patients with pathological fracture had a longer operative duration relative to osteoarthritis and nonpathological cohorts (+27 and +25 minutes, respectively), despite having high rates of HAs performed. CONCLUSION: Patients undergoing hip arthroplasty for pathologic proximal femur fracture have increased morbidity and mortality relative to an osteoarthritis cohort. However, patients with a pathological fracture have similar rates of morbidity and mortality when compared with a nonpathological fracture cohort, but did experience higher rates of perioperative blood transfusion and unplanned readmissions. LEVEL OF EVIDENCE: III.

Quantifying the Surgeon's Increased Burden of Postoperative Work for Modern Arthroplasty Surgery.

BACKGROUND: Arthroplasty payment traditionally includes 118 minutes for postoperative rounds and 69 minutes for postoperative office visits, amounting to 187 minutes and 7 work relative value units. Rapid recovery, ambulatory procedures, and bundled payments have altered the burden of care, with multiple studies showing an increase in physician work. Policy changes during the COVID-19 pandemic allow for precise documentation of patient touchpoints. We analyzed the duration of video, telephone, and text messaging to quantify modern arthroplasty work. METHODS: Consecutive primary hip, knee, and partial knee arthroplasties, performed 30 days before March 15, 2020 (date of practice closure), were included from a single institution, yielding 47 cases. We retrospectively quantified the duration of video telehealth documentation, telephone logs, and text messages over 90 days to calculate the postoperative work required in modern arthroplasty using descriptive statistics. RESULTS: An average of 9.4 touchpoints (2-14) by the surgeons occurred during the global period for this cohort, totaling 219 minutes (51-247 minutes). This included an average of 21 minutes of day-0 calls to family, 117 minutes for video visits, 52 minutes for phone calls, and 29 minutes for text messaging and wound photos. CONCLUSION: We found an undervaluation of 32 minutes of work. AAHKS leadership advocates for the fair payment of modern arthroplasty work. Cell phones have opened channels of contact that did not exist before, including phone accessibility, text messaging, and video calls. These data help defend against current payer efforts to cut work relative value units for arthroplasty. LEVEL OF EVIDENCE: II.

The Effect of Preoperative Anemia on Complications After Total Hip Arthroplasty.

BACKGROUND: Current literature suggests that preoperative hematocrit levels may play an important role in determining risk for complications after total hip arthroplasty (THA). The purpose of this study was to determine the role of preoperative anemia status on 30-day complications after THA. METHODS: Using the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on preoperative hematocrit levels (normal > 36% [N = 166,538], mild anemia 27%-36% [N = 13,214], and severe anemia <27% [N = 541]). Differences in 30-day postoperative medical complications and readmission rates were compared using bivariate and multivariate analyses. RESULTS: Multivariate logistic regression analysis identified mild anemia compared with normal hematocrit as a significant risk factor for total complications (OR: 1.46, P < .001), mortality (OR: 2.06, P < .001), renal complications (OR: 2.59, P < .001), respiratory complications (OR: 1.89, P < .001), sepsis (OR: 2.01, P < .001), wound infection (OR: 1.36, P < .001), and urinary tract infection (OR: 1.44, P < .001). Severe anemia was also risk factor, with a higher odds ratio, for total complications (OR: 1.99, P < .001). Both mild and severe anemia were significant risk factors for increased rates of perioperative blood transfusion (mild: OR, 4.04, severe: OR, 5.58), nonhome discharge (OR: 1.74, OR: 1.64), and unplanned hospital readmissions (OR: 1.42, OR: 1.66). CONCLUSION: Preoperative anemia is a significant risk for perioperative complications after primary THA. Even mild anemia can lead to significantly increased risks of mortality, medical complications, and unplanned hospital readmissions in THA. This study further supports the need for screening and preoperative intervention for patients in this at-risk group.

Decreasing Length of Hospital Stay and Postoperative Complications After Primary Total Hip Arthroplasty: A Decade Analysis From 2006 to 2016.

BACKGROUND: In an attempt to decrease costs without increasing complication burden, the development of rapid recovery protocols has led to an increased push for decreased length of hospital stay (LOS) following total hip arthroplasty (THA). The purpose of this study was to analyze trends in LOS and complications following THA over a 10-year period. METHODS: Using the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on the year of surgery (2006-2009 [N = 3873], 2010-2013 [N = 45,992], 2014-2016 [N = 86,099]). Differences in LOS, operative time, readmission rates, and 30-day postoperative medical complications were compared using bivariate and multivariate analyses. RESULTS: Multivariate regression analysis identified a significant decrease in LOS in days for the 2010-2013 cohort (3.2 ± 4.8, P < .001) and 2014-2016 cohort (2.7 ± 2.5, P < .001) compared to the 2006-2009 cohort (3.8 ± 2.5). Despite decreasing LOS, there were significantly lower complications in the later cohorts, with significantly lower rates of all complications (5.27% [2006-2009], 3.77% [2009-2013], 3.14% [2013-2016]), sepsis (0.70%, 0.31%, 0.16%), and urinary tract infection (1.94%, 1.23%, 0.83%) using both bivariate and multivariate analyses (P < .001). In addition, there was no significant difference in unplanned 30-day readmissions (3.66% [2010-2013] vs 3.5% [2014-2016], P = .142). CONCLUSION: Over the last decade, there has been a decrease in LOS and an improved short-term complication profile for THA. With continually increasing rates of utilization of THA along broader patient demographics, these changes are important to help mitigate the costs of higher volume.

Pediatric T-Condylar Humerus Fractures: A Systematic Review.

BACKGROUND: The pediatric T-condylar humerus fracture is different from its adult counterpart, and its rarity makes general consensus for treatment algorithms difficult to define. Pediatric orthopaedic surgeons tend to think of this fracture as a supracondylar humerus fracture with intra-articular extension. The transition age at which this injury resembles the adult distal humerus fracture and less so the pediatric supracondylar humerus fracture with intra-articular extension is unclear. The goal of this study is to synthesize the literature and identify factors associated with good and poor outcomes of these problematic injuries in children and adolescents. METHODS: We searched EMBASE, COCHRANE, and Medline computerized literature databases from the earliest date available in the database to 2014 using the following search term including variants and pleural counterparts: pediatric T-condylar humerus fracture. A final database of individual patients was assembled from the literature. Outcomes were rated using the method described by Jarvis and colleagues. Where possible the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification was used to stratify outcomes. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes. RESULTS: Patients with a triceps-splitting approach had improved Jarvis outcome scores compared with the other operative approaches as well as the best arc of motion at follow-up. In addition, 6/25 triceps split patients were 10 years old or younger compared with 3/38 Bryan-Morrey patients and 0/23 osteotomy patients. No patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association C3 fractures were treated with a triceps-splitting approach. When an articular approach was used, the Morrey Slide led to similar range of motion and functional outcomes as an olecranon osteotomy (P=0.616). However, the olecranon osteotomy resulted in more approach-related complications (P<0.001). An approach-related complication was associated with a poor outcome in 42% of cases. CONCLUSIONS: Pediatric T-condylar humerus fractures requiring an open approach may benefit from less invasive approaches such as the triceps split approach where the fracture pattern allows. Younger children are more amenable to less invasive means of fracture reduction and fixation. If an articular reduction is required, the aggregated literature suggests that the Morrey slide offers equivalent results to the olecranon osteotomy but with fewer approach-related complications. An olecranon osteotomy can be considered in cases of articular comminution. LEVEL OF EVIDENCE: Level IV-therapeutic.

Soft tissue laxity is highly variable in patients undergoing total knee arthroplasty.

BACKGROUND: One major goal of total knee arthroplasty (TKA) is to achieve balanced medial and lateral gaps in flexion and extension. While bone resections are planned by the surgeon, soft tissue laxity is largely intrinsic and patient-specific in the absence of additional soft tissue releases. We sought to determine the variability in soft tissue laxity in patients undergoing TKA. METHODS: We retrospectively reviewed 113 patients undergoing TKA. Data on preoperative knee deformity were collected. Data from a dynamic intraoperative stress examination were collected by a robotic tracking system to quantify maximal medial and lateral opening in flexion (85-95 degrees) and extension (-5-20 degrees). T-tests were used to assess the differences between continuous variables. RESULTS: A valgus stress opened the medial compartment a mean of 4.3 ± 2.3 mm (0.0-12.4 mm) in extension and 4.6 ± 2.3 mm (0.0-12.9 mm) in flexion. A varus stress opened the lateral compartment a mean of 5.4 ± 2.4 mm (0.3-12.6 mm) in extension and 6.2 ± 2.5 mm (0.0-13.4 mm) in flexion. The medial compartment of varus knees opened significantly more in response to valgus stress than valgus knees in both extension (5.2 mm vs. 2.6 mm; P < 0.0001) and flexion (5.4 mm vs 3.3 mm; P < 0.0001). The lateral compartment of valgus knees opened significantly more in response to varus stress than varus knees in both extension (6.7 mm vs. 4.8 mm; P < 0.0001) and flexion (7.4 mm vs. 5.8 mm; P = 0.0003). CONCLUSIONS: Soft tissue laxity is highly variable in patients undergoing TKA, contributing anywhere from 0-13 mm to the post-resection gap. Only a small part of this variability is predictable by preoperative deformity. These findings have implications for either measured-resection or gap-balancing techniques. LEVEL OF EVIDENCE: Level III.

Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty.

INTRODUCTION: The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD. METHODS: Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD. RESULTS: Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate. DISCUSSION: Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

Genicular nerve radiofrequency ablation: a systematic review of application for perioperative pain control in total knee arthroplasty and as treatment for chronic pain in well-appearing total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA. METHODS: PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA. RESULT: Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed. CONCLUSIONS: Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.

Incidence of Lateral Femoral Cutaneous Nerve Dysfunction After Total Hip Arthroplasty Through the Anterior-Based Muscle-Sparing Surgical Approach.

Background: The anterior-based muscle-sparing (ABMS) approach, using the intramuscular interval between the tensor fascia lata and gluteus medius, is an increasingly popular total hip arthroplasty (THA) approach. Its incidence of lateral femoral cutaneous nerve (LFCN) numbness has not been defined. The incidence of LFCN symptoms in direct anterior THA ranges from 7%-32% at 1-year follow-up. The purpose of this study is to determine the incidence of LFCN symptoms in patients who underwent ABMS THA at 1-year follow-up. Methods: This was a single-center, multisurgeon retrospective study of ABMS THAs with minimum 1-year follow-up data between January 2014 and September 2021. Eight hundred sixty-nine THAs were included. Mean age of the patients was 67.2 years, with 43.4% male and 56.5% female. Mean body mass index was 26.8, and mean American Society of Anesthesiologists was 2.3. Statistical analysis included chi-square tests, 2-sample t-test, and binomial logistic regression. A P-value of .05 was considered statistically significant for all tests. Results: Nine patients (1%) reported LFCN-associated symptoms at 1-year follow-up. The most common complaint was numbness (n = 5, 55.6%), followed by diminished sensation (n = 2, 22.2%), burning (n = 1, 11.1%), and generalized pain (11.1%). There was no difference in age, sex, body mass index, or American Society of Anesthesiologists between the group that experienced symptoms and the group that did not (P = 1.00, P = .34, P = .74, P = .80). Conclusions: The incidence of LFCN dysfunction is 1% at 1 year after surgery with the ABMS approach. Additional studies may elucidate all risks and benefits of the ABMS approach with respect to LFCN injuries.

Midterm results for revision total knee arthroplasty for component malrotation.

INTRODUCTION: Accurate positioning of components in total knee arthroplasty (TKA) is essential to a satisfactory outcome. Significant malrotation may lead to chronic pain, stiffness, and dysfunction. This study aims to quantify improvements in functional outcomes following revision surgery for malrotation of either one or both components in TKA versus revision for aseptic loosening. METHODS: This was a retrospective review of TKAs that matched and compared the two-year functional outcomes of the malrotation group to a functionally similar aseptic loosening group. Functional outcomes were compared between groups using Short Form (SF-12), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Knee Society Functional Score (KSFS). Student t-tests and chi-squared or Fisher's tests were used for statistical analysis. RESULTS: Of the patients revised, 24 had malrotation and 57 had aseptic loosening. A total of 16 femoral and 17 tibial components were revised for malrotation. All 16 femoral components were internally malrotated (mean -4.8 ± 4.1 degrees; range, -0.5 to -16.6). Of the tibial components, 15 were internally malrotated, (mean -9.5 ± 6.6 degrees; range, -2.2 to -23.5) and 2 were externally malrotated (mean 4.6 ± 2.1 degrees; range, 3.1 to 6.0). All functional outcome measures significantly improved comparably within both groups preoperatively to 24 months postoperatively. At 24 months, functional outcome measures were comparable between the groups and WOMAC function scores were significantly higher in the malrotation group. CONCLUSION: Revision TKA for malrotation can yield clinically and statistically significant functional improvements, similar in magnitude to those seen following revision TKA for aseptic loosening. LEVEL OF EVIDENCE: Level III.

The current utilization of the patient-reported outcome measurement information system (PROMIS) in isolated or combined total knee arthroplasty populations.

Patient reported outcome measures (PROMs) are essential for clinical research and patient-centric care because they allow us to capture patient perspectives on their health condition. In knee arthroplasty, PROMs are frequently used to assess the risks and benefits of new interventions, surgical approaches, and other management strategies. A few examples of PROMs used in total knee arthroplasty (TKA) include the Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Forgotten Joint Score (FJS) (collectively referred to as "legacy" PROMs). More recently, attention has been brought to another PROM called the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS was developed by the National Institute of Health (NIH) and has over 300 domains assessing various aspects of patient health, including pain, physical function, and mental health. With the use of PROMIS increasing in TKA literature, there is a need to review the advancements being made in understanding and applying PROMIS for this population. Thus, the purpose of this study is to provide insight on the utilization, advantages, and disadvantages of PROMIS within the field of knee arthroplasty and to provide a comparison to legacy PROMs.

Patient-reported outcomes measurement information system instruments in knee arthroplasty patients: a systematic review of the literature.

BACKGROUND: The purpose of this study is to provide a systematic review of the literature pertaining to Patient-Reported Outcome Measurement Information System (PROMIS) validation and utilization as an outcomes metric in total knee arthroplasty (TKA) patients. This is the first systematic review on PROMIS use in total knee arthroplasty patients. METHODS: A systematic search of the Pubmed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, psychometric properties (Pearson and Spearman correlation) with legacy patient-reported outcome measurement (PROM) instruments, floor and ceiling effects, responsiveness, and minimum clinically important difference (MCID) and PROMIS outcomes were recorded and analyzed. RESULTS: Fifteen studies investigating PROMIS in 11,140 patients were included. The weighted-average Pearson correlation coefficient comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.62 [standard error (SE) = 0.06] and the weighted-average Spearman correlation comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.59 (SE = 0.06), demonstrating moderate-to-strong correlation and validity. There were no differences in weighted average floor [0.03% (SE = 3.1) versus 0% (SE = 0.1) versus 0.01% (SE = 1.1); p = 0.25] or ceiling effects [0.01% (SE = 0.7) versus 0.02% (SE = 1.4) versus 0.04% (SE = 3.5); p = 0.36] between PROMIS and legacy instruments. The weighted average for percentage of patients achieving MCID was 59.1% for global physical health (GPH), 26.0% for global mental health (GMH), 52.7% for physical function (PF), 67.2% for pain interference (PI), and 37.2% for depression. CONCLUSION: Notably, PROMIS global physical health, physical function, and pain interference were found to be significantly responsive, with PROMIS pain interference most effectively capturing clinical improvement as evidenced by the achievement of MCID.

Bilateral Total Knee Arthroplasty: Current Concepts Review.

¼: Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days. ¼: Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others. ¼: While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA. ¼: When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart. ¼: Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.