What Factors are Associated With Conversion to Knee Arthroplasty After Subchondroplasty?

BACKGROUND: Subchondral bone marrow lesions identified on knee MRI are believed to play a role in osteoarthritis-associated pain. The subchondroplasty procedure is an arthroscopically assisted procedure for treating such lesions to avoid larger procedures such as knee arthroplasty. However, the survivorship free of conversion to arthroplasty and the factors associated with an increased likelihood of conversion of subchondroplasty to arthroplasty have not been well defined. QUESTIONS/PURPOSES: We performed this study to (1) determine the 5-year survivorship of subchondroplasty free from conversion to knee arthroplasty (unicompartmental or total) and (2) identify variables that were associated with progression to knee arthroplasty after a subchondroplasty procedure. METHODS: In all, 216 patients who underwent a subchondroplasty procedure performed by one surgeon with subchondroplasty experience at a single-center, multilocation facility between September 2014 and August 2017 were retrospectively evaluated to estimate survivorship free from conversion to knee arthroplasty at 5 years. The mean ± SD age and BMI at the time of subchondroplasty procedure were 59 ± 11 years and 33 ± 8 kg/m 2 , respectively; 60% (129 of 216) of the patients were women. Other variables collected were smoking status and grade and location of chondral lesions. The electronic medical record was reviewed to determine whether the patient had a knee arthroplasty after subchondroplasty. Survivorship free from conversion to knee arthroplasty at 5 years was calculated from a Kaplan-Meier survivorship estimator. Factors associated with progression to knee arthroplasty were examined using t-tests and chi-square analyses. Variables showing evidence of an association with knee arthroplasty were explored further using a Kaplan-Meier survivorship estimator (n = 190). RESULTS: Kaplan-Meier survivorship free from conversion to knee arthroplasty was 73% (95% CI 67% to 79%) at 5 years after subchondroplasty. We found that age older than 50 years and Grade 4 chondral lesions were associated with conversion to knee arthroplasty. Patients with a Grade 4 chondral lesion had 5-year survivorship of 62% (95% CI 54% to 71%) and 59% (95% CI 50% to 69%) for those older than 50 years with a Grade 4 chondral lesion. CONCLUSION: Currently, we recommend a detailed, informed discussion of the risks versus benefits with patients who are considering a subchondroplasty procedure, particularly patients aged 50 years and older and those with Grade 4 chondral lesions. Future randomized trials, including those that compare the subchondroplasty procedure with arthroscopy alone or nonoperative management options, are still needed to confirm the efficacy and role of the subchondroplasty procedure in patients with knee osteoarthritis, because only such prospective studies can determine the success of the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Posterior-approach total shoulder arthroplasty: a case series with a minimum of 2-year outcomes.

BACKGROUND: A posterior approach to shoulder arthroplasty has been described that may improve exposure to the retroverted glenoid and spare the rotator cuff. The purpose of this study was to evaluate posterior total shoulder arthroplasty (PTSA) at a minimum of 2 years. METHODS: Between September 2016 and October 2017, 28 patients (30 shoulders) who underwent PTSA were retrospectively identified. Patients were monitored at baseline and at 6 weeks, 3 months, 6 months, 1 year, and a minimum of 2 years after surgery for range of motion, American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores, radiographic outcomes, complications, and patient satisfaction. Radiographs were assessed for head height, neck-shaft angle, humeral head centering, and the presence or absence of glenoid-component cement lines. Repeated-measures analysis-of-variance models were implemented to compare the means for each outcome variable over time. RESULTS: Of the 28 patients (30 shoulders), 24 patients (26 shoulders) (87%) were available for follow-up at a minimum of 2 years (average, 31.2 months; range, 23-40 months). At latest follow-up, the average ASES pain score was 45.2 (standard deviation [SD], 10.9; range, 20-50; 95% confidence interval [CI], 40.8-49.6); average ASES function score, 42.3 (SD, 8.9; range, 21.7-50; 95% CI, 38.7-45.8); average ASES total score, 87.5 (SD, 18.8; range, 31.7-100; 95% CI, 79.8-95.1); and average Simple Shoulder Test score, 10.2 (SD, 2.0; range, 5-12; 95% CI, 9.4-11.0). Average forward flexion was 164° (SD, 13.9°; range, 130°-180°; 95% CI, 158.3°-170.4°); average external rotation, 78° (SD, 9.2°; range, 55°-90°; 95% CI, 74.3°-82.3°); and average internal rotation, T10 (SD, 2; range, L3 to T6; 95% CI, T10 to T8). The average head height was 0.86 mm above the greater tuberosity (range, -6.5 to 6.9 mm), the average neck-shaft angle was 128° (range, 113°-148°), and the average implant placement was 0.12 mm superior to the center of the neck cut (range, -3.3 to 3.5 mm). Six implants were considered malpositioned based on the criterion of >5 mm of head height above or below the tuberosity or >2 mm off-center. Glenoid cement lines were present in 7 shoulders. Two patients experienced complications: 1 patient had symptomatic glenoid loosening 29 months postoperatively that required revision to an anterior reverse total shoulder arthroplasty, and 1 patient had postoperative weakness that resolved by 6 months. CONCLUSION: PTSA is safe and efficacious at 2 years, spares the rotator cuff, and may improve early postoperative function. PTSA is more easily performed with stemless arthroplasty. Challenges with creation of the humeral head osteotomy and identification of the center of the cut humeral head surface can affect the accuracy of implant positioning. Further improvements in technique will likely improve the feasibility of this approach.

Improving Orthopedic Patient Outcomes: A Model to Predict 30-Day and 90-Day Readmission Rates Following Total Joint Arthroplasty.

BACKGROUND: Over the next 10-15 years, there is expected to be an exponential increase in the number of total joint arthroplasties in the American population. This, combined with rising costs of total joint arthroplasty and more recent changes to the reimbursement payment models, increases the demand to perform quality, cost-effective total joint arthroplasties. The purpose of this study is to build models that could be used to estimate the 30-day and 90-day readmission rates for patients undergoing total joint arthroplasty. METHODS: A retrospective review of patients admitted to a single hospital, over the course of 56 months, for total joint arthroplasty was performed. The goal is to identify patients with readmission in a 30-day or 90-day period following discharge from the hospital. Binary logistic regression was used to build predictive models that estimate the likelihood of readmission based on a patient's risk factors. RESULTS: Of 5732 patients identified for this study, 237 were readmitted within 30 days, while 547 were readmitted within 90 days. Age, body mass index, gender, discharge disposition, occurrence of cardiac dysrhythmias and heart failure, emergency department visits, psychiatric diagnoses, and medication counts were all found to be associated with 30-day admission rates. Similar associations were found at 90 days, with the exclusion of age and psychiatric drug use, and the inclusion of intravenous drug abuse, narcotic medications, and total joint arthroplasty within 12 months. CONCLUSION: There are patient variables, or risk factors, that serve to predict the likelihood of readmission following total joint arthroplasty.

Robotic-assisted total knee arthroplasty: Is there a maximum level of efficiency for the operating surgeon?

Aims: Recent studies have attempted to quantify the learning curve associated with integration of robotic technology into surgical practice, but to our knowledge, no study has demonstrated the number of cases needed to reach a steady state of maximum efficiency in operating times using robotic assisted technology. Patients and methods: This was a retrospective analysis of 682 consecutive knees that underwent a robotic-assisted TKA for osteoarthritis by a single surgeon between 2017 and 2020. Procedure times (minutes), length of stay (LOS), and short-term postoperative complications and reoperations were analyzed to define trends. Time series analyses were used to identify the approximate time-point at which a maximum level of surgical operating speed was achieved. Analysis of Variance (ANOVA) and chi-square analyses then followed to compare average procedure duration, LOS, and complications across distinct moving groups of 50 procedures. Results: Time series analyses suggest substantially improved times by the 50th procedure and reached a stable plateau between the 150th and 200th procedure. Average duration for the first 50 procedures was approximately 85 min, dropping to 69 min for procedures 51-100, 66 min for procedures 101-150, and then plateauing at approximately 61 min for procedures 151-682, demonstrating significant improvements in surgical efficiency at each 50-procedure interval (p < 0.05). There was no significant difference in LOS, readmissions, and reoperations with increasing groups of 50 procedures performed. Conclusion: Results from this study will allow surgeons to better understand the implications of integrating robotic arm-assisted technology into their practice. Surgeons can expect significant improvement of their operative time following completion of at least 50 procedures, while likely reaching a maximum level of surgical efficiency between 151 and 200 procedures.

Lower-Intensity Statins Contributing to Gaps in Care for Patients With Primary Severe Hypercholesterolemia.

Background Although severe hypercholesterolemia confers a 5-fold increased long-term risk for coronary artery disease, treatment guidelines may not be fully implemented, leading to underdiagnosis and suboptimal treatment. To further understand the clinical features and gaps in treatment approaches, we analyzed electronic medical record data from a midwestern US multidisciplinary healthcare system, between 2009 and 2020. Methods and Results We retrospectively assessed the prevalence, clinical presentation, and treatment characteristics of individuals currently treated with statin therapy having a low-density lipoprotein cholesterol (LDL-C) value that is either (1) an actual maximum electronic medical record-documented LDL-C ≥190 mg/dL (group 1, n=7542) or (2) an estimated pretreatment LDL-C ≥190 mg/dL (group 2, n=7710). Comorbidities and prescribed lipid-lowering therapies were assessed. Statistical analyses identified differences among individuals within and between groups. Of records analyzed (n=266 282), 7% met the definition for primary severe hypercholesterolemia. Group 1 had more comorbidities than group 2. More individuals in both groups were treated by primary care providers (49.8%-53.0%, 32.6%-36.4%) than by specialty providers (4.1%-5.5%, 2.1%-3.3%). High-intensity lipid-lowering therapy was prescribed less frequently for group 2 than for group 1, but moderate-intensity statins were prescribed more frequently for group 2 (65%) than for group 1 (52%). Conclusions Two percent of patients in our study population being treated with low- or moderate-intensity statins have an estimated LDL-C ≥190 mg/dL (indicating severe hypercholesterolemia), but receive less aggressive treatment than patients with a maximum measured LDL-C ≥190 mg/dL.

Prevalence and Characteristics of Patients With Primary Severe Hypercholesterolemia in a Multidisciplinary Healthcare System.

Severe hypercholesterolemia (SH) includes individuals with LDL-C ≥ 190 mg/dl, regardless of cause. These individuals have a fivefold increased long-term risk for coronary artery disease. Although systematic SH screening can trigger early treatment, current treatment guidelines may not be fully implemented or followed by patients. To further understand this treatment gap, we used electronic health record data to retrospectively assess SH prevalence, characteristics, and treatment in a midwest US healthcare system, between 2009 and 2020. Comorbidities, tobacco exposure, and prescribed lipid-lowering therapies were assessed. Statistical analyses were conducted to identify differences between individuals with primary SH (LDL-C ≥ 190 mg/dl, group 1) and those without primary SH (LDL-C < 190 mg/dl, group 2). Of 265,220 records analyzed, 7.4% met the definition for primary SH. These group 1 cases had more comorbidities than group 2 cases, including premature coronary artery disease (5.8% vs 2.7%). Results showed most individuals in group 1 were treated by primary care providers (43.2% to 45.7%), than by specialty providers (2.5% to 3.3%), and these primary care providers prescribed mainly moderate-intensity statins. Seventy-seven percent of group 1 individuals were treated with a statin, 27% were treated with a high-intensity statin, and 4% were treated with ezetimibe. Fewer young patients (< 40 years) were treated with statins (50% to 58.3%) than older patients (74.0% to 76.3%). Although use of general statins, high-intensity statins, and ezetimibe was higher in individuals with SH than those without SH, treatment remains below guideline recommendations, especially in younger individuals.