Which Interventions Are Effective in Treating Sleep Disturbances After THA or TKA? A Systematic Review.

BACKGROUND: Poor sleep quality is a common complaint after total joint arthroplasty (TJA), and it is associated with reports of higher pain and worse functional outcomes. Several interventions have been investigated with the intent to reduce the incidence of postoperative sleep disturbance with varying effectiveness. An aggregate of the best available evidence, along with an evaluation of the quality of those studies, is needed to provide valuable perspective to physicians and to direct future research. QUESTIONS/PURPOSES: In this systematic review, we asked: (1) What is the reported efficacy of the most commonly studied medications and nonpharmacologic approaches, and (2) what are their side effects and reported complications? METHODS: This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search using a combination of controlled vocabulary and keywords was performed utilizing Medline (Ovid), Embase (Ovid), Cochrane Central, and Web of Science databases from database inception to 2023, with the last search occurring October 24, 2023, to identify studies that evaluated a sleep intervention on the effect of patient-reported sleep quality after THA or TKA. Inclusion criteria were clinical trials, comparative studies, and observational studies on adult patients who underwent primary TKA or THA for osteoarthritis and who completed validated sleep questionnaires to assess sleep quality postoperatively. We excluded studies on patients younger than 18 years, patients with sleep apnea, TKA or THA because of trauma or conditions other than osteoarthritis, revision TJA, studies in languages other than English, and studies from nonindexed journals or preprint servers. Two investigators independently screened 1535 studies for inclusion and exclusion criteria and extracted data from the included studies. Ultimately, 14 studies were included in this systematic review, including 12 randomized controlled trials and 2 prospective comparative studies. A total of 2469 participants were included, with a mean ± SD age of 65 ± 7 years and 38% men in control groups and 65 ± 7 years and 39% men in intervention groups. Sleep quality questionnaires utilized included the Pittsburgh Sleep Quality Index, Self-Rating Scale of Sleep, 100-mm VAS - Sleep, Sleep Disturbance Numeric Rating Scale, Likert scales, and one institutionally designed questionnaire. Quality analysis was performed utilizing the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Randomized Controlled Trials, where higher scores of 13 indicated a more reliable study, and the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies, where higher scores of 9 indicated a more reliable study and scores < 5 represented a high risk of bias. Two of the randomized controlled trials scored a 12 of 13, and the remaining 10 met every criteria of the JBI checklist. Both comparative studies scored 5 of 9 possible points of the Newcastle-Ottawa Scale. RESULTS: Melatonin and selective cyclooxygenase-2 inhibitor rofecoxib were found to provide a clinically important benefit to sleep quality within the first postoperative week after TJA. However, rofecoxib was withdrawn from the market globally in 2004 over concerns about increased risk of cardiovascular events. Another cyclooxygenase-2 inhibitor, celecoxib, remains available. No other intervention demonstrated a clinical benefit. Side effects of melatonin include dizziness, headache, paresthesia, and nausea, and it is contraindicated in patients with liver failure, autoimmune conditions, or who are receiving warfarin. Long-term adverse effects of rofecoxib include hypertension, edema, and congestive heart failure, and it is contraindicated in patients with renal insufficiency or who are receiving warfarin. Melatonin is considered safe in older patients, but more caution should be taken with rofecoxib. CONCLUSION: Owing to limited evidence in support of most of the interventions we studied, none of these interventions can be recommended for routine use after TJA. Melatonin and rofecoxib may provide a benefit to sleep quality in some patients, but physicians need to understand the adverse effects and contraindications before recommending these interventions. Additionally, rofecoxib is no longer commercially available. Future investigation is warranted to evaluate the effectiveness of interventions with minimal side effect profiles for providers to be able to make an informed decision about interventions for sleep improvement after TJA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Stroke History and Time Elapsed are Predictors of Complications in Total Knee Arthroplasty.

BACKGROUND: A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors. METHODS: A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI). RESULTS: The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067). CONCLUSIONS: Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk.

Hydroxyapatite-Coated Femoral Stems in Primary Total Hip Arthroplasty: An Updated Meta-Analysis.

BACKGROUND: Most primary total hip arthroplasties (THAs) performed in the United States utilize cementless fixation with porous or hydroxyapatite (HA) coating. A previous meta-analysis comparing HA-coated versus non-HA-coated stems in primary THA published in 2013 found no significant difference between the 2. However, an updated analysis of the current literature is needed to assess the potential benefit of HA-coated stems in primary THA. METHODS: Various libraries were searched through May 2022 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Studies included were randomized controlled trials comparing HA-coated femoral stems to non-HA-coated stems in primary THA. Outcomes included Harris Hip Score (HHS), endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, thigh pain, and heterotopic ossification. RESULTS: There were significantly fewer revisions for aseptic loosening (P = .004) and decreased postoperative thigh pain (P = .03) for patients who have with HA-coated stems. There was no significant difference in HHS (P = .20), endosteal bone formation (P = .96), radiolucent lines (P = .75), linear wear rate (P = .41), or heterotopic ossification (P = .71) between HA-coated and non-HA-coated stems. CONCLUSION: We found that HA-coated femoral stems in primary THA led to significantly fewer stem revisions for aseptic loosening and less postoperative thigh pain compared to non-HA-coated stems. These findings suggest HA-coated femoral stems should be preferred over non-HA-coated femoral stems in primary THA.

Patient reported outcome measures (PROMs) as primary and secondary outcomes in total hip and knee arthroplasty randomized controlled trials: a systematic review.

BACKGROUND: Significant heterogeneity exists regarding patient reported outcome measures (PROMs) used in total hip (THA) and knee (TKA) arthroplasty randomized controlled trials (RCTs). This study investigates the PROMs used as primary and secondary outcomes in contemporary arthroplasty RCTs. METHODS: A literature search identified THA and TKA RCTs that were published in top ten impact factor orthopaedic journals from 2017 to 2021. Screening identified 241 trials: 76 THA, 157 TKA, and eight combined. Data were extracted to identify PROMs utilized as either primary or secondary outcomes and the time period of measurement. RESULTS: Visual Analog Scale (VAS) Pain was the most reported primary PROM in THA (9.2%) and TKA (22.9%) trials. This was followed by Numeric Rating Scale (NRS) Pain (7.9%) and the Harris Hip score (6.6%) in THA trials and NRS Pain (4.5%) and the Knee Society score (4.5%) in TKA trials. Many THA (37.0%) and TKA (52.1%) trials did not clearly specify primary outcome time points. Only pain scales were reported at time points less than one week, while various joint-specific functional outcomes were reported at later time points. As secondary outcomes, the Harris Hip score (28.9%) was most common in THA trials and the Knee Society score (26.1%) was most common in TKA trials. Indeterminate primary or secondary outcomes were reported in 18.2% of studies. CONCLUSIONS: Contemporary THA and TKA trials exhibit heterogeneity of PROMs as study outcomes after the first postoperative week. Our findings highlight the need for consensus in PROM reporting and better methodological reporting to improve the interpretability of RCT outcomes. PROSPERO REGISTRATION NUMBER: CRD42022337255.

The Role of Cryotherapy After Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Previous research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM). METHODS: A strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review. RESULTS: Opioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs. CONCLUSION: Cryotherapy's role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.

Examination of Randomized Trials and Corresponding Trial Registry Entries: Registration Timing and Primary Outcome Analysis in the Journal of Arthroplasty.

BACKGROUND: Prospective trial registration enhances transparency and rigor of trial reporting. We conducted an in-depth examination of randomized clinical trials (RCTs) published in The Journal of Arthroplasty (JOA) from 2010 to 2020 and their associated trial registries. METHODS: We examined all RCTs published in the JOA during the even years between 2010 and 2020. We determined the proportion of trials that were registered and prospectively registered as well as the extent of consistency between primary outcome characteristics in the trials vs the registries. Trial characteristics published between 2010 and 2014 were compared to trials published between 2016 and 2020. RESULTS: A total of 57 (33.7%) of 169 primary RCTs over the study period reported being registered and of these, 20 (11.8%) were prospectively registered. For the registered primary RCTs, 75% reported primary outcome findings that were inconsistent with the corresponding registry. Trial registration proportion substantially improved from 13.6% between 2010 and 2014 to 53% between 2016 and 2020 (z-test = -5.315, P < .001). CONCLUSION: High proportions of retrospectively registered or unregistered trials and a very high proportion of inconsistencies in reporting of primary outcomes compared to the trial registries were found. These data argue for a well-developed strategy by JOA to enhance editorial policies, reviewer and editorial board member training and oversight, and improved arthroplasty researcher awareness to improve the current state of RCT reporting in JOA.

Significant Reduction in Short-Term Complications Following Unicompartmental Versus Total Knee Arthroplasty: A Propensity Score Matched Analysis.

BACKGROUND: Total knee arthroplasty (TKA) is a gold standard surgical treatment for end-stage arthritis and unicompartmental knee arthroplasty (UKA) is an alternative for localized disease in appropriate patients. Both have been shown to have equivalent complications in the short-term period. We aimed to explore the differences in 30-day complication rates between UKA and TKA using recent data. METHODS: Current Procedural Terminology codes identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent primary TKA or UKA from 2014 to 2018. Propensity score matching addressed demographic differences. Rate of any adverse event (AAE) and complications were compared. RESULTS: We identified 279,852 patients with 270,786 and 9,066 undergoing TKA and UKA. No significant difference was observed in baseline demographics after matching. The AAE rate differed significantly between TKA (5.07%) and UKA (2.38%) cohorts (P < .001). TKA group experienced more wound dehiscence, cerebrovascular accident, postoperative blood transfusion, deep vein thrombosis, and requirement for postoperative intubation. Rate of extended length of stay differed between the TKA (11.35%) and UKA (4.89%) cohorts (P < .001). Accounting for all other variables, preoperative corticosteroid use, bleeding disorder, and chronic obstructive pulmonary disease increased the risk for AAE for both groups. Increasing American Society of Anesthesiologists class also increased the odds for complication proportionally with increasing age and operative time. CONCLUSION: Contrary to previous data, we found a significantly higher 30-day complication rate in TKA patients. TKA patients had a higher likelihood of having an extended length of stay. Multivariable analysis identified preoperative steroid use, bleeding disorder, and chronic obstructive pulmonary disease as risk factors for developing adverse events for both groups. LEVEL OF EVIDENCE: Level III.

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: Preoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA. METHODS: A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria. RESULTS: A total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285. CONCLUSIONS: Implementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients' access to surgery. LEVEL OF EVIDENCE: III, Systematic Review.

Factors affecting return to sport following hamstrings anterior cruciate ligament reconstruction in non-elite athletes.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common injury affecting non-elite and elite athletes. Although most ACL reconstructions restore the mechanical stability of the injured knee, the rate of return to sport (RTS) is varied. HYPOTHESIS/PURPOSE: We aimed to identify why non-elite athletes fail to return to pre-injury sport level. The primary objective was to assess the frequency of RTS (including type of sport, timing, level, and duration), and the secondary objective was to assess the surgical (injury, type of surgery, re-injury) and patient (demographics, function, symptoms, social, psychological) factors affecting RTS, using a multivariate analysis. STUDY DESIGN: Level III, retrospective cohort study. METHODS: We evaluated 78 consecutive non-elite athletes undergoing hamstring ACL reconstruction using medical records and questionnaires. Mean follow-up was 50 months (24-224 months). Athletes were divided into return to sport (RTS) and not returning to sport (NRTS) groups for comparative and multivariate analyses, to identify independent predictors of RTS status. RESULTS: Mean age was 31.5 years (18-51), and 46 were male (59%). The RTS rate was 56.4% (44), with most athletes returning between 9 and 12 months, and then continuing to play for > 60 months. Fear of re-injury was the highest reported reason for NRTS. There were no significant differences in demographics, concomitant injury, adjuvant surgery, and type of sport between the two groups. Mean Tegner scores were significantly higher in RTS group post-injury (6.9 vs 4.6) and at present (6.6 vs 4.6). The International Knee Documentation Committee (IKDC) score for the RTS group also increased significantly from pre-injury 70.8 (49.1-93.4) to 83.9 (24.1-100) post-injury (p < 0.001). Fear of re-injury, lack of confidence, lack of time, and change in job were significant factors in the NRTS group. Playing soccer, giving way, and change of job independently predicted RTS status from multivariate analysis. CONCLUSION: A significant number of non-elite athletes did not RTS following ACL reconstruction, and this was influenced by a combination of activity level, sport, self-reported knee instability, and psycho-social factors. Importantly, some of these can be predicted and managed with improved, individualized post-operative physical and psychological rehabilitation programmes. These data also allow surgeons to better counsel athletes before ACL reconstruction on their likelihood of RTS.

Do Press Ganey Scores Correlate With Total Knee Arthroplasty-Specific Outcome Questionnaires in Postsurgical Patients?

BACKGROUND: The purpose of this study was to assess whether Center for Medicaid and Medicare services-implemented satisfaction (Press Ganey [PG]) survey results correlate with established total knee arthroplasty (TKA) assessment tools. METHODS: Data from 736 patients who underwent TKA and received a PG survey between November 2009 and January 2015 were analyzed. The PG survey overall hospital rating scores were correlated with standardized validated outcome assessment tools for TKA (Short form-12 and 36 Health Survey; Knee Society Score; Western Ontario and McMaster Universities Arthritis Index; University of California, Los Angeles; and visual analog scale) at a mean follow-up of 1154 days post-TKA. RESULTS: There was no correlation between PG survey overall hospital rating score and the above-mentioned outcome assessment tools. CONCLUSION: Our study shows that there is no statistically significant relationship between established arthroplasty assessment tools and the PG overall hospital rating. Therefore, PG surveys may not be an appropriate tool to determine reimbursement for orthopedists performing TKAs.

Outcomes of Newer Generation Cementless Total Knee Arthroplasty: Beaded Periapatite-Coated vs Highly Porous Titanium-Coated Implants.

BACKGROUND: Newer generation cementless total knee arthroplasty (TKA) designs are available and have novel implant coatings. We evaluated and compared beaded periapatite (PA)-coated vs highly porous titanium-coated cementless TKAs. Specifically, we compared: (1) survivorship, (2) Knee Society Scores (KSSs) and range of motion, (3) complications, and (4) radiographic findings. METHODS: There were 805 TKAs with beaded PA-coated tibial and patellar components (PA group; mean age 67 years; range 41-86 years), and 219 TKAs with highly porous titanium-coated tibial and patella components (mean age 66 years; range 34-88 years). Mean follow-up was 4.4 years (range 2-9 years; median 4 years). Implant survivorship was calculated using Kaplan-Meier curves. Student t-tests and chi-square tests were used as appropriate. Radiographic evaluation was performed using Knee Society Roentgenographic Evaluation and Scoring System. RESULTS: All-cause implant survivorship in beaded PA-coated group was 99.5% (95% CI, 97.9%-99.9%) and 99.5% (95% CI, 92.7%-99.9%) in highly porous titanium-coated group. There were no significant differences in the KSS for pain and function. Improvement in flexion and extension was similar in the 2 groups. Overall, complication rate (2.2% vs 2.3%; P = .274) and number of revisions (6 [0.8%] vs 2 [0.2%]; P = .936) were similar in the 2 groups. Excluding the aseptic and septic failures, there were no progressive radiolucencies or osteolysis on radiographic evaluation. CONCLUSION: This study has shown good clinical and patient-reported outcomes of cementless TKA for both implants. Future multicenter large scale clinical and cost-effectiveness studies are needed to determine the superiority of one cementless implant type over the other.

What Influences How Patients Rate Their Hospital Stay After Total Hip Arthroplasty?

PURPOSE: Measuring the effect of operative interventions has been a challenge in orthopaedics. The assessment of patient satisfaction, as measured by the Press Ganey (PG) satisfaction surveys, has gained increasing attention. Our purpose was to determine the factors and patient characteristics that influence patient satisfaction after THA. MATERIALS AND METHODS: The PG database was queried identifying 692 THA patients (November 2009 to January 2015). A multiple regression analysis was conducted. RESULTS: Significant influence was found in communication with nurses (p=<0.001), response time of hospital staff (p=0.001), communication with physicians (p=0.002), and hospital environment (p=0.049). Management of pain and communication about medications were not significant for overall hospital rating. There were no differences between PG scores of patients who did and did not have complications. CONCLUSIONS: Hospital rating was significantly influenced by patients' communication with nurses, response time of hospital staff, and communication with physicians. Recognizing the importance of these elements, can greatly improve patient satisfaction after THA.

Does Obesity Affect Outcomes in Patients Undergoing Innovative Multi-Modal Physical Therapy Following Primary Total Knee Arthroplasty?

INTRODUCTION: Knee stiffness following total knee arthroplasty (TKA) is a common complication, especially in obese patients. The initial, non-operative treatments for this complication includes splinting and physical therapy. If these measures fail, manipulation under anesthesia (MUA) or surgical exploration can be considered to restore range of motion (ROM). However, it is generally desirable to avoid these procedures. For these reasons, newer physical therapy protocols have been developed. However, it is unknown whether these protocols are efficacious for obese patients. Therefore, the purpose of this study was to evaluate and compare: 1) ROM; 2) the rate of MUA; 3) number of physical therapy visits; and 4) costs in patients who underwent innovative multimodal physical therapy (IMPT) and were either obese or non-obese. MATERIALS AND METHODS: A review of a consecutive series of patients undergoing TKA at a single center within a three-year period was performed. All patients received IMPT post-TKA. Patients were divided into obese (body mass index (BMI >30kg/m2) and non-obese (BMI <30 kg/m2) groups. One-hundred and forty-nine patients underwent TKA and had a mean age of 67 years (range, 42 to 88 years). There were 48 patients in the non-obese group and 101 in the obese group. The obese group was significantly younger (mean, 60 years; range 38 to 54 years vs. mean, 69 years; range, 50 to 88 years), with a similar gender distribution. Comparisons of ROM, MUA, number of physical therapy visits, and costs were performed using Student's t-tests and Chi-square tests as appropriate. Cost-analysis was also performed based on the number of visits to physical therapy (PT). RESULTS: At latest follow-up, there were no significant differences in mean flexion (mean, 115°, range, 90 to 130° vs. mean, 113°, range 60 to 130°) and extension (mean, 0.81°, range, 0 to 10° vs. 0.54°, range 0 to 10°, p=0.469) between the two groups. The obese group had a 14% (n = 12) rate of MUA compared to 2% (n=1) in the non-obese group (p=0.045). Obese patients had a significantly higher number of mean visits to PT. There was significantly higher mean healthcare costs in the obese (mean, $3,919, range $1,043 to $11,749) as compared to the non-obese (mean, $2,950, range $741 to $7,865) group. DISCUSSION: Although both cohorts have similar mean ROM at final follow-up, the obese cohort had a significantly higher proportion of patients who underwent MUAs following TKA as compared to non-obese patients, despite IMPT. At latest follow-up, the ROM achieved between the two groups was similar. Obese patients required more PT visits resulting in significantly higher mean healthcare costs.

Sample size calculations in orthopaedics randomised controlled trials: revisiting research practices.

The purpose of this study was to identify how often sample size calculations were reported in recent orthopaedic randomized controlled trials (RCTs) and to determine what proportion of studies that failed to find a significant treatment effect were at risk of type II error. A pre-defined computerized search was performed in MEDLINE to identify RCTs published in 2012 in the 20 highest ranked orthopaedic journals based on impact factor. Data from these studies was used to perform post hoc analysis to determine whether each study was sufficiently powered to detect a small (0.2), medium (0.5) and large (0.8) effect size as defined by Cohen. Sufficient power (1-ß) was considered to be 80% and a two-tailed test was performed with an alpha value of 0.05. 120 RCTs were identified using our stated search protocol and just 73 studies (60.80%) described an appropriate sample size calculation. Examination of studies with negative primary outcome revealed that 68 (93.15%) were at risk of type II error for a small treatment effect and only 4 (5.48%) were at risk of type II error for a medium sized treatment effect. Although comparison of the results with existing data from over 10 years ago infers improved practice in sample size calculations within orthopaedic surgery, there remains an ongoing need for improvement of practice. Orthopaedic researchers, as well as journal reviewers and editors have a responsibility to ensure that RCTs conform to standardized methodological guidelines and perform appropriate sample size calculations.

High methodologic quality but poor applicability: assessment of the AAOS guidelines using the AGREE II instrument.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) is a globally recognized leader in musculoskeletal and orthopaedic education. Clinical guidelines are one important focus of the AAOS' educational efforts. Although their recommendations sometimes generate controversy, a critical appraisal of the overall quality of these guidelines has not, to our knowledge, been reported. QUESTIONS/PURPOSES: We wished to assess the overall quality of the AAOS guidelines using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument. METHODS: All 14 guidelines available on the AAOS website as of August 2, 2013 were evaluated. Appraisal was performed by three reviewers, independently, using the AGREE II instrument. This is an internationally recognized and validated assessment tool for evaluating guideline quality. Interrater reliability was calculated and descriptive statistics were performed. Strong interrater reliability was shown using a Spearman's Rho test (correlation coefficient ≥ 0.95). RESULTS: The overall results for AGREE II domains across all 14 guidelines were: scope and purpose (median score, 95%), stakeholder involvement (median score, 83%), rigor of development (median score, 94%), clarity of presentation (median score, 92%), applicability (median score, 48%), and editorial independence (median score, 79%). CONCLUSIONS: This study showed that the overall quality of the AAOS guidelines is high, however their applicability was found to be poor. The value of guidelines that have a high quality but that are difficult for clinicians to implement is questionable. Numerous suggestions have been proposed to improve applicability including; health economist involvement in guideline production, implementation of pilot studies and audit to monitor uptake of the guidelines and clinician feedback sessions and barrier analysis studies. Future AAOS guidelines should consider and implement steps that can improve their applicability.

Custom-made cement-linked mega prostheses: a salvage solution for complex periprosthetic femoral fractures.

Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.

Assessment of the Potential Role of Preoperative Dental Clearance in Total Joint Arthroplasty Optimization: A Pilot Study.

AIMS AND OBJECTIVES: Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA) and is associated with significant morbidity, mortality, and cost. This pilot study primarily aimed to investigate if preoperative dental screenings would impact the rate of PJI following TJA when compared to historical controls. Secondarily, this study aimed to evaluate the prevalence of dental pathology in patients undergoing TJA. METHODS: Charts from 103 consecutive patients undergoing primary or revision total hip arthroplasty (THA, rTHA) or total knee arthroplasty (TKA, rTKA) by a single surgeon at a single academic institution over a two-year period were reviewed and selected for inclusion. All patients were referred to a dentist for preoperative clearance using a standardized form. The rate of dental pathology before surgery, details of the dental intervention required, and any dental work performed within six months postoperatively were evaluated. The demographic and comorbidity composition of our patient population was also collected. Finally, rates of PJI following each type of TJA were obtained for demographic- and comorbidity-matched historical controls from similar study designs to examine the potential impact of preoperative dental intervention. RESULTS: Of the 103 patients, 31 (30.1%) were found to have preoperative dental pathology. Twenty-eight of these 31 patients (90.3%) required dental intervention prior to surgery. Based on demographic- and comorbidity-matched historical data, we expected two (95% CI (0, 6)) PJI cases for the THA group, 0 (95% CI (0, 2)) PJI cases for the TKA group, two (95% CI (0, 5)) PJI cases for the rTHA group, and two (95% CI (0, 5)) PJI cases for the rTKA group. However, in our study, there were no PJIs after any TJA up to the latest follow-up, which was unlikely for THA, rTHA, and rTKA groups given the calculated Poisson probabilities (9.39%, 15.11%, and 11.26%, respectively). Finding 0 cases was likely for the TKA group given the calculated Poisson probability of 72.61%. CONCLUSIONS: This pilot study demonstrated that preoperative dental screening, which aims to decrease the chance of PJI due to bacteremia, may have an impact on the rate of PJI following THA, rTKA, and rTHA but not TKA based on Poisson probabilities calculated from demographic- and comorbidity-matched historical controls that lacked preoperative dental screening. For THA, rTKA, and rTHA, the Poisson probabilities of observing 0 cases of PJI postoperatively, as was the case in our study, were unlikely, suggesting that some variable in our cohort was decreasing the PJI rate for these groups. However, in the case of TKA, the Poisson probability of observing 0 cases was likely and matched the results of our study, suggesting that no variable in our cohort was affecting the PJI rate for this group. We cannot draw direct conclusions from this retrospective observational study, but the preliminary findings prompt further investigation through an appropriately controlled, blinded, multi-centered, and powered prospective randomized controlled trial.

Improved outcomes with perioperative dietitian-led interventions in patients undergoing total joint arthroplasty: A systematic review.

Background: Nutritional assessment is important for optimization of patients undergoing elective total joint arthroplasty (TJA). Preoperative nutritional intervention is a potentially modifiable optimization target, but the outcomes of such intervention are not well-studied. The purpose of this study is to assess the impact of nutritional interventions on elective TJA outcomes. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to perform a systematic review of the Ovid Medline, Embase, and Cochrane Library systems. Included studies were comprised of patients greater than 18 years of age undergoing a primary unilateral TJA who received a perioperative dietitian-led intervention. Data analyzed included nutritional intervention protocol, patient demographics, length of stay (LOS), postoperative labs and complications, among others. Results: Our initial search identified a total of 1766 articles. Four studies representing 5006 patients met inclusion criteria. The studies utilized a protein-dominant diet, with or without a carbohydrate solution accompanied by dietitian assessment or education. The 4 studies found that the intervention group had significantly decreased LOS, fewer albumin infusions, less wound drainage, lower rates of hypocalcemia and hypokalemia, reduced C-reactive protein (CRP) values, improved time out of bed, and decreased overall costs. Conclusion: The findings support the potential benefits of perioperative dietitian-led intervention on key outcomes for patients undergoing primary TJA. Surgeons should consider nutritional intervention in their preoperative optimization protocols. Future studies could help elucidate the optimum nutritional regimens and monitoring for idealized intervention and surgical timing. Prospero registration number: CRD4202338494.

Cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial.

BACKGROUND: Clinical and radiographic diagnoses of scaphoid fractures are often challenging at the time of injury. Patients are therefore usually reassessed which has cost implications. Various investigations exist but MRI has been suggested as effective in diagnosing these injuries early. AIM: To determine whether early MRI in suspected occult scaphoid fractures is more clinically and cost effective than conventional management with immobilisation and reassessment. METHODS: All patients presenting to the Emergency Department at a district general hospital with a suspected occult scaphoid fracture were randomised into two groups, MRI (early scan of the wrist, discharged if no injury) and control (reassessment in clinic). RESULTS: 84 patients were randomised into MRI (45) and control (39) groups. There were no baseline differences apart from greater dominant hand injuries in the MRI group (62% (26) vs 36% (14), p=0.02). There were three (6.7%) scaphoid fractures in the MRI group and four (10.3%) in the control group (p=0.7). More fractures (15.6% (7) vs 5.1% (2), p=0.9) and other injuries were detected in the MRI group who had fewer mean clinic appointments (1.1 ± 0.5 vs 2.3 ± 0.8, p=0.001) and radiographs (1.2 ± 0.8 vs 1.7 ± 1.1, p=0.03). Mean management costs were £504.13 (MRI) and £532.87 (control) (p=0.9). The MRI group had better pain and satisfaction scores (not significant) with comparable time off work and sporting activities. CONCLUSION: Early MRI in occult scaphoid fractures is marginally cost saving compared with conventional management and may reduce potentially large societal costs of unnecessary immobilisation. It enables early detection and appropriate treatment of scaphoid and other injuries.