Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis.

BACKGROUND: Total hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu + Ex) programs may reduce the number of THAs needed, but supporting data are limited. This study aimed to estimate the treatment effect of THA versus Edu + Ex on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for hip OA. METHODS: Patients who had hip OA who underwent THA or an Edu + Ex program were included in this propensity-matched study. In 778 patients (Edu + Ex, n = 303; THA, n = 475), propensity scores were based on pretreatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference (MD) in change from pretreatment to 3-month and 12-month follow-up using linear mixed models. RESULTS: The matched sample consisted of 266 patients (Edu + Ex, n = 133; THA, n = 133) who were balanced on all pretreatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (MD 35.4; 95% confidence interval [CI] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17% and 30% of patients receiving Edu + Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84% and 90% of THA patients. CONCLUSIONS: A THA provides greater improvements in pain, function, and quality of life. A notable proportion of Edu + Ex patients had clinically meaningful improvements, suggesting Edu + Ex may result in THA deferral in some patients, but confirmatory trials are needed.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Quality indicators in primary elective total hip and knee arthroplasty.

PURPOSE: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation. METHODS: A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained. RESULTS: Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia. CONCLUSION: This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Effect of intravenous acetaminophen on postoperative outcomes in hip fracture patients: a systematic review and narrative synthesis.

PURPOSE: Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients. SOURCE: We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers. PRINCIPAL FINDINGS: Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium. CONCLUSION: There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population. STUDY REGISTRATION: PROSPERO (CRD42021198174); registered 15 August 2021.

RéSUMé: OBJECTIF: Les fractures de la hanche sont débilitantes chez les personnes âgées en raison de leur impact sur leur qualité de vie. Les opioïdes sont associés à des effets indésirables chez cette population, de sorte que l'acétaminophène par voie orale est couramment prescrit pour minimiser la consommation d'opioïdes. L'acétaminophène par voie intraveineuse (IV) a une efficacité et une biodisponibilité supérieures à celles de l'acétaminophène par voie orale. Néanmoins, son effet sur les devenirs postopératoires dans les fractures d'urgence de la hanche n'est pas clair. Cette revue systématique a évalué l'effet de l'acétaminophène IV sur les devenirs postopératoires chez les patients âgés avec une fracture de la hanche. SOURCES: Nous avons effectué des recherches dans plusieurs bases de données de leur création à juin 2021 pour en tirer les études portant sur des adultes > 50 ans bénéficiant d'une chirurgie d'urgence pour une fracture de la hanche et ayant reçu de l'acétaminophène IV (ou paracétamol), et qui rapportait les devenirs postopératoires. Les titres, résumés et textes intégraux pertinents ont été sélectionnés en fonction des critères d'admissibilité. L'échelle de Newcastle-Ottawa a été utilisée pour évaluer la qualité des articles sélectionnés. CONSTATATIONS PRINCIPALES: Sur les 3510 études initiales, quatre ont répondu aux critères d'inclusion. L'une était une étude de cohorte prospective et trois étaient des études de cohorte rétrospectives. Les quatre études ont utilisé des groupes témoins historiques. Trois études ont rapporté une dose moyenne d'opioïdes significativement plus faible avec l'acétaminophène IV qu'avec de l'acétaminophène par voie orale. Trois études ont également rapporté un séjour à l'hôpital significativement plus court. Une diminution significative du nombre de séances de physiothérapie manquées a été rapporté dans une étude, une autre a rapporté une diminution significative de la nécessité de supervision individuelle, et une troisième une réduction des épisodes d'état confusionnel aigu. CONCLUSION: : Il n'existe que très peu de données probantes qui sont de faible qualité et selon lesquelles l'acétaminophène IV améliore l'analgésie préopératoire et postopératoire et réduit la durée de séjour à l'hôpital chez les patients âgés atteints d'une fracture de hanche. Néanmoins, nos résultats doivent être interprétés avec prudence car il n'existe pas d'étude randomisée prospective évaluant si l'acétaminophène IV améliore les issues postopératoires dans cette population de patients. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021198174); enregistrée le 15 août 2021.

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis.

AIM: Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery. METHODS: Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO. RESULTS: Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar. CONCLUSIONS: Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D) Program across Canada for the Management of Hip and Knee Osteoarthritis.

Good Life with osteoArthritis in Denmark (GLA:D®) is a program for the management of patients with hip and knee osteoarthritis (OA). Adapted for the Canadian population, the GLA:DTM Canada program implements evidence-based strategies to support the prevention, early diagnosis and effective management of hip and knee OA. GLA:D assists local communities in implementing OA strategies across the spectrum of disease severity. An integral part of this program is a national quality and outcomes registry, which includes data concerning participant characteristics and both patient-reported and functional outcomes. This registry helps healthcare providers and healthcare decision makers ensure that individuals with OA receive effective, high-quality care through the GLA:D Canada program.

Practice does not always make perfect: need for selection curricula in modern surgical training.

BACKGROUND: It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty. METHODS: Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified. RESULTS: Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase. CONCLUSIONS: Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.

Topical tranexamic acid reduces transfusion rates in simultaneous bilateral total knee arthroplasty: a retrospective case series.

BACKGROUND: Topical tranexamic acid (TA) has been reported to be effective in reducing postoperative bleeding and transfusions after total knee arthroplasty (TKA). The main objective of this study was to retrospectively assess the effectiveness and safety of topical TA administration in patients undergoing simultaneous bilateral TKA. METHODS: We conducted a retrospective chart review of consecutive cohorts of patients undergoing simultaneous bilateral TKA. We compared the patients who received TA with patients from a similar time frame who did not receive TA. For those who received TA, a topical concentration of 2 g per 30 mL of normal saline was used in each knee. Preoperative and postoperative hemoglobin, transfusions, length of stay (LOS) and postoperative complications were recorded for each patient until discharge. Outcome measures were analyzed using independent t test, χ2 test and logistic regression. RESULTS: We included 49 patients in our analysis: 25 who received TA and 24 who did not. There were no statistical differences in demographics between the groups. The rate of transfusion in the TA group was 4% compared with 67% in the non-TA group (p < 0.001). The net hemoglobin loss in the TA group was 4.1 g/dL versus 6.2 g/dL in the non-TA group (p < 0.001). The use of TA was found to be associated with a greater than 99% reduced risk of receiving a transfusion (odds ratio 0.003, 95% confidence interval < 0.001-0.072, p < 0.001). There were no thromboembolic events in patients who received TA, and there was 1 pulmonary embolus in the non-TA group. Postoperative LOS was significantly reduced in the TA group (mean difference 1.1 d, p = 0.005). CONCLUSION: Topical administration of TA in patients undergoing simultaneous bilateral TKA significantly reduced transfusions, blood loss and postoperative LOS, with no increased risk of thromboembolic events.

CONTEXTE: Selon certains rapports, l'acide tranexamique (AT) topique réduirait efficacement les saignements postopératoires et le recours aux transfusions après une intervention pour prothèse totale du genou. Le principal objectif de cette étude était d'évaluer de manière rétrospective l'efficacité et l'innocuité de l'AT topique chez des patients soumis à une intervention pour prothèse totale des 2 genoux. MÉTHODES: Nous avons procédé à une analyse rétrospective des dossiers de cohortes consécutives de patients soumis à une intervention pour prothèse totale des 2 genoux. Nous avons comparé les patients ayant reçu l'AT aux patients d'une période similaire qui n'ont pas reçu l'AT. Pour ceux qui ont reçu l'AT, la concentration topique de 2 g par 30 mL de solution physiologique a été utilisée dans les 2 genoux. On a enregistré chez chaque patient les taux d'hémoglobine pré- et postopératoires, le nombre de transfusions, la durée du séjour hospitalier et les complications postopératoires jusqu'à leur congé. Les paramètres ont été analysés à l'aide du test t, du test du χ2 et de la régression logistique. RÉSULTATS: Nous avons inclus 49 patients dans notre analyse : 25 ayant reçu l'AT et 24 ne l'ayant pas reçu. Il n'y avait aucune différence statistique entre les groupes pour ce qui est des caractéristiques démographiques. Le taux de transfusions dans le groupe ayant reçu l'AT a été de 4 %, contre 67 % dans le groupe n'ayant pas reçu l'AT (p < 0,001). La baisse nette de l'hémoglobine dans le groupe ayant reçu l'AT a été de 4,1 g/dL, contre 6,2 g/dL dans le groupe n'ayant pas reçu l'AT (p < 0,001). L'utilisation de l'AT a été associée à une réduction de plus de 99 % du risque de transfusion (rapport des cotes 0,003, intervalle de confiance de 95 % < 0,001-0,072, p < 0,001). On n'a noté aucun incident thromboembolique chez les patients ayant reçu l'AT, et une embolie pulmonaire dans le groupe n'ayant pas reçu l'AT. La durée du séjour hospitalier postopératoire a été significativement plus brève dans le groupe ayant reçu l'AT (différence moyenne 1,1 j, p = 0,005). CONCLUSION: L'administration topique d'AT chez des patients soumis à une intervention pour prothèse totale des 2 genoux a significativement réduit le recours aux transfusions et les pertes sanguines et a abrégé les séjours hospitaliers postopératoires, sans accroître le risque d'incidents thromboemboliques.

Trunnionosis: the latest culprit in adverse reactions to metal debris following hip arthroplasty.

The imaging findings of periprosthetic soft tissue lesions (pseudotumours) have been typically defined in the context of newer second-generation metal-on-metal hip arthroplasty. More recently, similar findings have been described in the setting of non-metal-on-metal prostheses. Although uncommon, wear and corrosion between the metal surfaces at the head-neck ('trunnionosis') and neck-stem interfaces are the potential culprits. With modular junctions containing at least one cobalt chromium component frequently present in hip arthroplasty prostheses, the incidence of this mode of adverse wear may be higher than previously thought (irrespective of the specific bearing couple used). In the present report, we described a case of a severe adverse local tissue reaction secondary to suspected corrosion at the head-neck taper in a metal-on-polyethylene total hip arthroplasty and reviewed the literature. Knowledge of this topical entity should help radiologists facilitate early diagnosis and ensure early management of this potentially serious complication.

The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review.

BACKGROUND: Despite the overall success of total joint arthroplasty, patients undergoing this procedure remain susceptible to cognitive decline and/or delirium, collectively termed postoperative cognitive dysfunction. However, no consensus exists as to whether general or regional anesthesia results in a lower likelihood that a patient may experience this complication, and controversy surrounds the role of pain management strategies to minimize the incidence of postoperative cognitive dysfunction. QUESTIONS/PURPOSES: We systematically reviewed the English-language literature to assess the influence of the following anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction in patients undergoing elective joint arthroplasty: (1) general versus regional anesthesia, (2) different parenteral, neuraxial, or inhaled agents within a given type of anesthetic (general or regional), (3) multimodal anesthetic techniques, and (4) different postoperative pain management regimens. METHODS: A systematic search was performed of the MEDLINE(®) and EMBASE™ databases to identify all studies that assessed the influence of anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction after elective joint arthroplasty. Twenty-eight studies were included in the final review, of which 21 (75%) were randomized controlled (Level I) trials, two (7%) were prospective comparative (Level II) studies, two (7%) used a case-control (Level III) design, and three (11%) used retrospective comparative (Level III) methodology. RESULTS: The evidence published to date suggests that general anesthesia may be associated with increased risk of early postoperative cognitive dysfunction in the early postoperative period as compared to regional anesthesia, although this effect was not seen beyond 7 days. Optimization of depth of general anesthesia with comprehensive intraoperative cerebral monitoring may be beneficial, although evidence is equivocal. Multimodal anesthesia protocols have not been definitively demonstrated to reduce the incidence of postoperative cognitive dysfunction. Nonopioid postoperative pain management techniques, limiting narcotics to oral formulations and avoiding morphine, appear to reduce the risk of postoperative cognitive dysfunction. CONCLUSIONS: Both anesthetic and pain management strategies appear to influence the risk of early cognitive dysfunction after elective joint arthroplasty, although only one study identified differences that persisted beyond 1 week after surgery. Investigators should strive to use accepted, validated tools for the assessment of postoperative cognitive dysfunction and to carefully report details of the anesthetic and analgesic techniques used in future studies.

Platelet-rich plasma in the management of articular cartilage pathology: a systematic review.

OBJECTIVE: Using systematic review methodology, we endeavored to answer the following questions concerning the treatment of osteochondral pathology: (1) what pathologies have been treated in vivo with the use of platelet-rich plasma (PRP); (2) what methods of PRP preparation and delivery have been reported; (3) what assessment tools and comparison group have been used to assess its effectiveness; and (4) what are the clinical outcomes of its use. DATA SOURCES: A systematic literature search was performed of the OVID, EMBASE, and Evidence Based Medicine Reviews databases to identify all studies published up to October 2012 that assessed clinical outcomes of the use of PRP for the treatment of chondral and osteochondral pathology, excluding those including concomitant management of acute fractures or ligament reconstruction. DATA EXTRACTION: The included studies were reviewed and the following data were extracted and tabulated: study authors' year and journal, study design and level of evidence, pathology treated, methods of PRP preparation and delivery, and clinical outcome scores. DATA SYNTHESIS: Ten studies were included in the final analysis. The majority of studies assessed the use of PRP in the treatment of degenerative osteoarthritis of the knee or hip (representing 570 of a total of 662 joints). The majority of patients were treated with intra-articular injections, whereas 2 studies used PRP as an adjunct to surgical treatment. Significant improvements in joint-specific clinical scores (7 of 8 studies), general health scores (4 of 4 studies), and pain scores (4 of 6 studies) compared with baseline were reported up to 6-month follow-up, but few studies provided longer-term data. No studies reported worse scores compared with baseline at final follow-up. Three of 4 comparative studies reported significantly better clinical and/or pain scores when compared with hyaluronic acid injections at similar follow-up times. CONCLUSIONS: Currently, there is a paucity of data supporting the use of PRP for the management of focal traumatic osteochondral defects. There is limited evidence suggesting short-term clinical benefits with the use of PRP for symptomatic osteoarthritis of the knee, but the studies published to date are of poor quality and at high risk for bias. Further high-quality comparative studies with longer follow-up are needed to ascertain whether PRP is beneficial, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology.

Treatment of Concurrent Depression and Its Effect on Outcomes After Total Joint Arthroplasty: A Systematic Review of Comparative Studies.

PURPOSE: There is a growing body of evidence suggesting that patients with a diagnosis of depression suffer worse outcomes after total joint arthroplasty (TJA) procedures. It is unclear whether depression treatment is a modifiable risk factor that can be targeted to improve suboptimal outcomes. We conducted a systematic review to understand the role that various interventions have on outcomes of TJA in patients with diagnosed depression (PDDs). METHODS: PubMed, Ovid MEDLINE, Scopus, and EMBASE were searched systematically from inception until November 2022. Studies of PDDs who underwent TJA that compared any intervention/treatment of depression with a control group and reported pain, functional outcomes, depression scores, and/or revision rates after TJA were relevant for this review. RESULTS: Ten relevant studies were included in the final systematic review, with a total of 33,501 patients included. Two studies reported lower revision rates for patients receiving selective serotonin reuptake inhibitor treatment and psychotherapy. Two studies showed no difference in functional outcomes for patients receiving pharmacologic treatment. One study reported improved functional outcomes for patients receiving cognitive behavioral therapy and another reported improved postoperative functional outcomes for patients receiving alprazolam. CONCLUSION: Interventions targeted at PDDs may improve short-term pain and functional outcomes, and there may be an association between selective serotonin reuptake inhibitor use and implant survival. The current literature is limited and inconclusive, with important gaps in understanding regarding the optimization and treatment of this modifiable risk factor. Surgeons should consider depression treatment as a method to improve outcomes in this cohort.

Total Knee Arthroplasty Versus Education and Exercise for Knee Osteoarthritis: A Propensity-Matched Analysis.

OBJECTIVE: We estimate the treatment effect of total knee arthroplasty (TKA) versus an education and exercise (Edu+Ex) program on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for knee osteoarthritis (OA). METHODS: Patients with knee OA who had undergone TKA were matched on a 1:1 ratio with participants in an Edu+Ex program based on a propensity score fitted to a range of pretreatment covariates. After matching, between-group differences in improvement (the treatment effect) in Knee Injury and Osteoarthritis Outcome Score 12-item version (0, worst to 100, best) pain, function, and quality of life from baseline to 3 and 12 months were estimated using linear mixed models, adjusting for unbalanced covariates, if any, after matching. RESULTS: The matched sample consisted of 522 patients (Edu+Ex, n = 261; TKA, n = 261) who were balanced on all pretreatment characteristics. At 12-month follow-up, TKA resulted in significantly greater improvements in pain (mean difference [MD] 22.8; 95% confidence interval [95% CI] 19.7-25.8), function (MD 21.2; 95% CI 17.7-24.4), and quality of life (MD 18.3; 15.0-21.6). Even so, at least one-third of patients receiving Edu+Ex had a clinically meaningful improvement in outcomes at 12 months compared with 75% of patients with TKA. CONCLUSION: TKA is associated with greater improvements in pain, function, and quality of life, but these findings also suggest that Edu+Ex may be a viable alternative to TKA in a meaningful proportion of patients, which may reduce overall TKA need. Confirmatory trials are needed.

Measuring expectations in orthopaedic surgery: a systematic review.

BACKGROUND: Advances in the surgical treatment of musculoskeletal conditions have resulted in an interest in better defining and understanding patients' expectations of these procedures, but the best ways to do this remain a topic of considerable debate. QUESTIONS/PURPOSES: (1) What validated instruments for the assessment of patient expectations of orthopaedic surgery have been used in published studies to date? (2) How were these expectation measures developed and validated? (3) What unvalidated instruments for the assessment of patient expectations have been used in published studies to date? METHODS: A systematic literature search was performed using the OVID Medline and EMBASE databases, in duplicate, to identify all studies that assessed patient expectations in orthopaedic surgery. Sixty-six studies were ultimately included in the present review. RESULTS: Seven validated expectation instruments were identified, all of which use patient-reported questionnaires. Five were specific to a particular procedure or affected anatomic location, whereas two were broadly applicable. Details of reliability and validity testing were available for all but one of these instruments. Forty additional unvalidated expectation assessment tools were identified. Thirteen were based on existing clinical outcome tools, and the others were study-specific, custom-developed tools. Only one of the unvalidated tools was used in more than one study. CONCLUSIONS: Several validated expectation instruments have been developed for use by patients undergoing orthopaedic surgery. However, many tools have been reported without evidence of testing and validation. The wide range of untested instruments used in single studies substantially limits the interpretation and comparison of data concerning patient expectations.

Reduced re-infection rates with postoperative oral antibiotics after two-stage revision hip arthroplasty.

BACKGROUND: Surgeons are often trying to decreased reinfection rates following two-stage reimplantation arthroplasty, which range from 3.2% to 13% because multiple staged revision procedures for infection can be costly and have high morbidity. We therefore asked: (1) Did the use of postoperative oral antibiotics reduce reinfection rates after 2-staged revision of THA? And (2) how did this compare with the infection rate after aseptic revision procedures? METHODS: We identified all patients who underwent two-stage revision THA for a periprosthetic deep hip infection and found 66 patients (67 hips) who had a minimum 24 months' followup. Twenty-two of the 66 procedures (33%) were followed by a minimum of 14 days of postoperative oral antibiotics (mean, 36 days; range, 14 days to lifelong), while 44 were prescribed only immediate parenteral postoperative antibiotic therapy (mean, 1.3 days; range, 1-3 days). We then identified 407 patients (410 hips) who underwent aseptic revision hip arthroplasty and evaluated the infection rate in these patients for comparison; these patients were treated with 24 hours of postoperative parenteral antibiotics. The authors used previously described creteria to establish the presence of infection. RESULTS: There were no reinfections in the group receiving oral postoperative antibiotics compared to six reinfections (13.6%) in the 44 patients not receiving oral antibiotics. We observed infection in 2 of the 410 hips (0.5%) revised for aseptic reasons. CONCLUSIONS: We believe that our findings warrant further investigation for using postoperative oral antibiotics after reimplantation for periprosthetic infection in an effort to decrease the likelihood and risks associated with additional revision arthroplasty procedures.

Total hip arthroplasty in Down syndrome patients: an improvement in quality of life: replacement arthroplasty in Down syndrome (RADS) study group.

The purpose this study was to assess survival rates, clinical outcomes, and radiographic outcomes of total hip arthroplasty in Down syndrome patients. We reviewed 26 total hip arthroplasties (21 patients) performed by four experienced hip surgeons. These patients had a mean age of 35 years and a mean follow-up of 106months. Clinical outcomes were assessed using Harris Hip scores, and radiographic evaluation for component fixation and migration was performed. The overall survival with aseptic failure as an endpoint was 85%. The mean Harris Hip score improved to 84 points at final follow-up. While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function.