Simultaneous (two-surgeon) versus staged bilateral knee arthroplasty: an observational study of intraoperative and post-operative outcomes.

BACKGROUND: The advantages of simultaneous bilateral total knee arthroplasty (sim-BTKA) remain controversial. This study investigated the effects of two-surgeon sim-BTKA compared to separate admission staged BTKA regarding intraoperative and post-operative outcomes and health service costs. METHODS: Patients underwent sim-BTKA or staged BTKA between 1 November 2008 and 30 June 2016. Data were extracted from a joint replacement registry and medical records. Median regression and chi-squared tests were used for between-group comparisons. RESULTS: Median hospital total length of stay was 5 days less for sim-BTKA (n = 122) than staged BTKA group (n = 46) (7 versus 12; 95% confidence interval (CI) 3.9, 6.1), and 9 days less for inpatient rehabilitation (17 versus 26; 95% CI 3.7, 14.3). However, 80% of sim-BTKA patients went to inpatient rehabilitation (versus 27% following staged BTKA), so median total length of stay was 9 days less for staged BTKA (13 versus 22; 95% CI -12.8, -5.2). Total anaesthesia time was 135 min less for sim-BTKA (P < 0.001), while staged BTKA required less blood transfusions (P = 0.001). Complication rates were similar, except for superficial infections which were observed twice as often after staged BTKA (30% versus 15%, P = 0.048). Twelve months following sim-BTKA and the first staged total knee arthroplasty, sim-BTKA had better WOMAC pain, stiffness and function scores (P ≤ 0.05). Average inpatient costs (hospital and rehabilitation) were $6388 less for sim-BTKA. CONCLUSION: Sim-BTKA appears to be a comparatively safe alternative to staged BTKA. Sim-BTKA may be superior to staged BTKA due to faster improvements in pain and function and lower healthcare costs. How these results generalize to other health services requires further investigation.

Hip pathology: the diagnostic accuracy of magnetic resonance imaging.

BACKGROUND: Hip arthroscopy has led to a greater understanding of intra-articular hip pathology. Non-contrast magnetic resonance imaging (MRI) is currently the gold standard in non-invasive imaging diagnosis, with high sensitivity in identifying labral pathology but equivocal results for ligamentum teres damage and chondral defects. The aim of this study is to determine the accuracy of non-contrast MRI for diagnosis of intra-articular hip derangements and identify radiological features that could increase the accuracy of the diagnosis. METHODS: A prospective study of 71 hips on 68 patients undergoing hip arthroscopy was conducted comparing pre-operative analysis of MRI imaging versus an arthroscopic examination. Two musculoskeletal radiologists reported the data independently. All hip arthroscopies were performed by a single surgeon. Patients with MRIs performed within 6 months before hip arthroscopy were included. Outcome measures included observer accuracy identifying ligamentum teres tears, labral lesions, and chondral rim damage. Secondary outcome measures included inter-observer variability and correctly staged ligamentum teres tears. RESULTS: The accuracy of radiology reporting for ligamentum teres tears, labral damage, and chondral rim lesions was 85.92% for each instance. The MRI findings most consistent with labral tears include the presence of linear high signal traversing the articular surface into the labrum, presence of intra-labral fluid signal, and loss of homogenous low signal triangular morphology. Chondral rim damage was difficult to diagnose, but abnormal signal at the chondrolabral junction with partial thickness defects would suggest damage. Ligamentum teres tears are commonly found but poorly graded. Thickening and increased signal suggests synovitis while discontinuity and fraying suggests partial tearing. CONCLUSION: Conventional non-arthrographic MRI offers an accurate non-invasive method to screen patients with symptoms referable to the hip by revealing the presence of labral tears, chondral defects, and ligamentum teres tears/synovitis. This study demonstrates that tears and synovitis of the ligamentum teres as potential sources of hip pain can be accurately identified on conventional non-arthrographic MRI. However, MRI has poor specificity and negative predictive value, and thus, a negative MRI result may warrant further investigation.

A novel web-support intervention to promote recovery following Anterior Cruciate Ligament reconstruction: A pilot randomised controlled trial.

BACKGROUND: Self-efficacy is positively associated with adherence behaviours and rehabilitation outcomes following Anterior Cruciate Ligament (ACL) reconstruction. An internet resource can be an effective way to provide information, goal setting, patient monitoring and hence support overall self-management. PURPOSE: This study examined the feasibility of a three month 'internet-based intervention' (mobile-oriented site) to enhance recovery for patients following ACL reconstruction. The potential effect of the internet-based intervention on knee pain, function, self-efficacy and fear of pain were also assessed. METHOD: This was a pilot randomised controlled trial (RCT) with pre and post intervention design (assessments at one week and three months following ACL reconstruction) comparing: (1) a control group and (2) an intervention group (internet-based intervention). A set of qualitative and quantitative assessments were included to evaluate potential improvements in self-efficacy, pain and function and perception of the internet intervention. RESULTS AND CONCLUSION: Seventeen participants were available for analysis (n = 10 intervention and n = 7 control group). Participants reported the internet-based intervention to be a useful tool for information, reminder and reinforcement for performing their exercise rehabilitation with 30.3% (±35.3%) adherence to the internet-based intervention. No differences were observed between the groups over time on the outcome questionnaires (p > 0.05). Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001379404.

The Role of Hip Arthroscopy in Investigating and Managing the Painful Hip Resurfacing Arthroplasty.

PURPOSE: To determine the safety and efficacy of hip arthroscopy performed in the peripheral compartment as a diagnostic and therapeutic treatment option for patients with hip pain after hip resurfacing surgery. METHODS: Indications for hip arthroscopy after hip resurfacing included patients with a symptomatic hip-resurfaced arthroplasties who did not respond to nonoperative treatment. Patients who underwent a hip arthroscopy after a painful hip resurfacing were included with a minimum of 1 year follow-up. Subgroup analysis was performed according to whether an established diagnosis was made before arthroscopic intervention or not. Subjective measures were based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, and results were calculated and analyzed. RESULTS: We included 68 patients (26 male [38%] and 42 female [62%]) who underwent subsequent hip arthroscopy from a population of 978 consecutive hip-resurfaced arthroplasties performed between 1999 and 2010. The average age was 58 (range, 37 to 78 years). The mean follow-up after hip arthroscopy was 3.4 years (range, 12 months to 5.8 years). Patients who had an established diagnosis (n = 41) before hip arthroscopy showed statistical improvement in their WOMAC scores (7 to 2, P < .001). Only 3 (7%) of these 41 patients failed and were converted to a total hip replacement (THR); however, patients who did not have an established diagnosis (n = 27) before undergoing hip arthroscopy showed statistical worsening of the WOMAC (15 to 21, P = .002). Ten (37%) of these 27 patients without a diagnosis failed and needed to be converted to a THR. A significant correlation was found between the collections found on ultrasound (psoas bursa and/or in the hip joint) and the need for synovectomy (P = .01). The overall revision rate to THR after hip resurfacing in our group of patients was 1.3% (n = 13). Female patients were more likely to require postresurfacing hip arthroscopy with 42 (60%) female to only 26 (40%) male patients undergoing this procedure. In our study population, 70% (14/21, P < .05) of patients with hip pain caused by severe metal synovial reaction or metal-on-metal reaction were women. A total of 5 (7%) patients had minor-to-mild complications after hip arthroscopy. CONCLUSIONS: Hip arthroscopy is a safe surgical treatment option for those patients with a painful hip resurfacing arthroplasty. Having an accurate diagnosis before hip arthroscopy improves the likelihood a good outcome. LEVEL OF EVIDENCE: Level IV - therapeutic case series.

Eversion-Inversion Labral Repair and Reconstruction Technique for Optimal Suction Seal.

Labral tears are a significant cause of hip pain and are currently the most common indication for hip arthroscopy. Compared with labral debridement, labral repair has significantly better outcomes in terms of both daily activities and athletic pursuits in the setting of femoral acetabular impingement. The classic techniques described in the literature for labral repair all use loop or pass-through intrasubstance labral sutures to achieve a functional hip seal. This hip seal is important for hip stability and optimal joint biomechanics, as well as in the prevention of long-term osteoarthritis. We describe a novel eversion-inversion intrasubstance suturing technique for labral repair and reconstruction that can assist in restoration of the native labrum position by re-creating an optimal seal around the femoral head.

Arthroscopic Hip Labral Reconstruction and Augmentation Using Knotless Anchors.

Biomechanical stability is the primary function of the acetabular labrum. It provides a hip suction seal and optimal joint function. Labral tears are a common reason for hip arthroscopy, to improve patient function and to prevent long-term degenerative arthropathy. Arthroscopic labral repair has shown significantly better outcomes in return to premorbid activity levels when compared with labral debridement. Injury to the acetabular labrum is a challenge and can lead to long-term complications. In this scenario, arthroscopic labral reconstruction has shown good results regarding patient subjective and objective outcomes. We describe a technique for complete arthroscopic labral reconstruction using tensor fascia lata allograft.

The anterior approach for a non-image-guided intra-articular hip injection.

PURPOSE: The purpose of this study was to investigate and validate the accuracy and safety of a technique using an anterior approach for non-image-guided intra-articular injection of the hip by use of anatomic landmarks. METHODS: We enrolled 55 patients. Injections were performed before supine hip arthroscopy after landmarking and before application of traction. After the needle insertion, success was confirmed with an air arthrogram and by direct visualization after arthroscope insertion. Accuracy and difficulty achieving correct needle placement were correlated with age, weight, height, body mass index, body type, gender, and surgical indication, as well as femoral and pelvic morphology. Forty-five patients who underwent injection in the office were followed up separately to document injection side effects. Needle placement accuracy was correlated to patients' demographics. All statistical tests with P values were 2 sided, with the level of significance set at P < .05. RESULTS: There were 51 correct needle placements and 4 misses, yielding a 93% success rate. The most common location for needle placement was the upper medial head-neck junction. Female gender was correlated with a more difficult needle placement and misses in relation to group size (P = .06). The reasons for misplacements of the needle were a high-riding trochanter, increased femoral version, thick adipose tissue over the landmarks, and variant of ilium morphology. Of 45 patients in the side effect study arm, 3 reported sensory changes of the lateral femoral cutaneous nerve that resolved within 24 hours. CONCLUSIONS: Hip injections by use of the direct anterior approach, from the intersection of the lines drawn from the anterior superior iliac spine and 1 cm distal to the tip of the greater trochanter, are safe and reproducible. Patient characteristics, such as increased subcutaneous adipose tissue or osseous anatomic variants, can lead to difficulty in placing the needle successfully. These characteristics can be predicted with the aid of physical examination and careful study of the pelvic radiographs. LEVEL OF EVIDENCE: Level IV, therapeutic case series.