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

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

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

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

The Hip-spine Assessment of a Novel Surgical Planning Software Provides Acetabular Component Targets That Are Reliable and in Agreement With Current Clinical Recommendations.

Background: Spinopelvic immobility has been reported to increase dislocation risk following total hip arthroplasty. Surgically placing acetabular components in a functional orientation has been shown to mitigate risk. The aim of this study was to evaluate the validity and reliability of novel surgical planning software to generate clinically recommended cup targets. Methods: Hip-spine assessments were performed retrospectively on 40 patients. Five reviewers, including 3 arthroplasty-trained surgical fellows and 2 clinical research scientists performed the assessments. Hip-spine assessments consisted of measuring anterior pelvic plane tilt, sacral slope, pelvic incidence, and lumbar lordosis on standing anteroposterior pelvis and lateral standing and seated hip-spine images. Generated cup targets and a control group (40°/20° relative to the anterior pelvic plane) were compared to clinically recommended cup targets. Agreement was defined as a cup position within the recommended range or within 3° of a specific target (eg, 40° inclination) when no range was provided. Intraclass correlation coefficients were used to assess interrater and intrarater reliability, and McNemar's chi-square test was used to measure success relative to the control group. Results: The intraclass correlation coefficient was 0.88 for delta sacral slope and 0.92 for pelvic incidence-lumbar lordosis mismatch. For patients with spinopelvic risk factors, the generated targets matched the clinical recommendations in 81% of patients compared to only 16% in the control group. Conclusions: Excellent interrater and intrarater reliability was achieved using the novel surgical planning software. The resultant target values agreed with clinical recommendations to a greater extent than the control group.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center.

BACKGROUND: Patients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability. METHODS: We investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05). RESULTS: There were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020). CONCLUSIONS: To the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

Robotic Total Knee Arthroplasty is Associated with Earlier Return of Postoperative Range of Motion.

INTRODUCTION: Postoperative range of motion (ROM) is an important measure for the functional outcome and overall success after total knee arthroplasty (TKA). While robotic knee systems have been shown to reduce pain and improve early function, the return of postoperative ROM specifically has not been adequately studied. The purpose of this study was to compare postoperative ROM in robotic and conventional TKA. We hypothesized that robotic TKA leads to an improvement in postoperative ROM. MATERIALS AND METHODS: A retrospective cohort study of 674 primary TKAs by a single surgeon between January 2018 and February 2023 was completed. Patients that did not have both a two-week follow up and eight-week follow up were excluded. Revision/conversion TKAs were excluded. The population was divided into two cohorts based on technique utilized: robotic versus conventional. Preoperative extension/flexion data, postoperative extension/flexion data at two-week and eight-week follow ups, and manipulation under anesthesia data were collected. ROM was defined as flexion minus extension. Chi-square tests were used to examine for differences between categorical variables and t-tests for continuous variables. RESULTS: A total of 307 robotic and 265 conventional knees were included. There were no differences in demographics, mean follow up, or preoperative ROM between groups. The robotic group had significantly more flexion (99.20° vs. 96.98°; p=0.034) and ROM (97.81° vs. 95.56°; p=0.047) at the two-week follow up. The loss in ROM at the two-week follow up from preoperative ROM was significantly less for the robotic group (-11.21° vs. -14.16°; p=0.031). There were no significant differences in extension at either follow up, in flexion at the eight-week follow up, or in ROM at the eight-week follow up. CONCLUSION: Robotic TKA leads to an improvement in postoperative flexion and ROM when compared to preoperative ROM at two-week follow up. These findings could partially explain the quicker recovery associated with robotic TKA.

Registration of Bony Landmarks and Soft Tissue Laxity during Robotic Total Knee Arthroplasty is Highly Reproducible.

INTRODUCTION: There is growing interest and enthusiasm for robotic total knee arthroplasty (TKA). Many robotic systems require registration of bony landmarks as well as a dynamic soft tissue evaluation to plan femoral and tibial resections. Variability in this user-driven registration can introduce error and undermine the purported precision and accuracy offered by robotics. The purpose of this study was to evaluate inter- and intrarater reliability in robotic registration with a new robotic system (ROSA®; Zimmer-Biomet, Warsaw, IN). METHODS: Two unpaired cadaveric knee specimens were exposed, and optical arrays were placed into the femur and tibia. Three separate evaluators conducted repeated trials of anatomic registration and assessment of soft tissue laxity, as well as coronal alignment, sagittal alignment, femoral size, and maximum opening in the medial and lateral compartments in both flexion and extension. Repeated trials were conducted using these specimens with and without preoperative imaging for landmarking (image-based and image-free workflows). An Intraclass Correlation Coefficient (ICC) was calculated for each observer and across observers to determine intra-and interrater reliability, respectively, in robotic registration. RESULTS: There was good to excellent reliability for all conditions, and all correlation coefficients were >0.767. On average, ICCs for intrarater reliability were excellent for Doctor 1 (0.952), Doctor 2 (0.975), and Doctor 3 (0.925). On average, the ICCs for interrater reliability were excellent for both the "Registration + Gap Assessment" condition (0.961) and the "Gap Assessment" condition (0.994). CONCLUSION: Our results show a high repeatability of registration of anatomic landmarks and gap assessment among observers using this robotic system for both image-based and image-free software.

Reduction in hospital length of stay and increased utilization of telemedicine during the "return-to-normal" period of the COVID-19 pandemic does not adversely influence early clinical outcomes in patients undergoing total hip replacement: a case-control study.

BACKGROUND AND PURPOSE: Elective total hip replacement (THR) was halted in our institution during the COVID-19 surge in March 2020. Afterwards, elective THR volume increased with emphasis on fast-track protocols, early discharge, and post-discharge virtual care. We compare early outcomes during this "return-to-normal period" with those of a matched pre-pandemic cohort. PATIENTS AND METHODS: We identified 757 patients undergoing THR from June to August 2020, who were matched 1:1 with a control cohort from June to August 2019. Length of stay (LOS) for the study cohort was lower than the control cohort (31 vs. 45 hours; p < 0.001). The time to first postoperative physical therapy (PT) was shorter in the study cohort (370 vs. 425 minutes; p < 0.001). More patients were discharged home in the study cohort (99% vs. 94%; p < 0.001). Study patients utilized telehealth office and rehabilitation services 14 times more frequently (39% vs. 2.8%; p < 0.001). Outcomes included post-discharge 90-day unscheduled office visits, emergency room (ER) visits, complications, readmissions, and PROMs (HOOS JR, and VR-12 mental/physical). Mann-Whitney U and chi-square tests were used for group comparisons. RESULTS: Rates of 90-day unscheduled outpatient visits (5.0% vs. 7.3%), ER visits (5.0% vs. 4.8%), hospital readmissions (4.0% vs. 2.8%), complications (0.04% vs. 0.03%), and 3-month PROMs were similar between cohorts. There was no 90-day mortality. INTERPRETATION: A reduction in LOS and increased telehealth use for office and rehabilitation visits did not adversely influence 90-day clinical outcomes and PROMs. Our findings lend further support for the utilization of fast-track arthroplasty with augmentation of postoperative care delivery using telemedicine.

No Benefit to Sensor-guided Balancing Compared With Freehand Balancing in TKA: A Randomized Controlled Trial.

BACKGROUND: Soft tissue balancing in TKA has traditionally relied on surgeons' subjective tactile feedback. Although sensor-guided balancing devices have been proposed to provide more objective feedback, it is unclear whether their use improves patient outcomes. QUESTIONS/PURPOSES: We conducted a randomized controlled trial (RCT) comparing freehand balancing with the use of a sensor-guided balancing device and evaluated (1) knee ROM, (2) patient-reported outcome measures (PROMs) (SF-12, WOMAC, and Knee Society Functional Scores [KSFS]), and (3) various surgical and hospital parameters (such as operative time, length of stay [LOS], and surgical complications) at a minimum of 2 years of follow-up. METHODS: A total of 152 patients scheduled for primary TKA were recruited and provided informed consent to participate in this this study. Of these, 22 patients were excluded preoperatively, intraoperatively, or postoperatively due to patient request, surgery cancellation, anatomical exclusion criteria determined during surgery, technical issues with the sensor device, or loss to follow-up. After the minimum 2-year follow-up was accounted for, there were 63 sensor-guided and 67 freehand patients, for a total of 130 patients undergoing primary TKA for osteoarthritis. The procedures were performed by one of three fellowship-trained arthroplasty surgeons (RPS, HJC, JAG) and were randomized to either soft tissue balancing via a freehand technique or with a sensor-guided balancing device at one institution from December 2017 to December 2018. There was no difference in the mean age (72 ± 8 years versus 70 ± 9 years, mean difference 2; p = 0.11), BMI (30 ± 6 kg/m 2 versus 29 ± 6 kg/m 2 , mean difference 1; p = 0.83), gender (79% women versus 70% women; p = 0.22), and American Society of Anesthesiology score (2 ± 1 versus 2 ± 1, mean difference 0; p = 0.92) between the sensor-guided and freehand groups, respectively. For both groups, soft tissue balancing was performed after all bony cuts were completed and trial components inserted, with the primary difference in technique being the ability to quantify the intercompartmental balance using the trial tibial insert embedded with a wireless sensor in the sensor-guided cohort. Implant manufacturers were not standardized. Primary outcomes were knee ROM and PROMs at 3 months, 1 year, and 2 years. Secondary outcomes included pain level evaluated by the VAS, opioid consumption, inpatient physical therapy performance, LOS, discharge disposition, surgical complications, and reoperations. RESULTS: There was no difference in the mean knee ROM at 3 months, 1 year, and 2 years postoperatively between the sensor-guided cohort (113° ± 11°, 119° ± 13°, and 116° ± 12°, respectively) and the freehand cohort (116° ± 13° [p = 0.36], 117° ± 13° [p = 0.41], and 117° ± 12° [p = 0.87], respectively). There was no difference in SF-12 physical, SF-12 mental, WOMAC pain, WOMAC stiffness, WOMAC function, and KSFS scores between the cohorts at 3 months, 1 year, and 2 years postoperatively. The mean operative time in the sensor-guided cohort was longer than that in the freehand cohort (107 ± 0.02 versus 84 ± 0.04 minutes, mean difference = 23 minutes; p = 0.008), but there were no differences in LOS, physical therapy performance, VAS pain scores, opioid consumption, discharge disposition, surgical complications, or percentages of patients in each group who underwent reoperation. CONCLUSION: This RCT demonstrated that at 2 years postoperatively, the use of a sensor-balancing device for soft tissue balancing in TKA did not confer any additional benefit in terms of knee ROM, PROMs, and clinical outcomes. Given the significantly increased operative time and costs associated with the use of a sensor-balancing device, we recommend against its routine use in clinical practice by experienced surgeons. LEVEL OF EVIDENCE: Level I, therapeutic study.

Survivorship and Risk Factors for Re-Revision after Aseptic Revision Total Hip Arthroplasty in Patients Aged ≤55 Years.

BACKGROUND: There is a relative paucity of literature on the outcomes after revision total hip arthroplasty (rTHA) in young patients. This study reports the survivorship and risk factors for re-revision in patients aged ≤55 years. METHODS: We identified 354 patients undergoing aseptic nononcologic rTHA at mean follow-up of 5 years after revision, with mean age of 48 years, body mass index of 28 kg/m2, and 64% female. Thirty-five (10%) patients underwent at least 1 previous rTHA. The main indications for rTHA included wear/osteolysis (21%), adverse local tissue reaction (21%), recurrent instability (20%), acetabular loosening (16%), and femoral loosening (7%); and included acetabular component-only rTHA in 149 patients (42%), femoral component-only rTHA in 46 patients (13%), both component rTHA in 44 patients (12%), and head/liner exchanges in patients 115 (33%). The Kaplan-Meier method was used to measure survivorship free from re-revision THA, and multivariate regression was used to identify risk factors for re-revision THA. RESULTS: Sixty-two patients (18%) underwent re-revision THA at the mean time of 2.5 years, most commonly for instability (37%), aseptic loosening (27%), and prosthetic joint infection (15%). The rTHA survivorship from all-cause re-revision and reoperation was 83% and 79% at 5 years, respectively. Multivariate analysis demonstrated that patients undergoing femoral component only (hazard ratio 4.8, P = .014) and head/liner exchange rTHA (hazard ratio 2.5, P = .022) as risk factors for re-revision THA. CONCLUSION: About 1 in 5 patients aged ≤55 years undergoing rTHA required re-revision THA at 5 years, most commonly for instability. The highest risk group included patients undergoing head/liner exchanges and isolated femoral component revisions.

Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion.

BACKGROUND: There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion. METHODS: We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis. RESULTS: Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients). CONCLUSION: With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%.

Management of the Patella During Total Knee Arthroplasty.

¼: The optimal management of the patella during total knee arthroplasty (TKA) remains a controversial topic with no consensus. ¼: Patellar management techniques during TKA include patellar retention or resurfacing with or without patellaplasty, as well as circumferential denervation and partial lateral facetectomy (PLF). ¼: Special considerations such as patient age, etiology of disease, implant design, and surgeon preference should be accounted for when determining optimal management. ¼: We recommend that most patellae be circumferentially denervated, regardless of whether they are resurfaced, as the potential benefits outweigh the small associated risks. ¼: Evidence demonstrates improved functional outcomes with the addition of PLF to nonresurfaced patellae. There is currently a paucity of evidence of this technique with respect to resurfaced patellae. ¼: Patellar resurfacing adds additional costs and health-care resources that should be considered in the decision-making process.

Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty.

BACKGROUND: The choice of anesthesia plays a significant role in the success of total joint arthroplasty (TJA). Isobaric bupivacaine spinal anesthesia is often used. However, dosing of bupivacaine has not been extensively studied and is usually at the discretion of the treating anesthesiologist and surgeon. The goal of this study was to determine what, if any, effect the dose of bupivacaine spinal anesthesia had on perioperative outcomes in TJA. METHODS: A total of 761 TJAs performed with bupivacaine spinal anesthesia by arthroplasty surgeons were retrospectively reviewed. Perioperative outcomes evaluated were operation duration, estimated blood loss, length of stay (LOS) in the postanesthesia care unit, hospital LOS, discharge disposition, episodes of intraoperative hypotension, postoperative nausea and vomiting, and missed physical therapy sessions because of postoperative symptoms of hypotension. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of the 761 patients, 499 (65.6%) received 15 mg isobaric bupivacaine while 262 (34.4%) received <15 mg (range = 7.5-14.5 mg, median = 12.5 mg). With the numbers available in this cohort, lower doses of bupivacaine were not associated with any significant differences between groups for any of the studied perioperative outcomes, including proportion of patients discharged home or LOS. CONCLUSION: Dosage of bupivacaine spinal anesthetic did not affect perioperative outcomes. Bupivacaine may not have a dose-related response curve in this regard, and if seeking to perform same-day or outpatient TJA, other agents may need to be considered, rather than smaller doses of bupivacaine.

Patient Satisfaction, Functional Outcomes, and Implant Survivorship in Patients Undergoing Customized Unicompartmental Knee Arthroplasty.

Customized unicompartmental knee arthroplasty (C-UKA) utilizes implants manufactured on an individual patient basis, derived from pre-operative computed tomography images in an effort to more closely approximate the natural anatomy of the knee. The outcomes from 349 medial and lateral fixed-bearing C-UKA were reviewed. Implant survivorship analysis was conducted via retrospective chart review, and follow-up analysis was conducted via a single postoperative phone call or email. The rate of follow-up was 69% (242 knees). The average age at surgery was 71.1 years and the average body mass index was 28.8 kg/m2. Seven revision arthroplasties (2.1%) had knowingly been performed at an average of 1.9 years postoperatively (range: 0.1-3.9 years), resulting in an implant survivorship of 97.9% at an average follow-up of 4.2 years (range: 0.1-8.7) and 97.9% at an average of 4.8 years (range: 2.0-8.7) when knees with less than two years of follow-up were excluded. The reasons for revision were implant loosening (one knee), infection (two knees), progression of osteoarthritis (two knees), and unknown reasons (two knees). The average KOOS, JR. interval score was 84 (SD: 14.4). Of those able to be contacted for follow-up analysis, 67% were "very satisfied," 26% were "satisfied," 4% were "neutral," 2% were "dissatisfied," and 1% were "very dissatisfied." When asked if the knee felt "natural," 60% responded with "always," 35% responded with "sometimes," and 5% responded with "never." After analyzing a large cohort of C-UKA, we found favorable rates of survivorship, satisfaction, and patient-reported functional outcomes.

Improved Compartment Balancing Using a Robot-Assisted Total Knee Arthroplasty.

BACKGROUND: Robot-assisted surgery was developed to improve accuracy and outcomes in total knee arthroplasty (TKA). One important determinant of TKA success is a well-balanced knee throughout the range of motion. The purpose of this study is to determine if robot-assisted TKA (RA-TKA) results in improved intracompartmental ligament balance compared with conventional jig-based instrumentation (CM-TKA). METHODS: This retrospective cohort study included 2 cohorts-a CM-TKA (n = 49) vs RA-TKA (n = 37) cohort. Demographic and intraoperative data, including intraoperative compartment loads, were measured after final implant implantation in extension (10°), mid-flexion (45°), and full flexion (90°), using an intraoperative compartment pressure sensor. An a priori power analysis revealed our study exhibited >80% power in detecting a 5-pound (lb) difference in compartment loads in the 2 cohorts. RESULTS: There was no difference between medial and lateral compartment loads in extension, mid-flexion, and full flexion for the conventional (15.1 lbs, 15.9 lbs, and 13.4 lbs, respectively) vs RA-TKA (14.2 lbs, 15.1 lbs, and 10.3 lbs, respectively). The percentage of patients with high load compartment pressure in flexion (>40 lbs) by the conclusion of the surgery was significantly greater for the conventional (18%) vs the robotic TKA cohort (3%, P = .025). The percentage of patients with unbalanced knees (>20 lbs differential between medial and lateral compartments) in flexion was significantly greater in the conventional (24%) vs robotic TKA cohort (5%, P = .018). CONCLUSIONS: In this series, RA-TKA resulted in improved intraoperative compartment balancing in flexion with no observed difference in mid-flexion and extension compared with CM-TKA.

Patient Satisfaction, Functional Outcomes, and Implant Survivorship in Patients Undergoing Customized Cruciate-Retaining TKA.

BACKGROUND: Customized total knee arthroplasty (C-TKA) systems are becoming increasingly popular in patients with end-stage knee arthritis. Manufactured with use of patient data derived from computed tomography or magnetic resonance imaging, these systems aim to restore the individual bone anatomy of the patient by providing customized fit and geometries. This retrospective study investigated implant survivorship, patient satisfaction, and functional outcomes following C-TKA with a cruciate-retaining prosthesis. METHODS: We retrospectively reviewed data from 540 knees in 433 patients who underwent C-TKA performed by a single surgeon at a single institution. Patient demographics, surgical variables, complications, and reoperations were evaluated. Follow-up evaluations were performed via a single telephone call to assess patient satisfaction, functional outcomes according to the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) questionnaire, and implant survivorship following C-TKA. Descriptive statistics were analyzed. RESULTS: At the time of C-TKA, the mean age was 71.8 years and the mean body mass index was 29.1 kg/m2. The mean follow-up was 2.8 years. Patient satisfaction was high, with 89% of C-TKA patients being either satisfied or very satisfied. The mean KOOS-JR was 82. There were 8 revisions (1.5%) at an average of 0.7 years after the index C-TKA; hence, there was an implant survivorship of 98.5%. CONCLUSIONS: To our knowledge, this was the largest retrospective study to date to report on patient satisfaction, functional outcomes, and implant survivorship following C-TKA. We observed a high satisfaction rate, satisfactory functional outcomes, and high implant survivorship at midterm follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ankle Fractures: The Current State of Online Patient Information.

Background. We assessed the quality, accuracy, and readability of websites for ankle fractures. Methods. Ankle Fracture, Broken Ankle, and Fibular Fracture were entered into 3 search engines. The first 25 results from each search were collected. Quality, accuracy, and readability were assessed by a custom rubric, 3 surgeons, and Fleisch-Kincaid grade level (FKGL), respectively. Results. A total of 57 websites were included: 24 were assigned to Ankle Fracture, 26 to Broken Ankle, and 7 to Fibular Fracture. The average quality score out of 36, accuracy score out of 12, and FKGL for all websites were 13.1 ± 6.8, 10.8 ± 1.2, and 9.6 ± 1.7, respectively. Websites assigned to the term Broken Ankle had a significantly lower New Dale-Chall score. Websites of lower FKGL and appearing earlier in results had significantly higher quality scores. Physician specialty societies (PSSs) had a significantly lower FKGL than websites of other types. Conclusion. The readability of patient materials is above the recommended level for ankle fractures. Encouragingly, a trade-off between readability and quality was not found. Patients should use search terms they are familiar with and prioritize websites that appear earlier in search results, are easier to read, and produced by PSSs.Level of Evidence: Level 3.

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty.

BACKGROUND: Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics. RESULTS: We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates. CONCLUSION: Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.