Outcomes of Antibiotic-Impregnated Calcium Sulfate, Reamer-Irrigator-Aspirator, and Locked Intramedullary Static Spacer in the Treatment of Periprosthetic Joint Infection in the Multiply Revised and Infected Knee: A Single-Center Case Series.

Background: Periprosthetic joint infection after total knee arthroplasty is commonly treated via 2-stage revision utilizing either articulating or static antibiotic cement spacers. While recent literature exhibits a slight functional advantage in favor of articulating spacers, those patients with a history of recurrent infection/multiple revision procedures are frequently excluded from these studies. The purpose of this study was to report infection eradication rates and efficacy of utilizing antibiotic-loaded locked intramedullary nail for infection for the multiply revised, infected total knee arthroplasty. Methods: A retrospective review was performed of all consecutive patients receiving static spacers between 2017 and 2020 at an academic medical center. Surgical techniques for all patients included irrigation and debridement using a reamer-irrigator-aspirator, injection of antibiotic-loaded calcium sulfate into the intramedullary canal, and nail placement. Antibiotic-loaded cement is then used to create a spacer block in the joint space. A Cox proportional hazard regression was run to identify risk factors for reinfection. Results: Forty-two knees in 39 patients were identified meeting inclusion criteria. Overall, there was an 68.8% infection eradication rate at an average of 46.9 months following spacer placement. The only risk factors identified on cox regression were increasing number of previous spacers, a surrogate for previous infections (hazards ratio = 14.818, P value = .021), and increasing operative time during spacer placement (hazards ratio = 1.014, P value = .039). Conclusions: Use of static spacers, in conjunction with reamer-irrigator-aspirator and antibiotic-loaded calcium sulfate, can be effective in treating chronic, complex periprosthetic joint infections in the setting of bone loss and or soft-tissue compromise and produced similar results to more simple infection scenarios.

Pediatric Gender Diversity Beyond the Binary: An Exploration of Gender-Affirming Care for Nonbinary and Genderqueer Youth Seen Over Time at a Single Institution Gender Center.

Purpose: The nonbinary and genderqueer (NBGQ) youth population is growing, yet scant research focuses on this distinct group. We aim to gain a deeper understanding of desired gender-affirming care and interventions pursued by NBGQ youth. Methods: A retrospective chart review of NBGQ patients seen at the University of California, San Francisco Child and Adolescent Gender Center from January 1, 2009, to December 31, 2020, was performed. Demographic information, desired gender-affirming care, and gender-affirming interventions pursued at initial and most recent visits were collected. Results: Initial visit charts of 116 NBGQ youth who attended more than one clinic visit were reviewed. In total, 48 unique genders were documented; gender evolved over time for some youth, as did desired gender-affirming care. At the most recent visit, 15 youth (12.9%) had a binary gender, and 101 youth (87.1%) had an NBGQ gender. At the initial visit, 56 youth (48.3%) were interested in gender-affirming hormone therapy, compared with 75 youth (65.6%) at the most recent visit. In addition, 21 (18.1%) and 49 (42.2%) youth were interested in surgery at the initial and most recent visits, respectively. In general, interest in interventions was higher than pursuit of interventions. Conclusion: There is vast diversity of gender and differences in desired gender-affirming care within the NBGQ youth population. Desires for gender-affirming care within the cohort changed over time, and not all those who expressed a desire for an intervention received it. The reasons are likely multifactorial, highlighting the need for expectation-free and patient-specific affirming care and research on the NBGQ youth population, while also considering barriers to care.

Comparative outcomes after treatment of peri-implant, periprosthetic, and interprosthetic femur fractures: which factors increase mortality risk?

Objectives: To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF. Design: Retrospective. Setting: Single, Level II Trauma Center. Patients/Participants: A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures. Intervention: Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques. Main Outcome Measurements: Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality. Results: One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years (P-value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques. Conclusion: The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing. Level of Evidence: Level III.

Radiographic Robustness of Lumbar Interbody Fusion Techniques.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Lumbar interbody fusion (LIF) can be achieved with various techniques. Evidence supporting the long-term clinical advantages of one technique over another are inconclusive. The purpose of this study was to (1) determine the changes in sagittal parameters in the preoperative, intraoperative, and post-operative phase, (2) evaluate the radiographic maintenance of these parameters over time, and (3) compare the demographics and patient reported outcomes of patients undergoing various LIF techniques. METHODS: We performed a retrospective chart review of patients with degenerative spine disease undergoing single level anterior (ALIF), lateral (LLIF), posterior (PLIF), or transforaminal (TLIF) lumbar interbody fusion. Data collected included patient demographics and diagnosis at time of surgery. Upright lumbar radiographs taken pre-operatively, intra-operatively, and post-operatively were measured for lumbar lordosis (LL), segmental lordosis (SL), posterior disc height (PDH), and foraminal height (FH). RESULTS: 194 patients in a single center were included. PDH and FH increased intra-operatively following ALIF (P < .0001), PLIF (P < .0001), LLIF (P < .0001), and TLIF (P < .0001). SL also increased intra-operatively for ALIF (P = .002) and LLIF (P = .0007). Compared to intra-operative radiographs, PDH and FH decreased at latest post-operative phase for ALIF (P < .03), LLIF (P < .003), TLIF (P < .001), and PLIF (P < .005). SL decreased for ALIF (P = .0008), and TLIF (P = .02). LL did not change postoperatively across techniques. Patient reported outcomes improved post-surgically and disability index decreased, but neither differed between techniques. CONCLUSION: LIF, regardless of technique, was shown to provide significant radiographic changes in PDH and FH. Techniques utilizing larger intervertebral cage sizes (ALIF/LLIF) improved SL. Single level LIF did not affect overall LL. No single technique displayed superior radiographic robustness over time.

Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

Background: Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) is often indicated to treat the joint and improve function. Patients with metastatic cancer often receive radiotherapy, and orthopaedic oncologists must consider surgical risks with operating on irradiated bone and soft tissue. We evaluated surgical outcomes and implant survival (IS) of titanium acetabular components and femoral components in patients treated for MBD in the setting of perioperative radiation. Methods: This was a retrospective review of patients who underwent THA for MBD at 3 institutions between 2017 and 2021. Outcomes included rates of reoperation, complications, IS, and overall survival. Results: Forty-six patients who received primary THA for MBD were included in the study. Twenty patients (43.5%) received perioperative radiation for MBD. Six postoperative complications including one superficial wound infection, 2 dislocations, 2 pathologic fractures, and one aseptic acetabular component loosening led to 5 reoperations. There were no significant differences in postoperative outcomes, reoperation after THA, and IS based on radiotherapy status. Conclusions: To our knowledge, this is the first paper evaluating primary THA outcomes and IS between patients who receive perioperative radiation for MBD to the hip and those who do not. As surgical management is a crucial part of the treatment in alleviating pain and disability in patients with MBD, we continue to recommend THA for patients who received radiation at the operative site.

Early versus Standard Weight Bearing Following Operative Treatment of Tibial Plateau Fractures: Do We Really Have to Wait So Long?

Postoperative management of tibial plateau fractures classically involves a prolonged period between 10 and 12 weeks of nonweight bearing or partial weight bearing. In recent years, there has been some support for earlier weight-bearing protocols although this remains controversial. The goal of this study was to investigate the difference in outcomes between early weight-bearing (EWB) and traditional weight-bearing (TWB) protocols. This investigation is a retrospective review of 92 patients treated with open reduction and internal fixation of tibial plateau fractures at a single institution, from August 2018 to September 2020. Subjects were divided into EWB (< 10 weeks) and traditional nonweight bearing groups (≥ 10 weeks). Key outcome measures collected include injury classification, mechanism of injury, surgical fixation method, bone grafting, time to full weight bearing, radiographic time to union, range-of-motion, all-cause complications, and subsidence at an average follow-up time of 1 year. The EWB group had an earlier average time to weight bearing versus the TWB group (6.5 ± 1.4 vs. 11.8 ± 2.3 weeks, p < 0.0001). There was no difference in the classification of fractures treated between the two groups, with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association B3 fractures the most common in the EWB group, and C3 fractures the most common in the TWB group. Radiographic time to union was no different between the two groups (93.5 ± 53.7 days for EWB vs. 103.7 ± 77.6 days for TWB, p = 0.49). There was no significant difference in complication rates or subsidence. Following operative treatment of tibial plateau fractures, patients who underwent a weight-bearing protocol earlier than 10 weeks were able to recover faster with similar outcomes and complications compared with patients who started weight bearing after 10 weeks or more. LEVEL OF EVIDENCE: III.

Impact of a Novel Navigational Technology on Short-Term Patient Outcomes Following Total Knee Arthroplasty A Propensity Matched Cohort Study.

PURPOSE: The use of intraoperative technology is increasing among orthopedic surgeons in the United States. However, there is continued debate as to whether intraoperative technologies provide clinical benefits in patients undergoing total knee arthroplasty (TKA). This study sought to determine whether the use of a novel intraoperative navigation technology produces equivalent or superior short-term outcomes compared to conventional technique. METHODS: Fifty-nine consecutive patients underwent primary TKA with a novel imageless intraoperative navigational technology between October 2019 and January 2020 at a single, urban, orthopedic specialty hospital. A 1:1 cohort propensity matching was performed with patients with similar demographics who underwent primary TKA without the use of technology. Demographics, clinical data, as well as preoperative and 3-month Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) scores were collected. Demographic differences, clinical data, and mean KOOS, JR scores were assessed using chi-squared analysis for categorical variables and independent sample t-test for continuous variables. RESULTS: Upon 1:1 cohort matching, patients in both the navigational cohorts and non-navigational cohorts were statistically similar demographically. Length of stay (2.11 vs. 1.71 days; p = 0.108), surgical time (108.89 vs. 101.19 minutes, p = 0.066), discharge disposition (p = 0.675), 90- day readmissions (4 vs. 4, p = 0.999), and 90-day reoperations (2 vs. 2, p = 0.999) did not statistically differ between the two matched cohorts. Additionally, KOOS, JR scores evaluated between the two cohorts preoperatively (46.06 vs. 45.17, p = 0.836) and at 3-month follow-up (57.63 vs. 55.06, p = 0.580) were similar. CONCLUSION: This study demonstrates that the use of this novel intraoperative navigational technology yields similar short-term TKA results when compared to conventionally performed TKA. Further studies are required to validate new technologies and determine their effect on long-term clinical and patient-reported outcomes.

Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy.

INTRODUCTION: Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA). METHODS: All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition. RESULTS: A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015). CONCLUSION: The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.

Assessing the Necessity of Extra Reduction Aides in Intramedullary Nailing of Intertrochanteric Hip Fractures.

Purpose: This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Materials and Methods: Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Results: Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Conclusion: Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.

Patient "No-Show" Increases the Risk of 90-Day Complications Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study of 6,776 Patients.

BACKGROUND: Patients who "no-show" (NS) clinical appointments are at a high risk of adverse health outcomes. The objective of this study was to evaluate and characterize the relationship between NS visits prior to primary total knee arthroplasty (TKA) and 90-day complications after TKA. METHODS: We retrospectively reviewed 6,776 consecutive patients undergoing primary TKA. Study groups were separated based on whether patients who NS versus always attended their appointment. A NS was defined as an intended appointment that was not canceled or rescheduled ≤2 hours before the appointment in which the patient did not show. Data collected included total number of follow-up appointments prior to surgery, patient demographics, comorbidities, and 90-day postoperative complications. RESULTS: Patients who have ≥3 NS appointments had 1.5 times increased odds of a surgical site infection (odds ratio (OR) 1.54, P = .002) compared to always attended patients. Patients who were ≤65 years old (OR: 1.41, P < .001), smokers (OR: 2.01, P < .001), and had a Charlson comorbidity index ≥3 (OR: 4.48, P < .001) were more likely to miss clinical appointments. CONCLUSION: Patients who have ≥3 NS appointments prior to TKA had an increased risk for surgical site infection. Sociodemographic factors were associated with higher odds of missing a scheduled clinical appointment. These data suggest that orthopaedic surgeons should consider NS data as an important clinical decision-making tool to assess risk for postoperative complications to minimize complications following TKA.

Clinico-pathological correlations and outcomes of de novo glomerular diseases in patients after haematopoietic stem cell transplantation.

Background: Various glomerular pathologies have been reported in patients who have undergone haematopoietic stem cell transplantation (HSCT), but the data on clinico-pathological correlations and clinical outcome remain limited. Methods: We analysed the clinical and histopathological data of patients who had biopsy-proven de novo glomerular diseases after HSCT since 1999. Results: A total of 2204 patients underwent HSCT during the period 1999-2021, and 31 patients (1.4%) developed de novo glomerular diseases after a mean duration of 2.8 ± 2.7 years after HSCT. Fifteen of these patients (48.4%) had graft-versus-host-disease prior to or concomitant with renal abnormalities. Proteinuria and eGFR at the time of kidney biopsy were 4.1 ± 5.3 g/day and 50.8 ± 25.4 mL/min/1.73 m2, respectively. Kidney histopathologic diagnoses included thrombotic microangiopathy (TMA) (38.7%), membranous nephropathy (MN) (25.8%), mesangial proliferative glomerulonephritis (12.9%), minimal change disease (9.7%), focal segmental glomerulosclerosis (9.7%) and membranoproliferative glomerulonephritis (3.2%). Immunosuppressive treatment was given to patients who presented with nephrotic-range proteinuria and/or acute kidney injury, while renin-angiotensin-aldosterone blockade was given to all patients with proteinuria ≥1 g/day, with complete and partial response rates of 54.8% and 19.4%, respectively. One patient with TMA progressed to end-stage kidney disease after 24 weeks, and two patients, one with TMA and one with MN, (6.4%) progressed to chronic kidney disease (CKD) Stage ≥3. Kidney and patient survival rates were 96.6% and 83.5%, respectively, at 5 years. Conclusion: De novo glomerular diseases with diverse histopathologic manifestations affect 1.4% of patients after HSCT, and approximately 10% develop progressive CKD.

Reverse Total Shoulder Arthroplasty for Younger Patients: A Comparable Analysis of Patients Older and Younger Than 65 Years.

INTRODUCTION: Reverse total shoulder arthroplasty (rTSA) has become a popular option for the surgical management of rotator cuff arthropathy and complex fractures of the proximal humerus. However, there is a paucity of studies evaluating outcomes, especially between patients of different age groups. The purpose of this study was to compare functional outcomes and survivorship between patients older than 65 years (o65) and those 65 years and younger (y65). METHODS: A retrospective review was conducted at a single academic medical center identifying a consecutive cohort of patients undergoing rTSA between 2018 and 2020. The minimum follow-up time was 2 years. Patients were stratified into two groups for comparative analyses (y65 and o65). Patient demographics, perioperative and postoperative data, and functional outcomes were collected. A Kaplan-Meier survival analysis was conducted to determine survivorship, defined as revision surgery or implant failure. RESULTS: Forty-eight patients were included for final analysis. Nineteen patients comprised the y65 group while 29 patients comprised the o65 group. No difference was observed in Quick Disabilities of the Arm, Shoulder, and Hand scores at baseline nor at the latest follow-up between the two groups. Patients in the y65 group had significantly greater internal and external rotation (IR/ER) from 3 months to 2 years compared with patients in the o65 group (P ≤ 0.05). Finally, there were no differences in revision surgery rates between the y65 group and the o65 group (11% vs. 14%, P = 1.0). A KM survival analysis revealed no difference in implant failure, necessitating revision surgery between the two groups at the latest follow-up (P = 0.69). DISCUSSION: Despite a notable difference in the number of baseline comorbidities, there were no notable differences in functional outcomes, survivorship, and revision surgery rates between each cohort. Although both groups had a similar function initially, by 3 months postoperatively, the y65 group had markedly greater range of motion in IR and ER. Longer term survivorship is needed; however, rTSA may offer a reliable option for shoulder reconstruction even in the y65 patient group.

Risk Factors for Revision Surgery Following Revision Total Knee Arthroplasty Using a Hinged Knee Prosthesis for Septic and Aseptic Indications.

INTRODUCTION: The use of hinged knee replacements (HKRs) for limb salvage is a popular option for revision total knee arthroplasty (RTKA). Although recent literature focuses on the outcomes of HKR for septic and aseptic RTKAs, little is reported on the risk factors of returning to the operating room. The purpose of this study was to evaluate risk factors of revision surgery and revision after receiving HKR for septic versus aseptic etiology. METHODS: A multicenter, retrospective review was conducted on consecutive patients who received HKR from January 2010 to February 2020 with a minimum follow-up of 2 years. Patients were separated into two groups: septic and aseptic RTKAs. Demographic, comorbidity, perioperative, postoperative, and survivorship data were collected and compared between groups. Cox hazard regression was used to identify risk factors associated with revision surgery and revision. RESULTS: One-hundred fifty patients were included. Eighty-five patients received HKR because of prior infection, and 65 received HKR for aseptic revision. A larger proportion of septic RTKA returned to the OR versus aseptic RTKA (46% vs 25%, P = 0.01). Survival curves revealed superior revision surgery-free survival favoring the aseptic group ( P = 0.002). Regression analysis revealed that HKR with concomitant flap reconstruction was associated with a three-fold increased risk of revision surgery ( P < 0.0001). DISCUSSION: HKR implantation for aseptic revision is more reliable with a lower revision surgery rate. Concomitant flap reconstruction increased the risk of revision surgery, regardless of indication for RTKA using HKR. Although surgeons must educate patients about these risk factors, HKR remains a successful treatment option for RTKA when indicated. LEVEL OF EVIDENCE: prognostic, level III evidence.

Extensor Mechanism Reconstruction After Total Knee Arthroplasty with Allograft Versus Synthetic Mesh: A Multicenter Retrospective Cohort.

INTRODUCTION: Patellar and quadriceps tendon ruptures after total knee arthroplasty (TKA) have historically poor outcomes. To date, there is no consensus for optimal treatment. The purpose of this study is to directly compare clinical outcomes and survivorship between allograft versus synthetic mesh for reconstruction of native extensor mechanism (EM) rupture after TKA. METHODS: A multicenter, retrospective review identifying consecutive TKA patients operated between December 2009 to November 2019 was conducted. Patients aged ≥ 45 years old with native EM disruption treated with either allograft or synthetic mesh with minimum 2 year follow-up were included. Demographic information, injury mechanism, range of motion, surgical time, revision surgeries, and postoperative Knee Injury and Osteoarthritis Outcome Scores (KOOS Jr.) were collected. Student t-tests and Fisher exact tests were used to compare the demographic data between groups. The Kaplan-Meier survival curve method was used to determine the survivorship as treatment failure was defined as postoperative EM lag >30° or revision surgery. Survival curves were compared using the log-rank test. Univariate Cox proportional hazard regression identified risk factors associated with treatment failure. RESULTS: Twenty patients underwent EM reconstruction using allograft versus 35 with synthetic mesh. Both groups had similar demographics and an average follow-up time of 3.5 years (P = 0.98). Patients treated with allograft had significantly greater postoperative flexion than patients treated with mesh (99.4 ± 9.5 allograft versus 92.6 ± 13.6 synthetic mesh, P = 0.04). Otherwise, there was no difference in postoperative outcomes between the two groups in average KOOS Jr. (P = 0.29), extensor lag (P = 0.15), graft failure (P = 0.71), revision surgery rates (P = 0.81), surgical time (P = 0.42), or ambulatory status (P = 0.34) at the most recent follow-up. Survival curve comparison also yielded no difference at up to 5-year follow-up (P = 0.48). DISCUSSION AND CONCLUSION: Our findings suggest that reconstruction with allograft or synthetic mesh leads to similar clinical outcomes with good survivorship. Future studies, including larger randomized control trials, are required to determine the superior reconstruction method for this injury. LEVEL OF EVIDENCE: III.

The Use of Navigation or Robotic-Assisted Technology in Total Knee Arthroplasty Does Not Reduce Postoperative Pain.

The use of intraoperative technology (IT), such as computer-assisted navigation (CAN) and robot-assisted surgery (RA), in total knee arthroplasty (TKA) is increasingly popular due to its ability to enhance surgical precision and reduce radiographic outliers. There is disputing evidence as to whether IT leads to better clinical outcomes and reduced postoperative pain. The purpose of this study was to determine if use of CAN or RA in TKA improves pain outcomes. This is a retrospective review of a multicenter randomized control trial of 327 primary TKAs. Demographics, surgical time, IT use (CAN/RA), length of stay (LOS), and opioid consumption (in morphine milligram equivalents) were collected. Analysis was done by comparing IT (n = 110) to a conventional TKA cohort (n = 217). When accounting for demographic differences and the use of a tourniquet, the IT cohort had shorter surgical time (88.77 ± 18.57 vs. 98.12 ± 22.53 minutes; p = 0.005). While postoperative day 1 pain scores were similar (p = 0.316), the IT cohort has less opioid consumption at 2 weeks (p = 0.006) and 1 month (p = 0.005) postoperatively, but not at 3 months (p = 0.058). When comparing different types of IT, CAN, and RA, we found that they had similar surgical times (p = 0.610) and pain scores (p = 0.813). Both cohorts had similar opioid consumption at 2 weeks (p = 0.092), 1 month (p = 0.058), and 3 months (p = 0.064) postoperatively. The use of IT in TKA does not yield a clinically significant reduction in pain outcomes. There was also no difference in pain or perioperative outcomes between CAN and RA technology used in TKA.

Effect of documented and undocumented psychiatric conditions on length of stay and discharge destination after total knee arthroplasty.

INTRODUCTION: Length of stay (LOS) and readmissions are quality metrics linked to physician payments and substantially impact the cost of care. This study aims to evaluate the effect of documented and undocumented psychiatric conditions on LOS, discharge location, and readmission following total knee arthroplasty (TKA). METHODS: Retrospective review of all primary, unilateral TKA from 2015 to 2020 at a high-volume, academic orthopedic hospital was conducted. Patients were separated into three cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, discharge location, and 90 days readmissions were assessed. RESULTS: A total of 2935 patients were included; 1051 patients had no recorded psychiatric medications (control); 1884 patients took at least one psychiatric medication, of which 1161 (61.6%) were in the-Dx and 723 (38.4%) were in the +Dx cohort. Operative time (+Dx, 103.4 ± 29.1 and -Dx, 103.1 ± 28.5 vs. 93.6 ± 26.2 min, p < 0.001 for both comparisons) and hospital LOS stay (+ Dx, 3.00 ± 1.70 and -Dx, 3.01 ± 1.83 vs. 2.82 ± 1.40 days, p = 0.021 and p = 0.006, respectively) were greater for patients taking psychiatric medications when compared to the control group. Patients taking psychiatric medication with or without associated diagnosis were significantly more likely to be discharged to a secondary facility-22.8% and 20.9%, respectively-compared to controls, at 12.5% (p < 0.001). Ninety-day readmission rates did not differ between the control and both psychiatric groups (p = 0.693 and p = 0.432, respectively). CONCLUSION: TKA patients taking psychiatric medications with or without a documented psychiatric diagnosis have increased hospital LOS and higher chances of discharge to a secondary facility. Most patients taking psychiatric medication also had no associated diagnosis. Payment models should consider the presence of undocumented psychiatric diagnoses when constructing metrics. Surgeons and institutions should also direct their attention to identifying, recording, and managing these patients to improve outcomes. LEVEL III EVIDENCE: Retrospective Cohort Study.

Early outcomes of a novel bicruciate-retaining knee system: a 2-year minimum retrospective cohort study.

INTRODUCTION: Bicruciate retaining (BCR) total knee arthroplasty (TKA) was designed to simulate natural knee kinematics and improve proprioception by retaining both the ACL and PCL. While the prospect of the design appears favorable to patients, previous designs have demonstrated modest survivorship rates compared to traditional designs. This study aims to report the early functional outcomes and implant survivorship of a novel BCR design. MATERIALS AND METHODS: A multi-center, retrospective study was conducted identifying BCR TKA patients from 2016 to 2017. Patient demographics, quality outcomes, and post-operative complications were collected. A Kaplan-Meier analysis was used to evaluate revision-free survival. RESULTS: One-hundred thirty-three patients with a mean follow-up time of 2.35 ± 0.25 years (range: 2.00-2.87 years) were identified. Patients receiving BCR TKA were, on average, 61.46 ± 9.27 years-old, obese (BMI = 31.80 ± 6.01 kg/m2), predominantly white (71.4%), and female (69.9%). The device was most often implanted using standard instruments (85.7%) compared to computer-assisted navigation (13.5%). Average length-of-stay was 1.77 ± 0.97 days. Six patients had a reoperation; three (2.5%) full revisions occurred for: infection (n = 1), arthrofibrosis (n = 1), and ACL rupture (n = 1); one (0.8%) tibial revision occurred for: arthrofibrosis; two (1.5%) liner exchanges occurred for: infection (n = 1) and arthrofibrosis (n = 1). Kaplan-Meier survivorship analysis of cumulative failure at 2-year showed a survival rate of 96.2% (95% confidence interval, 91.2-98.4%) for all-cause reoperation, 97.3% (91.6-99.1%) for aseptic revision, and 100% for mechanical failure. CONCLUSION: Survivorship was 96.2% for all-cause reoperation, 97.3% for aseptic revision, and 100% for mechanical implant failure at 2-years. This novel BCR TKA demonstrated no implant-related complications and excellent survivorship outcomes over 2 years with comparable revision rates to those previously reported in the literature.

Intraoperative technology increases operating room times in primary total knee arthroplasty.

INTRODUCTION: Optimization of patient outcomes and identification of factors to improve the surgical workflow are increasingly important. Operating room time is one modifiable factor that leads to greater hospital efficiency as well as improved outcomes such as shorter length of stay and fewer infections and readmissions. The aim of this study was to identify factors associated with operative time disparities in total knee arthroplasty (TKA). METHODS: A retrospective review of 7659 consecutive primary TKA cases was conducted. Patient demographic data, discrete operating room (OR) times, use of technology (i.e. robotic-assisted surgery, computer navigation), surgeon experience and the level of training of the first assistant were collected. Multivariate regression analysis was used to determine the effect of hospital characteristics on operative times. Operative times of five minutes or greater were considered to be clinically significant. RESULTS: While the use of technology (182.64 ± 39.85 vs 158.70 ± 37.45 min; B = 26.09; p < 0.0001) and greater surgeon experience (162.14 ± 39.87 vs 158.69 ± 33.18 min, B = 3.15, p = 0.002) were found to increase OR times, level of training of the first assist (161.65 vs 156.4 min; Β = - 0.264; p = 0.487) did not. Of the discrete OR times examined, incision time and total time under anesthesia were negatively impacted by the use of technology. CONCLUSION: Use of technology was the only study variable found to significantly increase OR times. With increased operative times and limited evidence that technology improves long-term patient outcomes, surgeons should carefully consider the benefits and cost of technology in TKA.

The effects of tourniquet on cement penetration in total knee arthroplasty.

PURPOSE: Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS: A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS: A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION: Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

The accuracy of component positioning during revision total hip arthroplasty using 3D optical computer-assisted navigation.

INTRODUCTION: Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continue to burden the healthcare system. The use of computer-assisted navigation (CAN) offers the potential for more accurate placement of hip components during surgery. While intraoperative CAN systems have been shown to improve outcomes in primary THA, their use in the context of revision total hip arthroplasty (rTHA) has not been elucidated. We sought to investigate the validity of using CAN during rTHA. METHODS: A retrospective analysis was performed at an academic medical institution identifying all patients who underwent rTHA using CAN from 2016-2019. Patients were 1:1 matched with patients undergoing rTHA without CAN (control) based on demographic data. Cup anteversion, inclination, change in leg length discrepancy (ΔLLD) and change in femoral offset between pre- and post-operative plain weight-bearing radiographic images were measured and compared between both groups. A safety target zone of 15-25° for anteversion and 30-50° for inclination was used as a reference for precision analysis of cup position. RESULTS: Eighty-four patients were included: 42 CAN cases and 42 control cases. CAN cases displayed a lower ΔLLD (5.74 ± 7.0 mm vs 9.13 ± 7.9 mm, p = 0.04) and greater anteversion (23.4 ± 8.53° vs 19.76 ± 8.36°, p = 0.0468). There was no statistical difference between the proportion of CAN or control cases that fell within the target safe zone (40% vs 20.9%, p = 0.06). Femoral offset was similar in CAN and control cases (7.63 ± 5.84 mm vs 7.14 ± 4.8 mm, p = 0.68). CONCLUSION: Our findings suggest that the use of CAN may improve accuracy in cup placement compared to conventional methodology, but our numbers are underpowered to show a statistical difference. However, with a ΔLLD of ~ 3.4 mm, CAN may be useful in facilitating the successful restoration of pre-operative leg length following rTHA. Therefore, CAN may be a helpful tool for orthopedic surgeons to assist in cup placement and LLD during complex revision cases.