Hip Abductor Reconstruction with the Use of Mesh and Distal Cerclage Cable Fixation: A Case Report and Surgical Technique.

CASE: This is a case of a 71-year-old female patient with recurrent instability and complex hip abductor deficiency after total hip arthroplasty (THA) who was treated successfully with an abductor reconstruction with gluteal transfer with mesh reconstruction. The patient returned to nonassisted ambulation with no further THA dislocations at the 1-year follow-up. CONCLUSION: Abductor deficiencies after THA are complex and have a high potential for long-term disability if not properly diagnosed and treated. A modified gluteal transfer with mesh reconstruction and distal fixation with cerclage cable allowed for sustained restoration of functional hip abduction and stability after revision THA.

Cooling vest improves surgeons' thermal comfort without affecting cognitive performance: a randomised cross-over trial.

OBJECTIVES: Surgeons become uncomfortable while performing surgery because heat transfer and evaporative cooling are restricted by insulating surgical gowns. Consequently, perceptions of thermal discomfort during surgery may impair cognitive performance. We, therefore, aimed to evaluate surgeons' thermal comfort, cognitive performance, core and mean skin temperatures, perceptions of sweat-soaked clothing, fatigue and exertion with and without a CoolSource cooling vest (Cardinal Health, Dublin, Ohio, USA). METHODS: Thirty orthopaedic surgeons participated in a randomised cross-over trial, each performing four total-joint arthroplasties with randomisation to one of four treatment sequences. The effects of cooling versus no cooling were measured using a repeated-measures linear model accounting for within-subject correlations. RESULTS: The cooling vest improved thermal comfort by a mean (95% CI) of -2.1 (-2.7 to -1.6) points on a 0-10 scale, p<0.001, with no evidence of treatment-by-period interaction (p=0.94). In contrast, cooling had no perceptible effect on cognition, with an estimated mean difference (95% CI) in Cleveland Clinic Cognitive Battery (C3B) Processing Speed Test score of 0.03 (95% CI -2.44 to 2.51), p=0.98, or in C3B Visual Memory Test score with difference of 0.88 (95% CI -2.25 to 4.01), p=0.57. Core temperature was not lower with the cooling vest, with mean difference (95% CI) of -0.13 (-0.33°C to 0.07°C), p=0.19, while mean skin temperature was lower, with mean difference of -0.23 (95% CI -0.40°C to -0.06°C) lower, p=0.011. The cooling vest significantly reduced surgeons' perceptions of sweat-soaked clothing, fatigue and exertion. CONCLUSIONS: A cooling vest worn during surgery lowered core and skin temperatures, improved thermal comfort, and decreased perceptions of sweating and fatigue, but did not improve cognition. Thermal discomfort during major orthopaedic surgery is thus largely preventable, but cooling does not affect cognition. TRIAL REGISTRATION NUMBER: NCT04511208.

Do patient-reported outcome measures improve after aseptic revision total hip arthroplasty?

BACKGROUND: The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon. METHODS: A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs. RESULTS: Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS. CONCLUSIONS: Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

Blood management in total hip arthroplasty: a nationwide trend analysis from 2011 to 2018.

PURPOSE: With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. METHODS: From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT < 35.5% for females and < 38.5% for males), thrombocytopenia (platelet count < 150,000/µL), INR > 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. RESULTS: There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p < 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p < 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p < 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p < 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR > 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p < 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007). CONCLUSION: Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors. LEVEL OF EVIDENCE: III.

Similar Healthcare Utilization and 1-Year Patient-Reported Outcomes between Cemented and Cementless Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015-August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BACKGROUND: Decreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days. RESULTS: When comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD. CONCLUSION: The unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA. LEVEL OF EVIDENCE: III.

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty.

BACKGROUND: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches. METHODS: A prospective consecutive series of primary THA for osteoarthritis (n = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA (n = 913; 38%), AL/DL (n = 505; 21%), or PL (n = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed. RESULTS: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain (p = 0.002). Approach was not a significant factor for 1-year HOOS-PS (p = 0.16) or 1-year UCLA activity (p = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (p > 0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (p < 0.05). CONCLUSIONS: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

A clinical review of robotic navigation in total knee arthroplasty: historical systems to modern design.

Robotic-assisted total knee arthroplasty (RA-TKA) has shown improved reproducibility and precision in mechanical alignment restoration, with improvement in early functional outcomes and 90-day episode of care cost savings compared to conventional TKA in some studies. However, its value is still to be determined.Current studies of RA-TKA systems are limited by short-term follow-up and significant heterogeneity of the available systems.In today's paradigm shift towards an increased emphasis on quality of care while curtailing costs, providing value-based care is the primary goal for healthcare systems and clinicians. As robotic technology continues to develop, longer-term studies evaluating implant survivorship and complications will determine whether the initial capital is offset by improved outcomes.Future studies will have to determine the value of RA-TKA based on longer-term survivorships, patient-reported outcome measures, functional outcomes, and patient satisfaction measures. Cite this article: EFORT Open Rev 2021;6:252-269. DOI: 10.1302/2058-5241.6.200071.

Perioperative Management of Chronic Antithrombotic Agents in Elective Hip and Knee Arthroplasty.

Total hip and knee arthroplasty are common major orthopedic operations being performed on an increasing number of patients. Many patients undergoing total joint arthroplasty (TJA) are on chronic antithrombotic agents due to other medical conditions, such as atrial fibrillation or acute coronary syndrome. Given the risk of bleeding associated with TJAs, as well as the risk of thromboembolic events in the post-operative period, the management of chronic antithrombotic agents perioperatively is critical to achieving successful outcomes in arthroplasty. In this review, we provide a concise overview of society guidelines regarding the perioperative management of chronic antithrombotic agents in the setting of elective TJAs and summarize the recent literature that may inform future guidelines. Ultimately, antithrombotic regimen management should be patient-specific, in consultation with cardiology, internal medicine, hematology, and other physicians who play an essential role in perioperative care.

Robotic Arm-Assisted Total Knee Arthroplasty in the Setting of Severely Deficient Distal Femoral Bone Stock: A Case Report.

CASE: A 26-year-old woman with a complex sequelae of open distal femoral fracture at 4 years of age presented to the office with severe knee pain from posttraumatic osteoarthritis. Robotic arm-assisted total knee arthroplasty (RA-TKA) with the elevation of previous free-flap was performed because of the following: (1) anatomic deformity, (2) small femoral size, and (3) compromised soft-tissue envelope. CONCLUSION: This case highlights the complexity of planning and performing TKA in a young patient with these unique considerations. The successful outcome demonstrates the viability of RA-TKA techniques.

The Potential Effects of Imposing a Body Mass Index Threshold on Patient-Reported Outcomes After Total Knee Arthroplasty.

BACKGROUND: Operative eligibility thresholds based on body mass index (BMI) alone may risk restricting access to improved pain control, function, and quality of life. This study evaluated the use of BMI-cutoffs to offering TKA in avoiding: 1) 90-day readmission, 2) one-year mortality, and 3) failure to achieve clinically important one-year PROMS improvement (MCID). METHODS: A total of 4126 primary elective unilateral TKA patients from 2015 to 2018 were prospectively collected. For specific BMI(kg/m2) cutoffs: 30, 35, 40, 45, and 50, the positive predictive value (PPV) for 90-day readmission, one-year mortality, and failure to achieve one-year MCID were calculated. The number of patients denied complication-free postoperative courses per averted adverse outcome/failed improvement was estimated. RESULTS: Rates of 90-day readmission and one-year mortality were similar across BMI categories (P > .05, each). PPVs for preventing 90-day readmission and one-year mortality were low across all models of BMI cutoffs. The highest PPV for 90-day readmission and one-year mortality was detected at cutoffs of 45 (6.4%) and 40 (0.87%), respectively. BMI cutoff of 40 would deny 18 patients 90-day readmission-free, and 194 patients one-year mortality-free postoperative courses for each averted 90-day readmission/one-year mortality. Such cutoff would also deny 11 patients an MCID per avoided failure. Implementing BMI thresholds alone did not influence the rate of improvements in KOOS-PS, KRQOL, or VR-12. CONCLUSION: Utilizing BMI cutoffs as the sole determinants of TKA ineligibility may deny patients complication-free postoperative courses and clinically important improvements. Shared decision-making supported by predictive tools may aid in balancing the potential benefit TKA offers to obese patients with the potentially increased complication risk and cost of care provision.

Preoperative cut-off values for body mass index deny patients clinically significant improvements in patient-reported outcomes after total hip arthroplasty.

AIMS: Thresholds for operative eligibility based on body mass index (BMI) alone may restrict patient access to the benefits of arthroplasty. The purpose of this study was to evaluate the relationship between BMI and improvements in patient-reported outcome measures (PROMs), and to determine how many patients would have been denied improvements in PROMs if BMI cut-offs were to be implemented. METHODS: A prospective cohort of 3,449 primary total hip arthroplasties (THAs) performed between 2015 and 2018 were analyzed. The following one-year PROMs were evaluated: hip injury and osteoarthritis outcome score (HOOS) pain, HOOS Physical Function Shortform (PS), University of California, Los Angeles (UCLA) activity, Veterans Rand-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (VR-12 MCS). Positive predictive values for failure to improve and the number of patients denied surgery in order to avoid a failed improvement were calculated for each PROM at different BMI cut-offs. RESULTS: There was a trend to improved outcomes in terms of pain and function improvements with higher BMI. Patients with BMI ≥ 40 kg/m2 had median (Q1, Q3) HOOS pain improvements of 58 points (interquartile range (IQR) 41 to 70) and those with BMI 35 to 40 kg/m2 had median improvements of 55 (IQR 40 to 68). With a BMI cut-off of 30 kg/m2, 21 patients would have been denied a meaningful improvement in HOOS pain score in order to avoid one failed improvement. At a 35 kg/m2 cut-off, 18 patients would be denied improvement, at a 40 kg/m2 cut-off 21 patients would be denied improvement, and at a 45 kg/m2 cut-off 21 patients would be denied improvement. Similar findings were observed for HOOS-PS, UCLA, and VR-12 scores. CONCLUSION: Patients with higher BMIs show greater improvements in PROMs. Using BMI alone to determine eligibility criteria did not improve the rate of clinically meaningful improvements. BMI thresholds prevent patients who may benefit the most from surgery from undergoing THA. Surgeons should consider PROMs improvements in determining eligibility for THA while balancing traditional metrics of preoperative risk stratification. Cite this article: Bone Joint J 2020;102-B(6):683-692.

Catastrophic tibial baseplate failure of a modern cementless total knee arthroplasty implant.

Tibial baseplate fracture following primary total knee arthroplasty is a rare complication, particularly with modern implants and surgical techniques. This case details the first known report of mid-range follow-up catastrophic failure of a cementless modular, trabecular metal tibial baseplate. This failure highlights the importance of continued follow-up for novel implants, to include cementless knee arthroplasty designs, particularly if new symptoms arise or periarticular bone loss is identified on radiograph.

Artificial Intelligence and Arthroplasty at a Single Institution: Real-World Applications of Machine Learning to Big Data, Value-Based Care, Mobile Health, and Remote Patient Monitoring.

BACKGROUND: Driven by the recent ubiquity of big data and computing power, we established the Machine Learning Arthroplasty Laboratory (MLAL) to examine and apply artificial intelligence (AI) to musculoskeletal medicine. METHODS: In this review, we discuss the 2 core objectives of the MLAL as they relate to the practice and progress of orthopedic surgery: (1) patient-specific, value-based care and (2) human movement. RESULTS: We developed and validated several machine learning-based models for primary lower extremity arthroplasty that preoperatively predict patient-specific, risk-adjusted value metrics, including cost, length of stay, and discharge disposition, to provide improved expectation management, preoperative planning, and potential financial arbitration. Additionally, we leveraged passive, ubiquitous mobile technologies to build a small data registry of human movement surrounding TKA that permits remote patient monitoring to evaluate therapy compliance, outcomes, opioid intake, mobility, and joint range of motion. CONCLUSION: The rapid rate with which we in arthroplasty are acquiring and storing continuous data, whether passively or actively, demands an advanced processing approach: AI. By carefully studying AI techniques with the MLAL, we have applied this evolving technique as a first step that may directly improve patient outcomes and practice of orthopedics.

What is the level of evidence substantiating the Medicare local coverage determinations?

Total joint arthroplasty (TJA) accounts for large expenditures of Medicare resources. Recovery audit contractors (RACs) utilize Local Coverage Determinations (LCDs) documents to retrospectively assess the medical necessity of performed procedures. The Florida LCD requires 3 months of documented unsuccessful nonoperative care prior to TJA. The purpose of our study was to evaluate the applicability and quality of the evidence cited in the Florida LCD for patients undergoing TJA. Applicability was assessed by evaluating the efficacy of nonoperative treatment in candidates for TJA. There were 23 citations, of which 11 mentioned nonoperative treatment and only 5 provided references. No citations provided Level I or II evidence substantiating the effectiveness of 3 months of nonoperative treatment in patients who would otherwise be candidates for TJA.

Hip pain in the young, active patient: surgical strategies.

Hip disorders in young patients likely exist as a spectrum of prearthritic and arthritic conditions. With the increasing recognition of these disorders, surgical options are being popularized and more patients are being treated at a younger age. Hip surgeons must develop a careful set of evidenced-based indications and follow surgical outcomes in a rigorous, scientific manner. Hip arthroscopy can be used to successfully treat some hip disorders, including labral tears, with or without femoroacetabular impingement, resulting in mechanical symptoms. Long-term outcomes after arthroscopy are determined by the condition of the cartilage at the time of surgery. Patients with preoperative radiographic evidence of moderate to severe arthritis have poor outcomes when treated with arthroscopy. Open joint preservation procedures (including periacetabular osteotomy and surgical hip dislocation with osteochondroplasty) can be done in the absence of substantial arthritis to treat hip dysplasia, femoroacetabular impingement, and related conditions. The results of these procedures are good in appropriately selected patients at short-term to midterm follow-ups. In the presence of severe arthritis, joint replacement is the treatment of choice. Total hip arthroplasty using uncemented acetabular and femoral fixation provides reliable osseointegration; however, long-term results in young patients have historically been compromised by bearing surface wear, osteolysis, and component loosening. Contemporary, highly cross-linked polyethylene and ceramic-on-ceramic bearings have durable results, low complication rates, and offer the potential of long-term survivorship in this high-demand population. In general, metal-on-metal implants have higher complication rates versus other bearing surface options and should be avoided. The best results of hip resurfacing are seen in men younger than 55 years with large femoral head sizes. Although implant survivorship is comparable to that of total hip arthroplasty, the sequelae of metal wear debris continue to cause concern.

Total hip and knee replacement in the mature athlete.

CONTEXT: Total hip replacement and total knee replacement are among the most successful and common surgical procedures in orthopaedics. These operations were traditionally reserved for older, sedentary patients. However, these are now being increasingly performed in patients expecting to return to athletic activities. EVIDENCE ACQUISITION: The peer-reviewed medical literature was searched via PubMed from the years 2000 to 2013. Those studies pertinent to modern hip and knee replacement in an athletic population were selected for inclusion. STUDY DESIGN: Literature review. LEVEL OF EVIDENCE: Level 4. RESULTS: There is a lack of high-quality evidence in the peer-reviewed literature relating to the replacement of hips and knees in younger athletic patients. Although many patients undergoing joint replacement are active in recreational activities, a minority engage in high-impact sports. Following surgery, overall activities tend to increase, but high-demand athletic activities may be limited by pain, functional outcome, or activity restrictions imposed by health care providers. CONCLUSION: Patients receiving hip and knee replacements should be counseled in that returning to high-impact and repetitive-loading athletic activities after surgery may shorten the life span of their implant. STRENGTH-OF-RECOMMENDATION TAXONOMY SORT: C.

Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty.

Tranexamic acid (TA) has been reported to reduce blood loss after total joint arthroplasty; however, the literature is sparse in evaluating its efficacy in simultaneous bilateral total knee arthroplasty (TKA). In this retrospective study of consecutive patients, TA use in bilateral TKA was associated with a significant reduction in perioperative serum hemoglobin drop, as well as allogeneic blood transfusion needs from 50% to 11% of patients. No autologous blood donation or drains were used. There were no venous thromboembolic events reported. Implementation of a systematic intravenous TA protocol in simultaneous bilateral TKA appears highly effective in reducing transfusion requirements, potentially reducing healthcare resource utilization as well as the morbidity and complications associated with allogeneic blood transfusions.

The clinical outcome of patellofemoral arthroplasty.

Patellofemoral arthroplasty has a long record of use in the treatment of isolated patellofemoral arthritis, with outcomes influenced by patient selection, surgical technique, and trochlear implant design. The trochlear components have evolved from inlay-style to onlay-style designs, which have reduced the incidence of patellar instability. Minimizing the risk of patellar instability with onlay-design patellofemoral arthroplasties has enhanced mid-term and long-term results and leaves progressive tibiofemoral arthritis as the primary failure mechanism beyond 10 to 15 years.

Multimodal pain management in orthopedics: implications for joint arthroplasty surgery.

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.