RESUMEN
Inflammatory arthritis is a family of conditions including rheumatoid arthritis, juvenile inflammatory arthritis, and spondyloarthropathies affecting both the large and small joints. Total joint arthroplasty is commonly used for surgical management of end-stage disease. Preoperative and postoperative considerations as well as perioperative medical management and intraoperative treatment of patients with inflammatory arthritis undergoing total joint arthroplasty are reviewed. Although individualized, multidisciplinary approaches to treatment are necessary due to the complex nature of the disease and the varying levels of severity, patients generally have favorable outcomes with respect to pain scores and functional outcomes.
Asunto(s)
Artroplastia de Reemplazo , Humanos , Artroplastia de Reemplazo/métodos , Artritis Reumatoide/cirugía , Artritis Reumatoide/complicaciones , Artroplastia de Reemplazo de Rodilla/métodos , Artritis/cirugía , Artroplastia de Reemplazo de Cadera/métodosRESUMEN
BACKGROUND: Femoral neck retaining prostheses have gained popularity in Europe, but the United States has not seen the same trends occurring. Previous reports demonstrate high survivorship for these implants, but to our knowledge, there are no reports examining US data. METHODS: After institutional review board approval, 824 primary total hip arthroplasties utilizing a femoral neck-retaining prosthesis were examined for femoral component survivorship rates. European studies were systematically reviewed to determine survivorship rates. The data were used to formulate a Kaplan-Meier survivorship curve and compare US data to that of the European studies. RESULTS: European studies demonstrated survivorship rates for all causes of 97.7 and 99.0% for aseptic loosening at an average of 6 years (range, 4.5 to 10). The current study demonstrated an all-cause 94% Kaplan-Meier survivorship estimate at 5 years and when aseptic loosening only was considered, survivorship increased to 99.4% at 5 years and 98.4% at 11 years. CONCLUSION: This femoral neck-retaining prosthesis demonstrated excellent survivorship that is comparable to the rates seen in European studies as well as the rates of standard and mid-stem prostheses in the United States.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Prótesis de Cadera , Humanos , Estados Unidos , Estudios Retrospectivos , Cuello Femoral/cirugía , Resultado del Tratamiento , Fémur/cirugía , Diseño de Prótesis , Falla de Prótesis , Reoperación , Estudios de SeguimientoRESUMEN
BACKGROUND: Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). METHODS: We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). RESULTS: All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). CONCLUSIONS: Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. LEVEL OF EVIDENCE: Level 3, Retrospective Cohort Comparison.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Anestesia General , Anestesia Raquidea , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Dolor Postoperatorio , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Dolor Postoperatorio/etiología , Dolor Postoperatorio/tratamiento farmacológico , Estudios Retrospectivos , Estudios de Cohortes , Mepivacaína/administración & dosificación , Bupivacaína/administración & dosificación , Alta del Paciente/estadística & datos numéricos , Anestésicos Locales/administración & dosificaciónRESUMEN
INTRODUCTION: This study evaluated the effect of bupivacaine versus mepivacaine spinal anesthesia and preoperative adductor canal block (ACB) on recovery, length of stay, pain, and complications of same-day discharge total knee arthroplasty (TKA) at a free-standing ambulatory surgery center. METHODS: We performed a retrospective review of patients who underwent TKA between March 2018 and September 2019. The patients were grouped based on the neuraxial anesthetic regimen: bupivacaine with ACB, bupivacaine without ACB, and mepivacaine without ACB. Preoperative ACBs were discontinued in December 2018, and use of mepivacaine spinal anesthesia was initiated in March 2019. Length of stay in the postanesthesia care unit (PACU), time to controlled void and ambulation, postoperative pain, morphine milligram equivalents (MME), and transient neurologic symptoms were compared. RESULTS: Ninety consecutive patients who underwent TKA were identified. Fifty patients received bupivacaine with ACB, 20 received bupivacaine without ACB, and 20 received mepivacaine without ACB. Mepivacaine spinal anesthesia led to a 93-minute shorter PACU stay (P < 0.001), 115-minute quicker time to void (P < 0.001), 60-minute earlier ambulation (P = 0.024), and 109-minute shorter total facility time (P = 0.003) but increased total MME (P = 0.049) despite nonsignificant difference in pain at discharge (P = 0.908) compared with bupivacaine. Patients receiving bupivacaine with and without ACB had a nonsignificant difference in pain scores at discharge, time to ambulation, and time to discharge (P ≥ 0.1). No transient neurologic symptoms or overnight stays were observed. DISCUSSION: Mepivacaine spinal anesthesia for TKA safely facilitated more rapid same-day discharge through decreased times to controlled void and ambulation but with a slight increase in MME requirements. Discontinuing preoperative ACBs did not negatively affect PACU outcomes.
Asunto(s)
Anestesia Raquidea , Artroplastia de Reemplazo de Rodilla , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Anestésicos Locales , Mepivacaína , Estudios Retrospectivos , Procedimientos Quirúrgicos Ambulatorios , Alta del Paciente , Bupivacaína , Dolor Postoperatorio/diagnóstico , Anestesia Raquidea/métodos , Analgésicos OpioidesRESUMEN
BACKGROUND: Periprosthetic femoral fractures (PFFs) in total hip arthroplasty (THA), especially those in contact with the diaphyseal stem, carry high morbidity. This study evaluated how stem design influences the risk of early Vancouver B PFF or other PFF requiring operative intervention after THA. METHODS: A multicenter, retrospective study of 3,433 primary cementless THAs performed from 2014 to 2021 included 2,302 single-taper (micro M/L [n = 1,169]; M/L [n = 1,133]) and 1,131 double-taper (fit-and-fill [n = 420]; compaction-collared [n = 711]) stems. Mean follow-up was 2.2 years (range, 0.3 to 6.5 years). Primary outcomes were Vancouver B and surgically treated postoperative PFFs among differing femoral stems. Secondary outcomes included rates of intraoperative and postoperative Vancouver A and C PFFs. RESULTS: Forty five postoperative PFFs (1.3%) occurred within 8.8 weeks (median), 25 of which were Vancouver B (0.7%) and 20 total PFFs that required operative intervention (0.6%). Compaction-collared stems had a decreased risk of Vancouver B (hazard ratio 0.18, 95% confidence interval: 0.03-0.97 P = .044) and any surgically treated PFF (hazard ratio 0.10, 95% confidence interval: 0.01-0.95; P = .037). Intraoperative PFFs were most common with fit-and-fill stems (3.6%, P < .001) and Vancouver A with compaction-collared stems (1.8%, P < .001). The cohort with PFF had a higher Charlson comorbidity index (P = .004), more women (P = .001), more Dorr A or C femora (P = .013), and more posterior or lateral surgical approaches compared to those without PFF (P ≤ .001). CONCLUSION: After controlling for confounding variables, compaction-collared stems had a significantly lower risk of postoperative Vancouver B and PFF requiring operative treatment than single-taper and double-taper stems.
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Artroplastia de Reemplazo de Cadera , Fracturas del Fémur , Prótesis de Cadera , Fracturas Periprotésicas , Humanos , Femenino , Artroplastia de Reemplazo de Cadera/efectos adversos , Estudios Retrospectivos , Fémur/cirugía , Fracturas Periprotésicas/epidemiología , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/cirugía , Fracturas del Fémur/etiología , Fracturas del Fémur/cirugía , Reoperación , Prótesis de Cadera/efectos adversosRESUMEN
BACKGROUND: A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone. METHODS: Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone. RESULTS: Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001). CONCLUSION: Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.
Asunto(s)
Artroplastía de Reemplazo de Hombro , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Artroplastía de Reemplazo de Hombro/métodos , Articulación del Hombro/cirugía , Estudios Retrospectivos , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Rango del Movimiento Articular , Resultado del Tratamiento , Complicaciones Posoperatorias/etiología , Dolor/cirugíaRESUMEN
INTRODUCTION: Dislocation is amongst the most common complications following total hip arthroplasty (THA). Dual-mobility bearings have been suggested as one way to reduce the risk of dislocation, particularly among patients at increased risk. The purpose of this study was to determine the outcomes of a monoblock dual-mobility shell for patients at high risk for dislocation following primary THA. METHODS: A total of 155 primary THAs with a monoblock, cementless dual-mobility acetabular component were performed in patients at high risk for dislocation. Two patients died prior to their two-year follow-up. The remaining 153 THAs were followed for a mean of 5.1 years (range: 2.1 to 9.3). RESULTS: There were no dislocations; however, four patients underwent revision surgery: one for an early periprosthetic acetabular fracture, one for an early periprosthetic femoral fracture, one for a late periprosthetic femoral fracture, and one for leg-length discrepancy. Intraoperative complications included one periprosthetic acetabular fracture treated with protected weight-bearing and one intraoperative proximal femoral fracture treated with cerclage wiring. Harris Hip Scores improved from a mean of 42.4 points preoperatively to a mean of 82.4 points postoperatively (p < 0.001). No cups were radiographically loose. At a mean follow-up of 5.1 years, survivorship of the acetabular component was 99.3% (95% CI, 98.1-100%) and survivorship without any reoperation was 97.4% (95% CI, 95.9-100%). DISCUSSION: Although there were no dislocations in this high-risk population, periprosthetic fractures of the femur and acetabulum were common with the implants utilised.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fracturas del Fémur , Luxación de la Cadera , Prótesis de Cadera , Luxaciones Articulares , Fracturas Periprotésicas , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Fracturas del Fémur/cirugía , Estudios de Seguimiento , Luxación de la Cadera/etiología , Luxación de la Cadera/cirugía , Prótesis de Cadera/efectos adversos , Humanos , Luxaciones Articulares/cirugía , Fracturas Periprotésicas/complicaciones , Fracturas Periprotésicas/diagnóstico por imagen , Fracturas Periprotésicas/cirugía , Diseño de Prótesis , Falla de Prótesis , Reoperación/efectos adversos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts. METHODS: The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05. RESULTS: Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use. DISCUSSION: Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA. LEVEL OF EVIDENCE: Level IV; systematic review.
Asunto(s)
Artroplastía de Reemplazo de Hombro , Pacientes Ambulatorios , Artroplastía de Reemplazo de Hombro/efectos adversos , Análisis Costo-Beneficio , Humanos , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Mepivacaine spinal anesthetic may facilitate more rapid postoperative recovery in joint arthroplasty than bupivacaine. This study compared recovery, pain, and complications between the 2 anesthetics in anterior-approach total hip arthroplasty (THA) at a free-standing ambulatory surgery center (ASC). METHODS: This retrospective cohort study of 282 consecutive patients with mean age 55.7 ± 8.8 years and body mass index 30.6 ± 5.3 who underwent THA at an ASC from November 2018 to July 2020 compares mepivacaine (n = 141) vs bupivacaine (n = 141) spinal anesthesia, a transition made in March 2019. The main outcomes were length of stay in the postoperative unit (post acute care unit) prior to same-day discharge (SDD), time to controlled void, and ambulation. Secondarily, postoperative pain scores (0-10) with morphine equivalents were required and any postoperative complications were compared. RESULTS: Mepivacaine decreased mean post acute care unit stay (4.0 vs 5.7 hours, P < .001), time to void (3.1 vs 4.9 hours, P < .001), and ambulation (3.2 vs 4.5 hours, P < .001). No patients needed urinary catheterization or overnight stay. Two patients in the bupivacaine group had transient neurologic symptoms, consisting of foot drop and spinal headache, compared to none with mepivacaine (P = .498). Mepivacaine patients had increased postoperative pain at 2 hours (1.7 vs 0.9, P < .001), at discharge (1.1 vs 0.5, P = .004), and morphine equivalent doses received (7.8 vs 3.7 mg, P < .001). CONCLUSION: Mepivacaine spinal anesthesia for anterior-approach THA safely facilitated more rapid SDD from the ASC through decreased times to controlled void and ambulation with only minor increase in pain when compared to bupivacaine. LEVEL OF EVIDENCE: Level III - Retrospective comparative cohort study.
Asunto(s)
Anestesia Raquidea , Artroplastia de Reemplazo de Cadera , Procedimientos Quirúrgicos Ambulatorios , Anestesia Raquidea/efectos adversos , Anestésicos Locales , Artroplastia de Reemplazo de Cadera/efectos adversos , Bupivacaína , Estudios de Cohortes , Humanos , Mepivacaína , Persona de Mediana Edad , Dolor Postoperatorio/prevención & control , Estudios RetrospectivosRESUMEN
INTRODUCTION: Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty (THA) with potential advantages of preserving femoral bone stock and the ability to participate in higher impact activities. This study compares outcomes, satisfaction and preference in patients who underwent HRA in 1 hip and THA on the contralateral side. METHODS: 62 Patients with an HRA in 1 hip and a contralateral THA were retrospectively identified at 3 centres, consisting of 38 males and 24 females with 53 patients (85.5%) undergoing HRA first. A survey regarding satisfaction and preference for each procedure and outcome scores were obtained. RESULTS: Patients were younger (51.5 vs. 56.6 years, p = 0.002) and had longer follow-up on the HRA hip (11.0 vs. 6.0 years, p < 0.001). HRA was associated with larger increase in Harris Hip Score from preoperative to final follow-up (35.8 vs. 30.6, p = 0.035). 18 Patients (29.0%) preferred HRA, 19 (30.6%) preferred THA and 25 (40.3%) had no preference (p = 0.844). When asked what they would choose if they could only have 1 surgery again, 41 (66.1%, p < 0.001) picked HRA. Overall satisfaction (p = 0.504), willingness to live with their HRA versus THA for the rest of their life (p = 0.295) and recommendation to others (p = 0.097) were similar. CONCLUSIONS: Although HRA is associated with risks related to metal-on-metal bearings, it showed greater increase in patient-reported outcomes and a small subjective preference amongst patients who have undergone both conventional and resurfacing arthroplasty.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Prótesis de Cadera , Artroplastia de Reemplazo de Cadera/efectos adversos , Femenino , Articulación de la Cadera/cirugía , Humanos , Masculino , Metales , Diseño de Prótesis , Estudios RetrospectivosRESUMEN
BACKGROUND: Unicompartmental knee arthroplasty (UKA) is an effective alternative to total knee arthroplasty (TKA) in isolated unicompartmental disease; however, mid-term to long-term results in young patients are unknown. The purpose of this study is to determine the mid-term outcomes of fixed-bearing medial UKA in patients less than 55 years of age. METHODS: Seventy-seven fixed-bearing medial UKAs in patients less than 55 years of age (mean 49.9, range 38-55) from a previously published report were retrospectively reviewed at a mean follow-up of 11.2 years (range 4.1-19.2). RESULTS: Eleven knees were converted to TKA (14.3%) at 0.7-13.8 years postoperatively. The indications for revision included 7 for unexplained pain (9.1%), 2 for grade 4 arthritic progression (1 isolated lateral and 1 lateral and patellofemoral compartments; 2.6%), 1 for polyethylene wear (1.3%), and 1 for femoral component loosening (1.3%). Predicted survivorship free from component revision was 90.4% (95% confidence interval 86.9-93.9) at 10 years and 75.1% (95% confidence interval 66.2-84.0) at 19 years. The mean Knee Society Score improved from a mean of 51.9-88.6 points (P < .001). Of the 52 knees with 4-year minimum radiographs, 3 (5.8%) developed isolated grade 4 patellofemoral arthritis that was asymptomatic, and no knees had evidence of component loosening or osteolysis. CONCLUSION: Fixed-bearing medial UKA is a durable option for young patients with unicompartmental arthritis, with good clinical outcomes at mid-term follow-up. Unexplained pain was the most common reason for revision to TKA.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Osteoartritis de la Rodilla , Adolescente , Adulto , Artroplastia de Reemplazo de Rodilla/efectos adversos , Niño , Preescolar , Estudios de Seguimiento , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugía , Persona de Mediana Edad , Osteoartritis de la Rodilla/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Prior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA. METHODS: Primary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a "conversion" cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue. RESULTS: The conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001). CONCLUSION: Patients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Rodilla/cirugía , Articulación de la Rodilla/cirugía , Tiempo de Internación , Osteotomía , Complicaciones Posoperatorias/epidemiología , Reoperación , Estudios RetrospectivosRESUMEN
INTRODUCTION: Preoperative opioid use is detrimental to outcomes after hip and knee arthroplasty. This study aims to identify the prevalence of preoperative opioid prescriptions and the specialty and practice setting of the prescriber, as well as the percentage of patients who do not report their opioid prescriptions and any variables associated with preoperative opioid prescriptions. METHODS: A total of 461 consecutive new patients evaluated for an arthritic hip or knee were retrospectively studied using institutional data from a tertiary-care, urban center at a university-affiliated private-practice and the state Prescription Monitoring Program to identify opioid prescriptions (including medication, number of pills and dosage, refills, prescriber specialty, and practice setting) within 6 months before their first appointment. Demographic data included age, sex, ethnicity, body mass index, joint, laterality, diagnosis, Charlson Comorbidity Index, duration of symptoms, decision to have surgery, number of days from the first visit to surgery, smoking status, alcohol use, mental health diagnoses, preoperative outcome scores, nonopioid medications, and opioid medications. Patients were separated into opioid and nonopioid cohorts (opioid receivers were further subdivided into those who reported their opioid prescription and those who did not) for statistical analysis to analyze demographic differences using t-tests and Mann-Whitney U tests for continuous variables, the Fisher exact test for categorical variables, and multivariate logistic regression. RESULTS: One hundred five patients (22.8%) received an opioid before the appointment. Fifty-two (11.3%) received schedule II or III opioids, 43 (9.3%) received tramadol, and 10 (2.2%) received both. Primary care physicians were the most common prescriber (59.5%, P < 0.001) followed by pain medicine specialists (11.3%) and orthopaedic surgeons (11.3%). More prescribers practiced in the community than academic setting (63.8% versus 36.2%, P < 0.001). Seventy-eight patients (74.3%) self-reported their opioid prescriptions, with the remaining 27 patients (25.7%; 14 schedule II or III opioids and 13 tramadol) identified only after query of the Prescription Monitoring Program. In regression analysis, higher body mass index, diagnosis other than osteoarthritis, and benzodiazepine use were associated with receiving opioids (P < 0.05), while antidepressant use decreased the likelihood of self-reporting opioid prescriptions (P = 0.044). DISCUSSION: A striking number of patients are being treated with opioids for hip and knee arthritis. Furthermore, many patients who have received opioids within 6 months do not report their prescriptions. Although primary care physicians prescribed most opioids for nonsurgical treatment of arthritis, a substantial percentage came from orthopaedic surgeons. Further education of physicians and patients on the ill effects of opioids when used for the nonsurgical treatment of hip and knee arthritis is warranted. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
Asunto(s)
Analgésicos Opioides/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Prescripciones/estadística & datos numéricos , Centros de Atención Terciaria/estadística & datos numéricos , Analgésicos Opioides/efectos adversos , Antidepresivos , Artritis/cirugía , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Benzodiazepinas , Índice de Masa Corporal , Estudios de Cohortes , Humanos , Manejo del Dolor , Periodo Preoperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: The purpose of this randomized, controlled trial is to determine whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative periprosthetic joint infection (PJI) in aseptic revision total knee (TKA) and hip arthroplasty (THA). METHODS: A total of 478 patients undergoing aseptic revision TKA and THA were randomized to receive a 3-minute dilute betadine lavage (0.35%) or normal saline lavage before surgical wound closure. Fifteen patients were excluded following randomization (3.1%) and six were lost to follow-up (1.3%), leaving 457 patients available for study. Of them, 234 patients (153 knees, 81 hips) received normal saline lavage and 223 (144 knees, 79 hips) received dilute betadine lavage. The primary outcome was PJI within 90 days of surgery with a secondary assessment of 90-day wound complications. A priori power analysis determined that 285 patients per group were needed to detect a reduction in the rate of PJI from 5% to 1% with 80% power and alpha of 0.05. RESULTS: There were eight infections in the saline group and 1 in the betadine group (3.4% vs 0.4%, P = .038). There was no difference in wound complications between groups (1.3% vs 0%, P = .248). There were no differences in any baseline demographics or type of revision procedure between groups, suggesting appropriate randomization. CONCLUSION: Dilute betadine lavage before surgical wound closure in aseptic revision TKA and THA appears to be a simple, safe, and effective measure to reduce the risk of acute postoperative PJI. LEVEL OF EVIDENCE: Level I.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Povidona Yodada , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/prevención & control , Reoperación , Irrigación TerapéuticaRESUMEN
BACKGROUND: The most common indications for revision total hip arthroplasty are instability/dislocation and mechanical loosening. Efforts to address this have included the use of dual mobility (DM) articulations. The aim of this study is to report on the use of cemented DM cups in complex acetabular revision total hip arthroplasty cases with a high risk of recurrent instability. METHODS: A multicenter, retrospective study was conducted. Patients who received a novel acetabular construct consisting of a monoblock DM cup cemented into a fully porous metal shell were included. Outcome data included 90-day complications and readmissions, revision for any reason, and Harris Hip Scores. RESULTS: Thirty-eight hips in 38 patients were included for this study. At a median follow-up of 215.5 days (range 6-783), the Harris Hip Score improved from a mean of 50 ± 12.2 to 78 ± 11.2 (P < .001). One (2.6%) patient experienced a dislocation on postoperative day 1, and was closed reduced with no further complications. There was 1 (2.6%) reoperation for periprosthetic joint infection treated with a 2-stage exchange. CONCLUSIONS: In this complex series of patients, cementation of a monoblock DM cup into a newly implanted fully porous revision shell reliably provided solid fixation with a low risk of dislocation at short-term follow-up. Although longer term follow-up is needed, utilization of this novel construct should be considered in patients at high risk for instability.
RESUMEN
BACKGROUND: The guidelines for diagnosis of periprosthetic joint infection (PJI) introduced by the American Academy of Orthopaedic Surgeons served the orthopedic community well. However, they have never been validated and do not account for newer diagnostic modalities. Our aim was to update current guidelines and develop an evidence-based and validated diagnostic algorithm. METHODS: This multi-institutional study examined total joint arthroplasty patients from 3 institutions. Patients fulfilling major criteria for infection as defined by Musculoskeletal Infection Society were considered infected (n = 684). Patients undergoing aseptic revision for a noninfective indication and did not show evidence of PJI or undergo reoperation within 2 years served as a noninfected control group (n = 820). The algorithm was validated on a separate cohort of 422 cases. RESULTS: The first step in evaluating PJI should include a physical examination, followed by serum C-reactive protein, erythrocyte sedimentation rate, and D-dimer. If at least one of these tests are elevated, or if high clinical suspicion exists, joint aspiration should be performed, sending the fluid for a white blood cell count, leukocyte esterase, polymorphonuclear percentage, and culture. Alpha defensin did not show added benefit as a routine diagnostic test. In inconclusive cases, intraoperative findings including gross purulence, histology, and next-generation sequencing or a single positive culture can aid in making the diagnosis. The proposed algorithm demonstrated a high sensitivity (96.9%) and specificity (99.5%). CONCLUSION: This validated, evidence-based algorithm for diagnosing PJI should guide clinicians in the workup of patients undergoing revision arthroplasty and improve clinical practice. It also has the potential to reduce cost.
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Artritis Infecciosa/diagnóstico , Artroplastia de Reemplazo de Rodilla/efectos adversos , Infecciones Relacionadas con Prótesis/diagnóstico , Adulto , Anciano , Algoritmos , Artritis Infecciosa/cirugía , Sedimentación Sanguínea , Proteína C-Reactiva/análisis , Hidrolasas de Éster Carboxílico/sangre , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Humanos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/cirugía , Curva ROC , Reoperación , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido Sinovial/química , Líquido Sinovial/microbiologíaRESUMEN
BACKGROUND: Patients between 45 and 54 years old will be the fastest-growing cohort seeking total knee arthroplasty (TKA) over the next 15 years. The purpose of this investigation is to determine the clinical outcomes of TKA in patients less than 50 years old at a minimum of 10 years. We hypothesized that this patient population would have a high rate of survivorship that is similar to that of older patients. METHODS: We reviewed 298 consecutive TKAs on 242 patients at a minimum of 10 years postoperatively. Twenty patients died and 30 TKAs were lost to follow-up leaving 248 TKAs in 202 patients (91 male, 111 female) with a mean age of 45.7 years (range, 26-49) at the time of surgery. Patient-reported outcomes, survivorship, causes of reoperation, and initial postoperative radiographic parameters were collected. RESULTS: At a mean of 13.0 years, there were 9 revisions for tibial loosening (3.6%), 8 for deep infection (3.2%), 7 for polyethylene wear (2.8%), and 3 for failed ingrowth of a cementless femoral component (1.2%). Kaplan-Meier analysis demonstrated 92.0% survivorship with failures defined as aseptic component revision and 83.9% survivorship for all-cause reoperation at 13 years. Patients with tibial alignment of 4° or more of varus or 10° or more of posterior slope were found to have increased rate of failure. CONCLUSION: While overall durability was good in this young patient population, tibial fixation and deep infection were relatively common causes of failure. In addition, increased tibial varus and slope were found to increase the rate of failure. Furthermore, the nearly 3% risk of revision for wear suggests that the use of more wear-resistant bearing surfaces may reduce the risk of failure in this patient population.
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Artroplastia de Reemplazo de Rodilla/efectos adversos , Prótesis de la Rodilla/efectos adversos , Adulto , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Medición de Resultados Informados por el Paciente , Polietileno , Periodo Posoperatorio , Diseño de Prótesis , Falla de Prótesis , Reoperación/efectos adversos , Estudios Retrospectivos , Riesgo , Tibia/fisiología , Tibia/cirugíaRESUMEN
BACKGROUND: The ability to identify patients at risk of dissatisfaction after total knee arthroplasty (TKA) remains elusive. This study's purpose was to determine the external validity of a recently published prediction model for patient satisfaction (PMPS) with the hypothesis that it would achieve similar predictive success in our study sample. METHODS: A 10-question PMPS statistically derived from 5 patient-reported outcome questionnaires was tested for external validity in this prospective cohort investigation. The PMPS incorporates gender, age, stiffness, noise, and pain catastrophizing, with a score of 20 or greater predictive of satisfaction. As in the original study, to determine satisfaction the 2011 Knee Society Score (KSS) satisfaction subscale was collected at 3 months postoperatively. Two hundred seventy-four patients were administered the PMPS preoperatively, and 145 patients completed the KSS at 3 months postoperatively (53.0% response rate; 59% female; age, 64.9; body mass index, 32.5). A Bland-Altman analysis to assess agreement was performed. RESULTS: One hundred thirty-three patients (91.7%) were satisfied and 12 (8.3%) were dissatisfied based on their postoperative KSS. The mean difference between the PMPS and KSS was 3.6 ± 8, but with a 95% prediction interval of -15.3 to 22.1 signifying almost no correlation. The PMPS did not predict any of the 12 dissatisfied patients postoperatively, and falsely predicted 5 patients to be dissatisfied of which 4 actually had a maximum postoperative KSS of 40. CONCLUSION: A previously published, internally validated 10-question PMPS was unable to predict satisfaction after TKA in our external study sample. This study emphasizes the difficulty of developing a simple, but robust questionnaire that consistently predicts patient satisfaction after TKA.
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Artroplastia de Reemplazo de Rodilla , Osteoartritis de la Rodilla/psicología , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Artritis Reumatoide/psicología , Artritis Reumatoide/cirugía , Índice de Masa Corporal , Femenino , Humanos , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/cirugía , Dolor/cirugía , Manejo del Dolor , Percepción del Dolor , Periodo Posoperatorio , Estudios Prospectivos , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Encuestas y CuestionariosRESUMEN
BACKGROUND: Preoperative planning for total knee arthroplasty (TKA) is essential for streamlining operating room efficiency and reducing costs. Digital templating and patient-specific instrumentation have shown some value in TKA but require additional costs and resources. The purpose of this study was to validate a previously published algorithm that uses only demographic variables to accurately predict TKA tibial and femoral component sizes. METHODS: Four hundred seventy-four consecutive patients undergoing elective primary TKA were prospectively enrolled. Four surgeons were included, three of which were unaffiliated with the retrospective cohort study. Patient sex, height, and weight were entered into our published Arthroplasty Size Prediction mobile application. Accuracy of the algorithm was compared with the actual sizes of the implanted femoral and tibial components from 5 different implant systems. Multivariate regression analysis was used to identify independent risk factors for inaccurate outliers for our model. RESULTS: When assessing accuracy to within ±1 size, the accuracies of tibial and femoral components were 87% (412/474) and 76% (360/474). When assessing accuracy to within ±2 sizes of predicted, the tibial accuracy was 97% (461/474), and the femoral accuracy was 95% (450/474). Risk factors for the actual components falling outside of 2 predicted sizes include weight less than 70 kg (odds ratio = 2.47, 95% confidence interval [1.21-5.06], P = .01) and use of an implant system with <2.5 mm incremental changes between femoral sizes (odds ratio = 5.50, 95% confidence interval [3.33-9.11], P < .001). CONCLUSIONS: This prospective series of patients validates a simple algorithm to predict component sizing for TKA with high accuracy based on demographic variables alone. Surgeons can use this algorithm to simplify the preoperative planning process by reducing unnecessary trays, trials, and implant storage, particularly in the community or outpatient setting where resources are limited. Further assessment of components with less than 2.5-mm differences between femoral sizes is required in the future to make this algorithm more applicable worldwide.
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Artroplastia de Reemplazo de Rodilla/instrumentación , Prótesis de la Rodilla/estadística & datos numéricos , Aplicaciones Móviles/estadística & datos numéricos , Algoritmos , Peso Corporal , Demografía , Fémur/cirugía , Humanos , Estudios Prospectivos , Estudios Retrospectivos , Cirujanos , Tibia/cirugíaRESUMEN
BACKGROUND: The purpose of this study is to evaluate clinical and radiographic outcomes of patients less than 50 years of age undergoing primary total hip arthroplasty (THA) at a minimum of 10 years. METHODS: Three hundred nine consecutive THAs performed on 273 patients were reviewed. At a minimum of 10 years, 13 were deceased and 23 were lost to follow-up leaving 273 THAs in 237 patients who were followed for a mean of 16 years (range 10-19.9). The cohort consisted of 116 females (49%) and 121 males (51%), with a mean age of 42.3 years at the time of surgery (range 19-49). The majority of preoperative diagnoses included osteoarthritis in 149 (63%) and avascular necrosis in 55 (23%). Two hundred sixteen had highly crosslinked polyethylene (HXLPE) and 57 had non-HXLPE acetabular liners. The femoral stems were cementless in 98% (266/273) and the acetabular components were cementless in all cases. Femoral head composition was cobalt-chromium in all cases and the majority of sizes in the non-HXLPE cohort were 28 mm (52/57; 91%), while the HXLPE group primarily consisted of 28 mm (141/216; 65%) and 32 mm (74/216; 34%) heads. Analysis involved Kaplan-Meier survivorship with a log-rank test for equivalence, Fisher's exact test for pairwise comparisons, and a paired t-test for Harris Hip Score, with alpha = 0.05 being statistically significant. RESULTS: There were 6 revisions for wear in the non-HXLPE group (10.5%) compared to none in the HXLPE group (P < .001). Similarly, survivorship with revision for any reason as the endpoint at 16 years was significantly higher at 93.0% in the XLPE group (95% confidence interval 88.7-95.7) compared to 85.7% (95% confidence interval 73.5-92.6) in the non-HXLPE group (P = .023). Additional revisions in the HXLPE group included 6 for instability (2.8%), 5 secondary to infection (2.4%), and 3 stem failures (1.4%). Non-wear-related revisions in the non-HXLPE group included 5 due to instability (8.8%) and 3 due to stem failures (5.3%). The mean Harris Hip Scores for the entire cohort improved from a mean of 46.2 points preoperatively to 89.8 points at most recent follow-up (P < .001). CONCLUSION: The use of HXLPE has led to a significant reduction in the risk of failure in patients <50 years old, with over 93% survivorship at 16 years. Instability and infection, however, remain substantial causes of failure. LEVEL OF EVIDENCE: Therapeutic Level III.