Biomechanical Comparison of Impaction Techniques and Cross-Sectional Femoral Stem Shapes for Cementless Total Hip Arthroplasty.

Introduction: Traditional mallet broaching and stem seating in cementless total hip arthroplasty (THA) can result in femoral stem misalignment, potentially reducing implant longevity. This study aimed to compare the pullout strength of cementless THA femoral stems with different cross-sectional designs achieved through the powered impactor method versus the traditional mallet method. Methods: The authors utilized 24 polyurethane foam femurs and two femoral bone preservation stems with different proximal cross-sectional shapes (double taper: ACTIS®, size 5; flat taper: TRI-LOCK®, size 5). A single orthopedic surgeon broached each femur from size 0 to size 5 using either the powered impactor or mallet impaction methods. Broaching time and component implantation times were recorded. A load-to-failure pullout strength test was conducted, and the ultimate pullout load was recorded. Results: The broaching time for the TRI-LOCK® stem showed a statistically significant difference between the two impaction methods (powered: 37±7 seconds, mallet: 75±29 seconds, F[3, 20] = 4.56, p = 0.002), but no statistically significant difference was detected for the ACTIS® stem between the two impaction methods (powered: 47±22 seconds, mallet: 59±9 seconds, F[3, 20] = 4.56, p = 0.304). There was a statistically significant difference in pullout strength between the two impaction groups, and this strength was influenced by the implant cross-sectional shape (ACTIS®: 774±75N versus 679±22N, F(3,20) = 16.38, p = 0.018; TRI-LOCK®: 616±57N versus 859±85N, F(3, 20) = 16.38, p <0.001). Conclusions: The technique used for femoral bone preparation (powered impactor versus mallet) and the cross-sectional design of the cementless femoral stem are crucial factors that affect initial stem stability and operation time.

The Effect of Bone Quality on Treatment of Intertrochanteric Fractures with Helical Blade Versus Lag Screw Fixation in Cephalomedulary Nails.

Introduction: The specific aim of this retrospective study was to determine whether bone quality has any effect on the complication rates or overall survivorship between helical blades and lag screws in cephalomedullary nails used for intertrochanteric hip fractures. Methods: The authors reviewed clinical charts and radiographic studies of patients between January 2012 and August 2019. We reviewed radiographic images (pre-, intra-, and post-operative) to evaluate fracture fixation type, fracture reduction grade, and post-operative complications. We collected dual energy x-ray absorptiometry scan results (T-score) and serum alkaline phosphatase (ALP) isoenzyme activity values to evaluate patient bone quality. Results: We included 303 cases (helical: 197, screw: 106) in the study. Complications were found in 31 (16%) helical blade cases and 23 (22%) lag screw cases. No statistically significant difference was detected when comparing complication rates with patient bone quality between the two groups. These two groups had similar one-year implant survivorship with respect to T-score, the low ALP level group, and normal ALP level group. The helical blade had higher implant survivorship compared to lag screw in five-year survival rate with respect to osteoporotic group, high ALP level group, and normal ALP level group (osteoporotic: 77% vs 69%, high ALP: 73% vs 67%, normal ALP: 70% vs 64%). Conclusions: Similar complication rates were observed between helical blade and lag screw constructs in cephalomedullary femoral nails when accounting for patient bone quality. However, the helical blade design had a higher five-year survival rate.

A Biomechanical Evaluation of Casting Technique and Cast Core Size Effect.

BACKGROUNDS: The goals of this study were to (1) compare the effect of casting technique on biomechanical function with different casting materials and different cast core diameters, and (2) compare the strength of a cast based on the number of layers in relation to the core diameter. METHODS: Two standardized cylindrical cast model sizes were used to simulate forearm and short leg casts (core diameter: 60 mm, 100 mm) with 2 different casting techniques (non-smoothing vs. smoothing with lamination), utilizing 2 casting materials [fiberglass and Plaster of Paris (POP)]. Each cast was created using 3 different layers (Fiberglass: 2 to 4 layers; POP: 3 to 5 layers). Ultimate load-to-failure and flexural rigidity were analyzed through cyclic 4-point bend testing. RESULTS: The biomechanical comparison between forearm and short leg casts were significantly different regardless of the same number of layers for both casting materials and between 2 casting techniques. Increased cast thickness significantly increased the ultimate load-to-failure and bending strength. An increased core diameter size significantly decreased the cast's ultimate load-to-failure (fiberglass: 50% to 108%; POP: 10% to 93%) and bending strength (fiberglass: 17% to 35%; POP: 37% to 49%). Casting technique with smoothing with lamination technique had a negative biomechanical effect on POP and a minimal effect on fiberglass. CONCLUSION: The number of layers to apply for a cast should be based on the size of the extremity. Smoothing and lamination technique did not significantly improve the cast mechanical behavior. CLINICAL RELEVANCE: The findings of this study provide valuable evidence, analysis, and supplementary knowledge that helps guide physicians in proper casting technique.

Symptomatic Hammertoes Treatment Comparison: Peg-in-Hole Arthrodesis Versus End-to-End Screw Fixation.

Proximal interphalangeal (PIP) arthrodesis technique utilizing the peg-in-hole arthrodesis was founded to avoid the use of retained internal fixation implants and thereby potentially decrease the concern of hardware complication. The specific aim of this study was to report the complication rates of the modified peg-in-hole arthrodesis technique and the end-to-end arthrodesis with single screw fixation technique for correcting symptomatic hammertoe deformities in lesser digits. This retrospective chart review included patients who underwent surgical hammertoe correction of lesser digits between the dates of January 2012 and December 2019. Patient demographic data and charts were reviewed to evaluate need for revision including screw/pin removal and complications related to corrective surgery. Five hundred ninety-three symptomatic hammertoe deformity cases (443 female, 150 male) were identified, with 113 cases (88 female, 25 male) treated with peg-in-hole arthrodesis technique and 480 cases (355 female, 125 male) treated with end-to-end arthrodesis with a single screw technique. The deformity recurrence rate was not significantly different between the two techniques (peg-in-hole: 10%, end-to-end: 13%, p = .428). There were 97 cases with postoperative complications that required re-operation (peg-in-hole: 7 cases, end-to-end: 90 cases) with the majority detected at <6 months. There was no statistically significant difference in reoperation rate between the peg-in-hole technique and the end-to-end arthrodesis technique reoperated with reasons excluding simple screw removal (p = .068). This study tended to show these two arthrodesis techniques have equivalent risks and similar success in bone healing; however, the peg-in-hole arthrodesis technique offers an advantage that does not result in retained hardware.

Use of electrocautery devices for suture passage through the greater tuberosity: a biomechanical study.

BACKGROUND: The use of electrocautery to facilitate passage of a suture needle through bone without the aid of a drill or burr is a novel technique that has potential utility in orthopedic procedures, but there is a scarcity of research to support its utility. The specific aims of this cadaveric biomechanical study were to evaluate (1) the axial force reduction during suture passage using electrocautery when applied to rotator cuff repair, (2) the temperature change caused while using electrocautery, and (3) the failure loads and failure modes of this technique. METHODS: Five matched pairs of fresh frozen humeri were used, classified into 2 groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Four individual osseous tunnels were made on the greater tuberosity around the insertion of the supraspinatus tendon. Each specimen was sequentially tested in 2 parts: a needle penetration test (part I) to measure the peak axial force and temperature change and a single load-to-failure test (part II) to measure the maximum load to failure as well as the mechanism of failure. A No. 2 FiberWire suture with a straight needle was used. RESULTS: In part I, the mean peak axial force was lower in the study group compared with the control group for all osseous tunnels but was not statistically significant for individual tunnels. However, there was a significant decrease in peak axial force in the study group of 36% compared with the control group overall (P = .033). There was no significant change in temperature of the tunnel site with the use of electrocautery (mean: 0.2 ± 0.3°C, P = .435). In part II, 100% of the samples from each study group experienced bone tunnel failure. Forty percent of the trials in the study group found lower ultimate failure loads compared with the control group (reduction range: 7%-38%). There was no statistically significant difference in the ultimate failure load between either the loop tested or between the 2 study groups (loop 1: P = .352; loop 2: P = .270). CONCLUSION: Suture passage using electrocautery does significantly decrease the peak force needed to pass a needle directly through the greater tuberosity. This technique does not appear to burn the bone or weaken the bone tunnels. This technique may be useful during open rotator cuff repair or shoulder arthroplasty, although clinicians should be cautious when using this technique as its utility depends on bone quality and cortical thickness, and in vivo results may differ.

Can a Blade-Stopping Mechanism on Circular Table Saws Reduce the Severity of Hand Injuries in Contact Scenarios? A Cadaveric Study.

PURPOSE: Table saws are commonly used woodworking tools that carry a substantial risk of injury. Blade-stopping technology has been developed and has the potential to reduce the frequency and severity of injury. This study aimed to evaluate this technology on human tissue and characterize the resulting injuries. METHODS: Twenty-seven fresh, frozen cadaveric specimen hands were used. Three scenarios were tested, with the specimen (1) moving forward ("forward"); (2) moving backward, such as in a kickback scenario ("reverse"); and (3) dropped from above the saw blade ("top"). Each scenario was tested at both slow (0.001 m/sec) and fast (forward: 0.6 m/sec; reverse: 0.5 m/sec; top: 2.4 m/sec) approach speeds. The severity of the injuries was characterized by anatomic evaluation and confirmed with radiographic evaluation. Injuries were classified as no laceration, superficial soft tissue injury, deep soft tissue injury, and bony injury. RESULTS: For the slow approach speed, the brake cartridge engaged in 100% of the trials for all 3 scenarios, and 100% of the specimens sustained no injuries. Forward testing at a fast approach speed revealed the brake cartridge engaged in 89% of the trials (injuries: 4 superficial, 2 deep, 3 bony). Reverse testing at a fast approach speed revealed the brake cartridge engaged in 11% of trials (injuries: 1 superficial, 8 bony). Top testing at a fast approach speed revealed the brake cartridge engaged in 89% of the trials (injuries: 9 bony). CONCLUSIONS: Modern blade-stopping technology did not prevent all traumatic hand injuries in fast approach speed scenarios, but it reduced the incidence and severity of injuries. The technology was more effective at low approach speed scenarios. CLINICAL RELEVANCE: The findings of this study provide information to help understand the factors that can prevent or reduce the severity of contact injuries (hand, finger, or thumb) for operators of table saws.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair.

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

Computed Tomography Derived Patient-specific Instrumentation Total Ankle Arthroplasty Survivorship Outcomes.

Computed tomography (CT) derived patient-specific total ankle arthroplasty (TAA) systems have been utilized for improved accuracy and reproducible implant alignment. The purpose of the present study was to report the overall implant survivorship as well as radiographic analysis of patients who underwent primary TAA utilizing CT-derived patient-specific instrumentation. A retrospective review of medical charts and radiographs were performed on patients who had undergone primary TAA at a single institution in the Midwest region from March 2013 to October 2020. Radiographic analysis included preoperative, initial postoperative, and final follow-up coronal and sagittal tibiotalar alignment as well as periprosthetic radiolucency. A total of 96 patients with a mean follow-up of 3 years (range, 0.3-7.3 years) were included. Implant survivorship was found to be 92% at median follow-up of 3 years. A total of 8 cases (8.3%) required revision/reoperation, with 6 (6.3%) of these reoperations directly related for failure of one of the metallic implant components. There was significant improvement in both coronal and sagittal tibiotalar alignment from preoperative to initial postoperative follow-up (p < .001). At latest postoperative follow-up, there were 88% of TAAs that remained in a neutral alignment following surgery. A total of 10 cases were found to have radiolucency at latest follow-up. In conclusion, the use of CT derived patient-specific TAA showed high implant survivorship with significant improvement of sagittal and coronal tibiotalar alignment. With better implant alignment and position, it potentially reduces the risk of early implant failure or implant loosening in long-term follow-up.

Use of Electrocautery to Facilitate Suture Passage Through the Greater Trochanter of the Femur: A Biomechanical Study.

Introduction: The specific aims of this study were to evaluate (1) the axial force reduction of suture passage utilizing electrocautery when applied to the greater trochanter of the femur, (2) the temperature change caused while using electrocautery for suture passage, and (3) the failure loads and failure modes utilizing this technique. Methods: Five matched pairs of fresh-frozen femurs were used and classified into two groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Two bicortical, osseous tunnels were made around the insertion of the gluteus medius tendon. Each specimen was sequentially tested in a needle penetration test and a single load-to-failure test. A #5 Ethibond suture with a straight needle was used. Results: Electrocautery reduced the peak axial force for bone penetration in 40% (near cortex) and 70% (far cortex) of the trials, and no significant difference was detected between groups or between two osseous tunnels. The average peak force was significantly higher for the far cortex for both groups and for both osseous tunnels compared to the near cortex. There was no significant change in temperature of the tunnel site with electrocautery. Ninety percent of the samples experienced bone tunnel failure for the study group compared to 70% in the control group. The average ultimate failure load for the study group was lower compared with the control group, but this finding was not statistically significant (range: 6%-15%). Conclusions: Suture passage using electrocautery may not significantly decrease the peak force needed to pass a needle directly through the greater trochanter.

Clinical Outcome of Different Postoperative Prophylactic Strategies on Symptomatic Venous Thromboembolism after Total Knee Arthroplasty.

Introduction: The objective of this study was to evaluate the use of different post-operative prophylactic strategies on the rates of symptomatic venous thromboembolic events (VTE) incidence after primary total knee arthroplasty (TKA). Methods: A retrospective study of patients who underwent primary TKA procedure was performed from January 2015 through July 2020. Outcomes examined prophylaxis medication used during inpatient and outpatient care, amount of medication, length of medication, complications occurring within 90 days post-operatively, including symptomatic VTE (deep venous thrombosis (DVT), and pulmonary embolism (PE)), gastrointestinal (GI) bleeding requiring medical attention, change in management protocols after post-operative complications, and mortality. Results: In total, 5,663 cases were included (mean age 66 ± 10 years, mean BMI 34.1 ± 7.1kg/m2). The overall post-operative complication rate was 0.9% (DVT: 0.5%, PE: 0.3%, VTE: 0.04%, and GI bleeding: 0.09%). Enoxaparin use as inpatient anticoagulation medication was reduced significantly (67% vs. 13%, p < 0.001), and apixaban was increased significantly (6% vs. 49%, p < 0.001). Average hospital stays were reduced significantly among the years (3 ± 2 days vs. 2 ± 1 days, p < 0.001), and complication rates were not significantly different between the five years (~1%, p < 0.001). Most post-operative complications occurred on either aspirin 325 mg (36%) or apixaban (26%). However, the relative risk ratio results indicating that utilization of warfarin, rivaroxaban, and aspirin 81 mg as outpatient anticoagulation medication were more likely to increase the risk of symptomatic VTE incidence compared to other anticoagulants. The average time of complication detected was 21 ± 21 days (range: 1 - 87 days). More than 54% of complication events occurred after the patient had completed their medication (enoxaparin, rivaroxaban, and apixaban). Conclusions: The observed incidence of symptomatic VTE in this study was similar to previous studies regardless of the type of post-operative inpatient or outpatient prophylaxis prescribed. The ultimate choice of prophylaxis should remain with the treating physician and their knowledge of a particular patient's medical history.

Does Surgeon Subspecialty Training Affect Outcomes in the Treatment of Displaced Supracondylar Humerus Fractures in Children?

INTRODUCTION: The effect of the treating surgeon's subspecialty training on the outcomes of managing displaced supracondylar humerus fractures in the pediatric cohort remains under debate. The objective of this study was to examine patient outcomes and treatment variables for these injuries based on the surgeon subspecialty training. METHODS: A retrospective study of children who had undergone primary closed reduction and percutaneous fixation for displaced supracondylar humerus fractures was done from January 2012 through May 2019. The following four groups with differing orthopaedic subspecialty training were evaluated: (1) pediatric fellowship trained (2) trauma fellowship trained, (3) sports medicine fellowship trained, and (4) all others. Outcomes examined included time to surgery, surgical time, fluoroscopy usage, postoperative follow-up protocols, radiographic measurements of alignment, and complications between surgeon groups. RESULTS: Two hundred thirty-one cases were included (mean age 6 ± 2 years). Pediatric fellowship-trained surgeons took patients to surgery in a more delayed fashion (>12 hours, P = 0.02). Surgical time and fluoroscopy usage were significantly shorter for pediatric fellowship-trained surgeons (P < 0.001). No statistical difference was noted in pin configuration constructs between the groups. Pediatric fellowship-trained surgeons, on average, saw patients two times postoperatively within a year with most patients being within 30 days. Complications were not statistically different between the groups. CONCLUSIONS: Pediatric fellowship-trained orthopaedic surgeons provide more efficient care on a more delayed basis for displaced supracondylar humerus fractures than other subspecialty-trained orthopaedic surgeons. However, if barriers exist that limit the practicality or availability of these specialists, nonpediatric fellowship-trained surgeons achieve similar and satisfactory outcomes. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Impact of Cigarette Smoking on Re-operation and Revision Surgery after Femoral Neck Fracture Treatment.

INTRODUCTION: Smokers and nicotine users have a higher risk of femoral neck fracture non-union and prolonged time to fracture union. The impact of smoking resulting in revision surgery after fixation of femoral neck fractures, however, rarely has been studied. The aim of this retrospective study was to review if cigarette smoking had an influence on re-operation and revision after femoral neck fracture treatment. METHODS: Three groups of patients (Group 1: active smokers; Group 2: former smokers; and Group 3: non-smokers) who sustained a femoral neck fracture from January 2012 through August 2018 were included. Outcomes investigated included femoral neck fracture type, operative fixation type, fixation failure, and time interval between initial fixation and revision. RESULTS: A total of 1,452 subjects were identified (Group 1: 165 subjects; Group 2: 507 subjects; and Group 3: 780 subjects). In the male population, Groups 1 and 2 had higher rates of femoral neck fracture than Group 3. Twelve cases required revisions (Group 1: three cases (6%); Group 2: two cases (2%); Group 3: seven cases (4%)), with all but one revision within the first year following initial fixation. Group 1 patients tended to be younger than the other two groups. CONCLUSION: Smoking has a positive association with the risk of femoral neck fracture amongst active and former male smokers. This study concluded that active smokers have a higher risk of non-union compared with non-smokers or former smokers. Smoking history, especially heavy or long-term, should play a role in deciding which fixation construct type to use for femoral neck fractures.

Biomechanical Evaluation of the Accuracy in Radiographic Assessment of Femoral Component Migration Measurement after Total Hip Arthroplasty.

INTRODUCTION: Implant subsidence is one criteria utilized to monitor for prosthesis loosening after total hip arthroplasty (THA) with initial implant subsidence assessment often done utilizing plain radiographs. The specific aim of this study was to identify the most reliable references when using plain radiographs to establish an image magnification with the goals being easy to use, inexpensive, reliable, and accurate. METHODS: Two femoral stem implants (stem lengths: 127 mm, 207 mm) were utilized to simulate hemiarthroplasty of the hip with composite femurs. Different combinations of femoral stem distances from the radiographic film (ODD), source-detector differences (SDD), hip rotation, and hip flexion were elected. Standardized anterior-posterior pelvis for each parameter combination setup were taken. Radiographic measurements (head diameter, stem length, stem seating length) were undertaken five times by three examiners. Radiographic image magnification factors were generated from two references (head diameter and stem length). Radiograph measurement reproducibility and stem seating length errors using these magnification factors were evaluated. RESULTS: High level of repeated measurements reliability was found for head diameter (99 ± 0%) and stem length (90 ± 7%) measurements, whereas seating length measurements were less reliable (76 ± 6%). Stem length error using the femoral head magnification factor yielded 11% accuracy. Stem seating length error using both magnification factors were not reliable (< 7% accuracy). All parameters, except SDD, showed significant effect on calibrated measurement error. CONCLUSION: Current methods of assessing the implant subsidence after THA are inaccurate and unreliable. Clinicians should recognize these limitations and be cautious when diagnosing implant stability using plain radiographs alone.

Comparing the Influence of Different Overhand/Underhand Stacking Combinations of Reversing Half-Hitches on Alternating Posts on Arthroscopic Knot Security.

INTRODUCTION: Previous literature demonstrated the importance of stacking at least three reversing half-hitches on alternating posts (RHAPs) following arthroscopic knot placement. However, RHAPs construction involves looping the suture in either an "overhand" or an "underhand" manner as it relates to the post, which may affect knot security. This study investigated the presently unidentified influence of different stacking combinations of three RHAPs and suture material on arthroscopic knot security. METHODS: Four different RHAPs stacking combinations were tied with three different suture materials. Ten knots of each configuration were tied using each suture material, resulting in 120 evaluated knots. A single load-to-failure test was performed. The mode of failure and mean ultimate clinical failure load were recorded. RESULTS: Different overhand/underhand stacking combinations of three RHAPs had a statistically significant effect on arthroscopic knot strength and security; however, all combinations surpassed the minimum ultimate clinical failure threshold. Knots constructed with either Force Fiber® or braided fishing line had mean ultimate clinical failure loads of greater than 200 N and most commonly failed due to suture material breakage (100%, 60 - 80% respectively). Conversely, FiberWire® demonstrated lower mean ultimate clinical failure loads and had a higher incidence of elongated but intact failure (60 - 90%). CONCLUSION: Different overhand/underhand stacking combinations of three RHAPs yielded an arthroscopic knot capable of secure tissue fixation. A significant effect was observed for suture materials on the knot strength. This study increases our understanding of suitable RHAPs construction following arthroscopic knot placement that can lead to improving the ultimate clinical failure loads of constructed arthroscopic knots observed between orthopedic surgeons.

Variable Angle Locking Compression Plate as Alternative Fixation for Jones Fractures: A Case Series.

INTRODUCTION: Jones fractures pose many challenges for the treating surgeon and can cause significant disability for some patients. The aim of this study was to review the results of using a variable angle locking compression plate as an alternative fixation method in the treatment of Jones fractures. METHODS: A retrospective chart review was conducted of patients who had undergone fixation of Jones fracture with a variable angle locking compression plate from September 2012 through February 2016. Radiographs of the preoperative and six-week postoperative and postoperative follow-up outcomes, including complication and hardware removal, were collected. RESULTS: Twenty-three cases met the inclusion/exclusion criteria. The overall bony union rate was 96% at six-week postoperative and 100% at 20-week postoperative. Mean age was 30 ± 16 years, and mean BMI was 30.7 ± 5.2 kg/m2. Three patients (13%) had plate removal: two (9%) were due to irritation caused by shoe wearing and one patient (4%) had a skin infection (cellulitis) which was treated with intravenous antibiotics. One patient (4%) had developed deep vein thrombosis (DVT) that was resolved with anticoagulant without implant removal. No fixation loss and no associated complications developed from implant removal. CONCLUSIONS: Based on our limited experience, this study provided evidence that the variable angle locking compression plate may be an alternative form of fixation for Jones fractures with a low complication rate. This procedure seemed to provide a safe, reliable method that can achieve an anatomic reduction, stable fixation, rapid healing, and good results in the treatment of Jones fractures.

The Cost of Routine Follow-Up in Total Joint Arthroplasty and the Influence of These Visits on Treatment Plans.

INTRODUCTION: Many physicians recommend annual or biennial visits after total hip and knee arthroplasty (THA and TKA). This study sought to establish the cost of a post-operative visit to both the health care system and patient and identify if these visits altered patient management. METHODS: A prospective cohort study was conducted using patients presenting for follow-up after THA or TKA from April through December 2016. All surgeries were performed by a single orthopaedic surgeon in Wichita, Kansas. All eligible subjects that met the inclusion criteria received and completed a questionnaire about the personal cost of the visit and their assessment of their function and outcome after total joint arthroplasty. The physician also completed a questionnaire that examined the cost of the visit to the health care system and whether the clinical or radiographic findings altered patient management. RESULTS: Fifty-six patients participated with an average length of follow- up of 4.5 ± 4.1 years since surgery. The average patient cost was $135.20 ± $190.53 (range, $1.65 - $995.88), and the average visit time for the patient was 3.9 ± 2.9 hours. Eighty percent of patients reported no pain during the clinic encounter, and 11% reported loss of function. Eighty-four percent thought the visit was necessary. Physician time for each visit lasted 12.9 ± 3.7 minutes (range, 10 - 20 minutes). Only 9% of patient encounters resulted in an alteration in patient management. This occurred at an average follow-up time of 3.6 ± 1.8 years after the index procedure. The average cost of each visit to the health care system at large was $117.31 ± 60.53 (range, $93.90 - $428.28). CONCLUSIONS: The findings of this study advise total joint patients and orthopaedic surgeons regarding the cost of routine post-operative appointments and whether these visits alter patient management. The majority of the routine follow-up visits after THA and TKA did not result in an alteration in patient management, but added substantial cost to the health care system.

Prior Anterior Cruciate Ligament Reconstruction Effects on Future Total Knee Arthroplasty.

BACKGROUND: The impact of prior anterior cruciate ligament (ACL) reconstruction on total knee arthroplasty (TKA) has rarely been studied. The objective of this study was to compare intraoperative characteristics in patients who underwent TKA with pre-existing hardware from prior ACL reconstruction with a matched cohort control group. METHODS: A retrospective study of patients who had undergone primary TKA with pre-existing hardware from prior ACL reconstruction was performed from June 2012 through June 2017. These patients were 2-to-1 matched to the ACL group based on similar patient demographic and provider variables. Outcomes investigated included operative time, estimated blood loss (EBL), and postoperative complications. RESULTS: One hundred one patients met the inclusion/exclusion criteria. The mean age was 54 ± 9 years, and the mean body mass index was 32.6 ± 6.5 kg/m2. The ACL group was divided into 4 subgroups: group 1, no pre-existing hardware removed (22 TKAs); group 2, pre-existing hardware removed from the femur only (8 TKAs); group 3, pre-existing hardware removed from the tibia only (45 TKAs); and group 4, pre-existing hardware removed from both the femur and tibia (26 TKAs). There was no statistical difference in EBL and postoperative complication between the ACL group and controls. Statistical differences were detected between 2 subgroups regarding mean operative time variables: ACL group 3 (74 ± 23 minutes; control: 64 ± 21 minutes, P = .020) and group 4 (79 ± 24 minutes; control: 65 ± 19 minutes, P = .010). CONCLUSION: Hardware retained, especially on the tibia, from prior ACL reconstruction has a major impact on TKA surgical procedure operative time but not on EBL and/or complications.