Transition to Robotic Total Knee Arthroplasty With Kinematic Alignment is Associated With a Short Learning Curve and Similar Acute-Period Functional Recoveries.

Background Robotic instruments are increasingly being used in total knee arthroplasty (TKA). The adoption of robotics has allowed surgeons a new level of precision and facilitated the adoption of a kinematic approach in TKA. We sought to examine one surgeon's transition from a traditional mechanical alignment technique to a modified kinematic approach by comparing short-term recovery outcomes of robotic TKA patients with those who underwent traditionally instrumented TKAs. Methodology We examined six-week and six-month postoperative data from 99 traditionally instrumented, mechanically aligned and 66 kinematically aligned robotic TKA patients between January 2021-October 2021 and October 2021-April 2022, respectively. Robotic surgery was performed with VELYS™ (DePuy Synthes, Warsaw, IN, USA) a semi-active, imageless, table-affixed, robotic TKA solution. Results Robotic and traditionally instrumented TKAs did not differ significantly in any functional outcome measures examined, including pain scores, use of assistive devices, or range of motion at six weeks postoperatively. Robotic TKA patients had a better range of motion in knee flexion than traditional TKA patients at six months postoperatively. There were no differences in surgical complications or rates of manipulation under anesthesia within one year postoperatively. Robotic surgery tourniquet times exhibited a steep drop off and equaled traditional methods after only two robotic surgeries were performed. Conclusions Transition to a kinematic, semi-active, robotic TKA demonstrated encouraging results by demonstrating acute-period recovery of function consistent with the current standard of care, as well as a better range of motion at six months postoperatively. The learning curve of this new-to-market device was shorter than previous research on the transition to robotic TKA. Clear advantages of transitioning to robotic instrumentation by any specific functional measure are yet to be elucidated. Further randomized trials are necessary to characterize long-term outcomes.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review.

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Factors Associated With Early Improvement in Low Back Pain After Total Hip Arthroplasty: A Multi-Center Prospective Cohort Analyses.

This study identified factors associated with an improvement in low back pain (LBP) at six-month follow-up after total hip arthroplasty (THA). Data from a national registry of 3054 patients were analyzed. Factors under analysis included demographics, comorbid conditions, operative and nonoperative joint pain severity, physical function, and mental health. Differences in these factors between patients with and without improvement in LBP were examined. Among patients reporting severe or moderate LBP preoperatively, 56% improved 6 months after surgery. Patients without improvement were more likely to be on Medicare, have a high school education or less, have household income less than $45,000 and have one or more comorbid conditions. Patients with improvement in LBP experienced more resolution of pain in both the operative and nonoperative hip.

Suppressive Effects of Insulin on Tumor Necrosis Factor-Dependent Early Osteoarthritic Changes Associated With Obesity and Type 2 Diabetes Mellitus.

OBJECTIVE: Obesity is a state of chronic inflammation that is associated with insulin resistance and type 2 diabetes mellitus (DM), as well as an increased risk of osteoarthritis (OA). This study was undertaken to define the links between obesity-associated inflammation, insulin resistance, and OA, by testing the hypotheses that 1) tumor necrosis factor (TNF) is critical in mediating these pathologic changes in OA, and 2) insulin has direct effects on the synovial joint that are compromised by insulin resistance. METHODS: The effects of TNF and insulin on catabolic gene expression were determined in fibroblast-like synoviocytes (FLS) isolated from human OA synovium. Synovial TNF expression and OA progression were examined in 2 mouse models, high-fat (HF) diet-fed obese mice with type 2 DM and TNF-knockout mice. Insulin resistance was investigated in synovium from patients with type 2 DM. RESULTS: Insulin receptors (IRs) were abundant in both mouse and human synovial membranes. Human OA FLS were insulin responsive, as indicated by the dose-dependent phosphorylation of IRs and Akt. In cultures of human OA FLS with exogenous TNF, the expression and release of MMP1, MMP13, and ADAMTS4 by FLS were markedly increased, whereas after treatment with insulin, these effects were selectively inhibited by >50%. The expression of TNF and its abundance in the synovium were elevated in samples from obese mice with type 2 DM. In TNF-knockout mice, increases in osteophyte formation and synovial hyperplasia associated with the HF diet were blunted. The synovium from OA patients with type 2 DM contained markedly more macrophages and showed elevated TNF levels as compared to the synovium from OA patients without diabetes. Moreover, insulin-dependent phosphorylation of IRs and Akt was blunted in cultures of OA FLS from patients with type 2 DM. CONCLUSION: TNF appears to be involved in mediating the advanced progression of OA seen in type 2 DM. While insulin plays a protective, antiinflammatory role in the synovium, insulin resistance in patients with type 2 DM may impair this protective effect and promote the progression of OA.

Imageless computer-assisted versus conventional total hip arthroplasty: one surgeon's initial experience.

Computer-assisted surgery (CAS) systems are advocated to improve component positioning in THA, though potential operative risks and costs of CAS have fueled debate. The present study examines the radiographic outcomes, operative efficiency, cost, and midterm functional outcomes for patients who underwent THA, either with CAS or conventional instrumentation. Patient baseline characteristics were recorded for 126 lower-extremities in the CAS series, and 215 in the conventional series. There was no difference in Harris Hip Score or leg length discrepancy between series. Inclination angle, blood loss, and operating room times were increased for CAS. These results suggest that CAS confers no advantage over conventional methods regarding accuracy of THA component placement, drives unreimbursed increases in procedure costs, may expose patients to additional operative risk, and produces no functional benefit at midterm follow-up.

Hematogenous infection of total hip arthroplasty with Actinomyces following a noninvasive dental procedure.

This article describes a case of an infected total hip arthroplasty following a dental procedure. A 59-year-old man underwent total hip arthroplasty for osteoarthritis and had a routine recovery. Approximately 9 months postoperatively, he underwent a dental cleaning without antibiotic prophylaxis. One month later, he reported gradually worsening right hip pain and a purulent discharge. After several unsuccessful interventions, the patient was referred to the authors' facility. The patient's history, draining sinus tract, and radiographic changes were considered diagnostic of a late chronic infection, and the patient underwent 2-stage revision. Intraoperatively, the sinus tract extended directly to the acetabular component. Actinomyces spp were isolated from 3 of 7 intraoperative anaerobic cultures, and the patient received penicillin G for 8 weeks. Two weeks after discontinuing antibiotics, with no clinical manifestation of recurrent infection and a negative hip aspiration, a new hip prosthesis was implanted. The patient was prescribed penicillin for 12 months postoperatively. Harris Hip Score was 100 at 52-month follow-up. The American Dental Association and the American Academy of Orthopaedic Surgeons issued consensus guidelines for chemoprophylaxis in orthopedic patients undergoing dental procedures in 1997 and 2003. Although the American Academy of Orthopaedic Surgeons issued a revised guideline in 2009 recommending more robust antibiotic prophylaxis, significant controversy exists because at least one professional organization representing dentists has repudiated the 2009 American Academy of Orthopaedic Surgeons guideline. The authors describe the implications from their experience and similar cases in the literature with regard to such guidelines.

Evaluation of donor site intrinsic healing response in autologous osteochondral grafting of the knee.

We report the case of a 45-year-old male patient who underwent autologous osteochondral autografting in the knee for osteochondritis dissecans. The patient required revision surgery 1 year postoperatively, which allowed histologic and mechanical characterization of the intrinsic healing response of the initial graft donor sites. Histologic examination showed heterogeneous areas of dense fibrous tissue, bone, and discrete areas of cartilage. Mechanical testing using a confined compression testing technique determined the equilibrium stiffness as 0.97 MPa. The majority of dense fibrous tissue and areas of bone are likely responsible for the observed increased stiffness. When performing osteochondral autografting, consideration must be given to the benefit afforded to improving the areas of cartilage injury with the potential morbidity associated with graft harvest at the donor sites.