Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision.

BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Specific preoperative factors increase manipulations under anesthesia following primary TKA.

Background Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA. Methods We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or Chi-squared tests as appropriate. For each preoperative factor, we obtained an odds ratio for MUA risk using multivariate logistic regression. Results Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (odds ratio [OR]: 2.727, p=0.047) and diagnosed hypertension (OR: 4.764, p=0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative range of motion, the higher likelihood needed of MUA (OR: 1.031, p=0.034). Conclusions Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.

Scheduling and Vendor Consistency Improves Turnover Time Efficiency in Total Joint Arthroplasty.

BACKGROUND: Maximizing operative room (OR) efficiency is important for hospital efficiency, patient care, and positive surgeon and staff morale. Reducing turnover time (TOT) has become a popular focus to improve OR efficiency. The present study evaluated if TOT is influenced by changing case type, implant vendor, and/or laterality. METHODS: In total, 444 turnovers from January to July 2023 were retrospectively analyzed. All turnovers were same-surgeon turnovers between primary arthroplasty cases in dedicated, overlapping rooms. Single linear regression models tested the predictability of TOT based on case type, vendor, and laterality. A multivariate multiple regression and 1-way Analyses of Variance analyzed variables against each other. Independent sample t-tests evaluated TOTs when all variables were the same or different. RESULTS: Changing versus keeping the same case type increased TOT by 2.4 minutes (95% confidence interval [CI] = 0.7, 4.0; P = .004). Changing vendors increased TOT by 2.9 minutes (95% CI = 1.1, 4.7; P = .002). Laterality did not affect TOT, with a change of 0.9 minutes (95% CI = -0.6, 2.5; P = .229). Vendor (P = .030) independently predicted TOT when analyzed as a covariate with case type (P = .410). The TOT with same case type and vendor (mean 38.2 minutes; range, 22 to 62) was less than that of different case types and vendors (mean 41.4 minutes; range, 26 to 73) (P = .017). Mean TOT differed by 5.5 minutes when keeping all variables the same versus all different (P = .018). CONCLUSIONS: Maintaining a consistent case type, vendor, and laterality had a synergistic effect in reducing TOT in arthroplasty ORs with the same primary surgeon running 2 overlapping rooms. Changing vendor representatives was found to independently predict TOT increases, which is likely attributed to a disruption in workflow and collaboration of the multidisciplinary OR team. LEVEL OF EVIDENCE: Level III.

Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection.

BACKGROUND: This multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). METHODS: This retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. RESULTS: The average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. CONCLUSIONS: This study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. LEVEL OF EVIDENCE: Level III.

Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities.

BACKGROUND: Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS: We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS: Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS: In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.

The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial.

BACKGROUND: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. CONCLUSIONS: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. LEVEL OF EVIDENCE: Level 1, RCT.

Accuracy of the Lesser Trochanter Profile as a Marker of Femoral Rotation: Computed Tomography-Based Study of 1,722 Femora.

BACKGROUND: The lesser trochanter (LT) profile is an often-used marker for proximal femoral rotation, particularly during the operative fixation of femoral fractures. Previous studies have come to conflicting conclusions about its reliability for this purpose. METHODS: The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,722 computed tomographic (CT) scans of whole femora. Each femur was taken through an 80° rotational arc in 2.5° increments, and the LT profile was constructed for each position. These 56,826 LT profile measurements were then correlated with the femoral rotation. RESULTS: Across the arc of motion studied, the LT correlated weakly with proximal femoral rotation (R 2 = 0.32). There was a 35° arc, between 10° and 45° relative external rotation of the proximal femur, within which the LT profile only changed by 1 mm. The mean overall femoral anteversion was 21.2°, and women tended to have more femoral anteversion (23.9°) than men (19.2°). On average, men had a 1.6-mm more prominent LT than women. Side-to-side differences in femoral anteversion as well as LT position and size were not significant or were clinically unimportant. CONCLUSIONS: A large-scale, CT-based study shows that the LT profile is a less reliable marker of proximal femoral rotation than previously thought. This is true particularly if there is relative external rotation of the proximal femur, where the proximal femur can undergo up to 35° of rotation before 1 mm of change in the LT profile occurs. Care must be taken to check other markers of rotation such as by clinical examination during fixation of femoral fractures and not rely solely on the LT profile. CLINICAL RELEVANCE: In the largest study of its kind, this CT-based study of 56,826 LT profile measurements found that when the proximal femur is externally rotated, the LT profile becomes an unreliable marker of rotation, which can lead to excessive internal rotation of the distal fracture fragment. The LT profile should be used with caution, and confirmation of rotation by other means is recommended.

Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty?

INTRODUCTION: Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA). METHODS: The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated. RESULTS: This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05). DISCUSSION: Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.

Tourniquet-free minimally invasive total knee arthroplasty is associated with early aseptic loosening.

BACKGROUND: While tourniquet-free (T-) total knee arthroplasty (TKA) has gained popularity, tourniquet-use during minimally-invasive (MIS)-TKA has not been adequately studied. Traditional techniques employ knee hyper-flexion, compressing vasculature and reducing impact of bleeding, while MIS-TKA embraces the semi-extended knee position, which does not restrict the effects of bleeding on cementation and visualization. We compared the risk of aseptic loosening between patients undergoing T- MIS-TKA compared to T + MIS-TKA. METHODS: This single-surgeon cohort study included 329 consecutive MIS-TKA (226 T+,103 T-) patients with minimum 3-year follow-up. Aseptic loosening, radiolucent lines (RLL), health related quality of life scores, and complications were recorded. T-test and chi-square test were used to compare continuous and categorical variables, and logistic regression included BMI, age, ASA, patellar-resurfacing, and tourniquet-use. RESULTS: There were no differences in baseline demographics. One (0.4 %) aseptic loosening occurred with T+, versus 7 (6.8 %) with T- (p = 0.002). No T + and 3 T- patients (2.9 %, p = 0.01) had revision for aseptic loosening. The incidence of RLLs was 16.8 % in T + and 30.1 % in T- (p = 0.008). Logistic regression revealed T + was significantly associated with decreased aseptic loosening and risk of RLL (odds ratio = 16.4, odds ratio = 2.8). CONCLUSION: In this consecutive series, T- MIS-TKA was associated with increased rates of revision for aseptic loosening as compared to the T + MIS-TKA, even controlling for BMI, age, ASA level, and patellar resurfacing. Radiolucent lines were increased with T- MIS-TKA compared to T + MIS-TKA. Complications, all-cause revision, ROM, and HRQoL scores were similar between tourniquet-use and tourniquet-free cohorts.

Is It Necessary to Wake Patients for Overnight Vital Signs Following Total Joint Arthroplasty?

Benefits of sleep are well-established in postoperative recovery; however, patients undergoing total joint arthroplasty (TJA) often experience poor sleep during hospitalization. While multifactorial, among the major reasons are the frequent and ritualized overnight vital sign checks. In the absence of data in support of or against this practice, we asked whether it remains necessary. We retrospectively analyzed a cohort of 419 primary TJA patients. Demographics, comorbidities, operative, and vital sign data were collected through postoperative Day 3. Correlation between daytime (6:00 a.m. to 10:00 p.m.) and nighttime (10:01 p.m. to 5:59 a.m.) vitals was examined. The vast majority of nighttime vitals fell within normal ranges, including O2 saturation (O2; 99.4%), temperature (TEMP; 97.8%), heart rate (HR; 87.5%), systolic blood pressure (SBP; 85.8%), and diastolic blood pressure (DBP; 84.4%). Predictors of abnormal nighttime vitals included American Society of Anesthesiologists (ASA) score (abnormal SBP; odds ratio [OR] 1.64, p = .045), obesity (abnormal DBP; OR: 0.37, p = .011), and smoking status (elevated temperature; OR: 2.79, p = .042). Estimated blood loss was predictive of an abnormal nighttime TEMP (OR: 1.002; p < .001). Postoperatively, there were several correlations between abnormal daytime and nighttime vitals, including SBP (OR: 6.23, p < .001), DBP (OR: 4.31, p < .001), and HR (OR: 10.35; p < .001). Of the 419 patients, only 9 (2.1%) received any intervention based on abnormal nighttime vitals. Each exhibited daytime vital sign abnormalities prior to the abnormal nighttime readings. Patients with abnormal nighttime vitals can be predicted on the basis of medical comorbidities and abnormal daytime vitals. These findings suggest that healthy post-TJA patients with normal daytime vitals may not need to be routinely woken at night.

The temporal effects of variable tourniquet use on pain after total knee arthroplasty.

BACKGROUND: Tourniquet use in total knee arthroplasty (TKA) remains controversial. While widely studied, any temporal effects on pain and opioid utilization have not been investigated. We hypothesized that postoperative opioid utilization increases with increasing tourniquet times in TKA. METHODS: We retrospectively reviewed 1110 TKAs by three arthroplasty surgeons from October 2016 through September 2019. Exclusion criteria included ambulatory surgery, undocumented tourniquet times, simultaneous bilateral TKA, and diagnoses other than osteoarthritis, inflammatory arthritis, or osteonecrosis. Postoperative opioid medications were converted to daily morphine milligram equivalents (MME/day). Secondary outcomes included range of motion (ROM) at 1-month, 3-month, and 1-year visits as well as patient reported outcomes measures (PROMs) at 3 and 12 months. RESULTS: Nine-hundred and eleven patients were included and stratified based on tourniquet use. Three-hundred and four patients were assigned to a "No Use" group (≤10'); 138 patients to "Low Use" (11-60'); 177 patients to "Medium Use" (61-90'); and 292 patients to "Prolonged Use" (91-120). Compared to No Use, MME/day was significantly increased with Medium Use (+7.676 MME/day, p = 0.001) and Prolonged Use (+12.44 MME/day, p =< 0.001). No significant differences were found between No Use and Low Use groups. Estimated blood loss (EBL) in Low Use and No Use groups was significantly increased compared to other groups (+120 mL, p < 0.001, +109 mL, p < 0.001 respectively). Post-operative ROM and complication rates were similar between groups at 1 year post-TKA. CONCLUSIONS: A threshold of 60 min of tourniquet time is associated with increased MME/day postoperatively compared to No Tourniquet. Functional and patient-reported outcomes are comparable between groups at 1 year follow-up.

Invasive Gastrointestinal Endoscopy Following Total Joint Arthroplasty Increases the Risk for Periprosthetic Joint Infection.

BACKGROUND: The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI). METHODS: Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) versus total hip arthroplasty (THA)), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKAs and 45,251 THAs) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Preoperative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P < .05. RESULTS: Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (odds ratio (OR): 1.29 [1.08-1.53]; P = .004; OR: 1.41 [1.01-1.90]; P = .033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI. CONCLUSION: These data suggest that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI.

Collateral Ligament Tension and Balance Alone Does Not Ensure Improved Outcome After Total Knee Arthroplasty.

BACKGROUND: It is hypothesized that suboptimal soft tissue and collateral ligament balance is a cause of patient dissatisfaction following total knee arthroplasty (TKA). This analysis examined the association between compartment pressures during TKA and patient-reported outcome measurements (PROMs). METHODS: This single-institution, retrospective cohort study of prospectively collected compartment pressure data measured during TKA comprised 145 patients who underwent surgery between 2015 and 2021 and completed 1-year follow-up PROMs. The primary outcome included pressures, in pounds (lbs), of the medial and lateral compartments in extension (5°), mid-flexion (45°), and flexion (90°), and associated PROMs. The difference been the 1-year and preoperative PROMs was used to separate the top 25% from the bottom 75% performers. Pressures were compared using Student's T-tests and multivariate linear regressions, while controlling for preoperative deformity. A subgroup analysis of the most popular implant was performed. RESULTS: Higher medial compartment pressures were seen in our total cohort (Knee Society Score (KSS) mid-flexion 24 versus 18 lbs, P = .03, flexion 24 versus 17 lbs P = .01) and within our subgroup analysis (Short form- Mental (SF-M) extension 32 versus 21 lbs P = .01, KSS mid-flexion 27 versus 16 lbs P = .005, extension 31 versus 20 lbs P = .003). This trend persisted in the subgroup analysis when controlling for preoperative deformity (KSS extension +16.22 lbs P ≤ .001, mid-flexion +17.6 lbs. P = .001, and flexion +9.2 lbs, P = .005). CONCLUSION: Several groups demonstrated higher medial versus lateral pressures. However, this pattern was not consistent across PROMs, suggesting that compartment pressures at the time of TKA are an important factor but not the sole predictor of patient satisfaction.

A comparison of pin site complications between large and small pin diameters in robotic-assisted total knee arthroplasty.

PURPOSE: Robotic-assisted total knee arthroplasty typically necessitates use of tracking pins, which can vary in diameter. Complications such as infections and fractures at the pin-site have been observed, but clarification of the effect of pin diameter on complication is needed. The aim of this study is to compare the pin-related complication rates following robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm diameter pins. METHODS: In this retrospective cohort study, 90-day pin-site complication rates after robotic-assisted total knee arthroplasty were compared between 4.5 mm diameter and 3.2 mm diameter groups. In total, 367 patients were included: 177 with large pin diameter and 190 with small pin diameter. All four pin sites were evaluated using postoperative radiographs. Cases without orthogonal views or visualization of all four pin tracts were noted. Multivariate logistic regression was used to control for age, which differed between the two cohorts. RESULTS: The rate of pin-site complications was 5.6% in the large pin diameter cohort and 2.6% in the small pin diameter cohort, with no statistically significant difference between the groups. The adjusted odds ratio for complications in small compared to large diameter group was 0.48, with a p-value of 0.18. The most common pin-site complication was infection/persistent drainage, found in 1.9% of patients, followed by intraoperative fracture of the second cortex in 1.4%. Intraoperative fracture could not be ruled out in 96 cases due to inadequate radiographic visualization of all pin sites. There was one postoperative pin-site fracture in the large diameter cohort, which required operative fixation. CONCLUSION: This study demonstrates no statistically significant difference in pin-site complication rates after robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm pin diameter cohorts, although there was a trend towards increased intraoperative and postoperative pin-site fractures in the 4.5 mm group.

Bilateral Total Knee Arthroplasty: Current Concepts Review.

¼: Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days. ¼: Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others. ¼: While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA. ¼: When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart. ¼: Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Reference Axes for Tibial Component Rotation in Total Knee Arthroplasty: Computed Tomography-Based Study of 1,351 Tibiae.

BACKGROUND: Many anatomic landmarks have been described for setting tibial component rotation intraoperatively. There is no consensus as to which axis is best for reducing outliers and preventing malrotation. METHODS: The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,351 computed tomography (CT) scans of the entire tibia. Several reference axes for the tibia (including the Mayo axis, Akagi line, Insall line, anterior condylar axis [ACA], posterior condylar axis [PCA], lateral tibial cortex [LTC], Cobb axis, tibial crest line [TCL], and transmalleolar axis [TMA]) were constructed according to published guidelines. The Berger method served as the reference standard. RESULTS: The Mayo method (involving a line connecting the medial and middle one-thirds of the tibial tubercle and the geometric center of the tibia) and the Insall line (involving a line connecting the posterior cruciate ligament [PCL] insertion and the intersection of the middle and medial one-thirds of the tibial tubercle) both had low variability relative to the Berger method (7.8° ± 1.0° and 5.1° ± 2.2°, respectively) and a low likelihood of internal rotation errors (0.7% and 1.8%, respectively). No clinically significant gender-based differences were found (<0.7° for all). The same was true for ethnicity, with the exception of consistently greater tibial intorsion in Asian versus Caucasian individuals (mean difference in TCL position, +4.5° intorsion for Asian individuals; p < 0.001). CONCLUSIONS: This CT-based study of 1,351 tibiae (which we believe to be the largest study of its kind) showed that the Mayo and Insall methods (both of which reference the medial and middle one-thirds of the tibial tubercle) offer an ideal balance of accuracy, low variability, and a reduced likelihood of internal rotation errors. Setting rotation on the basis of distal landmarks (tibial shaft and beyond) may predispose surgeons to substantial malrotation errors, especially given the differences in tibial torsion found between ethnic groups in this study. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

No Benefit to Sensor-guided Balancing Compared With Freehand Balancing in TKA: A Randomized Controlled Trial.

BACKGROUND: Soft tissue balancing in TKA has traditionally relied on surgeons' subjective tactile feedback. Although sensor-guided balancing devices have been proposed to provide more objective feedback, it is unclear whether their use improves patient outcomes. QUESTIONS/PURPOSES: We conducted a randomized controlled trial (RCT) comparing freehand balancing with the use of a sensor-guided balancing device and evaluated (1) knee ROM, (2) patient-reported outcome measures (PROMs) (SF-12, WOMAC, and Knee Society Functional Scores [KSFS]), and (3) various surgical and hospital parameters (such as operative time, length of stay [LOS], and surgical complications) at a minimum of 2 years of follow-up. METHODS: A total of 152 patients scheduled for primary TKA were recruited and provided informed consent to participate in this this study. Of these, 22 patients were excluded preoperatively, intraoperatively, or postoperatively due to patient request, surgery cancellation, anatomical exclusion criteria determined during surgery, technical issues with the sensor device, or loss to follow-up. After the minimum 2-year follow-up was accounted for, there were 63 sensor-guided and 67 freehand patients, for a total of 130 patients undergoing primary TKA for osteoarthritis. The procedures were performed by one of three fellowship-trained arthroplasty surgeons (RPS, HJC, JAG) and were randomized to either soft tissue balancing via a freehand technique or with a sensor-guided balancing device at one institution from December 2017 to December 2018. There was no difference in the mean age (72 ± 8 years versus 70 ± 9 years, mean difference 2; p = 0.11), BMI (30 ± 6 kg/m 2 versus 29 ± 6 kg/m 2 , mean difference 1; p = 0.83), gender (79% women versus 70% women; p = 0.22), and American Society of Anesthesiology score (2 ± 1 versus 2 ± 1, mean difference 0; p = 0.92) between the sensor-guided and freehand groups, respectively. For both groups, soft tissue balancing was performed after all bony cuts were completed and trial components inserted, with the primary difference in technique being the ability to quantify the intercompartmental balance using the trial tibial insert embedded with a wireless sensor in the sensor-guided cohort. Implant manufacturers were not standardized. Primary outcomes were knee ROM and PROMs at 3 months, 1 year, and 2 years. Secondary outcomes included pain level evaluated by the VAS, opioid consumption, inpatient physical therapy performance, LOS, discharge disposition, surgical complications, and reoperations. RESULTS: There was no difference in the mean knee ROM at 3 months, 1 year, and 2 years postoperatively between the sensor-guided cohort (113° ± 11°, 119° ± 13°, and 116° ± 12°, respectively) and the freehand cohort (116° ± 13° [p = 0.36], 117° ± 13° [p = 0.41], and 117° ± 12° [p = 0.87], respectively). There was no difference in SF-12 physical, SF-12 mental, WOMAC pain, WOMAC stiffness, WOMAC function, and KSFS scores between the cohorts at 3 months, 1 year, and 2 years postoperatively. The mean operative time in the sensor-guided cohort was longer than that in the freehand cohort (107 ± 0.02 versus 84 ± 0.04 minutes, mean difference = 23 minutes; p = 0.008), but there were no differences in LOS, physical therapy performance, VAS pain scores, opioid consumption, discharge disposition, surgical complications, or percentages of patients in each group who underwent reoperation. CONCLUSION: This RCT demonstrated that at 2 years postoperatively, the use of a sensor-balancing device for soft tissue balancing in TKA did not confer any additional benefit in terms of knee ROM, PROMs, and clinical outcomes. Given the significantly increased operative time and costs associated with the use of a sensor-balancing device, we recommend against its routine use in clinical practice by experienced surgeons. LEVEL OF EVIDENCE: Level I, therapeutic study.

Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty.

BACKGROUND: The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA. METHODS: This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m2, diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications. RESULTS: One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ2 = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ2 = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI. CONCLUSION: Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis.

BACKGROUND: The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve. QUESTIONS/PURPOSES: We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice? METHODS: A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs. RESULTS: At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values. CONCLUSION: For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Preoperative Anemia Is Associated With 30-Day Morbidity in Total Knee Arthroplasty.

Given the heightened focus on decreasing length of stay and readmissions following total joint arthroplasty, meticulous preoperative optimization has become increasingly important. The goal of this study was to evaluate the association between preoperative anemia and postoperative morbidity and mortality at 30 days. We used the National Surgical Quality Improvement Program database to identify patients who underwent primary total knee arthroplasty (TKA) between 2006 and 2016. Cohorts were defined based on preoperative hemoglobin and were evaluated for 30-day complications as well as 30-day readmission and non-home discharge. The survey of the National Surgical Quality Improvement Program database yielded 198,233 patients who underwent TKA between 2006 and 2016. Preoperative anemia was found to be a risk factor for all complications (4.73% vs 3.22%, P<.001) as well as non-home discharge (37.0% vs 24.2%, P<.001) and unplanned readmission (4.99% vs 3.14%, P<.001) using both bivariate analysis and multivariate analysis. Meticulous optimization of patients at risk for complications is critical in the era of bundled care and increased focus on rapid transition from inpatient to outpatient care. Preoperative anemia was associated with the total postoperative complication rate at 30 days following TKA as well as non-home discharge and unplanned readmission. Surgeons should attempt to identify patients with preoperative anemia and correct underlying low blood levels to help minimize the rate of postoperative complications. [Orthopedics. 2022;45(2):e86-e90.].