Tourniquet Effect on Patients Undergoing Total Knee Arthroplasty: A Single-Blind, Randomized Controlled Trail.

BACKGROUND: Tourniquet is applied in Total Knee Arthroplasty (TKA) to reduce intraoperative blood loss and improve view of surgical field. However, tourniquet use in TKA is still in dispute. Some researchers find that tourniquet may lead to extra side effects such as aggravated pain and limb swelling, while others consider that tourniquet has no significant adverse impact on clinical outcomes of TKA patients. This trial is conducted to evaluate tourniquet effect on TKA patients. METHODS: A prospective, single-blind, randomized controlled trail is adopted with a sample size of 130 knees from August 2020 to February 2023. Patients undergoing TKA are randomly allocated to tourniquet group and non-tourniquet group. Outcomes including quadriceps thickness and stiffness, operation time, total blood loss, intraoperative blood loss, postoperative blood loss, transfusion rate, thigh circumference, knee and thigh VAS, D-Dimer and CRP level, knee function score, patient satisfaction, and complications are evaluated in this trial. Student's t-test, Mann-Whitney U test, Pearson's chi-square test, and Fisher's exact test are used in this study. RESULTS: No significant difference in demographic information and baseline outcomes were found (p > 0.05). Participants in the tourniquet group had significantly less total blood loss and intraoperative blood loss, more postoperative blood loss, and higher D-Dimer level on postoperative day 3 when compared with non-tourniquet group (p < 0.05). Other outcomes including quadriceps thickness and stiffness, operation time, postoperative blood loss, transfusion rate, thigh circumference, knee and thigh VAS, D-Dimer level on postoperative day 1, CRP level, knee function score, patient satisfaction, and complications showed no significant difference (p > 0.05). CONCLUSION: Tourniquet application can effectively reduce intraoperative blood loss and total blood loss, without significant side effects. Hence, we advocate the regular use of tourniquet in primary TKA.

Mid-term outcomes of acute and delayed total knee arthroplasty following tibial plateau fractures: A matched cohort study.

INTRODUCTION: Patients who sustain a tibial plateau fracture (TPF) have a higher risk of receiving total knee arthroplasty (TKA). Rarely, TKA is used as acute treatment for TPFs. This study aimed to compare both acute and delayed TKA following TPF with matched patients undergoing elective TKA for osteoarthritis. MATERIALS AND METHODS: A retrospective study was conducted including patients with either acute TKA as the primary treatment for TPF, or unplanned delayed TKA due to posttraumatic osteoarthritis. Both groups were matched to controls undergoing TKA for osteoarthritis. Questionnaires were completed cross-sectionally. Knee injury and Osteoarthritis Outcome Score - Physical Function Short Form (KOOS-PS), Oxford Knee Score (OKS), EQ-5D-5L, and complications were compared. RESULTS: Thirty-four TPF patients (12 acute TKA, 22 delayed TKA) were matched 1:1. Mean age was 67.2 ± 9.9 years, 82% was female, and mean follow-up was 5.0 ± 2.9 years. No differences were found for the acute group compared to their controls (median KOOS-PS 73.1 vs. 69.3, p = 0.977; median OKS 43 vs. 45, p = 0.246; median EQ-5D-5L 0.87 vs. 1.00, p = 0.078). In the delayed group, scores were inferior compared to their controls (median KOOS-PS 63.9 vs 78.0, p = 0.003; median OKS 39 vs 44, p = 0.001; median EQ-5D-5L 0.81 vs 0.87, p = 0.008). Complications showed no significant differences. CONCLUSION: Acute TKA for TPF shows no difference to a matched group of elective TKA, but delayed TKA following TPF yields worse results at mean 5-year follow-up. This suggests that TPFs in patients with a high risk of ultimately requiring TKA may benefit from primary treatment with TKA.

Incidence and related risk factors for postoperative delirium following revision total knee arthroplasty: a retrospective nationwide inpatient sample database study.

BACKGROUND: Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases. METHODS: Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications. RESULTS: The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75 years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD. CONCLUSION: Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.

Can the minimal clinically important difference (MCID) for the Oxford score, KOOS and its derivatives be identified in a French sample of total knee arthroplasties?

CONTEXT: To assess the effect of a surgical procedure on a patient, it is conventional to use clinical scores before and after the procedure, but it is increasingly common and recommended to weight the results of these scores with the notion of minimal clinically important difference ("MCID"). This MCID should be determined using either the data distribution method based on score variation, or the anchor method, which uses an external question to categorize the results. MCIDs vary from one population to another, and to our knowledge there has been no investigation in France for total knee arthroplasties (TKAs). We therefore conducted a prospective study on a population of TKAs in order to: 1) Define MCID in France on a population of TKAs for the Oxford score, KOOS (Knee injury and Osteoarthritis Outcome Score) and its derivatives, 2) Determine whether MCID for these scores in France is comparable to results in the literature. HYPOTHESIS: Is the MCID for total knee arthroplasty in France comparable to other results in the literature? MATERIAL AND METHOD: This was a prospective observational study in which 218 patients (85 men, 133 women) with a mean age of 72 years [27-90] who had undergone a primary TKA out of 300 initially included responded, before and after surgery, to the Oxford-12, KOOS and Forgotten Joint Score (FJS) questions (mean follow-up 24 months). MCID was calculated using the distribution method as well as the anchor method ("improvement 1 to 5" and "improvement yes or no"). RESULTS: At a mean follow-up of 24 months [18-36], the Oxford-12 score increased from 16 ± 8 [0-41] to 34 ± 11 [6-48] (p < 0.001), all components of the KOOS score were improved and the FJS at follow-up was 47 ± 32 [0-100]. For the anchor "improvement 1 to 5", there were 14 unimproved patients, 23 patients in identical condition and 179 patients improved by surgery. For the anchor "are you improved yes/no", there were 8 unimproved patients, 22 in identical condition and 187 surgically-improved patients. The mean MCID for all methods (anchor method and distribution) was 10 [7-13] for Oxford-12, 12 [12-12] for KOOS Symptom, 14 [12-17] for KOOS Pain, 12 [11-14] for KOOS Function, 14 [12-16] for KOOS Sport, 15 [15-16] for KOOS Quality of Life (QOL), 11 [10-12] for KOOS 12, 15 [12-18] for KOOS 12 Pa in. 12 [12-13] for KOOS 12 Function, 15 [15-15] for KOOS 12 QOL, 14 [13-14] for KOOS Physical Function Short-form (PS) and 14 [13-16] for KOOS Joint Replacement (JR). DISCUSSION: The MCID for the Oxford-12, KOOS and its derivatives scores in a French population is comparable to that observed in other populations in the literature. LEVEL OF EVIDENCE: IV; prospective study without control group.

Real-world accuracy of robotic-assisted total knee arthroplasty and its impact on expedited recovery.

Despite total knee arthroplasty (TKA) being the gold standard for end-stage knee osteoarthritis, 20% of patients remain dissatisfied. Robotic-assisted arthroplasty promises unparalleled control of the accuracy of bone cuts, implant positioning, control of gap balance, and resultant hip-knee-ankle (HKA) axis. Patients underwent clinical and radiological assessments, including knee CT scans and patient-reported outcome measures (PROMs), preoperatively. Follow-up assessments were conducted at 2 weeks, 6 weeks, and 3 months post-operatively, with imaging repeated at 6 weeks. A total of 155 patients underwent robotic-assisted TKA and have completed 3 months of follow-up. Mean pre-operative HKA axis was 7.39 ± 5.52 degrees varus, improving to 1.34 ± 2.22 degrees varus post-operatively. Restoration of HKA axis was 0.76 ± 1.9 degrees from intra-operative planning (p < 0.0005). Implant placement accuracy in the coronal plane was 0.08 ± 1.36 degrees (p = 0.458) for the femoral component and 0.71 ± 1.3 degrees (p < 0.0005) for the tibial component. Rotational alignment mean deviation was 0.39 ± 1.49 degrees (p = 0.001). Most patients (98.1%) had ≤ 2 mm difference in extension-flexion gaps. PROM scores showed improvement and exceeded pre-operative scores by 6 weeks post-surgery. Robotic-assisted knee arthroplasty provides precise control over traditionally subjective factors, demonstrating excellent early post-operative outcomes.Level of evidence Prospective observational study-II.

Fixation options for total knee arthroplasty: a comprehensive literature review.

Total knee arthroplasty is a consistently successful, cost-efficient, and highly effective surgical procedure for treating severe knee osteoarthritis. The success and longevity of total knee arthroplasty depend significantly on the fixation method used to secure the prosthetic components. This comprehensive review examines the primary fixation methods (cemented, cementless, and hybrid fixation), analysing their biomechanics, clinical outcomes, advantages, and disadvantages, focusing on recent advances and trends in total knee arthroplasty fixation.

Soft tissue laxity is highly variable in patients undergoing total knee arthroplasty.

BACKGROUND: One major goal of total knee arthroplasty (TKA) is to achieve balanced medial and lateral gaps in flexion and extension. While bone resections are planned by the surgeon, soft tissue laxity is largely intrinsic and patient-specific in the absence of additional soft tissue releases. We sought to determine the variability in soft tissue laxity in patients undergoing TKA. METHODS: We retrospectively reviewed 113 patients undergoing TKA. Data on preoperative knee deformity were collected. Data from a dynamic intraoperative stress examination were collected by a robotic tracking system to quantify maximal medial and lateral opening in flexion (85-95 degrees) and extension (-5-20 degrees). T-tests were used to assess the differences between continuous variables. RESULTS: A valgus stress opened the medial compartment a mean of 4.3 ± 2.3 mm (0.0-12.4 mm) in extension and 4.6 ± 2.3 mm (0.0-12.9 mm) in flexion. A varus stress opened the lateral compartment a mean of 5.4 ± 2.4 mm (0.3-12.6 mm) in extension and 6.2 ± 2.5 mm (0.0-13.4 mm) in flexion. The medial compartment of varus knees opened significantly more in response to valgus stress than valgus knees in both extension (5.2 mm vs. 2.6 mm; P < 0.0001) and flexion (5.4 mm vs 3.3 mm; P < 0.0001). The lateral compartment of valgus knees opened significantly more in response to varus stress than varus knees in both extension (6.7 mm vs. 4.8 mm; P < 0.0001) and flexion (7.4 mm vs. 5.8 mm; P = 0.0003). CONCLUSIONS: Soft tissue laxity is highly variable in patients undergoing TKA, contributing anywhere from 0-13 mm to the post-resection gap. Only a small part of this variability is predictable by preoperative deformity. These findings have implications for either measured-resection or gap-balancing techniques. LEVEL OF EVIDENCE: Level III.

Clinical outcomes of total joint arthroplasty in patients with bowel ostomies.

INTRODUCTION: The influence of prior colostomy or ileostomy on patients undergoing joint arthroplasty remains poorly understood. Our study aimed to assess whether patients with an ostomy undergoing hip and knee arthroplasties have worse postoperative outcomes and increased rates of revisions. METHOD: A single-center, retrospective review of patients with a history of bowel ostomy who underwent a primary total hip arthroplasty (THA), hemiarthroplasty (HA), and total knee arthroplasty (TKA) from 2012 to 2021. A total of 24 THAs, 11 HAs, and 25 TKAs in patients with open small or large bowel stoma were identified. A ten-to-one propensity score match was utilized to establish cohorts with comparable demographics but no prior ostomy procedure. RESULTS: Patients with stomas undergoing elective THA showed greater 90-day ED visits (20.0 vs. 5.0%, P = 0.009), 90-day all-cause readmissions (20.0 vs. 5.0%, P = 0.009), 90-day non-orthopedic readmissions (10.0 vs. 0.5%, P < 0.001), 90-day readmissions for infection (5.0 vs. 0.5%, P = 0.043), all-cause revisions (15.0 vs. 0.5%, P < 0.001), revisions for PJI (5.0 vs. 0%, P = 0.043), and revisions for peri-prosthetic fracture (10.0 vs. 0%, P < 0.001). Patients with stomas undergoing non-elective hip arthroplasties exhibited a longer mean LOS (12.1 vs. 7.0 days, P < 0.001) and increased 90-day all-cause readmissions (40.0 vs. 17.3%, P = 0.034), 90-day orthopedic readmissions (26.7 vs. 6.0%, P = 0.005), all-cause revisions (13.3 vs. 2.0%, P = 0.015), revisions for peri-prosthetic fracture (6.7 vs. 0%, P = 0.002), and revisions for aseptic loosening (6.7 vs. 0%, P = 0.002). There were no significant differences in readmission or revision rates between ostomy patients undergoing TKA and a matched control group. CONCLUSION: Patients undergoing hip arthroplasties with an open stoma are at an increased risk of hospital encounters and revisions, whereas TKA patients with stomas are not at increased risk of complications. These findings emphasize the importance of recognizing and addressing the unique challenges associated with this patient population.

Evaluating two implant designs in patients undergoing primary total knee arthroplasty using a novel measure of early optimal recovery: a retrospective observational study.

PURPOSE: Quality of care in total knee arthroplasty (TKA) between implants was assessed using a novel composite outcome measure, early optimal recovery (EOR), to indicate ideal clinical outcomes and minimal healthcare resource utilization. METHODS: Patients that underwent primary TKA in the study group (ATTUNE® Knee System) or control group (LCS® COMPLETE Knee System) were included in this retrospective, single-center study. EOR was defined as no complications, no readmissions, no extra outpatient visits, ≤ 48 h length of hospital stay (LOS), and restored range of motion and pain perception at 3-month follow-up. Multivariate logistic regression was used to compare EOR between the study and control groups. Results were adjusted for differences in baseline characteristics and are presented with 95% confidence intervals (CI). Data were collected from a specialized clinic for elective surgeries in the Netherlands, between January 2017 and December 2020. RESULTS: A total of 566 patients (62.4% female, mean age 67 years) were included for analysis; 185 patients (32.7%) underwent TKA in the study group. Compared to the control group, patients in the study group had greater probability of achieving EOR (65.8% [95% CI: 55.1-75.2] vs. 38.9% [95% CI: 32.8-45.3]; p < 0.001), a LOS ≤ 48 h (77.2% [95% CI: 67.7-84.5] vs. 61.4% [95% CI: 54.7-67.7]; p < 0.05), and ideal pain perception at 3-month follow-up (93.3% [95% CI: 85.7-97.0] vs. 78.2% [95% CI: 71.0-83.9]; p < 0.05). CONCLUSION: The study group was associated with a greater probability of achieving EOR versus the control group, suggesting improved quality of care.

Load-Dependent Characteristics of Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty: A Biomechanical Study.

Background: Increased load bearing across the patellofemoral and tibiofemoral articulations has been associated with total knee arthroplasty (TKA) complications. Therefore, the purpose of this study was to quantify the biomechanical characteristics of the patellofemoral and tibiofemoral joints and simulate varying weight-bearing demands after posterior cruciate ligament-retaining (CR) and posterior-stabilized (PS) TKAs. Methods: Eight fresh-frozen cadaveric knees (average age, 68.4 years; range, 40-86 years) were tested using a custom knee system with muscle-loading capabilities. The TKA knees were tested with a CR and then a PS TKA implant and were loaded at 6 different flexion angles from 15° to 90° with progressively increasing loads. The independent variables were the implant types (CR and PS TKA), progressively increased loading, and knee flexion angle (KFA). The dependent variables were the patellofemoral and tibiofemoral kinematics and contact characteristics. Results: The results showed that at higher KFAs, the position of the femur translated significantly more posterior in CR implants than in PS implants (36.6 ± 5.2 mm and 32.5 ± 5.7 mm, respectively). The patellofemoral contact force and contact area were significantly greater in PS than in CR implants at higher KFAs and loads (102.4 ± 12.5 N and 88.1 ± 10.9 N, respectively). Lastly, the tibiofemoral contact force was significantly greater in the CR than the PS implant at flexion angles of 45°, 60°, 75°, and 90° KFA, the average at these flexion angles for all loads tested being 246.1 ± 42.1 N and 192.8 ± 54.8 N for CR and PS implants, respectively. Conclusions: In this biomechanical study, CR TKAs showed less patellofemoral contact force, but more tibiofemoral contact force than PS TKAs. For higher loads across the joint and at increased flexion angles, there was significantly more posterior femur translation in the CR design with a preserved posterior cruciate ligament and therefore significantly less patellofemoral contact area and force than in the PS design. The different effects of loading on implants are an important consideration for physicians as patients with higher load demands should consider the significantly greater patellofemoral contact force and area of the PS over the CR design.

Higher Onset of Periprosthetic Joint Infections in Patients With Teeth Compared to Those Without Teeth.

INTRODUCTION: Bacteria can enter the bloodstream through simple actions such as brushing teeth, flossing, and even chewing food, increasing the chance of hematogenous seeding of prosthetic joints. Antibiotics before dental work in patients with orthopedic hardware is a topic of debate because of concerns for antibiotic resistance. Patients with dentures theoretically avoid this risk due to the lack of teeth and their maintenance. Most periprosthetic joint infections (PJIs) that occur in the first six months after surgery are due to wound infection, whereas late PJIs are more commonly caused by hematogenous seeding. MATERIALS AND METHODS: Charts from patients who received primary total joint arthroplasty were interrogated for the condition of their teeth at the time of operation. If the patient had a PJI, the time from surgery and the organism responsible were noted. Multivariate linear regressions were performed for statistical analysis to compare rates of dental status, infection, comorbidities, and demographics. RESULTS: From the 1,500 charts reviewed, patients with teeth and edentulous had similar rates of comorbidities. PJI patients had higher rates of chronic kidney disease than patients who did not have the infection. The overall rate of infections in patients with teeth was 2.14%, close to the national average. The rate of infection in patients without teeth was 0.78%. Patients with teeth have a higher rate of infection one month or longer from surgery than edentulous patients. CONCLUSIONS: There was an increased infection rate in patients with teeth at six months and greater since the primary total joint arthroplasty. The organisms responsible for many of the PJIs are commonly found in the mouth of humans. Having teeth is a potential risk factor for late PJI.

The Impact of Colostomy on Inpatient Outcomes Following Primary Total Knee Arthroplasty.

Introduction The inpatient postoperative outcomes of patients with colostomies following primary total knee arthroplasty (TKA) have not been well studied in the literature. The purpose of this study was to analyze how colostomy impacts the immediate postoperative outcomes of TKA. Our null hypothesis is that after correcting for common variables, a colostomy does not predispose patients undergoing TKA to surgical site infections (SSIs) and periprosthetic infections. Methods The National Inpatient Sample database was used to retrieve information on colostomy patients and patients without a colostomy who had undergone primary TKA from 2016 to 2019. Patients with colostomies were matched to a cohort of non-colostomy control groups in a 1:1 propensity score algorithm by age, sex, race, and pertinent comorbidities. Patient demographic characteristics, comorbidities, length of hospital stay (LOS), total hospital charges, and inpatient complications were compared. Results Following propensity score matching, 399 patients with colostomies were compared to 385 patients without a colostomy (control). The colostomy group had a prolonged LOS (3.15 ± 2.67 vs 2.44 ± 3.15 days, p<0.001) compared to the control group. Also, the colostomy group had significantly higher incidences of acute kidney injury (AKI) (6.02% vs 1.56%, odds ratio (OR): 4.04, 95% confidence interval (CI): 1.63-10.00, p<0.001), blood loss anemia (20.55% vs 13.25%, OR: 1.69, 95% CI: 1.16-2.48, p=0.008), and blood transfusions (4.01% vs 0.26%, OR: 16.04, 95% CI: 2.12-121.56, p<0.001). There was no difference in periprosthetic infection, superficial SSI, or deep SSI. Conclusion Patients with colostomies face a notably higher risk of experiencing AKI, blood loss anemia, and blood transfusion requirements during the immediate postoperative period following primary TKA. Despite the perceived risk of postoperative infection in colostomy patients, this patient population is not at an increased risk of developing periprosthetic infection, superficial SSI, or deep SSI following TKA.

Is Popliteus Tendon a Redundant Structure in Total Knee Arthroplasty?

Background: Many studies have shown that injury to the popliteus tendon has little consequence for the static stability of the knee following total knee arthroplasty (TKA). However, very few studies have evaluated the effect of intraoperative iatrogenic popliteus tendon injury on the patient-reported outcome measures (PROMs) following TKA. This study aimed to determine the incidence of iatrogenic popliteus tendon injury in our subset of the population and to find out its effect on PROMs. Methods: 100 consecutive osteoarthritic varus knees with flexion deformities less than 20° were operated upon by a single senior experienced arthroplasty surgeon. Patients were assessed intraoperatively for any iatrogenic popliteus tendon injury, the injury site, and the amount of injury which was quantified and graded. PROMs applied for assessment at 1-year follow-up were Knee Society Score (KSS 1), Knee Function Score (KSS 2), and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Results: 17% of cases had an iatrogenic popliteus tendon injury. Thirteen had grade II injuries, whereas four had grade III injuries. There was no statistical significance in post-operative knee mobility and PROMs among those with popliteus tendon injury versus non-injured patients. Conclusion: The incidence of iatrogenic popliteus tendon injury is higher than what we expected. The tendon injury remains a risk, but it is unclear how the popliteus tendon injury will affect patients after the TKA. In our series, such an injury during knee replacement does not affect the functioning of the knee in the short term; however, a long-term follow-up is warranted.

Same Day Discharge Total Knee Arthroplasty: Hospital Demonstrates Similar Outcomes to Ambulatory Surgery Center in a More Complex Patient Population.

BACKGROUND: The purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting. METHODS: A single tertiary academic center's institutional database was reviewed for patients that underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least one year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures (PROMs), emergency department (ED) visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria. RESULTS: Patients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (BMI) (P < 0.001), Elixhauser comorbidity index (ECI) (P < 0.001), proportion of patients who had an American Society of Anesthesiologists (ASA) classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0422) scores as well as similar rates of achieving minimum clinically important difference (MCID) for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of ED visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years. CONCLUSION: Although ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting.

Is there an increased revision rate due to early tibial component loosening with a modern total knee arthroplasty design? A retrospective analysis from a large volume arthroplasty centre.

BACKGROUND: The Attune TKR was introduced in 2011 as a successor to its predicate design The PFC Sigma. However, following reports of early failures, there are ongoing concerns related to increased loosening rates. Given the concerns, this study aimed to compare revision rates of the Attune implant to an established predicate, and other implant designs used in a high-volume arthroplasty center. METHODS: We identified 10,202 patients who underwent primary cemented TKR at our institution with a minimum of 1 year follow-up, involving 2406 Attune TKR (557 S +), 4642 PFC TKR, 3154 other designs. Primary outcomes were revision for all-causes, aseptic loosening of any component, and aseptic tibial loosening. Kaplan-Meier survival and Cox regression models were used to compare groups. Matched cohorts were selected for radiographic analysis. RESULTS: 308 knees were revised. The Attune cohort had the lowest risk of revision, with a rate of 2.98 per 1000 implant-years while the PFC and All Other Implant groups had a rate of 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision, with 76% (65/88) involving the tibia. Survival analysis showed no significant differences between the Attune and other cohorts. Radiolucent lines were detected in 7.1% of the Attune S + group, 6.8% of the standard Attune group, and 6.3% of the PFC group, with no significant differences found between them. CONCLUSION: This study represents the largest non-registry review of the Attune TKR in comparison to a predicate and other designs. There was no significant increased revision rate for all-cause revision or aseptic loosening, or peri-implant radiolucencies. It appears that increased loosening may not be as concerning as originally thought. LEVEL OF EVIDENCE: Level III.

A Cross-Sectional Study on Patient Preferences for Selecting Surgeons for Joint Replacement Surgery in India.

Introduction This study aims to investigate the complex decision-making process of patients in India when choosing surgeons for joint replacement surgery, with a focus on both clinical and non-clinical factors influencing their preferences. Methods This was a cross-sectional observational study conducted at the KIMS-Sunshine Hospitals, Hyderabad, a high-volume tertiary care institute in India, in which patients with end-stage osteoarthritis requiring primary total knee arthroplasty were evaluated using a self-administered questionnaire, which assessed both patient-related and surgeon-related factors in choosing their joint replacement surgeon. Results A total of 210 participants were surveyed among whom the majority were females with an average age of 60.2 years with the majority belonging to the upper-middle-class socioeconomic status (48.6%, N=102). Fifty-nine percent preferred surgeons with over 20 years of experience, and 63.8% were willing to travel out-of-state for recognized expertise. Family recommendations (33.8%) and surgeon reputation (24.3%) were primary factors in surgeon selection. A vast majority (73.3%) preferred surgeons who were skilled in robotic surgery and had foreign training (32.9%). However, the majority (67.6%) did not express any gender preference. The survey highlighted a broad range of informational sources affecting decisions, including financial consideration (63.8%), personal referrals, and online platforms (17.1%). Preferences were also shaped by hospital reputation and insurance options (10.5%), illustrating a nuanced interplay of quality, cost, and personal connections in the selection process. Conclusion The findings of this survey illuminate the intricate and diverse preferences exhibited by patients when selecting a surgeon for joint replacement surgery. A significant rise in patient expectations is evident, underscoring a demand for more personalized, contemporary, and high-quality healthcare services. Importantly, geographical proximity appears to be a diminishing concern in their decision-making process. This trend presents an opportunity for centers of excellence to extend their influence and attract patients on both a regional and national level.

The Role of Imageless Computer-Assisted Navigation During Total Knee Arthroplasty on Femoral Component Sagittal Alignment and Outcomes.

Background: While total knee arthroplasty (TKA) is highly successful, 15%-20% of patients are not satisfied postoperatively, which may be due to alignment of the TKA components. Imageless computer navigation was developed to increase implant alignment accuracy and precision, but controversy surrounds the patient benefit of this technology. The target of femoral sagittal alignment and its role in patient-reported outcomes (PROMs) after TKA using assistive technology has not been well-defined. Methods: Femoral sagittal alignment, 30-day complications, and PROMs through 1 year were collected retrospectively from unilateral elective TKA patients who underwent surgery between July 2020 and February 2023. Two surgeons equally versed in conventional and imageless navigation techniques participated in patient record identification. Students t-tests and chi-square tests of proportion were used to compare outcomes, 30-day complications, and alignment. Results: Completed PROMs were available for 387 patients; 181 in the computer navigation group and 206 in the conventional arthroplasty group. PROMs were statistically significantly different between groups, favoring computer navigation (P = .014 at 12 months). Lateral femoral angle measurements were greater in females who underwent TKA with computer navigation (P < .001). Of note, 14 patients in the conventional technique group returned to the emergency department within 30 days, as compared to 4 in the navigation group (P = .033). Conclusions: PROMs are improved in the navigation group compared to the conventional technique group. Fewer patients in the navigation group returned to the emergency department. Navigation appeared to provide a small benefit compared to conventional techniques, though final lateral femoral angle was not predictive of outcomes. Additional surgical characteristics may need to be examined to determine the reasons for the differences in outcomes between these techniques.

The Trend of Medicare Reimbursement for Total Joint Arthroplasty: Using Mathematical Models to Predict Possible Per-Hour Rate Out to 2030.

Background: While multiple studies have assessed the trends of Medicare reimbursement for orthopedic total joint arthroplasty (TJA) surgeries, none have forecasted reimbursement in relatable per-hour figures. The purposes of this study are to examine trends of reimbursement for primary and revision TJA and translate forecasted primary TJA reimbursement to relatable per-hour compensation. Methods: The Center for Medicare and Medicaid Services reimbursement data from 1992 to 2024 were used to create a historical view of reimbursement for primary and revision TJA. All monetary values were converted to 2023 USD to account for inflation. Polynomial and linear forecast equations were used to predict the future of the TJA reimbursement to 2030. Relative Value Scale Update Committee standard times for procedures were used with the forecasts to establish per-hour rates. Results: Total reimbursement for primary total hip arthroplasty/total knee arthroplasty is forecasted to decrease 85.36%/86.14% by 2030. Using prior trends in reimbursement, TJA procedures are predicted to reimburse at or less than $100.00 2023 USD per Medicare case by 2030. Moreover, TJA surgeons are forecasted to earn $13.93/h per primary total hip arthroplasty and $14.97/h per primary total knee arthroplasty by 2030. Conclusions: This study highlights the concerning trends for both primary and revision arthroplasties as TJA surgeons are on a path to earn below minimum wage for primary TJAs by 2030. Mathematical models forecast a bleak future for orthopedic TJA reimbursement. This downward trajectory poses a risk to access and quality of care.

Revisiting the universal femoral component: Midterm outcomes of a modern design.

Introduction: Approximately 10 years ago a total knee arthroplasty system with a modern universal femoral component was introduced. It includes a symmetrical femoral and tibial component. The purpose of this study was to evaluate the 6-year clinical outcomes of this implant from a single surgeon. Materials and methods: A retrospective chart review was performed on all patients who received a TJO Klassic® Knee from January 2014 to January 2015 (Total Joint Orthopedics Inc., Salt Lake City, Utah). In total there were 131 patients (149 knees) who underwent total knee arthroplasty with this system. A retrospective chart review was performed including demographics, preoperative and postoperative clinical assessments including Knee Society score (KSS), range of motion, and radiographic assessment. Results: There were 60 males (45.8 %) and 71 females (54.2 %) with 149 knees available for review. Mean age at time of surgery was 67.4 years (45-91) and BMI was 32.6 kg/m2 (16.6-54.6). The patella was left unresurfaced in 37 knees (24.8 %), KSS scores including the clinical and functional components all improved significantly (p < 0.001). ROM improved significantly (p < 0.001). 9 knees underwent reoperation within 6 years of their index operation: 2 quadriceps tendon repairs, 3 polyethylene exchanges for laxity, 2 two-stage revisions for infection, 1 revision for aseptic loosening of the femur, and 1 for post-traumatic patella fracture. Conclusion: 6-year outcomes of a modern universal femoral design demonstrate excellent clinical results and survivorship equal to modern asymmetrical femur designs. There were no known instances of patellar maltracking.

Neighborhood socioeconomic disadvantage does not predict need for manipulation under anesthesia or range of motion following total knee arthroplasty.

Background: Studies have linked socioeconomic factors including lower income and minority race with worse functional outcomes following total knee arthroplasty (TKA). Arthrofibrosis is a common complication following TKA, and manipulation under anesthesia (MUA) is an effective treatment option for arthrofibrosis. This study aimed to determine if neighborhood-level socioeconomic disadvantage predicts need for MUA and postoperative range of motion (ROM) among patients undergoing primary elective TKA. Methods: We performed a retrospective cohort study of primary TKAs performed at a single institution over a three-year duration. Area Deprivation Index (ADI) was used to determine each patient's level of socioeconomic disadvantage based on their home address. Patients were allocated into three groups based on ADI: least socioeconomic disadvantage (ADI 1-3), middle socioeconomic disadvantage (ADI 4-6), and most socioeconomic disadvantage (ADI 7-10). Demographic factors and comorbid conditions were recorded. Bivariate analysis was used to evaluate the relationship between degree of socioeconomic disadvantage and need for MUA and postoperative ROM. Results: In total, 600 patients were included and 26.7 % were categorized as most disadvantaged. In comparison to the middle and least disadvantaged groups, these patients were more likely to be Women (71.2 vs. 67.9 and 58.6 %; p = 0.027), younger (60.7 vs. 62.9 and 66.3 years; p < 0.001) and have higher BMI (34.9 vs. 33 and 31.7; p < 0.001) (most disadvantaged vs. middle and least). Analysis revealed no difference in rate of MUA (6.3 vs. 2.5 vs. 4 %; p = 0.179) or postoperative ROM (98 vs. 98 vs. 100°; p = 0.753) between the three groups (most, middle, and least disadvantaged, respectively). Conclusion: Neighborhood socioeconomic disadvantage does not predict rate of MUA or postoperative ROM following TKA. Patients residing in neighborhoods with higher ADI who underwent TKA were more likely to be younger, Women, and have higher BMI, consistent with previous literature. Our results support efforts to improve access to orthopaedic care, including TKA, to patients of all socioeconomic levels.