Characterization of Patient Expectations and Satisfaction after Total Hip Arthroplasty.

We conducted a prospective multicenter study in which outcome-related expectations of 236 primary total hip arthroplasty patients were determined. Clinical surveys and radiographs were used to determine the relationship between postoperative level of patient satisfaction and patient-reported and radiographic outcomes. At 1 year, 82.6% of expectations were achieved, most of the time with high satisfaction (89.3%). Younger, lower body-mass index, male patients were more likely to expect the surgery to benefit "return to work" and "sexual function", whereas older, heavier patients, selected "elimination of assistive devices" and "independence in daily activities". The ability of the patient to meet their expectations fully did not correlate directly with level of satisfaction or clinical outcomes, suggesting limitations in current clinical surveys. The characterization of patient expectations is essential in providing patient-centered care.

Astym® Therapy for the Management of Recalcitrant Knee Joint Stiffness after Total Knee Arthroplasty.

Knee stiffness is a common complication after total knee arthroplasty (TKA). Despite studies published on the surgical management of reduced range of motion (ROM) after TKA, there is limited evidence on the nonoperative management of joint and soft tissue imbalances possibly contributing to reduced knee ROM. This report assesses changes in ROM, pain, function, and patellar tendon length after Astym® joint mobilization use. A 38-year-old male professional skier had a right TKA 3 months before presentation with 2 subsequent manipulations under anesthesia secondary to persistent knee stiffness. He had patellar baja on radiograph, a reduced arc of ROM, reduced patellar mobility and muscular extensibility, and pain to palpation along the patellar tendon. He had 12 visits of physical therapy with the use of Astym®, patellar mobilization, and tibio-femoral mobilizations with movement. The patient also used a customized knee device at home for prolonged knee extension stretching. The patient was treated for 12 visits, along with home use of customized bracing for knee extension. Significant improvements were seen in pain, function, and ROM. He returned to work full-time, ambulated prolonged distances, and negotiated stairs pain-free. He also demonstrated resolution of patellar baja radiographically. Conservative management of recalcitrant knee joint stiffness after primary TKA can be effective in restoring knee mobility and reducing pain and activity limitation. A multimodal approach using Astym® treatment, customized knee bracing, and targeted joint mobilization can be effective in resolving knee joint stiffness.

Robot-assisted total hip arthroplasty.

Precise and accurate biomechanical reconstruction during total hip arthroplasty (THA) is essential for durable long-term survivorship. Accurate fit of cementless hip implants is also crucial to reduce micromotion between the bone-implant interfaces to allow for stable osseointegration. Robotic technology aims to minimize potential human errors and improve implant alignment and fit, and address persisting concerns with modern-day cementless THA. Although robotic THA dates back to the early 1990s, concerns with increased operating times, costs, and complications led to its withdrawal. However, semi-active systems have renewed interest in robot-assisted joint arthroplasty. We reviewed the current technology, its potential benefits, and the reported clinical and radiographic outcomes. Early evidence suggests that robotic use may lead to more accurate reconstruction of radiographic parameters, such as implant positioning, fit, center-of-rotation, and leg-length discrepancy. Further research is needed to determine if these will translate into better outcomes and improved implant longevity to justify increased costs.

Use of a Flexible Intramedullary Rod and its Influence on Patient Satisfaction and Femoral Size in Total Knee Arthroplasty.

Improper femoral component size remains a source of multiple postoperative complications following total knee arthroplasty (TKA). However, the use of a flexible intramedullary (IM) rod may help optimize femoral component size and therefore improve outcomes. The purpose of this study was to assess (1) patient-reported functional outcomes, (2) overall quality of life, and (3) changes in implant sizing associated with total knee arthroplasties performed with a flexible IM rod compared to a conventional, rigid rod. We reviewed 277 patients who had surgery using the rigid rod and 364 using the flexible rod to determine the tendency of each rod for selecting particular component sizes. Additionally, 100 patients were prospectively randomized (1:1) to the flexible or the conventional rigid IM rod cohorts. Outcomes were assessed using Knee Society scores (KSSs), SF-36 physical scores, and SF-36 mental scores preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. The retrospective arm of the study showed that the flexible IM rod cohort tends to have smaller component sizes than their conventional counterparts. In the prospective phase of the study, the increase in clinical KSSs from preoperative levels was better in the flexible rod cohort (160% vs. 143% increases, respectively). The functional KSSs had slightly higher increases in the flexible rod cohort from their preoperative levels (68% vs. 62% increases, respectively). With both clinical and functional KSSs, the flexible rod cohort had a higher score than the rigid rod cohort at all follow-up points. There was better postoperative range of motion (ROM) in the flexible rod cohort (28% vs. 22% increases, respectively). The SF-36 physical scores were slightly different, with the flexible IM rod cohort having a more marked improvement in scores (64% vs. 46% increases, respectively). The SF-36 mental score had a slightly better improvement at latest follow-up in the flexible IM rod cohort (12% vs. 6% increases, respectively). Those patients who underwent TKA using a flexible IM rod had better improvements in their patient-reported outcomes and decreased risk of oversizing the femoral component. The use of such a rod is not detrimental to outcomes and may have a positive impact on outcomes. Future studies should focus on alignment and long-term outcomes associated with the use of a flexible rod.

Osteonecrosis of the Hip in Hematologic Disease: A Review of Conditions and Treatment Options.

Osteonecrosis of the hip can lead to advanced arthritis in typically young patients. Hematologic disorders comprise one group of potential causes. These include sickle cell anemia, hemophilia, aplastic anemia, thalassemia, and acute lymphoblastic leukemia. Depending on the stage of disease, treatment options include non-operative management, joint-preserving procedures (percutaneous drilling, core decompression, and vascularized or non-vascularized bone grafting), and joint arthroplasty (resurfacing arthroplasty and THA). Numerous small studies have investigated the efficacy of these options in patients who have specific hematologic disorders. Therefore, this report provides a comprehensive review of the osteonecrosis treatment options and results across the spectrum of patients who have various hematologic disorders.

Incidence and Future Projections of Periprosthetic Femoral Fracture Following Primary Total Hip Arthroplasty: An Analysis of International Registry Data.

As the number of total hip arthroplasties (THA) increases, the number of fractures will increase as well. The purpose of this study was to determine the incidence and prevalence of intra- and post-operative periprosthetic fractures following THA based on national joint registry data and to create a projection model that estimates the future fracture burden. Registry data from multiple joint registries were analyzed. Data on the incidence and prevalence of intra- and post-operative periprosthetic fractures were extracted. The prevalences between individual countries were analyzed to determine the mean prevalence. Three quantitative models were then generated to predict the fracture burden in the United States based on future population trends between 2015 and 2060. The mean incidence of post-operative periprosthetic fractures requiring revision was 0.8% while the incidence of intraoperative fractures was 0.8%. When all revision arthroplasties were assessed, the mean proportion of hips revised due to periprosthetic fracture was 6.6%. Projection models demonstrated that the number of periprosthetic fractures is expected to rise by a mean 4.6% every decade over the next 30 years. Periprosthetic fractures represent a small but important proportion of the revision THA burden worldwide. The incidence of both intra- and post-operative fractures is low, but the number is likely to steadily increase along with the number of surgeries performed. The number of fractures may rise even further as the incidence may potentially be higher in elderly, osteoporotic patients who are likely to represent a greater proportion of the arthroplasty population, particularly.

Prospective Case Series of NMES for Quadriceps Weakness and Decrease Function in Patients with Osteoarthritis of the Knee.

Osteoarthritis of the knee can lead to substantial disability. The purpose of this study was to evaluate the outcomes of a neuromuscular electrical stimulation (NMES) device in a small case series of treatment of quadriceps muscle weakness and decreased function in patients with knee osteoarthritis. We evaluated isokinetic quadriceps muscle strength, objective functional improvement, subjective functional improvement, quality of life, and pain relief. Patients were then matched with a previously studied cohort with similar osteoarthritic characteristics. Testing demonstrated improvement in isokinetic quadriceps and hamstring muscle strength, as well as several functional and patient-reported metrics. Conversely, patients reported a decrease in Knee Society Score (KSS) functional score, short-form 36 health survey (SF-36), lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain; however, no changes were observed in relation to the mean reported VAS pain score and SF-36 physical component. Control cohort analysis of the patient reported outcomes showed that patients improved from their first visit to 3 months follow-up in functional KSS, SF-36 physical component, and LEFS. However, VAS pain score and objective KSS were unchanged at follow-up. Similarly, a decrease was observed in the scores of the SF-36 mental component. In conclusion, the use of NMES for quadriceps muscle weakness has been shown to improve muscle strength. Additionally, NMES was shown to potentially improve functionality but demonstrated minimal effects on quality of life and patient-reported outcomes compared with the initial visit. However, larger, longer-term, prospective, randomized studies are needed to better evaluate these outcomes.

Thirty-Day Readmission Rates Comparing Specific Cruciate Retaining and Posterior Stabilizing Knee Arthroplasties to the National Readmission Rates.

Unplanned hospital readmissions within 30 days of surgery result in reimbursement penalties following total knee arthroplasty (TKA). Therefore, evaluating current readmission rates and comparing these to national levels is one way to self-assess and determine possible areas where improvements can be made. In this study, the 30-day readmission data for 845 TKAs performed with a single prosthesis were compared to the readmission data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database of 12,035 TKAs. We determined this following: (1) whether the TKA groups readmission rates were comparable; (2) the similarities and differences between readmission causes between the cohorts; and (3) the patient factors associated with increased readmission rates. The 30-day readmission rate for our cohort was lower than the NSQIP rate (2.1% versus 4.3%, respectively). Among all readmissions, our database had fewer readmissions due to surgically related complications (44% versus 57%, respectively). Patients in the single-prosthesis database had higher body mass indexes and higher rates of cardiovascular disorders, diabetes, and musculoskeletal disease. Within the NSQIP cohort, a higher proportion of males than females were readmitted. The most common comorbidities in the readmitted cohort were diabetes, chronic obstructive pulmonary disease, cardiac surgery, hypertension, bleeding disorders, and American Society of Anesthesiologists (ASA) grade 3. Of the surgically related factors, readmitted patients had significantly longer operative procedures. The 30-day readmission rate for patients undergoing primary TKAs in our database was lower than that of a national database.

Static and Dynamic Bracing for Loss of Motion Following Total Knee Arthroplasty.

Pain and dysfunction leading to decreased range-of-motion following total knee arthroplasty (TKA) is a common complication that may require treatment beyond standard rehabilitation efforts. In this review, we discuss the use of static and dynamic stretch devices to treat these range-of-motion dysfunctions. There are two mechanisms by which these devices work: dynamic stretch applies a constant low force, which allows for a variable soft-tissue displacement as they stretch, and static progressive stretch increases displacement, which allows for a constant displacement at a variable force leading to tissue stress relaxation. The uses of both devices have been reported to be effective in treating range-of-motion dysfunction after TKA. These devices are excellent options for the treatment of TKA stiffness, but they may undergo even further refinement in the future, as more information about exact indications and device modification emerge.

Early results of total hip arthroplasty in the super-obese patients.

The purpose of this study was to assess the outcomes of primary total hip arthroplasty (THA) in super-obese patients compared to a cohort who had a normal body mass index (BMI). Twenty patients (23 hips) who had a minimum BMI of 50 kg/m2 who underwent a primary THA between 2001 and 2010 were reviewed. They had a mean age of 50 years and follow-up of 36 months. These patients were compared (1:2 ratio) to a matched group of 40 patients (46 hips) who had a normal body mass index (less than 25 kg/m2) who underwent a THA during the same time period. Outcomes evaluated included implant survivorship, Harris hip scores, and complication rates. Overall, aseptic implant survivorship was lower in the super-obese patients compared to the matching group (96% versus 100%), but the difference was not significant. However, super-obese patients had significantly lower mean Harris hip scores (84 vs 91 points) and higher complication rate at final follow-up. Although the clinical outcomes of primary total hip arthroplasty were poorer in the super-obese patients, it is encouraging that even in these patients, total hip arthroplasty can have acceptable outcomes. However, these patients may benefit from a discussion with their orthopaedic surgeons to develop realistic expectations from the outcomes of their arthroplasty procedure.

Treatment of primary hip osteoarthritis for the primary care physician and the indications for total hip arthroplasty.

Osteoarthritis is a degenerative condition that commonly affects knees and hips with an annual incidence of 88 in 100,000 people in the United States. The purpose of this study was to review the clinical presentation of osteoarthritis of the hip as well as the available management options. We reviewed the recent literature in regard to epidemiology, presentation, and treatment options available to patients. Nonoperative treatments include weight loss and low-impact, aerobic exercises. Along with weight loss and exercise, nonsteroidal anti-inflammatory drugs (NSAIDS), narcotics, and intra-articular steroid injections have been used to improve patient's symptoms. Surgical intervention is a viable option; however, indications such as severe pain that is refractory to nonsurgical management, osteophytes, or joint space narrowing on radiographic films, or impairment of function should be present. The most common surgical option, total hip arthroplasty, has been shown to improve a patient's physical and psychological well-being. However, inherent risks are present with surgery and these should be addressed with the patient so a sound decision can be made. Osteoarthritis of the hip can be bothersome to patients, but physicians can begin management with lifestyle changes or pharmaceuticals. In the event nonoperative measures fail to markedly improve quality of life, total hip arthroplasty remains a viable option.