Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal-Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0-13.0] vs. 11.5 [9.5-15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.

In-hospital Mortality after Septic Revision TKA: Analysis of the New York and Florida State Inpatient Databases.

The aims of this study were to investigate (1) in-hospital mortality rates following septic revision total knee arthroplasty (rTKA); (2) compare septic rTKA mortality rates between differing knee revision volume (KRV) hospitals; and (3) identify independent risk factors associated with in-hospital mortality after septic rTKA (up to 2-year follow-up). The Healthcare Cost and Utilization Project State Inpatient Databases of New York and Florida were used to identify septic rTKA, and control groups of aseptic rTKA and primary TKA between 2007 and 2012 via International Classification of Diseases, Ninth Revision codes. Mortality was compared between septic rTKA and aseptic rTKA/primary TKA control groups. Hospital KRV was stratified, and independent risk factors of in-hospital mortality were identified and analyzed using unadjusted and adjusted logistic regression analyses. In this study, 3,531 septic rTKA patients were identified; 105 (3%) patients suffered in-hospital mortality, compared with the control aseptic rTKA (n = 178; 1.7%; p < 0.0001) and primary TKA groups (n = 930; 0.6%; p < 0.0001). Being an octogenarian (adjusted odds ratio [AOR]: 2.361; 95% confidence interval [CI]: 1.514-3.683; p < 0.0002) and having a medium- or high-Elixhauser comorbidity score was associated with in-hospital mortality (AOR: 2.073; 95% CI: 1.334-3.223; p = 0.0012, and AOR: 4.127; 95% CI: 2.268-7.512, p < 0.0001). There were no significant in-hospital mortality rate differences in high- versus medium- versus low-KRV hospitals (1.9 vs. 3.6 vs. 2.9%, respectively, p = 0.0558). Age >81 years and higher comorbidity burden were found to contribute to increased risk of 2-year postoperative mortality after septic rTKA. This association could not be established for hospital KRV.

Nonunion and Reoperation Following Proximal Interphalangeal Joint Arthrodesis and Associated Patient Factors.

BACKGROUND: Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis. METHODS: This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation. RESULTS: There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex (P < .01) and hepatic disease (P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk (P < .01). CONCLUSION: Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

In-Hospital Mortality Is Associated With Low-Volume Hip Revision Centers After Septic Revision Total Hip Arthroplasty.

Revision total hip arthroplasty (rTHA) after septic failure is associated with higher morbidity and mortality compared with aseptic revisions. The goals of this study were to characterize (1) the in-hospital mortality rate for patients with septic rTHA, (2) the effect of hospital hip revision surgery volume (HRV) on mortality after septic rTHA, and (3) the independent risk factors associated with in-hospital mortality rates after rTHA with 2-year follow-up. The authors analyzed the Healthcare Cost and Utilization Project State Inpatient Databases of New York and Florida to identify cases of septic rTHA from 2007 to 2012 with International Classification of Diseases, Ninth Revision, codes. The authors included patients with (1) no history of THA for 2 years before the index admission and (2) 2 years of follow-up. Groups with primary THA and aseptic rTHA were identified as control groups. Logistic regression was used to evaluate independent associations. Of 3057 patients with septic rTHA, 5.2% (n=160) had in-hospital mortality vs 2.9% of those with primary THA (n=3525, P=.0001) and 2.1% of those with aseptic rTHA (n=252, P=.0001). Octogenarian status, medium-risk Elixhauser comorbidity score, and high-risk Elixhauser comorbidity score were independent risk factors for mortality (adjusted odds ratio [AOR]=1.587, 95% CI=1.103-2.282, P=.0128; AOR=2.439, 95% CI=1.680-3.541, P<.0001; and AOR=6.367, 95% CI=4.134-9.804, P<.0001, respectively). Undergoing rTHA in a high-HRV hospital was associated with lower odds of in-hospital mortality (AOR=0.539, 95% CI=0.332-0.877, P=.0127). Receiving care in a low-HRV hospital increased the risk of 2-year postoperative patient mortality. Similarly, older age and a higher comorbidity burden were independently associated with increased 2-year postoperative mortality. [Orthopedics. 2022;45(1):57-63.].

MAKO Robotic-Arm Assisted Total Knee Arthroplasty: Surgical Technique From the Office to the Operating Room.

Recently, robotic assistance has become more readily available to perform total knee arthroplasties. However, training can often be time consuming and there can be a learning curve. Therefore, the purpose of this article is to clearly and concisely describe the preoperative planning and surgical technique for using one version of robotic assistance, specifically the MAKO platform (MAKO Surgical Corp. [Stryker], Fort Lauderdale, Florida), for a standard osteoarthritic knee with a varus deformity that is commonly encountered by joint arthroplasty surgeons.

Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending. SUMMARY OF BACKGROUND DATA: PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF. METHODS: This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time. RESULTS: In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events. CONCLUSIONS: Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The Olerud Extensile Anterior Approach for Complex Distal Femoral Fractures: A Systematic Review.

The management of AO/OTA (AO Foundation/Orthopaedic Trauma Association) 33-C3 complex distal femoral fractures presents challenges for orthopaedic surgeons. The extensile anterior approach may be an appropriate alternative treatment technique. The purpose of this systematic review is to (1) evaluate the Olerud approach (extensile anterior approach) for the treatment of 33-C3 complex distal femoral fractures and (2) evaluate postoperative patient outcomes. A systematic literature search was performed to retrieve studies that evaluated the treatment of 33-C3 complex distal femoral fractures. The PubMed database query resulted in 429 studies. Two reviewers independently reviewed the studies, of which six were identified. Patient demographics, AO/OTA fracture, surgical intervention, follow-up duration, clinical outcomes, and postoperative complications were collected and analyzed. The systematic review included six studies reporting on 85 patients (43 males and 42 females); the mean patient age was 45 years (range: 16-101 years). The most common cause of injury was road/traffic accident (51 patients). The mean follow-up time was 26 months (range: 3-72 months). In five studies, the mean time for union was 5.8 months (range: 2-9 months). The three most commonly reported complications were infection (seven [8.2%] patients), failure/malunion (three [3.5%] patients), and delayed tibial tuberosity osteotomy healing (three [3.5%] patients). Seventy (82.4%) patients did not suffer any postoperative complications. Out of 72 patients, 7 (9.7%) had resultant varus/valgus deformity. Overall, 57.1% had excellent/good functional outcomes. Based on the systematic literature review, the extensile anterior approach may be a viable alternative surgical option for 33-C3 complex distal femoral fractures. Given the current literature, more comprehensive and extensive studies need to be performed to ensure the best possible outcome.

Operative Times in Primary Total Knee Arthroplasty: Can We Predict the Future Based on Contemporary Nationwide Data.

Recently, the Centers for Medicare & Medicaid Services announced its decision to review "potentially misvalued" Current Procedural Terminology (CPT) codes, including those for primary total knee arthroplasty (TKA). CPT 27447 is being reevaluated to determine contemporary relative value units for work value, with operative time considered a primary factor in this revaluation. Despite broader indications for TKA, including extension of the procedure to more complex patient populations, it is unknown whether operative times may remain stable in the future. Therefore, the purpose of this study was to specifically evaluate future trends in TKA operative times across a large sample from a national database. The American College of Surgeons National Surgical Quality Improvement Project database was queried from January 1, 2008 to December 31, 2017 to identify 286,816 TKAs using the CPT code 27447. Our final analysis included 140,890 TKAs. Autoregressive integrated moving average forecasting models were built to predict 2- and 10-year operative times. While operative times were significantly different between American Society of Anesthesiologists (ASA) classes 1 and 2 (p = 0.035), there were not enough patients in ASA class 1 to perform rigorous inference. Additionally, operative times were not significantly different between ASA classes 3 and the combined ASA classes 4 and 5 cohort (p = 0.95). Therefore, we were only able to perform forecasts for ASA classes 2 and 3. Operative time was found to be nonstationary for both ASA class 2 (p = 0.08269) and class 3 (p = 0.2385). As a whole, the projection models indicated that operative time will remain within 2 minutes of the present operative time, up to the year 2027. Our projections indicate that operative times will remain stable over the next decade. This suggests that there is a lack of evidence for reducing the valuation of CPT code 27477 based on intraservice time for TKA. Further study should examine operative time trends in the setting of evolving alternative payment models, increasing patient complexity, and governmental restrictions.

Removal of Well-Fixed Tibial Cone in Revision Total Knee Arthroplasty-A Uniquely Challenging Yet Necessary Scenario.

The number of revision total knee arthroplasties (TKA) performed in the United States continues to increase. While advancements in implant design and surgical technique have led to improved outcomes compared with historical data, these cases remain technically demanding with high rates of aseptic failure and worse patient reported outcome scores compared with primary total knee arthroplasty. One particular problem commonly encountered in revision knee arthroplasty is bone loss, particularly in the epiphyseal region, which negatively impacts the structural integrity of the implants. Various modular metaphyseal sleeves and cones in conjunction with stemmed implants have been designed to enhance metaphyseal fixation, corroborated by multiple studies demonstrating excellent midterm results involving cones, and sleeves. Commercially available revision systems that incorporate metaphyseal cones are currently widely utilized in revision TKA. For tibial defects, both symmetric and asymmetric cone options are available. Excellent midterm results have been reported with use of this device in the setting of severe proximal tibial bone loss in revision TKA surgery. With the enhanced fixation provided by various sleeve and cone augments, implant removal in the setting of recurrent infection or implant failure can be extremely challenging. Consequently, in this work, we sought to describe an algorithmic approach for removing a tibial cone in conjunction with the overlying tibial baseplate. A review of the literature has also been conducted for complex surgical techniques regarding removal of well-fixed implants in revision total knee arthroplasty.

Subchondral insufficiency fractures of the femoral head: systematic review of diagnosis, treatment and outcomes.

Subchondral insufficiency fractures of the femoral head (SIFFH) are a cause of femoral head collapse leading to degenerative hip disease. SIFFH is often mistaken for osteonecrosis given similar clinical and radiographic features. These similarities often lead to missed or delayed diagnosis which can often delay or change management. The purpose of this article is to systematically review the spectrum of demographics, diagnostic and treatment options, including hip preservation in young patient populations. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. All related peer-reviewed publications from January 1999 to January 2019 were reviewed using the following databases: Medline, EMBASE, Scopus and Web of Science. The systematic review identified 54 articles, encompassing 482 patients (504 hips) diagnosed with SIFFH. One hundred and seventy-six (35%) males and 306 (63%) females were included, with a mean age of 53.6 ± 17.5 years and mean body mass index of 23.4 ± 4.0 kg/m2. Mean follow-up was 23.4 ± 15.9 months. Treatment decisions were 256 (55%) non-operative, 157 (34%) total hip arthroplasty (THA), 24 (5%) transtrochanteric anterior rotational osteotomy, 9 (2%) hip arthroscopy, 7 (2%) hip resurfacing, 3 (1%) bone grafting, 3 (1%) hemiarthroplasty and 1 (1%) tantalum rod insertion. Overall, 35% of SIFFH hips were converted to THA at latest follow-up. A majority of SIFFH patients had symptom resolution with non-operative management. Failure most often resulted in THA. In younger patients, hip preservation techniques have shown promising early results and should be considered as an alternative.

Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children: A Controlled Cohort Study.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). CONCLUSIONS: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. LEVEL OF EVIDENCE: Level III.

Utilization of Telemedicine Virtual Visits in Pediatric Spinal Deformity Patients: A Comparison of Feasibility and Patient Satisfaction at a Large Academic Center.

BACKGROUND: Telemedicine platforms have been developed to support the convenient delivery of health care services to their patients while maintaining appropriate quality of care. However, it is unclear whether they can be utilized effectively in patients with pediatric spinal deformity (PSD). Therefore, this study aimed to evaluate the feasibility and patient satisfaction associated with virtual visit (VV) utilization in PSD patients in comparison to general pediatric orthopaedic indications. METHODS: Of the 482 VVs offered to pediatric orthopaedic patients at a large academic health care system between January 1, 2017, and December 31, 2018, a total of 189 VVs conducted by board-certified orthopaedic surgeons were included in the final analysis. Patient satisfaction scores were collected at the end of each VV by patient and parent rankings of the surgeon and the telemedicine service. Data on patients, visits, and connectivity sessions characteristics were collected and statistically compared between PSD visits (n=33) versus those conducted for general pediatric orthopaedic indications (n=156). RESULTS: Although PSD patients were older (15±3.7 vs. 12±4.7 y; P<0.01), mostly female (76% vs. 47%, P=0.003), and had longer VVs (8±4.6 vs. 5±3.6 min; P=0.003) versus their general pediatric orthopaedic counterparts, they demonstrated similarly high satisfaction scores for surgeon performance (5±0 vs. 4.8±0.1 points; P=0.08) and overall satisfaction (3±2.4 vs. 3.5±2.1; P=0.23). Approximately 80% of all VVs were conducted over mobile devices. Wait time was substantially less for PSD VVs relative to subsequent office visits (13±10 vs. 41±30 min; P<0.001). CONCLUSIONS: Our analysis found that telemedicine VVs provided a convenient alternative to traditional in-office visits for PSD patients. Specifically, we found that PSD patients received faster care with comparable satisfaction. The findings of our present analysis should encourage health care systems to continually evaluate and implement telehealth platforms to improve both the accessibility and appropriate quality of care. LEVEL OF EVIDENCE: Level IV.

Correction to: Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

The original version of this article unfortunately contained a mistake. The spelling of Erin Ohliger's name was incorrect.

Osteoid Osteoma Masquerading as Cholelithiasis: A Case Report.

CASE: We present a case report of an 18-year-old woman who presented to a general surgeon with a several month history of intermittent right upper quadrant pain, strongly suggestive of symptomatic cholelithiasis and underwent a laparoscopic cholecystectomy. She was eventually found to have an osteoid osteoma (OO) of the right eighth rib. She was treated with radiofrequency ablation with complete resolution of symptoms 1 month after treatment. CONCLUSIONS: In cases where a patient's age and risk factors would make the diagnosis of cholelithiasis less likely, OO should be added to the differential diagnosis of symptomatic right upper quadrant pain.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

The effect of body mass index on 30-day complications after total hip arthroplasty.

BACKGROUND: Evaluating body mass index (BMI) as a continuous variable eliminates the potential pitfalls of only considering BMI as a binary or categorical variable, as most studies do when correlating BMI and total hip arthroplasty (THA) outcomes. Therefore, the objective of this study was to correlate the effect of continuous BMI on 30-day complications post-THA. Specifically, we correlated BMI to: (1) 30-day readmissions and reoperations; (2) medical complications; and (3) surgical complications in: (a) normal-weight; (b) over-weight; (c) obese; and (d) morbidly obese patients. METHODS: Using the NSQIP database, 93,598 primary THAs were identified. 30-day rates of readmissions, reoperations, and medical/surgical complications as well as patient BMI data were extrapolated. A comparative analysis using univariate, multivariate, and spline regression models adjusting for demographics and comorbidities were created to study the continuous effect of BMI on different outcomes. RESULTS: Readmission (p < 0.001), reoperation (p = 0.007), superficial infection (p = 0.003), prosthetic joint infection (p < 0.001), and sepsis (p = 0.026) had a J-shaped relationship with BMI, with the lowest rates seen in patients with BMI around 28 kg/m2. The risks of mortality (p = 0.007) and transfusion (p < 0.001) had a reverse J-shaped relationship, with the risk steadily decreasing for BMIs in the normal weight and overweight range, and then flattening afterwards. CONCLUSION: This data proposes a multifactorial effect of BMI on post-THA complications. Considering BMI as a continuous variable allows for a better assessment when considering the interplay between modifiable risk factors, such as smoking or alcohol use, as well as multiple comorbidities.

Cementless 3D Printed Highly Porous Titanium-Coated Baseplate Total Knee Arthroplasty: Survivorship and Outcomes at 2-Year Minimum Follow-Up.

Newer generation cementless total knee arthroplasty (TKA) implants continue to develop with demonstrated clinical success in multiple recent reports. The purpose of this study was to investigate (1) survivorship, (2) complications, and (3) clinical outcomes of a newer generation cementless and highly porous titanium-coated base plate manufactured using three-dimensional (3D) printing technology. We reviewed a single-surgeon, longitudinally maintained database of patients who underwent primary TKA using cementless, highly porous titanium-coated base plate implants from July 1, 2013 to December 31, 2016. A total of 523 patients were identified. Of this cohort, 496 patients had a minimum of 2-year follow-up and were included in our final analysis. Among these patients, 72 had bilateral TKA yielding a total of 568 TKAs. There were 133 men and 363 women who had a mean body mass index of 33 kg/m2 (range, 20-61 kg/m2). The mean age was 66 years (range, 33-88 years). Average follow-up was 36 months (range, 24-48 months). Indications for TKA included osteoarthritis in 432 patients (87%), rheumatoid arthritis in 40 patients (8%), and knee osteonecrosis in 24 (5%) patients. Implant survivorship was defined as any revision leading to explantation of the base plate for any reason. Kaplan-Meier analysis was performed to determine all-cause implant survivorship at final follow-up for every patient. Complications were assessed using the Knee Society standardized list of TKA complications. Clinical outcomes were determined using the Knee Society pain and function scores. Range-of-motion values were also collected. There were a total of four failures, all were due to aseptic loosening with a survivorship rate of 99% at mean follow-up of 3 years (95% confidence interval = 0.984-0.999). In addition, there were a total of 12 surgical and 10 medical complications. Surgical complications did not affect the base plate or result in any additional implant revisions. A total of nine patients had thromboembolic disease complications; all received medical treatment and recovered adequately. Radiological evaluation did not show any signs of loosening or failures in other patients at final follow-up. Knee Society Scores for pain and function improved from 55 and 56 points preoperatively to 92 and 84 points at 2 years postoperatively. Our results are in concordance with the excellent clinical outcomes and survivorship demonstrated for the newer generation cementless TKA implants. In our experience, 3D printed titanium base plates demonstrated clinical success and excellent survivorship at minimum follow-up of 2 years.

Survivorship and Functional Outcomes of Cementless versus Cemented Total Knee Arthroplasty: A Meta-Analysis.

The purpose of this meta-analysis was to assess the evidence supporting the use of cementless versus cemented total knee arthroplasties (TKAs). Specifically, we evaluated (1) all-cause survivorship, (2) aseptic survivorship, and (3) functional outcomes (Knee Society Scores [KSS], Oxford Knee Scores, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores, and ranges of motion [ROMs]). A literature search was performed for studies that evaluated cementless versus cemented TKAs published between 2000 and 2017. Selected studies included three randomized controlled trials, three retrospective observational studies, and one prospective observational study that met the following criteria: (1) primary TKAs, (2) compared cementless and cemented TKAs, (3) implant survivorship that described the causes of failure, and (4) at least one functional outcome. To compare the two cohorts, pooled odds ratios (OR) and 95% confidence intervals (95% CI) were used to calculate tibial and femoral implant survivorship, and pooled mean differences (MD) and 95% CI calculated the functional scores and ROMs. Based on pooled data from the few number of studies, cementless TKAs had a better all-cause survivorship (OR = 0.37; 95% CI, 0.15-0.92) and tended to have a better aseptic survivorship (OR = 0.44; 95% CI, 0.17-1.14). However, this is likely due to the 83.3% weight of the single cementless study potentially influencing the analysis. There were no differences in terms of KSS knee (MD = 1.03; 95% CI, -1.13-3.20) or function scores (MD = 5.36; 95% CI, -3.75-14.51), Oxford knee scores (MD = 0.36; 95% CI, -3.84-4.56), or WOMAC scores (MD = 0.62; 95% CI, -0.87-2.11). Moreover, there was no difference in ROMs (MD = 1.47; 95% CI, -0.11-3.05). Cementless TKA had a better all-cause survivorship when compared with cemented fixation, and similar functional outcomes were demonstrated. However, these findings are based on only a few number of studies (n = 7). Therefore, additional prospective, randomized control trials need to be performed to best compare cementless versus cemented outcomes.

Soft Tissue Reconstruction for Deep Defects over a Complicated Total Knee Arthroplasty: A Systematic Review.

Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.

Malnutrition increases the 30-day complication and re-operation rates in hip fracture patients treated with total hip arthroplasty.

INTRODUCTION: This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates. METHODS: The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates. RESULTS: Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43-2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31-3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42-2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20-3.23). CONCLUSIONS: The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk.