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1.
J Arthroplasty ; 2020 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-32019689

RESUMO

BACKGROUND: Current literature suggests that preoperative hematocrit levels may play an important role in determining risk for complications after total hip arthroplasty (THA). The purpose of this study was to determine the role of preoperative anemia status on 30-day complications after THA. METHODS: Using the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on preoperative hematocrit levels (normal > 36% [N = 166,538], mild anemia 27%-36% [N = 13,214], and severe anemia <27% [N = 541]). Differences in 30-day postoperative medical complications and readmission rates were compared using bivariate and multivariate analyses. RESULTS: Multivariate logistic regression analysis identified mild anemia compared with normal hematocrit as a significant risk factor for total complications (OR: 1.46, P < .001), mortality (OR: 2.06, P < .001), renal complications (OR: 2.59, P < .001), respiratory complications (OR: 1.89, P < .001), sepsis (OR: 2.01, P < .001), wound infection (OR: 1.36, P < .001), and urinary tract infection (OR: 1.44, P < .001). Severe anemia was also risk factor, with a higher odds ratio, for total complications (OR: 1.99, P < .001). Both mild and severe anemia were significant risk factors for increased rates of perioperative blood transfusion (mild: OR, 4.04, severe: OR, 5.58), nonhome discharge (OR: 1.74, OR: 1.64), and unplanned hospital readmissions (OR: 1.42, OR: 1.66). CONCLUSION: Preoperative anemia is a significant risk for perioperative complications after primary THA. Even mild anemia can lead to significantly increased risks of mortality, medical complications, and unplanned hospital readmissions in THA. This study further supports the need for screening and preoperative intervention for patients in this at-risk group.

2.
J Arthroplasty ; 35(3): 774-778, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31685395

RESUMO

BACKGROUND: The mini-anterolateral (AL) approach for total hip arthroplasty (THA) has gained popularity. In contrast to other approaches, risk factors for periprosthetic femur fractures have not been well established for the AL approach. METHODS: Six hundred eighty-four primary THAs performed using the AL approach were retrospectively reviewed for risk factors associated with perioperative periprosthetic femur fractures within 3 months of surgery. Risk factors evaluated were gender, age, body mass index, laterality, and Dorr ratio of the proximal femur. Cemented stems and collared uncemented stems were compared to uncemented tapered-wedge and meta-diaphyseal stems. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of 684 primary THAs performed, 57 (8.3%) resulted in fracture. Twenty-eight (4.1%) occurred intraoperatively and 29 (4.2%) occurred postoperatively within 90 days. All intraoperative fractures were fixed at the time of surgery and healed uneventfully. Of the postoperative fractures, 15 (2.2%) were amenable to nonoperative management and healed. Fourteen (2.0%) required revision arthroplasty. There was a significantly lower rate of fracture in patients receiving cemented or collared stems (0%, n = 101) than in those receiving tapered-wedge or meta-diaphyseal fitting stems (9.8%, n = 583; P = .0009). Odds of fracture increased with female gender (P = .0063) and increasing Dorr ratio (P = .0003). Analysis showed a trend toward increased risk with older age, but did not achieve statistical significance. Body mass index and laterality showed no statistically significant effect. CONCLUSION: Performing primary THA via the AL approach, 2.0% of patients had a postoperative fracture requiring revision within the first 3 months. With cemented and collared stems, the fracture rate was significantly lower. Surgeons should consider using cemented or collared stems in high-risk patients.

3.
Knee ; 27(1): 151-156, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31761707

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) design continues to be refined. As part of the pre-clinical design process, kinematic evaluation under ideal circumstances must be simulated. Previously, this was accomplished mechanically through the use of elastomeric bumpers and human cadaver models, which can be costly and time-intensive. With improved technology, a six-axis joint simulator now allows for virtual ligament reconstruction. The aim of this study was to create and evaluate a virtual posterior cruciate ligament (PCL) model to simulate native knee kinematics for component testing in TKA. METHODS: Three human cadaveric knee specimens were utilized, each mounted in a six-axis joint simulator and the femoral and tibial ligament insertion points digitized. Ligament stiffness and kinematics were first tested with the intact knee, followed by retesting after PCL transection. Knee kinematic testing was then repeated, and the virtual PCL was reconstructed until it approximated that of the intact knee by achieving less than 10% random mean square (RMS) error. RESULTS: A virtual three-bundle PCL was created. The RMS error in anterior-posterior motion between the virtually reconstructed PCL and the intact knee ranged from six to eight percent for simulated stair climbing in the three knee specimens tested, all within our target goal of less than 10%. CONCLUSION: This study indicated that a virtually reconstructed three-bundle PCL with a joint simulator can replicate knee kinematics. Such an approach is valuable to obtain clinically relevant kinematics when testing cruciate-retaining total knee arthroplasty under force control.

4.
J Bone Joint Surg Am ; 101(23): e125, 2019 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-31800427

RESUMO

BACKGROUND: Many reference axes are used to evaluate rotation of the femoral component during total knee arthroplasty, including the Whiteside line, surgical transepicondylar axis (sTEA), anatomical transepicondylar axis (aTEA), posterior condylar axis externally rotated 3° (PCA+3°ER), sulcus line, and femoral transverse axis (FTA). There is no consensus about which of these axes is most accurate. METHODS: The Stryker Orthopaedic Modeling and Analytics (SOMA) database was used to identify 2,128 entire-femur computed tomography (CT) scans. The Whiteside line, aTEA, PCA+3°ER, sulcus line, and FTA were constructed according to published guidelines. Every axis was compared with the sTEA, which is widely regarded as the gold standard reference axis for rotation of the distal part of the femur but has low intraobserver and interobserver reliability intraoperatively. RESULTS: The PCA+3°ER differed from the sTEA by a mean (and standard deviation) of 0.60° ± 1.64°; it was the most accurate but also had the highest degree of intersubject variability. The mean PCA-sTEA angle was 2.40°, close to the accepted "rule of thumb" of 3°. This value was significantly higher in women (2.64° ± 1.74°) than in men (2.18° ± 1.52°; p < 0.001). The Whiteside line differed from the sTEA by a mean of 1.90° ± 1.38°, and the sulcus line differed from the sTEA by a mean of 1.94° ± 1.49°; neither of these values varied significantly with sex or ethnicity. The FTA differed from the sTEA by a mean of 2.04° ± 1.50°. Least accurate was the aTEA, which differed from the sTEA by a mean of 2.05° ± 1.33°. The combination of 3 axes that are readily available intraoperatively (the Whiteside line, aTEA, and PCA+3°ER) differed from the sTEA by a mean of 1.80° ± 0.70°. CONCLUSIONS: In the largest study of its kind, analysis of CT scans of 2,128 femora revealed that no 1 axis could serve as a marker of femoral component rotation with both high accuracy and low variability. Utilizing a combination of 3 methods (PCA+3°ER, the Whiteside or sulcus line, and aTEA) to maximize accuracy and sex and ethnic generalizability when positioning the femoral component is recommended. CLINICAL RELEVANCE: A large-scale study using a CT-based biomorphometric database demonstrated that use of a combination of 3 axes (PCA+3°ER, the Whiteside or sulcus line, and aTEA) was the optimal strategy for judging femoral component rotation.

5.
Hip Int ; : 1120700019891427, 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31822131

RESUMO

BACKGROUND: Arthroplasty is the treatment of choice for elderly patients with displaced femoral neck fractures. When compared to total hip arthroplasty (THA), higher revision rates have been reported for hemiarthroplasty (HA). Conversion of failed HA to THA can be complex, especially in the elderly population at risk for revision surgery complications. We report a single institution's experience with conversion of failed HA to THA at mid-term follow-up. METHODS: We identified patients converted from failed HA to THA from 2006 to 2016. Clinical data including indication for index and conversion surgery, maintenance or revision of femoral component during conversion, operative time, estimated blood loss, postoperative complications, and need for revision surgery were collected. Descriptive statistics were analysed in SPSS. RESULTS: The cohort included 21 men and 39 women (mean age of 74.5 years). The mean follow-up after conversion HA to THA was 2.8 years. During conversion surgery, the femoral component was revised in 75.0% and retained in 25.0% of cases. After conversion HA to THA, the rate of major complications and re-revision at 2 years was 11.7% and 10.0%, respectively. Femoral revision versus retention did not affect complication rates (11.1% vs. 6.7%; p = 0.31) or re-revision rates (8.9% vs. 13.3%; p = 1.0). CONCLUSIONS: In this high-risk population, mid-term follow-up demonstrated tolerable complication and re-revision rates, the majority of which were for instability. We observed high rates of femoral component revision during conversion THA, although this did not increase the likelihood of postoperative complications or need for future surgery.

6.
J Bone Joint Surg Am ; 2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31567689

RESUMO

BACKGROUND: Many reference axes are used to evaluate rotation of the femoral component during total knee arthroplasty, including the Whiteside line, surgical transepicondylar axis (sTEA), anatomical transepicondylar axis (aTEA), posterior condylar axis externally rotated 3° (PCA+3°ER), sulcus line, and femoral transverse axis (FTA). There is no consensus about which of these axes is most accurate. METHODS: The Stryker Orthopaedic Modeling and Analytics (SOMA) database was used to identify 2,128 entire-femur computed tomography (CT) scans. The Whiteside line, aTEA, PCA+3°ER, sulcus line, and FTA were constructed according to published guidelines. Every axis was compared with the sTEA, which is widely regarded as the gold standard reference axis for rotation of the distal part of the femur but has low intraobserver and interobserver reliability intraoperatively. RESULTS: The PCA+3°ER differed from the sTEA by a mean (and standard deviation) of 0.60° ± 1.64°; it was the most accurate but also had the highest degree of intersubject variability. The mean PCA-sTEA angle was 2.40°, close to the accepted "rule of thumb" of 3°. This value was significantly higher in women (2.64° ± 1.74°) than in men (2.18° ± 1.52°; p < 0.001). The Whiteside line differed from the sTEA by a mean of 1.90° ± 1.38°, and the sulcus line differed from the sTEA by a mean of 1.94° ± 1.49°; neither of these values varied significantly with sex or ethnicity. The FTA differed from the sTEA by a mean of 2.04° ± 1.50°. Least accurate was the aTEA, which differed from the sTEA by a mean of 2.05° ± 1.33°. The combination of 3 axes that are readily available intraoperatively (the Whiteside line, aTEA, and PCA+3°ER) differed from the sTEA by a mean of 1.80° ± 0.70°. CONCLUSIONS: In the largest study of its kind, analysis of CT scans of 2,128 femora revealed that no 1 axis could serve as a marker of femoral component rotation with both high accuracy and low variability. Utilizing a combination of 3 methods (PCA+3°ER, the Whiteside or sulcus line, and aTEA) to maximize accuracy and sex and ethnic generalizability when positioning the femoral component is recommended. CLINICAL RELEVANCE: A large-scale study using a CT-based biomorphometric database demonstrated that use of a combination of 3 axes (PCA+3°ER, the Whiteside or sulcus line, and aTEA) was the optimal strategy for judging femoral component rotation.

7.
Arthroplast Today ; 5(3): 301-305, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31516970

RESUMO

A 56-year-old male laborer with severe superior and medial acetabular protusio was treated with a cementless left total hip arthroplasty (THA) using an inexpensive technique that preserved the incarcerated femoral head in situ. The head was never dislocated, so the ligamentum was not disrupted. Wires stabilized the femoral head while reaming to prevent it from spinning, and multiple screws united the cup, autograft, and pelvis. At 2-year follow-up, the patient has pain-free hip function, radiographic union, and no component loosening or graft resorption.

8.
Arthroplast Today ; 5(3): 325-328, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31516976

RESUMO

Background: Adductor canal blocks (ACBs), typically administered with a local anesthetic such as bupivacaine, help control perioperative pain after total knee arthroplasty. Recently, liposomal bupivacaine (LB) was introduced in an attempt to extend the duration of analgesia, used primarily in periarticular injections (PAIs). The purpose of this study was to compare pain control and early perioperative outcomes with ACB using LB vs standard bupivacaine (SB). Methods: We retrospectively compared pain control in a group of 75 patients with ACB and PAI with SB to that of a cohort of 75 patients who received ACB and PAI with LB. The primary outcome measure was pain measured using the visual analog score. The secondary outcome measures were morphine equivalents of pain medication (ME), physical therapy distance ambulated, disposition status, and length of stay. Results: There were no significant differences between the two cohorts for age, gender, body mass index, preoperative diagnosis, or American Society of Anesthesiologists. Visual analog scores were significantly lower in the LB group for postoperative day (POD) 0 (2.1 vs 2.8, P = .046), POD 1 (2.2 vs 3.3, P < .001), and POD 2 (2.1 vs 3.7, P = .001) than those in the SB group. The LB group consumed significantly fewer ME on the POD 0 (18.7 vs 25.2, P = .02) and POD 1 (23.4 vs 37.8, P = .003), as well as overall ME/day (24.6 vs 41.7, P < .001). The LB group walked more on POD 0 (261.6 vs 108.2, P < .001) and POD 1 (761.5 vs 372.0, P < .001). Conclusions: We report improved outcomes across all measures for the LB group. There were no adverse events. This study supports the use of LB for ACBs in total knee arthroplasty.

9.
Arthroplast Today ; 5(3): 348-351, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31516980

RESUMO

Background: This registry study assesses 30-day outcomes, including complications, length of stay (LOS), transfusions, and discharge disposition, as a function of time to revision surgery for knee periprosthetic fracture (PPF). Methods: We compared outcomes when surgery occurred ≤ (expedited) or > 24 hours (nonexpedited) after admission using the 2005-2016 National Surgical Quality Improvement Program registry. Outcome variables were assessed using bivariate and multivariate analyses. Results: Of 484 patients undergoing revision knee arthroplasty for PPF, 337 (77.9%) had expedited surgery and 107 (22.1%) had nonexpedited surgery. The average time to surgery in the nonexpedited group was 3.2 days (range 0-11). Patients with nonexpedited surgery were more likely to be older, female, and diabetic, received general anesthesia, and had a higher American Society of Anesthesiologists class, dependent functional status, and longer operative time. On multivariate analysis, nonexpedited patients had more complications (odds ratio [OR], 2.35; P = 0.037), surgical site infections (OR, 12.87; P = 0.029), urinary tract infections (OR, 10.46; P = 0.048), nonhome discharge (OR, 4.27; P < 0.001), need for blood transfusion (OR, 4.53; P < 0.001), and longer LOS (2.4 days; P < 0.001). There was no difference in mortality (P = 0.352). Conclusions: Nonexpedited revision surgery for knee PPF had worse outcomes, specifically more surgical site and urinary tract infections, longer LOS, need for blood products, and more discharge to acute care facilities. This registry study cannot assess reasons for unavoidable delay, such as medical optimization and team or implant availability. Level of Evidence: III.

10.
J Arthroplasty ; 34(12): 2878-2883, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31402074

RESUMO

BACKGROUND: Preemptive multimodal analgesia (PMA) is a commonly used technique to control pain following total joint arthroplasty. PMA protocols use multiple analgesics immediately preoperatively to prevent central sensitization and amplification of pain during surgery. While benefits of some individual components of a PMA protocol have been established, there are little data to support inclusion or exclusion of opioids in this context. METHODS: This is a retrospective cohort study of 550 patients undergoing elective, primary total joint arthroplasty at a single institution using a standardized preoperative perioperative protocol. Two hundred seventy-five patients received oxycodone in addition to a standard multimodal preoperative analgesia regimen just before surgery and were compared to a matched cohort of 275 patients who received the standard regimen alone. Outcome measures included inpatient visual analog scale pain scores, inpatient opioid consumption, length of stay, and ambulation distance with physical therapy. RESULTS: Patients who received opioids in preoperative holding reported significantly greater visual analog scale pain scores on postoperative day 1 (3.7 vs 3.1; P = .01), when compared to those who did not. These patients also walked shorter distances on postoperative day 0 (59.5' vs 125.7'; P < .001) and consumed greater morphine equivalents per hospital day over the course of their hospital stay (52.2 vs 37.2 mg; P < .001). These differences remained significant when stratified by procedure, total knee arthroplasty or total hip arthroplasty. Differences in pain and function between groups were more pronounced in patients undergoing total hip arthroplasty than those undergoing total knee arthroplasty. CONCLUSION: Total joint patients who were given preemptive opioids immediately before surgery experienced more pain, consumed more postoperative opioids, and exhibited impaired early function as compared to those who were not given preemptive opioids. Orthopedic surgeons should reconsider routine use of preemptive opioids in this context.

11.
J Arthroplasty ; 34(12): 2931-2936, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31427131

RESUMO

BACKGROUND: Early ambulation with physical therapy (PT) following total knee arthroplasty (TKA) has demonstrated benefits in the literature. However, the impact of early PT on rehabilitation performance and opioid consumption has not been elucidated. We evaluate the effect of same-day PT on inhospital functional outcomes and opioid consumption. METHODS: We retrospectively identified 2 cohorts of primary TKA patients from July 2016 to December 2017: PT0 (n = 295) received PT on the day of surgery, and PT1 (n = 392) received PT on postoperative day (POD) 1. Outcomes studied included number of feet walked on POD0-3, visual analog scale pain scores, morphine equivalents (ME) consumed, length of stay, and discharge disposition. Analysis was conducted using the Student t-test and Fisher exact test. RESULTS: In comparison to the PT1 group, the PT0 group walked significantly more steps on POD1 (347.6 vs 167.4 ft, P < .0001), POD2 (342.1 vs 203.5 ft, P < .0001), and POD3 (190.3 vs 128.9 ft, P = .00028). There was no difference between the 2 groups for visual analog scale. The PT0 group also consumed significantly fewer total ME when compared to the PT1 group (149.0 vs 200.3 mg, P = .0002). The PT0 group had a significantly shorter length of stay when compared to the PT1 group (2.7 vs 3.2 days, P = .00075). More patients were discharged home in the PT0 group (81.7% vs 54.8%, P < .0001). CONCLUSION: We observed that initiation of PT on POD0 led to better PT performance, reduced ME during hospitalization, and more patients discharged home. LEVEL OF EVIDENCE: III, Retrospective cohort study.

12.
J Knee Surg ; 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31269524

RESUMO

Pain control following knee arthroplasty is extremely important to both patients and surgeons to improve the perioperative experience; however, the implication of early pain control on long-term outcomes following knee arthroplasty remains poorly understood. We hypothesized that poor early pain control results in poor functional outcomes 2 years following total (TKA) and unicondylar knee arthroplasty (UKA). This retrospective study reviewed 242 TKA and 162 UKA performed at a single institution by two surgeons. Mean visual analog scale (VAS) pain scores were collected for first 3 postoperative days. Patients were prospectively evaluated using short form (SF-12), the Western Ontario and McMaster University osteoarthritis index (WOMAC), and the Knee Society functional score (KSFS) questionnaires. Pearson's correlation coefficients were calculated between mean VAS pain scores and functional outcome scores at 2 years. In the TKA group, poorly controlled perioperative pain correlated with poorer functional scores at 2 years. There was a significant negative correlation between early mean VAS pain scores (mean, 3.2 ± 2.0) and most 2-year functional outcomes including SF-12 physical score (r = -0.227, p ≤ 0.01), WOMAC pain scores (r = -0.268, p ≤ 0.01), WOMAC stiffness scores (r = -0.224, p < 0.01), WOMAC function score (r = -0.290, p 0.01), and KSFS (r = -0.175, p = 0.031). Better control of early pain was associated with improved functional outcomes at 2 years following TKA. We also found significant negative correlations between preoperative functional scores and early postoperative pain scores. Collectively, using preoperative and early postoperative pain scores, we identified an "at-risk" patient group that manifested an inferior functional outcome at 2 years; these patients may benefit from closer surveillance and a multidisciplinary approach to pain and function to optimize their clinical outcome following knee arthroplasty.

13.
J Arthroplasty ; 34(11): 2789-2792.e1, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31279604

RESUMO

BACKGROUND: Studies have identified a possible morbidity and mortality benefit with expedited time to surgery after a native hip fracture. This association after hip periprosthetic fractures (PPF) has been less clearly delineated. The purpose of this study is to assess the effect of time to surgery on rates of 30-day complications. METHODS: The National Surgical Quality Improvement Program registry was used to identify all patients who underwent surgical intervention for hip PPF between 2005 and 2016. Patients were stratified into 2 cohorts based on time from hospital admission to surgery, either ≤24 hours (expedited) or >24 hours (non-expedited). Thirty-day outcome variables were assessed using bivariate and multivariate analyses. RESULTS: We identified 857 patients undergoing surgical intervention for hip PPF, of whom 402 (46.9%) underwent expedited surgery and 455 (53.1%) underwent non-expedited surgery. Patients with non-expedited surgery had an average time to surgery of 2.4 days (range, 1-14 days). Multivariate analysis adjusting for differences in baseline patient characteristics revealed that patients with a non-expedited procedure had higher rates of overall complications (odds ratio [OR] = 1.72; P = .014), respiratory complications (OR = 4.15; P = .0029), urinary tract infections (OR = 2.77; P = .020), nonhome discharge (OR = 2.22; P < .001), and blood transfusions (OR = 1.86; P < .001). There was no statistical difference in mortality (P = .093). Patients with non-expedited surgery also had longer total and postoperative (+2.7 days; P < .001) length of stay. CONCLUSION: This study did not identify any statistical difference in mortality but found an association with increased postoperative complications and non-expedited surgery for PPF. Additional prospective studies may be warranted to identify the causative factors behind this association.

14.
Artigo em Inglês | MEDLINE | ID: mdl-31190247

RESUMO

PURPOSE: Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration. METHODS: 140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates. RESULTS: There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion. CONCLUSIONS: Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.

15.
J Knee Surg ; 2019 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-31108558

RESUMO

Proper femoral component rotation in total knee arthroplasty (TKA) is important, given the prognostic impact of a poorly positioned component. The purpose of this observational study was to determine the incidence of femoral component malrotation using posterior condylar axis (PCA) referencing. A total of 100 knees in 92 patients with varus gonarthritis of the knee undergoing primary TKA using a standard medial parapatellar approach were evaluated intraoperatively. After distal femoral resection, the standard femoral sizing guide referencing the posterior condylar axis was used to set femoral component rotation. This was then compared with both the transepicondylar (TEA) and trochlear anteroposterior axes (TRAx). Disparites were recorded and corrected in line with the epicondylar axis. Rotational adjustment for addition of further external rotation was made in 13 (13.0%) cases. In seven cases, the medial pin sites were raised between 1 and 3 mm, and in six cases, the lateral pin site was lowered between 1 and 3 mm (based on risk of notching the femoral cortex). It is critical to not rely exclusively on the PCA to confirm rotational positioning of the femoral component as predicted by posterior condylar referencing guides. Intraoperative adjustment and confirmation using the TEA and TRAx occurred in 13% of primary TKA cases, which might have, otherwise, had a significant effect on the clinical outcome.

16.
J Arthroplasty ; 34(8): 1553-1556, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31109757

RESUMO

BACKGROUND: Primary arthroplasty current procedural terminology codes have been proposed for reexamination due to concern that the intraservice skin-to-skin time is overestimated at 100 minutes. We sought to determine actual intraservice times for primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). METHODS: We queried hospital administrative databases to determine average intraservice times for 4 fellowship-trained arthroplasty surgeons at an urban, academic institution. RESULTS: There were 1313 primary THA performed over the study period. The mean intraservice time was 102 minutes (standard deviation 26 minutes). There were no consistent trends over time. There were 1300 primary TKA performed over the study period. The mean intraservice time was 116 minutes (standard deviation 25 minutes). There were no consistent trends over time. CONCLUSIONS: We found an average operative time that was very close to the current benchmarked times for THA and 16% longer than the benchmarked times for TKA. The incentives of for-profit insurance companies and third-party organizations must be considered when considering requests for a rereview of the physician work and carefully weighed against real data, such as presented here, and the impact on access to care for patients.

17.
J Arthroplasty ; 34(8): 1575-1580, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31064724

RESUMO

BACKGROUND: Hospital length of stay (LOS) is a quality metric and target of recent efforts in the last decade to decrease healthcare costs and postoperative nosocomial complications after total knee arthroplasty (TKA). However, decreasing LOS has raised concerns of possible increased complication and readmission rates. We present a decade-long analysis in trends of LOS and 30-day complication and unplanned readmissions following TKA. METHODS: The National Surgical Quality Improvement Program registry was utilized to identify patients undergoing elective primary TKA between 2006 and 2016. Three cohorts of patients were created based on year of surgery (2006-2009 [N = 7111], 2010-2013 [N = 71,943], and 2014-2016 [N = 142,710]). Patient demographics, perioperative variables, LOS, 30-day postoperative complications, and readmission rates were analyzed between the 3 cohorts using bivariate and multivariate analyses. RESULTS: LOS decreased significantly over time when the 2006-2009 cohort (3.7 days) was compared to the 2010-2013 cohort (3.3 days, P < .001) and 2014-2016 cohort (3.0 days, P < .001). Similarly, there was a decrease in the rate of total 30-day complications in the 2006-2009 cohort (5.37%) compared to 2010-2013 (3.86%) and 2014-2016 (3.13%, P < .001), with significantly lower rates of deep vein thrombosis, sepsis, and urinary tract infection in the latter cohorts. Decreasing rates of 30-day readmission were also observed in the 2010-2013 cohort (3.63%) compared to 2013-2016 cohort (3.23%, P < .001). CONCLUSION: In the last decade, there has been a trend toward decreasing LOS after TKA. Despite concerns about early discharge, data from a national registry demonstrated a simultaneous decrease in total 30-day complication and readmission rates. LEVEL OF EVIDENCE: III, Retrospective cohort study.

18.
J Orthop Res ; 37(9): 1979-1987, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31062877

RESUMO

The synovium plays a key role in the development of osteoarthritis, as evidenced by pathological changes to the tissue observed in both early and late stages of the disease. One such change is the attachment of cartilage wear particles to the synovial intima. While this phenomenon has been well observed clinically, little is known of the biological effects that such particles have on resident cells in the synovium. The present work investigates the hypothesis that cartilage wear particles elicit a pro-inflammatory response in diseased and healthy human fibroblast-like synoviocytes, like that induced by key cytokines in osteoarthritis. Fibroblast-like synoviocytes from 15 osteoarthritic human donors and a subset of three non-osteoarthritic donors were exposed to cartilage wear particles, interleukin-1α or tumor necrosis factor-α for 6 days and analyzed for proliferation, matrix production, and release of pro-inflammatory mediators and degradative enzymes. Wear particles significantly increased proliferation and release of nitric oxide, interleukin-6 and -8, and matrix metalloproteinase-9, -10, and -13 in osteoarthritic synoviocytes, mirroring the effects of both cytokines, with similar trends in non-osteoarthritic cells. These results suggest that cartilage wear particles are a relevant physical factor in the osteoarthritic environment, perpetuating the pro-inflammatory and pro-degradative cascade by modulating synoviocyte behavior at early and late stages of the disease. Future work points to therapeutic strategies for slowing disease progression that target cell-particle interactions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1979-1987, 2019.


Assuntos
Cartilagem/fisiologia , Citocinas/farmacologia , Inflamação/etiologia , Sinoviócitos/imunologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibroblastos/imunologia , Humanos , Interleucina-1/farmacologia , Masculino , Pessoa de Meia-Idade , Osteoartrite/etiologia , Fator de Necrose Tumoral alfa/farmacologia
19.
J Arthroplasty ; 34(7): 1307-1311, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31031153

RESUMO

BACKGROUND: Rapid-pathway outpatient (OTJA) and one-night inpatient (ITJA) arthroplasty require close follow-up by the surgeon. We quantify and characterize the total perioperative touches required in the first 7 days, and compare OTJA and ITJA patients. METHODS: We reviewed 103 consecutive primary total joint arthroplasty (TJA) patients from April 2014 without exclusion; all patients were discharged either within 5 hours or the morning after surgery. All telephone and office visits during the first 7 days following surgery were studied. Specialized outpatient TJA education was included. We measured the frequency, duration, and subject matter of phone calls. Simple Poisson regression analysis and t-tests were used to determine significance. RESULTS: None of the 103 rapid pathway patients were lost to follow-up. Average age was 61.2 years (range 26.9-83.0), with 49 females (47.6%), 78 total knee arthroplasties, average Charlson Comorbidity Index score of 2.1, and average body mass index of 29.5 kg/m2. There were 253 touches required, averaging 2.5/patient. One hundred sixty were outgoing phone calls by the surgical team and 93 were incoming calls from patients. The average duration of each call was 4.74 minutes (SD 3.7). The entire group required 19 hours and 35 minutes of telephone contact. After including specialized education time, this cohort required 83.1 hours of clinical time, or 48.4 minutes per patient. CONCLUSION: Postoperative care after rapid pathway TJA requires a significant burden of resources, shifted from the hospital to the surgeon. We found that both rapid pathway groups require similar work by the surgeon's team. This additional work should be considered by policymakers.

20.
J Arthroplasty ; 34(7S): S159-S163, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30992239

RESUMO

BACKGROUND: Postoperative nausea and vomiting (PONV) after surgery degrades patient experience, tolerance of pain medication, rehabilitation progress, and functional outcomes. Given the importance of early rehabilitation following total joint arthroplasty (TJA), we asked whether transdermal scopolamine is effective in reducing rates of PONV and improving functional outcomes following TJA. METHODS: We retrospectively reviewed the charts of 1580 consecutive patients who underwent TJA between 2014 and 2017 and compared patients before the addition of the scopolamine patch (control group) to those after the addition (study group). Patients were given the scopolamine patch in the holding area unless contraindicated. A total of 495 patients were excluded. Charts were reviewed for PONV, demographic information, surgical time, length of stay, distance walked with physical therapy, and Visual Analog Scale pain scores. Student t-test was used to compare continuous data and chi-square was used for categorical variables. RESULTS: The incidence of PONV was significantly lower in the study group compared to the control group (14.4% vs 29.3%, P < .0001). Patients who were given scopolamine had lower Visual Analog Scale pain scores on postoperative days (POD) 0 through 2 (P < .01), were able to walk further distances on POD 0 through 3 (P < .001), and received fewer morphine equivalents on POD 1 and 2 (P < .001). Greater morphine equivalents were received by the study group on POD 0. CONCLUSION: Use of a scopolamine patch was associated with significant reduction in PONV and improvement in functional outcomes following TJA. These data support the use of transdermal scopolamine as part of a multimodal, perioperative pain protocol in patients undergoing TJA.

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