Concomitant Total Shoulder Arthroplasty and Ipsilateral Carpal Tunnel Release: Is It Safe?

PURPOSE: Symptomatic carpal tunnel syndrome in patients with advanced ipsilateral glenohumeral arthritis requiring total shoulder arthroplasty (TSA) may be easily overlooked. Even when diagnosed beforehand, most upper extremity surgeons have historically chosen to perform TSA and carpal tunnel release (CTR) separately. We hypothesized that combined single-stage TSA and CTR is feasible and yields results comparable with those when the 2 procedures are performed separately, while avoiding 2 surgeries. METHODS: This was a retrospective review of patients who underwent single-stage primary TSA and ipsilateral CTR between 2015 and 2019. The shoulder outcomes included pain, range of motion, and validated quality of life (QoL) questionnaires: Veterans RAND 12-Item Health Survey (VR-12) and Penn Shoulder Score. The CTR outcomes included pain, grip, pinch, VR-12, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), and Boston Carpal Tunnel Questionnaire. The time to the initiation of rehabilitation and complications were also analyzed. The comparison group consisted of patients who underwent independent TSA or CTR during the same period. RESULTS: Forty-one patients underwent concomitant TSA and CTR, 248 underwent isolated TSA, and 154 underwent isolated CTR. The shoulder outcomes of patients who underwent the combined procedure were similar to those of patients who underwent isolated TSA in terms of pain, range of motion, general QoL (VR-12), and shoulder-specific QoL (Penn Shoulder Score). The outcomes of patients who underwent the combined procedure were similar to those of patients who underwent isolated CTR in terms of pain, grip and pinch, general QoL (VR-12), QuickDASH, and Boston Carpal Tunnel Questionnaire. The time to the initiation of rehabilitation was also comparable. CONCLUSIONS: Concomitant CTR and TSA are feasible. The functional outcomes and QoL of patients who underwent the concomitant treatment were comparable with those of patients who underwent the 2 procedures separately. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

What Are Drivers of Readmission for Readmission-Requiring Venous Thromboembolic Events After Primary Total Hip Arthroplasty? An Analysis of 544,443 Cases.

BACKGROUND: Venous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission. METHODS: The Agency of Healthcare Research and Quality's National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities. RESULTS: Higher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05). CONCLUSION: One in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE complications.

No Evidence to Support Lowering Surgeon Reimbursement for Total Joint Arthroplasty Based on Operative Time: An Institutional Review of 12,567 Cases.

BACKGROUND: The Centers for Medicare and Medicaid Services has recently added primary total joint arthroplasty (TJA) codes to the 2019 Potentially Misvalued Codes List. The American Association of Hip and Knee Surgeons and the American Medical Association have called for contemporary data that would assess operative time to inform the decision on reimbursement valuation. Therefore, the purpose of this study was to report total hip arthroplasty (THA) and total knee arthroplasty (TKA) operative times within a large multihospital and physician organizational enterprise to assess stability over time. METHODS: The study was a retrospective review (2015-2019) of a prospectively maintained multihospital health system database. A total of 12,567 consecutive TJAs were included (5742 THAs by 16 surgeons; 6825 TKAs by 20 surgeons). Operative time was between incision and completion of wound closure. Descriptive statistics were performed for categorical/continuous variables, and trend analysis was performed to assess if there was a change in time over the study period. RESULTS: For THA, 43.1% were male, with a mean age of 64.1 ± 11.8 years and a mean BMI of 30.1 ± 6.6. The mean operative time was 96.4 ± 36.8 minutes. For TKA, 39.4% were male, with a mean age of 66.2 ± 9.4 years and a mean BMI of 32.7 ± 6.8. The mean operative time was 103.6 ± 29.9 minutes. Trend analysis demonstrated no significant difference in operative time across the study period. CONCLUSION: Our analysis demonstrated that operative time has remained stable, with mean time for THA and TKA consistently within 3.6 minutes of the historical benchmark of 100 minutes. Given these findings in a large institutional cohort, there is no definitive evidence to support changing current procedural valuation for TJA based on operative time.

Difficult Revision Total Hip Arthroplasty Cases Treated with an Offset Head Center Acetabular Shell.

Acetabular bone loss is common during revision total hip arthroplasty (THA). A new acetabular shell was developed with a goal of maintaining native hip center-of-rotation (COR) while achieving good fixation with standard instrumentation and technique. Previous radiographic studies have demonstrated the efficacy of this shell in lowering hip COR. In this case series, we demonstrate the use of this shell in patients undergoing difficult revision THAs. Based on these cases, we have presented how this offset COR acetabular shell may help bring down the hip COR in patients who undergo revision total hip arthroplasty with severe bone loss.

Current Concepts in Osteoarthritis of the Ankle: Review.

Ankle osteoarthritis constitutes a large burden to society and is a leading cause of chronic disability in the United States. Most commonly, it is post-traumatic, occurs in younger individuals, and is associated with obesity. This entity presents similarly to osteoarthritis of the other joints, with the typical nonspecific symptoms of stiffness, swelling, and pain. Radiographic investigation includes four weight-bearing standard views: antero-posterior and lateral foot, mortise view of the ankle, and a specialized view of the hindfoot. In this review, we covered epidemiology, anatomy and biomechanics, etiology, pathology, differential diagnoses, symptoms, physical examination, appropriate radiological investigation, as well as current treatment options and algorithms. Non-operative treatment options include weight loss, physical therapy, bracing, orthoses, pharmacologic treatments, corticosteroid injections, viscosupplementation, and biologic modalities. Viscosupplementation with hyaluronic acid has the most evidence-based support and has been shown to be safe and efficacious. For patients who have moderate to severe disease, surgery may be indicated. However, current surgical options are either associated with high rates of complications or restrict ankle range of motion (ROM). Early stages of the ankle osteoarthritis should be treated with the above-mentioned non-surgical methods, and once the disease progresses, surgical options can be utilized.

Classification systems of hip osteonecrosis: an updated review.

PURPOSE: Osteonecrosis of the femoral head (ONFH) typically impacts middle-aged patients who are typically more active and in whom many surgeons would try to delay performing a total hip arthroplasty (THA). This poses a clinical decision-making challenge. Therefore, several options for joint preservation have been advocated, but varying indications and success rates have led to debate on when to use the various procedures. This is due in part to the lack of a generalized system for assessing ONFH, as well as the absence of a standardized method of data collection for patient stratification. Due to the paucity of studies, in this review, we aimed to provide an up-to-date review of the most widely utilized classification systems and discuss the characteristics of each system. METHODS: A comprehensive literature review was conducted. Studies published between January 1st, 1975 and March 1st, 2018 were reviewed. The following key words were used in combination with Boolean operators AND or OR for the literature search: "osteonecrosis," "avascular necrosis," "hip," "femoral head," "classification," "reliability," and "validity." We defined the inclusion criteria for qualifying studies for this review as follows: (1) studies that reported on the classification systems for hip osteonecrosis, (2) studies that reported on the inter-observer reliability of the classification systems, and (3) studies that reported on the intra-observer reliability of any ONFH classification systems. In addition, we employed the following exclusion criteria: (1) studies that assessed classification systems for traumatic osteonecrosis, (2) Legg-Calvé-Perthes disease, or (3) Developmental Dysplasia of the Hip. Additionally, we excluded case reports and duplicate studies among searched databases. RESULTS: The following classification systems were the most commonly utilized: The Ficat and Arlet, Steinberg, the Association Research Circulation Osseous (ARCO), and the Japanese Investigation Committee (JIC) classification systems. The details of each system have been discussed and their inter- and intra-observer reliability has been compared. CONCLUSION: To this date, there is a lack of consensus on a universal and comprehensive system, and the use of any of the previous classification systems is a matter of dealer's choice. The Ficat and Arlet system was the earliest yet remains the most widely utilized system. Newer classification systems have been developed and some such as the JIC shows promising prognostic value while maintaining simplicity. However, larger validating studies are needed. While all of these systems have their strengths, the lack of a unified classification and staging system is still a problem in the diagnosis and prognosis ONFH. Further multi-center collaborative efforts among osteonecrosis experts are needed to adopt a universal classification system that may positively reflect on patient's outcomes.

Novel Acetabular Cup for Revision THA Improves Hip Center of Rotation: A Radiographic Evaluation.

BACKGROUND: Bone loss in patients undergoing revision THA poses a considerable challenge for orthopaedic surgeons. Often, to achieve better fixation in remaining bone, larger diameter acetabular components and reaming superiorly may be necessary. However, this is likely to raise the hip center of rotation, which may lead to altered biomechanics, specifically, insufficiency of the abductor muscles, altered gait, and increased risk of dislocation from impingement. More recently, a newer acetabular shell has been designed to more closely replicate the native hip center of rotation in these circumstances while maintaining adequate fixation. QUESTIONS/PURPOSES: The purpose of this study was to compare the radiographic parameters of this newer design with conventional hemispheric cups in revision THA. Specifically, we assessed the differences in (1) vertical center of rotation (COR) displacement and (2) horizontal COR displacement. METHODS: Between January 2016 and April 2016, five reconstructive surgeons at five institutions utilized a newer highly porous acetabular shell designed with peripheral screw holes and vertically eccentric COR to allow for restoration of center of hip rotation in revision THA. We included all patients who received this device. During this time, the general indications at these sites for using the new device included Paprosky Stage IIA, IIB, IIC, or IIIA acetabular defects. This yielded 29 patients who were subsequently matched (one to two) by cup size and sex to a cohort who underwent revision THA with conventional hemispheric cups between January 2015 and May 2016. To determine hip COR, radiographic measurements were performed. A circle contiguous to the acetabulum was drawn and the center was determined as the hip COR. All measurements were made from the interteardrop line for both the revised and native hips. A line through the teardrops was used for all horizontal measurements. Center position adjustments were made based on the manufacturer-specified values. Comparisons were performed using chi-square tests for categorical and t-tests for continuous variables. There was no difference in the severity of bone loss before the revision in the groups, as evidenced by Paprosky staging of preoperative radiographs. RESULTS: The mean vertical COR displacement was smaller in patients who had the novel cup (3.5 mm; range, -12 to 15 mm; mean difference, -7.3 mm; 95% confidence interval [CI], -13.2 to -1.5) as compared with those who had the conventional cup (10.5 mm; range, -4 to 50 mm; mean difference, 7.3 mm; 95% CI, -12.5 to -2.2; p = 0.003). There was no difference in mean horizontal displacement between the two groups (-0.06 ± 6.1 versus 1.7 ± 7.1; mean difference, -1.8; p = 0.903). CONCLUSIONS: Although hip COR was improved based on radiographic measurements with the use of this novel acetabular design, and although this may improve hip biomechanics, more studies are required before its widespread adoption for revision cases of this nature can be recommended. Both implant costs and the risks associated with using a new design in practice will have to be justified by studies that evaluate fixation, clinical function and implant survival, and patient-reported outcome scores, all of which were beyond the scope of this preliminary report. LEVEL OF EVIDENCE: Level III, therapeutic study.

Robotic Arm-Assisted Total Knee Arthroplasty.

BACKGROUND: Robotic arm-assisted total knee arthroplasty (RATKA) has a number of potential advantages. Therefore, in order to more comprehensively assess this technology, we reviewed the (1) accuracy and precision; (2) soft-tissue protection; (3) patient satisfaction; (4) learning curve; and (5) its other potential benefits. METHODS: A literature review was conducted using PubMed search database for studies reporting clinical outcomes, cadaver results, radiographic outcomes, surgeon experience, and robotic accuracy. Forty articles were included for the final analysis. RESULTS: Advantages of RATKA may include greater component accuracy and precision, soft-tissue protection, increased patient satisfaction, a short learning curve, optimal ergonomic design, and less surgeon and surgical team fatigue. The aforementioned advantages might help improve clinical, surgical, and patient-reported outcomes. CONCLUSION: Although there are a number of studies that highlight the potential advantages of RATKA, most of these studies report of short-term outcomes. It is hoped that longer term studies will continue to support the use of this technology in providing higher patient satisfaction and other clinical outcomes.

Mid-Term Outcomes of Dual Mobility Acetabular Cups for Revision Total Hip Arthroplasty.

BACKGROUND: This study evaluated (1) survivorship, (2) clinical outcomes, (3) complications, and (4) radiographic outcomes of dual mobility (DM) systems when compared to fixed-bearing prostheses in revision total hip arthroplasty (THA). METHODS: A cohort of 85 patients who underwent revision THA using DM implants were compared to a prior matching cohort of 170 patients who received fixed-bearing implants. Mean follow-up time was 4 years in the DM cohort and 10 years in the fixed-bearing cohort. Kaplan-Meier analysis was performed to assess survivorships. Clinical outcomes were evaluated using the Harris Hip Score (HHS). Complications and radiographs were evaluated and reported at the final follow-up. RESULTS: Overall aseptic and all-cause survivorships of the DM cohort were 96.5% and 95.3% compared to 94.7% and 93.5% in fixed-bearing cohort (P = .01 for aseptic and all-cause survivorships). The DM cohort had statistically significant higher survivorship when compared at equivalent follow-up interval in the fixed-bearing cohort. There were 3 aseptic (one due to dislocation) and 1 septic revision in the DM cohort compared to 9 aseptic (6 due to dislocation) and 2 septic revisions in the fixed-bearing cohort. Postoperative HHS scores were 88 and 86 points in the DM and fixed-bearing cohorts. However, the difference in mean improvement in HHS scores from preoperative to postoperative (ΔHHS) was not statistically significant (35 vs 34, P = .533). Except for the aforementioned revisions, there were no progressive radiolucencies or osteolysis on radiographic evaluation in both cohorts. CONCLUSION: DM articulations demonstrated superior survivorship at equal follow-up intervals when compared to fixed-bearing implants and showed a trend toward lower dislocation rates.

Wound Closure Techniques for Total Knee Arthroplasty: An Evidence-Based Review of the Literature.

BACKGROUND: This literature review is aimed at identifying the different methods for superficial and deep wound closure in total knee arthroplasty and evaluating their outcomes. We evaluated (1) closure time, (2) infection and other complication rates, and (3) local wound-related outcomes. METHODS: A thorough search of the literature was performed using 3 electronic databases. Inclusion criteria included manuscripts that were written in English and available in full-text format. Reports were stratified into those that describe deep closure (7) and those that describe superficial closure (11). RESULTS: In superficial closure, staples may provide the fastest closure, adhesives, lower incidence of superficial complications, and subcuticular suture closures, greatest blood flow. In deep closure, barbed sutures may allow for faster closure time while providing similar postoperative complication rates and outcomes when compared to traditional sutures. The use of barbed sutures has been shown to utilize fewer resources and may potentially lead to a slight reduction in costs. CONCLUSION: Ultimately, no optimal closure technique has been developed, and current studies do not provide a clear evidence-based answer. This field needs much more evidence-based studies before one can draw conclusions. Even though some of these studies are prospective and randomized, they may not be generalizable. Also, many of the studies have small numbers and are subject to type II errors and fragility. Certainly, more studies are needed to truly understand the advantages and disadvantages of these new methods. Nevertheless, this review allows orthopedists to evaluate the differences between closure methods.

The Impact of Spino-Pelvic Alignment on Total Hip Arthroplasty Outcomes: A Critical Analysis of Current Evidence.

BACKGROUND: In this review, we (1) evaluated the effect of adult spine deformity (ASD) and its surgical correction on patients who had a total hip arthroplasty (THA); (2) evaluated the outcomes of THA in patients who have had previous spinal fusion; and (3) we presented an algorithm on how to surgically address patients who simultaneously require THA and ASD correction. METHODS: A comprehensive literature search was conducted. Our final analysis included 14 studies. Overall, there were 3 studies that reported on the impact of ASD on THA outcomes, 6 studies reported on the effect of ASD correction on THA outcomes, and 5 studies reported on the effect of spinal fusion on THA outcomes. RESULTS: Patients with concurrent ASD and THA are at increased risk of THA dislocations and revisions with studies reporting a compiled 2.9% dislocation rate in 1167 patients. Patients who underwent ASD correction demonstrated a post-operative reduction of acetabular anteversion (mean reduction range 4.96°-11.2°, P < .001) and tilt (mean -7° ± 10°, P < .001). In THA patients with concurrent lumbosacral fusion, dislocation rates ranged between 3% at 1 year and 7.5% at 2 years compared to 0.4%-2.1% dislocation rates in matching cohorts (P < .001). CONCLUSION: Spine balance can alter THA outcomes, but the exact mechanism is yet to be elucidated. We aimed at bridging the gap between hip and spine surgeons with an up-to-date analysis of the best available evidence and presented an algorithm for approaching patients who may simultaneously need ASD correction and THA.

No Correlation Between Press Ganey Survey Responses and Outcomes in Post-Total Hip Arthroplasty Patients.

BACKGROUND: In the era of the online orthopedic market, patients tend to equate publicly available online satisfaction surveys with what they presume their ultimate surgical outcome will be. Therefore, the purpose of this study was to assess whether there is a correlation between Press Ganey (PG) scores and (1) Hip Western Ontario and McMaster Universities Osteoarthritis Index and Harris Hip Score; (2) Short Form-12 and Short Form-36 scores; (3) University of California Los Angeles and Visual Analog Scale scores assessed at a mean of 3 years (range, 1 to 6 years) after surgery. In addition, we assessed whether (4) these correlations persist in patients who were evaluated under 2 years and 3 or more years after surgery. METHODS: Six-hundred ninety-two patients from November 2009 to January 2015 were identified from our institutional PG database. One-hundred ninety (27%) responded to the survey. One-hundred forty-nine (78%) patients were given the total hip arthroplasty assessment tools at a minimum of 2-year follow-up, and 33 patients (17%) completed their survey before 2 years after surgery. We assessed whether overall hospital rating scores correlated with the above assessment tools. RESULTS: Pearson correlation analysis revealed no correlation between the PG survey score and the assessment tools. HHS had the highest correlation coefficient (r = .120; P = .316); however, this was not significant. After removing the patients who had their follow-up survey administered under 2 years after surgery (33 patients), there was still no statistically significant correlation between the above-mentioned outcome scores and PG overall hospital rating (P > .05). CONCLUSION: No statistically significant relationship was found between commonly used total hip arthroplasty assessment tools and the PG overall hospital rating. Based on these results, PG surveys may not be a suitable implementation of the Center for Medicare and Medicaid services. A set of measures that can be widely collected and reported by hospitals for patients to use in order to evaluate hip arthroplasty outcomes needs to be developed. These results are of paramount importance, indicating a necessary reevaluation of PG surveys as a major determinant for reimbursements rendered by orthopedists and their use by patients.

Readmission, Reoperation, and Complications: Total Hip vs Total Knee Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are currently grouped under the same Diagnosis-Related Group (DRG). With the introduction of bundled payments, providers are accountable for all the costs incurred during the episode of care, including the costs of readmissions and management of complications. However, it is unclear whether readmission rates and short-term complications are similar in primary THA and TKA. METHODS: The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 248,150 primary THA/TKA procedures using Current Procedural Terminology codes. After excluding 1602 hip fractures and 5062 bilateral procedures, 94,326 THAs and 147,160 TKAs were included in the study. Length of stay, discharge disposition, and 30-day readmission, reoperation and complication rates were compared between THA and TKA using multivariate regression models. RESULTS: After adjusting for baseline characteristics, length of stay (P = .055) and discharge disposition (P = .304) were similar between THA and TKA. But the 30-day rates of readmission (P < .001) and reoperation (P < .001) were higher in THA. Of the 18 complications evaluated in the study, 7 were higher in THA, 3 were higher in TKA, and 8 were similar between THA and TKA. CONCLUSION: THA patients had higher 30-day rates of readmission and reoperation. As both readmissions and reoperations can result in higher episode costs, a common target price for both THA and TKA may be inappropriate. Further studies are required to fully understand the extent of differences in the episode costs of THA and TKA.

Hip and Knee Arthroplasty Orthopedic Literature in Medical Journals-Is It Negatively Biased?

BACKGROUND: Healthcare policy is often determined by well-designed studies most often published in high-impact medical journals. However, concern about the presence of publication bias against lower-extremity arthroplasty-related studies has called into question some of the validity of certain reports. There are only a few studies investigating the presence of the bias in high-impact medical journals against lower-extremity arthroplasty intervention, particularly in the Journal of American Medical Association (JAMA), New England Journal of Medicine (NEJM), and the Lancet. Thus, the purpose of this study was to assess (1) the distribution of positive, neutral, and negative results; (2) the number of reports focused on lower-extremity arthroplasty complications among these 3 journals; and (3) difference in bias between 2 time periods (1975 to 1990 and 2000 to 2016). METHODS: A review of the literature from 3 major medical journals (NEJM, Lancet, and JAMA) was performed using PubMed electronic databases, which retrieved articles between January 1976 and December 2016. Studies were categorized as being positive, neutral, and negatively biased by 2 reviewers. Studies were categorized as reporting on lower-extremity arthroplasty-related complications if they were based on complications including deep vein thrombosis, infection, metal-related complication, fat embolism, readmission, or mortality. In addition, we have compared the journal bias between 2 different time points (1975 to 1990 and 2000 to 2016). Descriptive analyses were performed to assess frequencies. Chi-squared analysis was conducted for categorical variables, whereas a z-test was performed for dichotomous data. RESULTS: When assessing all 3 journals, there were 46 positive (30.3%), 46 negative (30.3%), and 60 neutral reports (39.5%). There was no statistically significant difference in classification proportions between the 3 groups (P = .905). There was a higher percentage of medical literature reporting on the complications of arthroplasty (55.9%); however, this was not statistically significant (z-score = 1.38; 95% confidence interval, 0.48-0.64; P = .17). There was no difference in overall journal reporting between 1975 to 1990 and 2000 to 2016 (P = .548). CONCLUSION: There was no evidence of publication bias of lower-extremity arthroplasty reports in the major medical journals (JAMA, NEJM, and Lancet). However, there were more published studies reporting on complications of lower-extremity arthroplasty. This may be due to systematic bias among journal editors in these journals, or due to low journal submission reporting noncomplications after arthroplasty intervention. We did not find the time period to be a factor in bias reporting of orthopedic literature in major medical journals. More work is needed to verify the results of this study.

The Role of Virtual Rehabilitation in Total Knee and Hip Arthroplasty.

Virtual rehabilitation therapies have been developed to focus on improving care for those suffering from various musculoskeletal disorders. There has been evidence suggesting that real-time virtual rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these conditions. This study specifically evaluated the use of a virtual physical therapy/rehabilitation platform for use during the postoperative period after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of this technology has the potential benefits that allow for patient adherence, cost reductions, and coordination of care.

Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, and Rotation: A Comparative, Gait-Analysis Study.

INTRODUCTION: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared. MATERIALS AND METHODS: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts. RESULTS: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66° , [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects. CONCLUSION: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.

Postoperative Pain and Analgesia: Is There a Genetic Basis to the Opioid Crisis?

BACKGROUND: Multiple factors have been implicated in determining why certain patients have increased postoperative pain, with the potential to develop chronic pain. The purpose of this study was to: 1) identify and describe genes that affect postoperative pain perception and control; 2) address modifiable risk factors that result in epigenetic altered responses to pain; and 3) characterize differences in pain sensitivity and thresholds between opioid-naïve and opioid-dependent patients. MATERIALS AND METHODS: Three electronic databases were used to conduct the literature search: Pubmed, EBSCO host, and SCOPUS. A total of 372 abstracts were reviewed, of which 46 studies were deemed relevant and are included in this review. RESULTS: Specific gene alterations that were shown to affect postoperative pain control included single nucleotide polymorphisms in the mu, kappa, and delta opioid receptors, ion channel genes, cytotoxic T-cells, glutamate receptors and cytokine genes, among others. Alcoholism, obesity, and smoking were all linked with genetic polymorphisms that altered pain sensitivity. Opioid abuse was found to be associated with a poorer response to analgesics postoperatively, as well as a risk for prescription overdose. CONCLUSION: Although pain perception has multiple complex influences, the greatest variability seen in response to opioids among postoperative patients known to date can be traced to genetic differences in opioid metabolism. Further study is needed to determine the clinical significance of these genetic associations.

Perioperative Outcomes and Short-Term Complications Following Total Knee Arthroplasty in Chronically, Immunosuppressed Patients.

BACKGROUND: Although there are studies regarding immunosuppressed patients undergoing total knee arthroplasty (TKA) for inflammatory arthritis or osteonecrosis, there is a paucity of studies evaluating immunosuppressed patients undergoing TKA for diagnoses other than these. MATERIALS AND METHODS: We identified all patients undergoing primary TKA for osteoarthritis from 2008-2014 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Overall, 111,624 patients were included. The immunosuppressed group consisted of 3,466 patients, and the control group included 108,158. Outcomes measured included operative time, lengths-of-stay, discharge destination, and 30-day complication rates. Univariate analysis was used to compare the outcomes. Multivariate regression analysis was then applied to determine if immunosuppression was an independent risk factor for differences in outcomes. RESULTS: Immunosuppressant use did not change operative time, lengths-of-stay, or discharge disposition. Immunosuppressed patients were at higher risks of developing the following surgical and medical complications: organ/space surgical site infection (SSI), wound dehiscence, deep venous thrombosis (DVT), pneumonia, urinary tract infection (UTI), and systemic sepsis. Return to the operating room and 30-day readmission were also significantly higher in the immunosuppressed group. CONCLUSIONS: Patients taking chronic immunosuppressants and undergoing TKA for osteoarthritis are at higher risk of specific surgical and medical complications. These complications include organ/space SSI, wound dehiscence, DVT, pneumonia, UTI, and systemic sepsis. In addition, these patients were at increased odds of returning to the operating room and being readmitted.

Cellular therapy injections in today's orthopedic market: A social media analysis.

BACKGROUND: The current state of cellular therapy for musculoskeletal conditions is at a crossroads. Marketing efforts are often outpacing clinical evidence and regulatory control. QUESTIONS/PURPOSES: This study was an effort to describe the marketing of cellular therapy in musculoskeletal medicine by evaluating the content in popular social media channels. Specifically, media posts were evaluated for the following: (1) perspective, (2) tone, (3) content and (4) visibility. PATIENT AND METHODS: Social media content related to cell therapy for musculoskeletal conditions was assessed in a search using 28 hashtags on the public domains of Instagram and Twitter over a 2-year period (2014-2016) that resulted in analysis of 698 posts. Supplemental analyses of LinkedIn and Facebook domains were also conducted. A categorical scoring system was used to analyze perspective (patient, family or friend, business or organization), tone (positive, negative), content (education, advertisement, research, media coverage or patient experience) and visibility (number of hashtags per post). Sub-analyses of the advertisement content from various perspectives (patients, physicians and businesses) were performed. RESULTS: The media perspective was most frequently from a business or organization (83%; n = 575). A total of 94% of the posts had a positive tone and only 6% had a negative tone, and the only negative posts came from patients (60% positive and 40% negative). The most common content of social media posts were advertisements, representing 68% (n = 477) of all posts; this was confirmed in the Facebook analysis. The mean number of hashtags was five per post. Sub-analyses revealed approximately half of the advertising posts originated from a single business that recruited physicians to market their cell-based therapies on social media, which was confirmed in the LinkedIn analysis. CONCLUSION: The market messages related to cell-based therapies for musculoskeletal conditions available on social media are dominated by businesses that seem to use a network of physicians, apply several hashtags to enhance visibility and advertise these largely unproven modalities. The posts portray an almost exclusively positive tone, without providing a "fair balance" on the risks, benefits and limitations.

Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review.

BACKGROUND: Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). METHODS: A search for "knee" and "cryotherapy" using PubMed, EBSCO Host, and SCOPUS was performed, yielding 187 initial reports. After selecting for RCTs relevant to our study, 16 studies were included. RESULTS: Of the 8 studies that compared the immediate postoperative outcomes between patients who did and did not receive cryotherapy, 5 studies favored cryotherapy (2 cold packs and 3 continuous cold flow devices). Of the 6 studies comparing the use of cold packs and continuous cold flow devices in patients who underwent UKA or TKA, 3 favor the use of continuous flow devices. There was no difference in pain, postoperative opioid consumption, or drain output between 2 different temperature settings of continuous cold flow device. CONCLUSION: The optimal device to use may be one that offers continuous circulating cold flow, as there were more studies demonstrating better outcomes. In addition, the pain relieving effects of cryotherapy may help minimize pain medication use, such as with opioids, which are associated with numerous potential side effects as well as dependence and addiction. Meta-analysis on the most recent RCTs should be performed next.