RESUMO
OBJECTIVE: To identify the presence and distribution of histopathological features of synovial inflammation and tissue damage, and to test their associations with ultrasound (US) imaging measures of synovitis and patient-reported measures of pain in knee osteoarthritis (OA). DESIGN: In the cross-sectional study of 122 patients undergoing surgery for painful late-stage (Kellgren-Lawrence Grade 3 or 4) knee OA, we compared US measures of synovitis (n = 118) and pain (Knee Injury and Osteoarthritis Outcome Score) to histopathological measures of inflammation vs. synovial tissue damage in synovial tissue biopsies. Associations of histopathological features with US measures of inflammation or pain were assessed using linear or logistic regression while controlling for covariates. RESULTS: Histopathological features of inflammation were associated with higher odds of moderate/severe US synovitis (odds ratio [OR] = 1.34 [95%CI 1.04, 1.74), whereas features of synovial tissue damage were associated with lower odds of moderate/severe US synovitis (OR = 0.77 [95%CI 0.57, 1.03]). Worse histopathological scores for synovial tissue damage were associated with more pain (-1.47 [95%CI -2.88, -0.05]), even while adjusting for synovial inflammation (-1.61 [95%CI -3.12, -0.10]). CONCLUSIONS: Synovial tissue damage is associated with pain in late-stage knee OA, independent from inflammation and radiographic damage. These novel findings suggest that preventing synovial tissue damage may be an important goal of disease-modifying OA therapy.
RESUMO
BACKGROUND: Despite the growing popularity of cementless total knee arthroplasty (TKA) in younger patients, the outcomes are unclear in the elderly population. We aimed to compare the clinical outcomes and survivorship of cementless TKA between different age groups. METHODS: Utilizing our prospectively collected institutional database, we retrospectively reviewed all patients undergoing primary cementless TKAs at a tertiary care institute. We identified 347 TKA, which were divided into 3 groups based on age at the time of surgery. Group A was ≤ 60 years, Group B was 60 to ≤ 70 years, and Group C was > 70 years. We compared clinical outcomes (Knee Society Clinical Rating System [KSCRS], Western Ontario and McMaster University Osteoarthritis Index [WOMAC], and Veterans Rand 12 Item Health Survey [VR-12]) and survivorship between the groups. RESULTS: At final follow-up, range of motion, KSCRS, WOMAC, and VR-12 physical score were comparable (P > .05). The VR-12 Mental score was higher in Group B and Group C than in Group A (P = .003). Compared to preoperative scores, the change in KSCRS, WOMAC, and VR-12 physical and mental scores was comparable at the final follow-up (P > .05). No patient underwent revision for aseptic loosening. CONCLUSIONS: There were no cases of revision surgery for aseptic loosening in our cohort of 347 cementless TKAs. Patients > 70 years of age undergoing cementless TKA can achieve clinical scores equivalent to those of younger patients at short term (2-year) follow-up. Longer-term survivorship is still required, but based on early data, cementless TKA can be a safe option for older patients.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Humanos , Artroplastia do Joelho/métodos , Artroplastia do Joelho/instrumentação , Idoso , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Fatores Etários , Falha de Prótese , Osteoartrite do Joelho/cirurgia , Amplitude de Movimento Articular , Idoso de 80 Anos ou mais , Articulação do Joelho/cirurgia , Seguimentos , Reoperação/estatística & dados numéricosRESUMO
BACKGROUND: The incidence of total joint arthroplasty is increasing, with added emphasis on shifting care toward outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion. METHODS: We identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a 2-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including reoperation, readmission, and emergency room visits within a 90-day postoperative period. RESULTS: We identified a total of 80 patients who converted from inpatient to outpatient surgery over a 2-year interval. Over the first 90 days postoperatively 4 (5%) patients were readmitted: 2 (2.5%) for medical complications and 2 (2.5%) for reoperation. There were 2 (2.5%) reoperations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were 5 (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of 5 (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission. CONCLUSIONS: Hospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.
RESUMO
BACKGROUND: The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA. METHODS: Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines. RESULTS: The study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol. CONCLUSIONS: The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.
RESUMO
BACKGROUND: Bicruciate-stabilized (BCS) total knee arthroplasty (TKA) designs attempt to approximate natural knee mechanics. Multiple surgical techniques, including gap balancing (GB) and measured resection (MR), have been developed to provide optimal implant positioning and soft-tissue balance. The goal of this study was to determine the effect of surgical technique on BCS TKA contact kinematics. Secondary goals included investigating the change of kinematics over time and comparing BCS TKA kinematics to a posterior-stabilized (PS) design. METHODS: The study included the BCS-GB, BCS-MR, and PS-MR groups. The BCS-GB and BCS-MR groups underwent weight-bearing radiostereometric analysis for multiple knee flexion angles at 3 months and 1 year postoperatively, whereas the PS-MR group was imaged at 1 year postoperatively. The medial and lateral contact kinematics were determined from implant poses. RESULTS: There were no differences in BCS TKA kinematics between the GB and MR techniques. There were differences in the mid-flexion ranges when comparing the 3-month and 1-year kinematics of the BCS design; however, they were less than 1.5 mm. Differences existed between the kinematics of the BCS and PS designs at all flexion angles for the medial condyle (P < .0006) and at 0° of flexion on the lateral condyle (P < .0001). CONCLUSIONS: Contact kinematics for a BCS design were similar for both surgical techniques, suggesting both are appropriate for this design. Small, likely clinically insignificant differences were found between 3-month and 1-year kinematics. The BCS TKA kinematics differed from the PS design; however, it is unclear whether these differences improve clinical outcomes.
Assuntos
Artroplastia do Joelho , Articulação do Joelho , Prótese do Joelho , Desenho de Prótese , Amplitude de Movimento Articular , Humanos , Artroplastia do Joelho/métodos , Artroplastia do Joelho/instrumentação , Fenômenos Biomecânicos , Feminino , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologia , Articulação do Joelho/fisiologia , Masculino , Idoso , Pessoa de Meia-Idade , Suporte de Carga , Análise Radioestereométrica , Osteoartrite do Joelho/cirurgiaRESUMO
BACKGROUND: Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following total hip arthroplasty (THA). The objectives of the study were to (1) determine the minimum 2-year infection-free survivorship of 2-stage revision THA, (2) determine the causative organisms for repeat 2-stage revision THA, and (3) characterize the results of failed 2-stage revisions and evaluate patient-reported outcome measures (PROMs). METHODS: A retrospective chart review was completed for patients who underwent 2-stage revision THA for PJI. Prospective data were collected on each patient, including demographics, causative organisms, complications, and type of reoperation. The PROMs, including Harris Hip Score, 12-item Short-Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained prior to 2-stage revision THA surgery and annually as part of standard clinical and radiographic follow-up. RESULTS: A total of 328 patients who underwent a 2-stage revision THA for a PJI were included in the study (mean age 67 years [range, 28 to 90], mean body mass index of 30.6 [range, 15 to 57]). The overall infection-free survivorship for 2-stage revision THA was 73.8% at a minimum of 2 years (range, 2 to 20). Overall, 194 (59.1%) patients who had successful infection eradication underwent a 2-revision THA only. The most common single organisms infected were Staphylococcus aureus (12.5%) and Staphylococcus epidermidis (11%). Higher reoperation rates were found in cases with methicillin-resistant Staphylococcus aureus and polymicrobial infections. All PROMs showed statistical improvement from preoperatively to the latest follow-up appointment. CONCLUSIONS: Two-stage revision THA is associated with a good success rate in the treatment of PJIs at mid-term to long-term follow-up. Polymicrobial and methicillin-resistant Staphylococcus aureus infections are poor prognostic factors, making the eradication of infection more difficult. The management of PJIs continues to be one of the most important orthopaedic challenges to treat.
RESUMO
BACKGROUND: Modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. This study reports the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years of follow-up. METHODS: We identified 126 patients who received a single monoblock TFT stem: 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous periprosthetic joint infection, 42 for aseptic loosening, 9 for trunnionosis, and 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3-month follow-up were determined. We evaluated the number and indications for reoperations. RESULTS: The mean time from surgery was 3.9 years (range, 2.0 to 6.9). A paired t-test analysis showed significant improvement from preoperative versus postoperative clinical outcome scores (P < .001) for Harris Hip Score (38.76 ± 15.24 versus 83.42 ± 15.38), Western Ontario and McMaster Universities Arthritis Index (45.6 ± 19.0 versus 69.9 ± 21.3), Veterans RAND 12 Item Health Survey Physical component (31.7 ± 8.1 versus 37.8 ± 11.3), and Veterans RAND 12 Item Health Survey Mental component (48.2 ± 12.2 versus 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%), and Grade 4 (1.6%) cases. There were 18 reoperations (14.7%), with 13 for periprosthetic joint infection (7 treated with implant retention and 6 treated with a 2-stage revision), 4 for instability, and 1 for acetabular aseptic loosening. There were no aseptic failures of the stem. CONCLUSIONS: This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution.
RESUMO
BACKGROUND: The objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death. METHODS: We conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA. RESULTS: There were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision. CONCLUSIONS: In our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs.
Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Masculino , Humanos , Artroplastia do Joelho/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Osteoartrite do Joelho/cirurgia , Osteoartrite do Joelho/etiologia , Ontário/epidemiologia , Reoperação/métodos , Articulação do Joelho/cirurgiaRESUMO
BACKGROUND: Interest in cementless total knee arthroplasty (TKA) has increased with advancement of biomaterials and implant design and associated improved longevity. We sought to evaluate the gap patterns and radiolucent zones radiographically for 2 newer-generation cementless TKA designs. METHODS: We retrospectively reviewed our single-institution database between January 2017 and December 2019. We identified patients with a porous keeled tibia base-plate with 4-bullet cruciform spikes and peri-apatite coated femoral component (study group 1) and patients who received a cementless porous coated femoral component and rotating platform tibia baseplate with 4 peripheral porous coated pegs around a central cone (study group 2). We identified gap patterns at 6 weeks and at 1 year or more postoperatively on radiographs, noting indications for reoperation. RESULTS: We identified 228 patients in study group 1 and 41 patients in study group 2. At 1-year follow-up, we found evidence of resolved femoral gaps in 52 (72.2%) of 72 patients in study group 1 and 10 (58.8%) of 17 patients in study group 2 (p = 0.124). We identified 27 (84.3%) of 32 patients in study group 1 and 7 (70.0%) of 10 patients in study group 2 with resolved tibia gaps (p = 0.313). After 1 year, there were significantly more Zone 3a femoral zonal radiolucent gaps (p = 0.001) and Zone 8 tibia zonal radiolucent gaps (p = 0.002) in study group 2 than in study group 1. There were 4 reoperations for study group 1 and 0 reoperations for study group 2. CONCLUSION: The modern cementless TKA systems have varied gap patterns in postoperative radiographs, which may be attributed to the implant design. Most radiolucent gaps resolve radiographically on follow-up.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Humanos , Seguimentos , Estudos Retrospectivos , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Reoperação , Desenho de Prótese , Resultado do Tratamento , Falha de PróteseRESUMO
BACKGROUND: Several studies have reported negative results after total knee arthroplasty (TKA) in obese patients. This study aims to analyze the minimum 2-year outcomes in patients who have a body mass index (BMI) > 35 undergoing cemented TKA using an all-polyethylene tibial component (APTC) at a minimum of 2 years of follow-up. METHODS: We retrospectively studied 163 obese patients (192 TKAs) who underwent a primary cemented TKA using an APTC comparing the outcomes of 96 TKA patients who had a BMI > 35 to 39.9 (group A) with 96 patients who a TKA and a BMI ≥40 (group B). Median follow-up of groups A and B were 3.8 years and 3.5 years respectively (P = .02). Multiple regression analyses were performed to evaluate independent risk factors associated with complications. Kaplan-Meier survival curves were estimated, defining failure as the need for any further femoral or tibial revision surgery with implant removal, irrespective of the reason. RESULTS: There was no significant difference at the latest follow-up patient-reported outcomes between both groups. Survivorship, as defined by revision for any reason, was 99% for group A and 99% for group B (P = 1.00). There was 1 aseptic tibial failure in group A, and 1 septic failure in group B. Multiple regression analyses showed no significant associations between age (odds ratio [OR] = 1.00; P = .98; 95% confidence interval (CI) = 0.93 to 1.08), sex (OR = 1.38; P = .70; 95% CI = 0.26 to 7.25), BMI (OR = 1.00; P = .95; 95% CI = 0.87 to 1.16), and complication rate. CONCLUSION: At a median 3.7-year follow-up, the use of an APTC provided excellent outcomes and survivorship in patients who had Class 2 and Class 3 obesity. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Prótese do Joelho , Humanos , Articulação do Joelho/cirurgia , Índice de Massa Corporal , Polietileno , Estudos Retrospectivos , Falha de Prótese , Obesidade/complicações , Obesidade/cirurgia , Reoperação , Resultado do Tratamento , Desenho de PróteseRESUMO
BACKGROUND: Contact kinematics in total knee arthroplasty (TKA) has been shown to affect tibial component migration. However, previous studies correlating kinematic variables to implant migration were completed with older TKA designs. The goal of this study was to determine if there are associations between contact kinematics and tibial component migration for a cemented, bicruciate stabilized (BCS) TKA system. METHODS: A total of 54 knees implanted with a BCS TKA system were analyzed using radiostereometric analysis (RSA). Patients underwent RSA exams at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years post operation to measure tibial component migration. At 1 year, contact kinematics was evaluated during a quasi-static deep knee bend. Linear regression analyses were performed between kinematic variables and migration values. RESULTS: Significant correlations were found between contact kinematics and tibial component migration. Excursion on the lateral condyle was the most consistent variable correlating with implant migration. Six patients had > 0.2 mm migrations from 1 to 2 years post operation indicating continuously migrating tibial components, and most had atypical contact kinematics. CONCLUSION: Kinematics was shown to influence tibial component migration. Reduced lateral excursion, suggesting a more constrained lateral condyle, resulted in greater implant migration. The 6 patients who had continuously migrating tibial components had demographic factors that may limit the ability to endure unintended force transmissions caused by abnormal kinematics. These results highlight the importance of restoring knee kinematics with this BCS TKA design to minimize improper force transmissions and resultant increased implant migrations.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Fenômenos Biomecânicos , Articulação do Joelho/cirurgia , Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Amplitude de Movimento ArticularRESUMO
BACKGROUND: Subsidence remains a concern when utilizing tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability, and failure to obtain osseointegration. This study aims to compare stem subsidence across 3 modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or "scratch fit" on subsidence, as well as the role of intraoperative imaging in maximizing bicortical contact and preventing stem subsidence. METHODS: A retrospective review of 271 hip arthroplasties utilizing modern TFT stems at a single institution was performed. Three stem designs were included in the analysis: 1 monoblock TFT stem (n = 91) and 2 modular TFT stems (n = 90; n = 90). Patient demographics, Paprosky femoral bone loss classification, bicortical contact, utilization of intraoperative imaging, and stem subsidence (comparison of initial postoperative radiograph to the latest follow-up radiograph-minimum 3 months) were recorded. RESULTS: There was no statistically significant difference in overall subsidence (P = .191) or the incidence of subsidence >5 millimeters between stems (P = .126). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was associated with reduced subsidence (P = .004). Intraoperative imaging was used in 46.5% (126 of 271) of cases; this was not correlated with bicortical contact (P = .673) or subsidence (P = .521). CONCLUSION: All 3 modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate.
Assuntos
Artroplastia de Quadril , Prótese de Quadril , Humanos , Titânio , Desenho de Prótese , Reoperação , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Hybrid fixation, utilizing diaphyseal press-fit stems and cement fixation in the tibial and femoral metaphyseal areas, has long been a strategy for revision total knee arthroplasty (rTKA). The purpose of this study was to evaluate the clinical outcomes and survivorships of hybrid fixation using a single rTKA revision system with a minimum of 5 years follow-up. METHODS: We reviewed our prospectively collected database to identify 281 patients who underwent rTKA using a single revision system with hybrid fixation and press-fit stems between July 2006 and August 2016. We reviewed the clinical outcome scores, including the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis index, and Veterans RAND 12 Item Health Survey. We also evaluated the 5 and 10-year survivorships and the indications for reoperations. The cohort had a mean age of 70 years (range, 45.2 to 92.0) and a mean body mass index of 33.4 (range, 17.3 to 55.8). The mean time from rTKA surgery was 11.1 years (range, 5.3 to 15.5). RESULTS: Paired t-test analyses showed significant improvements from preoperative versus postoperative clinical outcome scores (P < .001) for Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis, and Veterans RAND 12 Item Health Survey Physical component. Prosthetic joint infections after index rTKA were the most common failure mode with 29 patients requiring reoperations. Rerevision due to aseptic loosening was uncommon (6 patients) with a cumulative survival rate of 95.2% at 5 years and 94.2% at 10 years. CONCLUSION: The use of this single rTKA system utilizing press fit stems combined with hybrid fixation provided significant improvements in the clinical outcomes and excellent survivorships at 5 and 10 years.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite , Humanos , Idoso , Articulação do Joelho/cirurgia , Sobrevivência , Desenho de Prótese , Reoperação , Osteoartrite/cirurgia , Estudos Retrospectivos , Falha de Prótese , Resultado do TratamentoRESUMO
PURPOSE: Acute arterial thrombosis after hip arthroplasty is a rare event associated with potentially catastrophic complications. Early clinical diagnosis of progressive limb ischemia is often difficult in the immediate postoperative period because of residual neuraxial blockade and the nonspecific nature of signs. We describe the use of point-of-care ultrasound (POCUS) in the postanesthesia care unit (PACU) to diagnose this complication early and facilitate timely intervention. CLINICAL FEATURES: A 78-yr-old female patient underwent elective right hip revision arthroplasty under spinal anesthesia and postoperatively had an absent dorsalis pedis pulse on her operative leg as screened by an audible-only Doppler. No obvious clinical symptoms were present as the patient was still under subarachnoidal blockade. A bedside POCUS vascular evaluation was performed in the PACU and showed an absence of blood flow in the superficial femoral artery, expediting the confirmation of a surgical emergency. The patient underwent a successful open thrombectomy and made an uneventful postoperative recovery. CONCLUSION: Our case report highlights the novel use and impact of bedside POCUS to assess the presence or absence of distal limb arterial blood flow and, in this case, the level of arterial occlusion.
RéSUMé: OBJECTIF: La thrombose artérielle aiguë après arthroplastie de la hanche est un événement rare associé à des complications potentiellement catastrophiques. Le diagnostic clinique précoce de l'ischémie progressive du membre est souvent difficile à poser dans la période postopératoire immédiate en raison du bloc neuraxial résiduel et de la nature non spécifique des signes. Nous décrivons l'utilisation de l'échographie ciblée (POCUS) en salle de réveil (SDR) pour diagnostiquer cette complication rapidement et faciliter une intervention rapide. CARACTéRISTIQUES CLINIQUES: Une patiente de 78 ans a bénéficié d'une arthroplastie non urgente de révision de la hanche droite sous rachianesthésie; après l'intervention, le pouls pédieux, tel que dépisté par un Doppler uniquement sonore, était absent au niveau de la jambe opérée. Aucun symptôme clinique évident n'était présent alors que la patiente était toujours sous bloc sous-arachnoïdien. Une évaluation vasculaire d'échographie ciblée a été réalisée en salle de réveil et montrait l'absence de circulation sanguine dans l'artère fémorale superficielle, confirmant l'urgence chirurgicale. La patiente a bénéficié d'une thrombectomie ouverte réussie et s'est rétablie sans incident après l'opération. CONCLUSION: Notre présentation de cas met en évidence l'utilisation innovante et l'impact de l'échographie ciblée pour évaluer la présence ou l'absence du flux sanguin artériel distal et, dans ce cas, le niveau de l'occlusion artérielle.
Assuntos
Arteriopatias Oclusivas , Artroplastia de Quadril , Trombose , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/cirurgia , Artroplastia de Quadril/efeitos adversos , Feminino , Pé/cirurgia , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/cirurgiaRESUMO
BACKGROUND: The aim of this study was to compare the stem alignment and the quality of cement mantle of collarless polished tapered cemented stems inserted through the direct anterior approach (DAA) and the direct lateral approach (DLA). METHODS: A comparative retrospective study of 232 hybrid total hip arthroplasties using a cemented collarless polished tapered stem through either the DAA (n = 147) or DLA (n = 85) was performed. Radiographic evaluation included stem alignment, cement mantle quality, and cement mantle thickness. RESULTS: On anteroposterior radiographs, stems implanted through the DLA were more likely to be in neutral alignment, than those implanted through the DAA (83.5%[n = 71] versus 71.4% [n = 105]; P = <.001). No difference between approaches was noted for stem alignment on lateral radiographs or cement mantle quality. Multivariate analysis revealed factors associated with suboptimal cement mantle and included Dorr type B or C femur as well as male gender. A mean cement mantle thickness ≥2mm was achieved in all Gruen zones for both approaches. CONCLUSION: In our series, the DAA was associated with a higher incidence of coronal plane stem malalignment compared to the DLA when using cemented tapered polished femoral components for total hip arthroplasty. No difference in lateral stem alignment or cement mantle quality was found.
Assuntos
Artroplastia de Quadril , Prótese de Quadril , Cimentos Ósseos , Humanos , Masculino , Desenho de Prótese , Estudos RetrospectivosRESUMO
BACKGROUND: The prevalence and outcomes of unexpected positive intraoperative cultures (UPC) in presumed aseptic revision total knee arthroplasty (TKA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondly, we aimed to compare the infection-free implant survival between cohorts based on number of UPCs and antibiotic treatment. METHODS: We reviewed our institutional database from 2006 to 2019 for all TKA revisions (n = 1795) to identify all presumed aseptic TKA revisions with intraoperative culture(s). After exclusions, 775 revisions were eligible and those with UPC were included in the Kaplan-Meier analysis to determine infection-free implant survival for the cohorts. RESULTS: The prevalence of UPC was 9.8%. The 2- and 5-year infection-free survival was 97.4% and 95.3%, respectively. The 5-year infection-free survival from the same microorganism as the UPC was 98.7%. Infection-free survival was similar for the 1 versus ≥2 UPC cohorts (P = .416), however was poorer for the cohort treated with antibiotics (P = .021). Only one of 3 subsequent PJI-related implant failures was caused by the same microorganism (polymicrobial) as the UPC. There were no subsequent infections in patients with a single UPC not treated with antibiotics. CONCLUSIONS: The prevalence of UPC was 9.8% and the infection-free implant survival is excellent. Infection-free survivorship from PJI caused by the same UPC microorganism is outstanding. Comparisons between cohorts must be interpreted with caution due to study limitations. A single UPC in patents without other signs of infection does not require antibiotic treatment. LEVEL OF EVIDENCE: IV.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Infecções Relacionadas à Prótese , Antibacterianos/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Humanos , Prótese do Joelho/efeitos adversos , Prevalência , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Reoperação/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: Implant migration and altered kinematics have been thought to impact patient-reported outcome measures (PROMs) and postoperative patient satisfaction. In this study comparing satisfied and dissatisfied total knee arthroplasty (TKA) patients, we hypothesized that dissatisfied patients will have greater continuous implant migration and that there will be differences in joint kinematics, objective functional measurements, and PROMs between satisfied and dissatisfied patients. METHODS: The Knee Society Score Satisfaction Subsection questions regarding satisfaction with function were used at least 6 months postoperation to split 50 patients into satisfied and dissatisfied groups. Patients underwent radiostereometric analysis to evaluate migration and kinematics. A wearable sensor system obtained objective measurements of patient function during timed up and go tests. PROMs were recorded preoperation and postoperation. RESULTS: No statistically significant differences were found in migration between satisfied and dissatisfied groups. Statistical kinematic differences existed in lateral anteroposterior contact location at 20° and 40° of flexion at 1 year, where the dissatisfied group had more anteriorly located lateral contact. No statistically significant differences were present in objective functional measurements. Satisfied and dissatisfied groups had differing PROMs at 4 timepoints or greater for each questionnaire. CONCLUSIONS: No differences were found in tibial component migration or objectively measured function between satisfied and dissatisfied patients. Functionally dissatisfied patients had more anteriorly positioned contact on the lateral condyle in early flexion and reported more pain and unmet expectations. These findings suggest that improving the functional satisfaction of TKA requires restoration of kinematics in early flexion and management of patient's pain and expectations.
Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Fenômenos Biomecânicos , Humanos , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Dor/cirurgia , Satisfação do Paciente , Satisfação Pessoal , Amplitude de Movimento ArticularRESUMO
BACKGROUND: The goal of this study is to investigate the migration and inducible displacement of a bicruciate-stabilized (BCS) total knee arthroplasty implanted using gap balancing (GB) or measured resection (MR) surgical techniques. We hypothesized equal migration and displacement between the techniques. METHODS: The study is a single-blinded, prospective, randomized controlled trial, with allocation of 71 patients to either GB or MR groups. Fifteen patients were withdrawn, resulting in 31 patients in the GB group and 25 in the MR group. Patients received the JOURNEY II™ BCS implant. Migration and inducible displacement were evaluated using radiostereometric analysis and patient examinations were performed at a 2-week baseline, and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperation. RESULTS: No differences (P > .05) existed between GB and MR groups for any measurement of tibial or femoral migration. Both groups had tibial migrations below 0.5 mm from baseline to 6 months, and below 0.2 mm from both 6 months to 1 year and 1-2 years postoperation. No differences (P > .05) were found between GB and MR groups for inducible displacement. CONCLUSION: No differences were found in implant migration or inducible displacement between GB and MR groups. The BCS implant can be expected to have migration risks on par with industry standards and both surgical techniques are safe and effective options for implantation of this implant design.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Artroplastia do Joelho/efeitos adversos , Humanos , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Estudos Prospectivos , Análise Radioestereométrica , Tíbia/diagnóstico por imagem , Tíbia/cirurgiaRESUMO
BACKGROUND: Bone loss remains an anticipated challenge in revision total knee arthroplasty (rTKA). Recent efforts to enhance rTKA fixation and stability have focused on metaphyseal implants, namely cones and sleeves. We sought to compare cone and sleeve implant survivorship in rTKA. METHODS: One hundred eighty patients who underwent rTKA with metaphyseal implants from 2005 to 2018 were retrospectively reviewed. A total of 83 cones (22 femoral, 62 tibial) and 121 sleeves (58 femoral, 63 tibial) were identified. The mean age at the time of surgery was 72 years (range 43-97). Intraoperative Anderson Orthopaedic Research Institute bone loss classifications included the following: type 2A (25), type 2B (98), and type 3 (81). Mean follow-up was 41 months. RESULTS: Revision-free survival for cones was 91.3% vs 92.2% for sleeves (P = .29). Twelve knees (4 cones, 8 sleeves) underwent irrigation, debridement, and polyethylene exchange with metaphyseal implant retention for acute postoperative periprosthetic joint infection (PJI). Development of chronic PJI warranted removal of 7 cones (8.4%), 6 of which were initially placed as part of a 2-stage revision TKA. Eight sleeves (6.6%) were removed for PJI, with all initially placed during a second stage reimplantation. In the absence of infection, survival was 100% and 99.1% for cones and sleeves, respectively. One sleeve was revised for periprosthetic fracture. CONCLUSION: Metaphyseal cones and sleeves offer equally durable survivorship in revision TKA. PJI was the most common mode of implant failure in this series. Importantly, no cases of cone or sleeve aseptic loosening were observed.
Assuntos
Artrite Infecciosa , Artroplastia do Joelho , Prótese do Joelho , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite Infecciosa/cirurgia , Artroplastia do Joelho/efeitos adversos , Humanos , Articulação do Joelho/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Reoperação , Estudos Retrospectivos , SobrevivênciaRESUMO
BACKGROUND: Evidence suggests that up to 21% of patients are dissatisfied after total knee arthroplasty (TKA), but the link between dissatisfaction and use of health care resources is unknown. The objective of this study was to compare costs after TKA between satisfied and dissatisfied patients. METHODS: This was a secondary analysis of a randomized clinical trial among patients who underwent primary TKA at our institution between 2015 and 2018. We estimated rates of satisfaction with pain relief and with return to function 1 year postoperatively. Patients prospectively reported use of health care resources 6 weeks, and 3, 6, 9 and 12 months after surgery. We compared costs between satisfied and dissatisfied patients from a public payer and a societal perspective. RESULTS: We included 156 patients in our analysis, of whom 42 (26.9%) were dissatisfied with pain, and 57 (36.5%) were dissatisfied with function. There was no significant difference in costs between patients dissatisfied with pain or function compared to satisfied patients from a health care payer perspective. From a societal perspective, patients dissatisfied with pain incurred a mean cost of $21 156.18, compared to $13 453.84 for satisfied patients (mean difference $7702.34, 95% confidence interval [CI] -89.43 to 15 494.11). Similarly, patients dissatisfied with function incurred a mean cost of $19 007.70, compared to $13 523.83 for those who were satisfied (mean difference $5483.87, 95% CI -526.34 to 11 494.10). CONCLUSION: Dissatisfied patients incurred greater costs than satisfied patients during the first year after TKA. The results justify further evaluation of factors contributing to patient satisfaction that may help to reduce the economic burden of TKA.