Journal of Arthroplasty

Journal of Arthroplasty

The Impact of Running, Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis

12-06-2019 – Ryan R. Thacher, Carl L. Herndon, Emma L. Jennings, Nana O. Sarpong, Jeffrey A. Geller

Journal Article

Background

Recently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture.

Methods

Patients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection.

Results

There was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04).

Conclusion

The use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure.

Level of Evidence

Level IV; retrospective cohort study.

Reply to the Letter to the Editor on “Is Routine Urinary Screening Indicated Prior to Elective Total Joint Arthroplasty? A Systematic Review and Meta-Analysis”

24-06-2019 – Ricardo J.G. Sousa, Miguel A. Abreu

Letter

Letter to the Editor on “Is Routine Urinary Screening Indicated Prior to Elective Total Joint Arthroplasty? A Systematic Review and Meta-Analysis”

02-07-2019 – Axel Probst, Ronny Langenhan

Letter

Response to Letter to the Editor on “Mortality and Implant Survival With Simultaneous and Staged Bilateral Total Knee Arthroplasty Experience From the Australian Orthopaedic Association National Joint Replacement Registry”

27-06-2019 – Sarah L. Whitehouse, Hwa Sen Chua, Michelle F. Lorimer, Richard N. de Steiger, Ross W. Crawford

Letter

Letter to the Editor on “Mortality and Implant Survival With Simultaneous and Staged Bilateral Total Knee Arthroplasty Experience From the Australian Orthopedic Association National Joint Replacement Registry”

18-06-2019 – Sam J. Martin, Corey J. Scholes, Michel P. Genon

Letter

Outcomes of Nonoperative Management, Iliopsoas Tenotomy, and Revision Arthroplasty for Iliopsoas Impingement after Total Hip Arthroplasty: A Systematic Review

31-05-2019 – Jacob Shapira, Sarah L. Chen, Natalia M. Wojnowski, Ajay C. Lall, Philip J. Rosinsky, David R. Maldonado, Benjamin G. Domb

Journal Article

Background

Nonoperative and operative management of iliopsoas impingement (IPI) is commonly performed following total hip arthroplasty (THA). The purpose of this systematic review is to compare patient-reported outcomes (PROs) following conservative treatment, iliopsoas (IP) tenotomy, and revision arthroplasty in patients presenting with IPI after THA.

Methods

The PubMed and Embase databases were searched for articles regarding IPI following THA. Studies were included if (1) IPI after THA was treated with conservative management, an IP tenotomy, or acetabular component revision and (2) included PROs.

Results

Eleven articles were selected for review and there were 280 hips treated for IPI following THA. Harris Hip Scores reported for the conservative group, the IP tenotomy group, and the cup revision group were 59.0 preoperatively to 77.8, 58.0 preoperatively to 85.4, and 58.1 preoperatively to 82.4 at latest follow-up, respectively. The IP tenotomy cohort also demonstrated superior postoperative functional outcomes using the Western Ontario and Mc
Master Universities Index, Medical Research Council score, Oxford Hip Score, and Merle d
Aubigné-Postel Pain Score. Patients who had a revision exhibited higher Oxford Hip Scores, higher Medical Research Council scores, and lower Visual Analog Scale Pain scores postoperatively.

Conclusion

Management of IPI following THA includes nonoperative measures, IP tenotomy, or acetabular component revision. Patients have been shown to experience favorable PROs at latest follow-up, with an apparent advantage for surgical treatment. Compared to revision arthroplasty, IP tenotomy resulted in a lower overall rate of complications with less severe complication types. Therefore, IP tenotomy should be considered as a second line of treatment for patients who failed conservative measures. Revision arthroplasty should be reserved for recalcitrant cases.

Level of Evidence

IV.

The Efficacy of Liposomal Bupivacaine Over Traditional Local Anesthetics in Periarticular Infiltration and Regional Anesthesia During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

11-06-2019 – Michael Yayac, William T. Li, Alvin C. Ong, P. Maxwell Courtney, Arjun Saxena

Journal Article

Background

Since its Food and Drug Administration approval in 2011 as a local anesthetic for postsurgical analgesia, liposomal bupivacaine (LB) has been incorporated into the periarticular injection (PAI) of many knee surgeons. The slow release of this medication from vesicles should significantly extend the duration of its analgesic effect, but current evidence has not clearly demonstrated this benefit.

Methods

We systematically searched electronic databases including PubMed, MEDLINE, Cochrane Library, EMBASE, Science
Direct, and Scopus, as well as the Journal of Arthroplasty web page for relevant articles. All calculations were made using Review Manager 5.3.

Results

We identified 42 studies that compared LB to an alternate analgesic modality. Seventeen of these studies were controlled trials that were included in meta-analysis. Significant differences were seen in pain scores with LB over a peripheral nerve block (mean difference = 0.45, P = .02) and LB over a traditional PAI (standard mean difference = −0.08, P = .004).

Conclusion

While LB may offer a statistically significant benefit over a traditional PAI, the increase in pain control may not be clinically significant and it does not appear to offer a benefit in reducing opioid consumption. However, there is no standardization among current studies, as they vary greatly in design, infiltration technique, and outcome measurement, which precludes any reliable summarization of their results. Future independent studies using a standardized protocol are needed to provide clear unbiased evidence.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

12-06-2019 – Ajay Shah, Muzammil Memon, Jeffrey Kay, Thomas J. Wood, Daniel M. Tushinski, Vickas Khanna, McMaster Arthroplasty Collective (MAC) group

Journal Article

Background

Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors.

Methods

Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms “total knee arthroplasty” and “length of stay”. Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (Rev
Man) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014).

Results

A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference MD = 0.81; 95% confidence interval CI = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98).

Conclusion

This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative “fast-track” programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications.

Level of Evidence

IV, systematic review, and meta-analysis of level III and IV evidence.

Stand-to-Sit Kinematics of the Pelvis Is Not Always as Expected: Hip and Spine Pathologies Can Have an Impact

30-05-2019 – Youngwoo Kim, Claudio Vergari, François Girinon, Jean Yves Lazennec, Wafa Skalli

Journal Article

Background

Stand-to-sit pelvis kinematics is commonly considered as a rotation around the bicoxofemoral axis. However, abnormal kinematics could occur for patients with musculoskeletal disorders, affecting the hip-spine complex. The aim of this study is to perform a quantitative analysis of the stand-to-sit pelvis kinematics using 3D reconstruction from biplanar x-rays.

Methods

Thirty volunteers as a control group (C), 30 patients with hip pathology (Hip), and 30 patients with spine pathology (Spine) were evaluated. All subjects underwent standing and sitting full-body biplanar x-rays. Three-dimensional reconstruction was performed in each configuration and then translated such as the middle of the line joining the center of each acetabulum corresponds to the origin. Rigid registration quantified the finite helical axis (FHA) describing the transition between standing and sitting with two specific parameters. The orientation angle (OA) is the signed 3D angle between FHA and bicoxofemoral axis, and the rotation angle (RA) represents the signed angle around FHA.

Results

The mean OA was −1.8° for the C group, 0.3° for Hip group, and −2.4° for Spine group. There was no significant difference in mean OA between groups. However, variability was higher for the Spine group with a standard deviation (SD) of 15.9° compared with 10.8° in the C group and 12.3° in the Hip group. The mean RA in the C group was 18.1° (SD, 9.0°). There was significant difference in RA between the Hip and Spine groups (21.1° SD, 8.0° and 16.4° SD, 10.8°, respectively) (P = .04).

Conclusion

Hip and spine pathologies affect stand-to-sit pelvic kinematics.

Non-Destructive Testing of Ceramic Knee Implants Using Micro-Computed Tomography

16-06-2019 – Klemens Trieb, Jonathan Glinz, Michael Reiter, Johann Kastner, Sascha Senck

Journal Article

Background

Because of the accumulated numbers and the increasing rate of knee replacement surgeries larger numbers of revision cases are likely. Although the success rate of knee arthroplasties is high, complications like the loosening of the implant necessitate subsequent treatments. Therefore, new concepts such as metal-free ceramic implants are necessary, for example, using zirconium dioxide (Zr
O2). Several studies showed that the strength of ceramic Zr
O2 implants is equivalent to cobalt-chromium components.

Methods

Non-destructive testing remains challenging due to the high density (6 g/cm³) of Zr
O2. In this feasibility study, we investigated 8 tibial and 8 femoral implants respectively using an industrial X-ray micro-computed tomography (XCT) system at a voxel size of 100 μm. We established a non-destructive testing protocol for ceramic knee implants optimizing scanning parameters and sample orientation using CT simulations. Finally, we used an iterative artifact reduction procedure for beam hardening correction.

Results

The results show that corrected image data enable the non-destructive inspection of high-density components. In this sample, none of the investigated components show any internal defects like pores or cracks. In general, XCT is a major imaging method that is able to provide a 3-dimensional representation of higher dense objects that allows the inspection of metal or ceramic knee implants. Even though we established an optimized scanning routine for tibial and femoral ceramic components, it is not possible to completely eliminate scanning artifacts of XCT.

Conclusion

Altogether, after visual inspection, none of the beam-hardening corrected XCT data sets for femoral and tibial implants showed any defects, that is, no inclusions, cracks, or pores were detected. XCT test is therefore an essential addition to the fatigue testing since it is the only non-destroying testing method.

Impact of Hip Antibiotic Spacer Dislocation on Final Implant Position and Outcomes

01-07-2019 – Simon Garceau, Yaniv Warschawski, Ethan Sanders, Allan Gross, Oleg Safir, Paul Kuzyk

Journal Article

Background

Dislocation of dynamic antibiotic hip spacers during the treatment of periprosthetic joint infection is a well-described complication. Unfortunately, the repercussions of such events after reimplantation of the definitive prosthesis remain largely unknown. As such, we devised a study comparing the perioperative and postoperative outcomes of patients having undergone reimplantation with and without spacer dislocation.

Methods

A search of our institutional database was performed. Two retrospective cohorts were created: dislocated and nondislocated hip spacers. The radiographic and clinical outcomes for each cohort were collected.

Results

The two retrospective cohorts contained 24 patients for the dislocated group and 66 for the nondislocated group. Continuous variables noted to be significantly different between the dislocated and nondislocated groups were as follows: clinical leg-length discrepancy (1.35 cm vs 0.41 cm, P = .027), acetabular center of rotation (1.34 cm vs 0.60 cm, P = .011), total packed red blood cell transfusions (4.05 vs 2.37, P = .019), operative time (177.4 min vs 147.3 min, P = .002), and hospital length of stay (7.79 days vs 5.89 days, P = .018). Categorical variables noted to be significantly different were requirement for complex acetabular reconstruction (58.3% vs 13.7%, P < .001), requirement of constrained liners (62.5% vs 37.3%, P = .040), and dislocation after second stage (20.8% vs 6.1%, P = .039).

Conclusion

Dislocation of dynamic hip spacers leads to inferior clinical results and perioperative outcomes after reimplantation of the definitive prosthesis. Additionally, complex acetabular reconstruction is often required. As such, every effort should be made to prevent hip spacer dislocation.

Have We Actually Reduced Our 30-Day Short-Term Surgical Site Infection Rates in Primary Total Hip Arthroplasty in the United States?

28-05-2019 – Nipun Sodhi, Hiba K. Anis, Luke J. Garbarino, Peter A. Gold, Steven M. Kurtz, Carlos A. Higuera, Matthew S. Hepinstall, Michael A. Mont

Journal Article

Background

The purpose of this study is to track the 30-day postoperative annual rates and trends of (1) overall, (2) deep, and (3) superficial surgical site infections (SSIs) following total hip arthroplasty (THA) using a large nationwide database.

Methods

The National Surgical Quality Improvement Program database was queried for all THA cases performed between 2012 and 2016. After an overall 5-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 4 years. Correlation coefficients and chi-squared tests were used to determine correlation and statistical significance.

Results

The lowest incidence of SSIs was in the most recent year, 2016 (0.81%), while the greatest incidence was in the earliest year, 2012 (1.12%), marking a 31% decrease (P < .01). The lowest rate was in the most recent year, 2016 (0.23%), marking a 26% decrease from 2012. The lowest superficial SSI incidence occurred in the most recent year, 2016 (0.58%), while greatest incidence was in 2012 (0.83%), marking a 31% decrease over time (P < .05). There was an inverse correlation among overall, deep, and superficial SSI rates with operative year.

Conclusion

The findings from this study suggest a decreasing trend in SSIs within 30 days following THA. Furthermore, deep SSIs, which can pose substantial threats to implant survivorship, have also decreased throughout the years. These results highlight that potentially through improved medical and surgical techniques, we are winning the fight against short-term infections, but that more can still be done.

The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates

28-05-2019 – Michael Yayac, Alexander J. Rondon, Timothy L. Tan, Hannah Levy, Javad Parvizi, P. Maxwell Courtney

Journal Article

Background

To reduce the substantial clinical and financial burden of periprosthetic joint infection (PJI), some surgeons advocate for the use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA), although its effectiveness continues to be debated in the literature. The purpose of this study was to determine whether the routine use of ALBC is cost-effective in reducing PJI after primary TKA.

Methods

We retrospectively reviewed a consecutive series of patients undergoing cemented primary TKA at two hospitals within our institution from 2015 to 2017. We compared demographics, comorbidities, costs, and PJI rates between patients receiving ALBC and plain cement. We performed a multivariate regression analysis to determine the independent effect of ALBC on PJI rate. We calculated readmission costs for PJI and reduction in PJI needed to justify the added cost of ALBC.

Results

Of 2511 patients, 1077 underwent TKA with ALBC (43%), with no difference in PJI rates (0.56% vs 0.14%, P = .0662) or complications (1.2% vs 1.6%, P = .3968) but higher cement costs ($416 vs $117, P < .0001) and overall procedure costs ($6445 vs $5.968, P < .0001). ALBC had no effect on infection rate (P = .0894). Patients readmitted with PJI had higher overall 90-day episode-of-care claims costs ($49,341 vs $19,032, P < .001). To justify additional costs, ALBC would need to prevent infection in one of every 101 patients.

Conclusion

Routine use of ALBC in primary TKA is not cost-effective, adding $299 to the cost of episode of care without a reduction in PJI rate. Further study is needed to determine whether select use of ALBC would be justified in high-risk patients.

Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty

22-05-2019 – Hiba K. Anis, Nipun Sodhi, Mhamad Faour, Alison K. Klika, Michael A. Mont, Wael K. Barsoum, Carlos A. Higuera, Robert M. Molloy

Journal Article

Background

The purpose of this study is to evaluate the effect of commercially available antibiotic-impregnated bone cement (AIBC) on (1) prosthetic joint infections (PJIs) and (2) surgical site infections (SSIs) after primary total knee arthroplasty (TKA).

Methods

A review of primary TKAs between 2014 and 2017 from an institutional database was conducted. This identified 12,541 cases which were separated into AIBC (n = 4337) and non-AIBC (8,164) cohorts. Medical records were reviewed for PJIs and SSIs (mean 2-year postoperative period). Infection rates between the cohorts were compared with univariate analyses followed by subanalysis of high risk patients (defined as having 2 or more of the following characteristics: >65 years, body mass index >40, or Charlson Comorbidity Index score >3). To control for confounders, multivariate analyses were performed with regression models adjusted for age, gender, body mass index, comorbidities, year, operative times, and lengths of stay.

Results

On univariate analysis, PJI rates were higher in the AIBC cohort (1.0%) compared to the non-AIBC cohort (0.5%, P < .001). Subanalysis of the high risk patients also showed that PJI rates were higher in the AIBC cohort (1.9% vs 0.6%, P < .01). After adjusting for potential confounders, no significant associations between PJIs and AIBC use were found (odds ratio 1.4, 95% confidence interval 0.9-2.3, P = .133). Similarly, no significant differences in SSI rates were observed between the AIBC (2.9%) and non-AIBC cohorts (2.4%, P = .060) and no significant associations between SSIs and AIBC were found with multivariate analysis (odds ratio 1.0, 95% confidence interval CI 0.8-1.3, P = .948).

Conclusion

This study found that there was no clinically or statistically significant decrease in infection rates with AIBC in primary TKAs.

Surgical Treatment of Chronic Periprosthetic Joint Infection: Fate of Spacer Exchanges

12-06-2019 – Timothy L. Tan, Karan Goswami, Michael M. Kheir, Chi Xu, Qiaojie Wang, Javad Parvizi

Journal Article

Background

Patients with periprosthetic joint infection (PJI) undergoing 2-stage exchange arthroplasty may undergo an interim spacer exchange for a variety of reasons including mechanical failure of spacer or persistence of infection. The objective of this study is to understand the risk factors and outcomes of patients who undergo spacer exchange during the course of a planned 2-stage exchange arthroplasty.

Methods

Our institutional database was used to identify 533 patients who underwent a 2-stage exchange arthroplasty for PJI, including 90 patients with a spacer exchange, from 2000 to 2017. A retrospective review was performed to extract relevant clinical information. Treatment outcomes included (1) progression to reimplantation and (2) treatment success as defined by a Delphi-based criterion. Both univariate and multivariate Cox regression models were performed to investigate whether spacer exchange was associated with failure. Additionally, a propensity score analysis was performed based on a 1:2 match.

Results

A spacer exchange was required in 16.9%. Patients who underwent spacer exchanges had a higher body mass index (P < .001), rheumatoid arthritis (P = .018), and were more likely to have PJI caused by resistant (0.048) and polymicrobial organisms (P = .007). Patients undergoing a spacer exchange demonstrated lower survivorship and an increased risk of failure in the multivariate and propensity score matched analysis compared to patients who did not require a spacer exchange.

Discussion

Despite an additional load of local antibiotics and repeat debridement, patients who underwent a spacer exchange demonstrated poor outcomes, including failure to undergo reimplantation and twice the failure rate. The findings of this study may need to be borne in mind when managing patients who require spacer exchange.

Effect of Preoperative Dental Extraction on Postoperative Complications After Total Joint Arthroplasty

30-05-2019 – Kevin A. Sonn, Christopher G. Larsen, William Adams, Nicholas M. Brown, Craig J. McAsey

Journal Article

Background

Poor dental hygiene has historically been considered a potential risk factor for infection in total joint arthroplasty (TJA), which has resulted in the common practice of requiring preoperative dental clearance and often results in dental extractions. However, the association between dental pathology and periprosthetic joint infection (PJI) has recently been called into question.

Methods

A consecutive series of 2457 primary total hip and total knee arthroplasties were retrospectively reviewed. Documented dental evaluation was found in 1944 (79.1%) procedures, 223 (11.5%) of which had extraction of at least 1 tooth. No documented dental evaluation was found in 369 (15.0%) patients.

Results

The overall complication rate was 3.87% with an overall PJI rate of 1.51%. There was no statistically significant association between a complication and procedure type, sex, preoperative dental evaluation or extraction, diabetes status, immunosuppression, malnutrition, or age. However, our sample demonstrated a higher complication rate among patients undergoing dental extraction as well as for those with diabetes and immunosuppressed patients.

Conclusion

Our findings suggest that routine formal dental clearance for all TJA patients may not be necessary. Additionally, patients with poor oral hygiene may not have elevated risk of postoperative PJI, and preoperative tooth extraction may represent an unnecessary step for patients undergoing elective TJA.

Does the Method of Sterile Glove-Opening Influence Back Tablexa0Contamination? A Fluorescent Particle Study

19-06-2019 – David C. Holst, Marc R. Angerame, Douglas A. Dennis, Jason M. Jennings

Journal Article

Background

Surgical site infections (SSI) may result from inadvertent intraoperative contamination events. This study investigated the method of opening surgical gloves onto the operative field (OF) and potential contamination rates.

Methods

Twenty surgical glove packets were coated with a commercially available fluorescent particle powder. Two methods of glove openings (10 surgical glove packets in each cohort) were investigated: direct drop (DD) onto the OF vs opening and direct hand-off (DH) to a sterile intermediary (SI). Ultraviolet black light was used to quantify fluorescent particles for dispensed glove packets and the OF in both cohorts. The gloves of the SI were inspected in the DH cohort. A previously used contamination scale for fluorescent particle model contamination was employed: 0: no detectable fluorescent particle specks, 1: 1-5 specks, 2: 5-10 specks, 3: 11-100 specks, 4: >100 specks.

Results

The DD cohort had a median OF contamination of 4 (range, 3-4) vs 3 for the DH trials (range, 1-3; P = .001). Likewise, the median glove contamination was higher in the DD cohort, 3 (range, 2-4) vs 1 for DH (range, 0-3; P = .007). Minimal contamination was found on the hands of the SI. Total fluorescent contamination rates, including the gloves of SI in the DH cohort, revealed greater overall contamination in DD (median, 3.5; range, 2-4) vs DH cohort (median, 1; range, 0-3); (P < .001).

Conclusion

Using a fluorescent particle model, there is a greater burden of potential contamination from dispensed glove packets and OF with DD vs DH. The DH method did not show significant fluorescent particle contamination on the SI gloves. These data support the use of the opening of gloves via DH over the DD method in total joint arthroplasty to decrease the risk of potential contamination.

One-Stage Periprosthetic Joint Infection Reimbursement—Is It Worth The Effort?

04-06-2019 – Keith A. Fehring, Brian M. Curtin, Bryan D. Springer, Thomas K. Fehring

Journal Article

Background

One-stage protocols for the management of periprosthetic infection take an extended period of time requiring two separate preps and sets of instruments to ensure optimal sterility. While intraoperative service time is one part of the reimbursement algorithm, reimbursement has lagged behind for single-stage treatment with respect to the time and resources necessary to perform these complex treatment regimens. If one-stage results are shown to be acceptable, but not reimbursed appropriately, surgeons will be discouraged from managing periprosthetic joint infection (PJI) in a one-stage fashion.

Methods

The reimbursement and operative time for 50 PJI procedures were compared with 250 primary total hips and 250 primary total knees by the same 4 surgeons.

Results

The average reimbursement for a one-stage knee procedure was $2,597.08, with an average intraoperative service time of 259 minutes ($601.60/h). The average reimbursement for a primary total knee was $2,435.00, with an average intraoperative service time of 100 minutes ($1,461/h). The average reimbursement for a one-stage hip procedure was $2,826.17, with an average intraoperative service time of 311 minutes ($545.24/h). The average reimbursement for a primary total hip was $2,754.71 with an average intraoperative service time of 104 minutes ($1,589.26/h).

Conclusion

One-stage procedures for PJI are reimbursed at approximately 1/3 the hourly rate of a primary procedure, which may discourage surgeons from selecting this treatment alternative even if recent studies confirm efficacy. Payers should be encouraged to reimburse physicians commensurate with the intraoperative service time needed to perform a one-stage procedure as adoption will decrease morbidity and save the healthcare system financially.

Delta-on-Delta Ceramic Bearing Surfaces in Revision Hip Arthroplasty

05-06-2019 – Francesco Castagnini, Barbara Bordini, Enrico Tassinari, Susanna Stea, Cristina Ancarani, Francesco Traina

Journal Article

Background

Fourth-generation ceramic-on-ceramic couplings were developed to improve ceramic toughness and strength. Encouraging outcomes in primary total hip arthroplasty were reported. This coupling was proposed as an attractive option even in the case of revision procedures, particularly in younger patients with a longer life expectancy. However, the pertinent literature is scarce. Thus, a registry study was conducted to investigate the midterm survival rates and reasons for re-revision of the fourth-generation ceramic-on-ceramic bearing surfaces in revision hip arthroplasties.

Methods

A total of 327 revision implants (all the components were exchanged) with BIOLOX Delta couplings were investigated using the regional orthopedic registry RIPO. The demographics, the survival rates, and the reasons for re-revision were assessed. Revisions with bearings other than Delta were compared.

Results

Delta bearings achieved a survival rate of 90.5% at 7 years, with stable results. Twenty-six (8%) re-revisions occurred at a mean follow-up of 4.1 years. And 2.8% of the re-revisions were due to recurrent dislocations; 1.5% of the cases were due to cup aseptic loosening. Septic loosening occurred in 1.6% of the cases. No ceramic fractures were reported. When compared to revisions with bearings other than Delta-on-Delta, Delta coupling cohort achieved similar performances at 5 and 7 years. Lower, nonsignificant rates of aseptic and septic loosening were reported in Delta cohort.

Conclusion

Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up. Clinical studies and longer follow-ups are required to investigate potential adverse effects, like squeaking and fractures, and confirm these preliminary findings.

Level of Evidence

Level III, therapeutic study.

Declining Revision Burden of Metal-on-Metal Hip Arthroplasties

09-06-2019 – Olli S. Lainiala, Aleksi P. Reito, Jyrki J. Nieminen, Antti P. Eskelinen

Journal Article

Background

Adverse reactions to metal debris (ARMD) have been a problem with metal-on-metal (Mo
M) hip systems for a decade. Unacceptably high revision rates have been described for both stemmed Mo
M total hip arthroplasties (THAs) and hip resurfacings. The aim of this study was to report survivorship and temporal trends of hip revisions in patients with Mo
M hips.

Methods

We identified 2520 patients with 3013 Mo
M hip arthroplasties performed at our institution. These included 1532 primary stemmed Mo
M THAs, 1262 Mo
M hip resurfacings, and 219 stemmed Mo
M THAs implanted in revision surgery.

Results

Revision surgery was performed on 551 (36%) primary stemmed Mo
M THAs and on 179 (14%) resurfacings. The most common reason for revision was ARMD both among primary Mo
M THAs (83%) and hip resurfacings (70%). The 15-year implant survivorship was 69% (95% confidence interval CI 67-71%) for the whole study group, 56% (CI 53-60%) for stemmed primary Mo
M THAs, and 84% (CI 82-87%) for hip resurfacings. Clear temporal peak in the number of revisions for ARMD was seen in 2011-2013, and the trend has been decreasing since.

Conclusion

After a decade since outburst of the ARMD problematics with Mo
M hips, a large proportion of them have gone through revision surgery at our single high-volume center. The peak years were 2011-2013, and thereafter, the number of ARMD revisions has decreased every year. With the threshold for revision remaining constant at our institution, it is not likely that large amount of new cases of ARMD will be seen. As these results are derived from a single centers data, similar studies from other institutions are needed to see whether our results represent a global trend.

Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? Axa0Complication Rate Analysis

05-06-2019 – Fernando Diaz-Dilernia, Pablo Ariel Slullitel, Jose Ignacio Oñativia, Fernando Martin Comba, Francisco Piccaluga, Martin Alejandro Buttaro

Journal Article

Background

Because the gold standard for the treatment of Vancouver type-B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate between the impaction bone grafting (IBG) technique with a cemented stem and reconstruction with an uncemented distally-fixed modular stem (DFMS).

Methods

We retrospectively studied 54 B3 PFFs operated between 2000 and 2016, comparing the complication rate of 33 patients treated with the IBG technique (group A) with 21 patients treated with a DFMS (group B). Median follow-up of groups A and B were 75 months (interquartile range IQR, 36-111 months) and 55 months (IQR, 32-73 months), respectively (P = .008). Median age of groups A and B were 78 years (IQR, 74-83 years) and 81 years (IQR, 74-86 years), respectively (P = .30). Median grade of Endo-Klink femoral bone defect was 3 (IQR, 3-3) for both groups (P = .11). We performed a multiple regression analysis to determine risk factors for complications including the following variables: age, initial diagnosis, and surgical technique.

Results

As for infection outcomes, 2-stage revision surgery was more frequent in group A than in group B (4 vs 0, P = .003). Group A presented more implant failures than group B (5 vs 1, P = .195). We found 4 dislocations in group B and 2 in group A (P = .192). Multiple regression analysis showed a significant association between surgical technique and complication rate (P = .01). The IBG technique presented an odds risk for complications of 4.77 (P = .016; IQR, 1.33-17.21).

Conclusion

Femoral reconstruction with the IBG technique evidenced an ostensibly higher complication rate than that of DFMS for the treatment of B3 PFF.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

04-06-2019 – Elke Jeschke, Thorsten Gehrke, Christian Günster, Karl-Dieter Heller, Hanna Leicht, Jürgen Malzahn, Fritz Uwe Niethard, Peter Schräder, Josef Zacher, Andreas M. Halder

Journal Article

Background

With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.

Methods

Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.

Conclusion

We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

Conversion of Hip Resurfacing With Retention of Monoblock Acetabular Shell Using Dual-Mobility Components

11-06-2019 – Jason L. Blevins, Tony S. Shen, Rachelle Morgenstern, Thomas A. DeNova, Edwin P. Su

Journal Article

Background

Retention of the acetabular component is an option during conversion from hip resurfacing arthroplasty (HRA) to total hip arthroplasty (THA). The purpose of this study was to compare clinical outcomes of conversion of the femoral resurfacing component with retained acetabular components (RAC) and use of dual-mobility femoral heads to outcomes of patients treated with both component (BC) revisions.

Methods

A retrospective review was performed of the clinical outcomes of HRA to THA conversions performed at a single institution between 2008 and 2017.

Results

Seventy-one conversions were included (27 RAC and 44 BC). Average age at time of conversion was 54.4 years (range, 30-68 years). Median time to conversion was 5.14 (2.77-7.41) years and median follow-up post-conversion was 1.7 (0.33-4.0) years. There were no significant differences in indications for conversion between the 2 groups with the majority performed for complications related to elevated metal ions and aseptic loosening. Harris Hip Scores improved from pre-conversion to post-conversion in both cohorts (P < .01). There were no significant differences in pre-conversion and post-conversion metal ion levels between the RAC and BC groups. Serum metal ion levels decreased significantly in both cohorts (P < .01). There were 6 additional revisions in the cohort (4 in BC, 2 in RAC) at a median 2.94 (1.99-3.85) years post-conversion. Two RAC patients had intraprosthetic dislocations with extensive polyethylene wear requiring acetabular revision at median 3.92 (3.85-3.98) years post-conversion. Overall, there were a higher number of complications in the BC group related to acetabular fracture, failure of osseointegration, and periprosthetic joint infection; however, this did not reach statistical significance (P = .27).

Conclusion

Salvage of an appropriately positioned, well-fixed HRA acetabular component is a reasonable option in the setting of conversion to THA using dual-mobility components. This technique avoids the morbidity of acetabular revision and was associated with a decrease in metal ion levels and improvements in short-term functional outcomes comparable to a BC revision.

Conversion of Failed Hemiarthroplasty to Total Hip Arthroplasty Remains High Risk for Subsequent Complications

31-05-2019 – Nicholas M. Hernandez, Kristin M. Fruth, Dirk R. Larson, Hilal Maradit Kremers, Rafael J. Sierra

Journal Article

Background

Few studies have described the outcomes following conversion of failed hemiarthroplasties to total hip arthroplasty (THA) and the impact of mortality when estimating implant survivorship. The aims of this study were to evaluate the following: (1) the risks and predictors of complications, dislocations, reoperations, and revisions and (2) the extent of competing risk of death when evaluating outcomes in patients converted from hemiarthroplasty to THA.

Methods

The study comprised 389 patients treated with conversion THA following hemiarthroplasty for femoral neck fractures between 1985 and 2014. Revision rates were calculated using both the Kaplan-Meier method and cumulative incidence accounting for death as a competing risk. Risk factors were evaluated using Cox regression models.

Results

During an average 9.3 years of follow-up, there were 122 complications, 34 dislocations, 69 reoperations, and 51 revisions. Conversion for periprosthetic fractures was associated with a higher risk of reoperations (hazard ratio 4.30, 95% confidence interval 1.94-9.52). Increasing age was a risk factor for reoperations (hazard ratio 1.32, 95% confidence interval 1.10-1.59). No decrease in the rate of complications, dislocations, reoperations, or revisions was observed over the entire 30 years of the study either when evaluating year of surgery as a continuous variable or when comparing specific calendar year intervals (1985-1989, 1990-1999, 2000-2009, 2010-2014) (P > .05). Compared to the cumulative incidence accounting for the competing risk of death, the Kaplan-Meier method overestimated the risk of revision by 7% at 15 years and 10% at 20 years.

Conclusion

Conversion from hemiarthroplasty to THA remains at high risk for subsequent complications. The cumulative incidence estimate provides a more accurate estimate of revision risk.

Osteointegrative Sleeves for Metaphyseal Defect Augmentation in Revision Total Knee Arthroplasty: Clinical and Radiological 5-Year Follow-Up

14-05-2019 – Nils Wirries, Hans Jörg Winnecken, Gabriela von Lewinski, Henning Windhagen, Michael Skutek

Journal Article

Background

Cementless metaphyseal implant fixation of revision total knee arthroplasty has encouraging early results. We analyzed midterm results and implant survival of osteointegrative augments in Anderson Orthopedic Research Institute (AORI) type 2a, 2b, and 3 defects. Reasons for implant failure were explored and the potential for anatomic joint line reconstruction evaluated.

Methods

Sixty-seven consecutive patients (68 revision total knee arthroplasties) received cementless metaphyseal sleeves between 2011 and 2014. The mean follow-up was 5.0 years, mean age was 68.5 years, and mean body mass index was 31.4 kg/m2. The clinical and radiographic results were determined using established scoring systems. Additionally, the survival rate was calculated and reasons for failure were analyzed.

Results

In 2 patients (4.3%), sleeves had to be removed early postoperatively for deep infection after second-stage reimplantation. With continuously functioning remaining implants, the aseptic survival rate was 93.6%. Cleared up for initial technical issues due to poor bone quality, it is as high as 98%. The scores remained to be significantly improved by 64.8 points (Western Ontario and Mc
Master Universities Osteoarthritis Index) and 25.8 points (Knee Society score) (P < .001). In 10 patients (29.4%), diaphyseal radiolucencies were observed without suspicion of loosening. The mean joint line was noted to be 0.36 mm lower to the anatomic level.

Conclusion

At a mean follow-up of 5.0 years, cementless osteointegrative sleeves for metaphyseal fixation in AORI 2a, AORI 2b, and AORI 3 defects yielded continuous implant fixation even in cases with preceding revisions. The cleared up aseptic survival rate was 98% at 5 years. The modular sleeve design allowed joint line reconstruction near the anatomic level.

Ten- to Sixteen-Year Follow-Up of Highly Cross-Linked Polyethylene in Total Hip Arthroplasty: What Factors Affect Wear?

10-06-2019 – Amy Cheung, Chun Hoi Yan, Henry Fu, Man Hong Cheung, Ping Keung Chan, Kwong Yuen Chiu

Journal Article

Background

Increase in acetabular cup abduction in total hip arthroplasty (THA) using conventional polyethylene is associated with greater linear wear. Whether this relationship holds true for highly crosslinked liners, particularly with long-term follow-up, is still controversial. The effect of liner thickness on wear of highly cross-linked liners also remains to be clarified.
This study sought to determine (1) the long-term clinical and radiological performance of highly cross-linked polyethylene in THA and (2) the effect of acetabular component positioning, polyethylene thickness, and patient demographics on wear.

Methods

Ninety-three THAs using a 28-mm hip ball, single brand of highly cross-linked polyethylene liner, and cementless cup were performed in 87 patients. Clinical outcomes were evaluated using the Harris Hip Score and need for revision surgery. Linear and volumetric wear, presence of osteolysis, and cup abduction angle were assessed.

Results

The mean age at operation was 51.4 years. The mean duration of follow-up was 12.7 years (10-16 years). Patients aged >50 years had higher rates of linear wear than those aged <50 years (P = .015). Positive correlation was found between cup abduction angle (P = .014) and cup version (P = .035) with a linear wear rate. Thinner liners (≤7 mm) had similar rates of linear and volumetric wear as thicker liners (≥8 mm) (P = .447).

Conclusion

This is the only study to demonstrate a positive significant relationship between cup abduction angle and version with linear wear rate in THA with at least 10 years of follow-up. Liner thickness was not found to affect wear rates.

Subsidence of Hydroxyapatite-Coated Femoral Stem in Dorr Type C Proximal Femoral Morphology

12-06-2019 – Piti Rattanaprichavej, Artit Laoruengthana, Thanainit Chotanaphuti, Saradej Khuangsirikul, Chanadol Phreethanutt, Krit Pongpirul

Journal Article

Background

Good bone quality and proper proximal femoral morphology are thought to be necessary for tapered design, cementless femoral stems to resist subsidence. Using tapered, cementless stem for patients with stovepipe morphology or Dorr type C is controversial. The purpose of this study is to analyze (1) subsidence of the fully hydroxyapatite (HA)-coated, tapered, cementless stem in different morphology according to Dorr classification, (2) subsidence of the stem related to radiographic canal-fill ratio.

Methods

The digitized radiographs of 311 consecutive cementless primary total hip arthroplasty with fully HA-coated, tapered stem were retrospectively reviewed. Subsidence and the canal-fill ratio at 4 locations were evaluated postoperatively after a minimum of 2 years of follow-up. The threshold of subsidence >3 mm was considered as a clinically significant migration.

Results

A multivariate regression analysis of subsidence across Dorr type, controlling for age, gender, and intraoperative calcar fracture, demonstrated 0.40 mm (P = .28) and 0.18 mm (P = .51) greater subsidence in Dorr type C and B when compared to Dorr type A. Age, gender, and calcar fracture had no influence on subsidence, whereas greater canal-fill ratio at 2 cm below lesser trochanter resulted in significantly less subsidence (P = .02). Additionally, all variables did not affect the risk of having subsidence >3 mm.

Conclusion

The proximal femoral morphology has no statistically significant effect on the subsidence of fully HA-coated stem. Therefore, this stem type might be a viable option for Dorr type C. Increasing the canal-fill ratio at metadiaphyseal junction may ensure the stability of the stem.

Letter to the Editor on “Unexplained Painful Hip Arthroplasty: What Should We Find? Diagnostic Approach and Results”

30-06-2019 – Daniel L. Riddle

Letter

Age-Related Decline in Patient-Reported Outcomes 2 and 5 Years Following Total Hip Arthroplasty

14-04-2019 – Anum Lalani, Yuo-Yu Lee, Michael Pitta, Geoffrey H. Westrich, Stephen Lyman

Journal Article

Background

Patient-reported outcome measures (PROMs) help assess therapeutic effectiveness. This study assessed the effect of advanced age on the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Lower Extremity Activity Scale (LEAS) after total hip arthroplasty (THA).

Methods

A prospective cohort of patients underwent primary THA at our institution between May 2007 and December 2011. Exposure was age at the time of surgery and outcomes were HOOS and LEAS scores 2 and 5 years postsurgery. We used a multivariable longitudinal generalized estimating equation to elucidate the effect of age on PROM scores.

Results

Our analysis of 3700 THA patients (mean age, 66 years; 56.4% female) demonstrated a decline in scores by age for the LEAS, HOOS Activities of Daily Living, and HOOS Sport and Recreation domains. There was also association between age and HOOS Symptoms and HOOS Quality of Life domains, but not between age and the HOOS Pain domain. Critical ages at which the relationship between age and outcome changed was 63 years for the HOOS Pain, Symptom, Activities of Daily Living, and Quality of Life domains, and 72 years for the HOOS Sport and Recreation domain and the LEAS.

Conclusion

Patients undergoing THA at older ages reported lower activity and sports and recreation scores than younger patients, but similar pain, symptoms, and quality of life scores. This knowledge can help physicians guide patients’ expectations before THA. Our findings also indicate that PROM scores should be age adjusted when used for quality or value comparisons between hospitals or physicians.

Computer Navigation vs Conventional Total Hip Arthroplasty: Axa0Medicare Database Analysis

10-06-2019 – Blake K. Montgomery, Abiram Bala, James I. Huddleston, Stuart B. Goodman, William J. Maloney, Derek F. Amanatullah

Journal Article

Background

Computer-assisted surgery (CAS) is applied to total hip arthroplasty (THA) in an attempt to optimize implant positioning. The effect of CAS on postoperative complications after THA remains unknown. Our study aims to assess the change in complication rates when CAS is used in THA.

Methods

The Medicare database was studied from 2005 to 2012. All THAs performed with CAS were identified. A total of 64,944 THAs were identified, including 5412 CAS-THAs and 59,532 conventional THAs. Medical and surgical adverse events were collected at various time points.

Results

CAS-THA was not associated with a decreased rate of dislocation at 30 days (1.0% vs 1.2%; odds ratio OR, 1.14; P = .310), 90 days (1.1% vs 1.4%; OR, 1.23; P = .090), or 2 years (2.3% vs 2.3%; OR, 1.01; P = .931). CAS-THA was associated with a significantly higher rate of periprosthetic fracture at 30 days (0.4% vs 0.6%; OR, 1.46; P = .040) as well as revision THA at 30 days (1.0% vs 1.4%; OR, 1.43; P = .003) and 90 days (1.2% vs 1.7%; OR, 1.42; P < .002) when compared to conventional THA. CAS-THA was associated with a significantly lower rate of deep vein thrombosis and pulmonary embolism when compared to conventional THA at all time points (P < .05).

Conclusion

Administrative coding data fail to demonstrate any clinically significant reduction in short-term adverse events with CAS-THA. Further study is warranted to evaluate whether the purported benefits of CAS result in a reduction of the adverse events after THA.

Current Trends in Clinical Practice for the Direct Anterior Approach Total Hip Arthroplasty

12-05-2019 – Nick N. Patel, Jason A. Shah, Greg A. Erens

Journal Article

Background

Despite increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), current practice trends and specific driving factors leading to adoption are not well established.

Methods

We conducted an electronic e-mail survey of members of the American Association of Hip and Knee Surgeons inquiring into the choice of THA surgical approach, perceptions of clinical outcomes, and economic implications associated with the DAA.

Results

Of 996 total respondents (44.3% American Association of Hip and Knee Surgeons member response rate), 56.2% currently perform the DAA. DAA performers have been in practice for statistically less time than non-performers (17.0 years vs 20.9 years, P < .001). Similarly, high-volume DAA surgeons have been in practice for less time than low-volume surgeons. DAA performers felt that revision case status (79.3%), complex anatomy (65.0%), and body habitus (53.0%) were factors leading to preferential use of the posterior approach. We also provide comprehensive data for perceived outcomes comparing the DAA and posterior approach. For current non-performers, the top reasons for not utilizing the DAA were feelings of worse outcomes, no clinical benefit, and concern for the learning curve. Economically, 76.1% of DAA performers reported increased patient market share by performing the DAA while 65.8% of non-performers endorsed lost patient market share. Only 3.0% of current non-performers plan to adopt the DAA in the future.

Conclusion

This is the first study of its kind to highlight current trends and clinical practices from a surgeon perspective regarding the DAA. Specifically, it provides comprehensive data regarding perceptions of clinical outcomes, practice economics, and driving factors for choice of surgical approach for surgeons who do and do not perform the DAA.

Does Surgeon Fellowship Training Influence Outcomes in Hemiarthroplasty for Femoral Neck Fracture?

21-05-2019 – Scott E. Mabry, Kyle H. Cichos, James T. McMurtrie, Jeffrey M. Pearson, Gerald McGwin, Elie S. Ghanem

Journal Article

Background

The aim of this study is to compare the outcomes (90 days and 1 year) of patients with femoral neck fracture undergoing hemiarthroplasty by surgeons with different fellowship training: trauma, arthroplasty, and general orthopedics.

Methods

This study is a retrospective review of consecutive patients undergoing hip hemiarthroplasty for femoral neck fracture from 2010 to 2018. Comorbidities, perioperative details, demographics, injury variables, and time-to-surgery were compared between the fellowship training cohorts, in addition to outcomes including dislocation, periprosthetic joint infection, and mortality at 90 days and 1 year.

Results

A total of 298 hips with an average age of 77.8 years underwent hemiarthroplasty for femoral neck fracture. Arthroplasty surgeons had a significantly shorter operative duration (82 minutes, P = .0014) and utilized the anterior approach more frequently (P < .0001). The general orthopedists had a significantly increased total surgical complication risk compared to both the arthroplasty and trauma fellowship-trained cohorts at both 90 days (11.8% vs 1.6% vs 3.9%, P = .015) and 1 year (18.2% vs 4.9% vs 7.1%, P = .008). The overall mortality risk was 11.7% at 90 days and 22.8% at 1 year. When adjusted for covariates, including comorbidities, gender, age, and preoperative walking capacity, both the arthroplasty fellowship-trained cohort (odds ratio 0.381, 95% confidence interval 0.159-0.912, P = .030) and the general orthopedist cohort (odds ratio 0.495; 95% confidence interval 0.258-0.952, P = .035) had reduced risk of 1-year mortality compared to the trauma fellowship-trained cohort.

Conclusion

Hemiarthroplasty performed for femoral neck fractures may result in fewer complications when performed by arthroplasty fellowship-trained surgeons. An arthroplasty weekly on-call schedule and adjusted institutional protocols may be utilized to improve outcomes and reduce complications.

Level of Evidence

Level II, retrospective cohort.

Ten-Year Minimum Outcomes and Survivorship With a High Flexion Knee System

21-05-2019 – David A. Crawford, Joanne B. Adams, Jason M. Hurst, Keith R. Berend, Adolph V. Lombardi

Journal Article

Background

The purpose of this study is to report the long-term outcomes and survivorship of a high flexion knee system.

Methods

We identified 1312 patients (1664 knees) who underwent primary total knee arthroplasty with the Vanguard Complete Knee System with 10-year minimum follow-up. Preoperative and postoperative range of motion, Knee Society scores, complications, and reoperations were evaluated.

Results

At an average of 11.9 years of follow-up, 88 knees were revised (5.3%). The deep infection rate was 1.4%. There was an average range of motion improvement of 3.9°, pain level decreased by 35.8, Knee Society clinical scores improved by 48, and Knee Society functional scores improved by 15.1 (all P < .001). Survival was 96.4% at 10 years for aseptic causes and 95.5% for all causes.

Conclusion

At a 10-year minimum follow-up, this high flexion knee system demonstrates excellent survivorship.

Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Reduces Patellar Crepitus Complication: A Randomized, Controlledxa0Trial

28-05-2019 – Satit Thiengwittayaporn, Kakanand Srungboonmee, Bhakawat Chiamtrakool

Journal Article

Background

Patellar crepitus (PC) is a common complication after total knee arthroplasty (TKA) using a posterior-stabilized (PS) prosthesis. While numerous factors have been associated with PC development after PS-TKA, patellar resurfacing (PR) which directly impacts the patellofemoral joint kinematics has been underinvestigated. A prospective, randomized, controlled trial was conducted to (1) compare the PC incidence in PR and non-PR PS-TKA, (2) determine the time of PC presentation in PS-TKA, (3) identify radiographic parameters associated with PC, and (4) compare clinical outcomes of patients with and without PR.

Methods

A total of 84 patients who underwent unilateral TKA using the Legion PS Total Knee System were randomized into PR group or non-PR group. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3 months, 6 months, 9 months, and 1 year postoperatively.

Results

PC occurred significantly more in the non-PR group (23.1% vs 7.3%, P = .048). Time of PC presentation in both groups was not different. Anterior knee pain was found in 16.7% of crepitus patients, and none required any surgical procedure. The non-PR knees had significant decreases in patellar shift index, patellar displacement, Insall-Salvati ratio, and patellar component height and increase in change in posterior femoral offset. Oxford and patellar scores were significantly better in the PR group at 9 months and 1 year.

Conclusion

Given higher PC incidence and several worse clinical outcomes in the non-PR, we recommend resurfacing during PS-TKA with this knee system to avoid PC development.

Routine Patellar Resurfacing During Total Knee Arthroplasty Is Not Cost-Effective in Patients Without Patellar Arthritis

21-05-2019 – Benjamin M. Zmistowski, Yale A. Fillingham, Harold I. Salmons, Derek T. Ward, Robert P. Good, Jess H. Lonner

Journal Article

Background

Currently, the decision to resurface the patella is often made irrespective of the presence of patellar arthritis. The purpose of this study is to utilize the existing literature to assess cost-utility of routinely vs selectively resurfacing the patella.

Methods

Prospective randomized studies of patella resurfacing vs non-resurfacing in total knee arthroplasty (TKA) were identified through literature review. Data from these studies represented probabilities of varied outcomes following TKA dependent upon patella resurfacing. Using previously validated utility scores from the Mc
Knee modified Health Utilities Index, endpoint utility values were provided for each potential outcome.

Results

Literature review yielded a total of 14 studies with 3,562 patients receiving 3,823 TKAs, of which 1,873 (49.0%) patellae were resurfaced. Persistent postoperative anterior knee pain occurred in 20.9% vs 13.2% (P < .001) and patella reoperation was performed in 3.7% vs 1.6% (P < .001) of unresurfaced and resurfaced patella, respectively. In studies excluding those with arthritic patellae, the incidence of anterior knee pain was equivalent between groups and reoperation decreased to 1.2% vs 0% (P = .06). Patella resurfacing provided marginally improved quality-adjusted life-years (QALY) for both selective and indiscriminate patella resurfacing. When including all studies, the incremental cost per QALY was $3,032. However, when analyzing only those studies with nonarthritic patellae, the incremental cost per QALY to resurface the patella increased to $183,584.

Conclusion

Patellar resurfacing remains a controversial issue in TKA. Utilizing data from new prospective randomized studies, this analysis finds that routinely resurfacing arthritis-free patellae in TKA are not cost-effective.

Mean Three-Year Survivorship of a New Bicruciate-Retaining Total Knee Arthroplasty: Are Revisions Still Higher Than Expected?

05-06-2019 – Christopher E. Pelt, Phillip A. Sandifer, Jeremy M. Gililland, Mike B. Anderson, Christopher L. Peters

Journal Article

Background

Given the need for continued post-market surveillance, especially on novel implants, the present study attempts to determine the 3-year survivorship and patient-reported outcomes of a contemporary bicruciate-retaining total knee arthroplasty design, and to determine if a learning curve existed which could explain previously reported revision rates.

Methods

We performed a retrospective review on a consecutive series of 141 bicruciate-retaining total knee arthroplasties performed at our institution between May 2013 and October 2015. Thirty-four knees (19%) missing 2-year follow-up were excluded. Mean follow-up was 3 years (range 0.34-4.9). Patients who died (n = 5) or were revised prior to 2 years (n = 6) were included. A Kaplan-Meier analysis was used to evaluate revision-free survival.

Results

Survivorship at 3 years was 88% (82%-93%). Revisions were for isolated tibial loosening (5/19), anterior cruciate ligament (ACL) impingement (3/19), pain (4/19), unknown reasons (3/19), femoral and tibial loosening (2/19), ACL deficiency (1/19), and arthrofibrosis (1/19). The mean physical function computerized adaptive test T-score was 45 units (range 23-63). The mean T-scores for Patient-Reported Outcomes Measurement Information System Global measures were 49 (range 27-68) for physical health, 50 (range 28-68) for mental health, and a median 3 (interquartile range 1-8) on the numeric pain scale.

Conclusion

Revision-free survival of 88% at 3 years was lower than existing traditional TKA designs. The primary failure mechanisms were tibial loosening, ACL impingement, and pain. In the setting of higher than anticipated revision rates, despite patient-reported outcomes that are not different than seen in the general population, it is possible that further refinement in implant design or surgical technique may be needed prior to widespread use of this, or similar implant designs.

Fibromyalgia Increases the Risk of Surgical Complications Following Total Knee Arthroplasty: A Nationwide Database Study

11-05-2019 – Nipun Sodhi, Tara Moore, Rushabh M. Vakharia, Patrick Leung, Thorsten M. Seyler, Martin W. Roche, Michael A. Mont

Journal Article

Background

Although fibromyalgia is a common comorbidity with knee osteoarthritis, the orthopedic literature on this population is limited. Therefore, the purpose of this study is to assess if fibromyalgia patients have a higher likelihood of developing surgical complications after total knee arthroplasty (TKA) than a matched control cohort.

Methods

The Medicare Standard Analytical Files of the Pearl
Diver supercomputer was utilized to identify patients who underwent a TKA between 2005 and 2014. Patients were 1:1 propensity score matched based on the diagnosis of fibromyalgia, age, gender, and the Charlson Comorbidity Index, yielding a total of 305,510 patients. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P-values (<.05) were calculated to examine the likelihood of developing any surgical complication, as well as specific surgical complications.

Results

Compared to a matched cohort, fibromyalgia patients had increased odds of developing any surgical complication (OR 1.55, 95% CI 1.51-1.60, P < .001), such as bearing wear (OR 2.11, 95% CI 1.48-3.01, P < .0001) and periprosthetic osteolysis (OR 1.71, 95% CI 1.10-2.66, P = .018). Furthermore, these patients had significantly greater odds of developing revision of tibial insert (OR 1.5, 95% CI 1.14-2.05, P = .046), mechanical loosening (OR 1.34, 95% CI 1.26-1.53, P < .0001), infection/inflammation (OR 1.33, 95% CI 1.26-1.14, P < .0001), dislocations (OR 1.33, 95% CI 1.21-1.47, P < .0001), as well as other complications (OR 1.74, 95% CI 1.68-1.80, P < .0001).

Conclusion

This analysis of over 300,000 patients identified that fibromyalgia patients can have a greater risk of developing certain surgical complications after TKA. Therefore, fibromyalgia patients must be made aware of the increased postoperative risks and surgeons should consider enhanced preoperative medical and surgical optimization.

Comparison of Expectations and Outcomes in Rheumatoid Arthritis Versus Osteoarthritis Patients Undergoing Total Knee Arthroplasty

01-07-2019 – Jason L. Blevins, Yu-Fen Chiu, Stephen Lyman, Susan M. Goodman, Lisa A. Mandl, Peter K. Sculco, Mark P. Figgie, Alexander S. McLawhorn

Journal Article

Background

We hypothesized that patients undergoing primary total knee arthroplasty (TKA) for rheumatoid arthritis (RA) would have different preoperative expectations compared to osteoarthritis (OA) patients, and that postoperative satisfaction would correlate with specific postoperative pain and functional domains.

Methods

This is a retrospective cohort study of RA patients matched based on age, gender, American Society of Anesthesiologists score, and Charlson Comorbidity Index score 1:2 with OA patients (76 RA, 152 OA) who underwent primary TKA. The Hospital for Special Surgery Knee Replacement Expectations Survey, Visual Analogue Scale for Pain (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), and the Short Form-12 (SF-12) were compared at baseline and at 2 years postoperatively. Minimum clinically important differences (MCIDs) were calculated for KOOS and SF-12 subdomains.

Results

Preoperatively, RA patients had lower expectations, worse VAS Pain, and worse KOOS Pain, Symptoms, and Activities of Daily Living (P < .05). However, at 2 years, RA patients had significantly larger improvements in VAS (P = .01) and these 3 KOOS subdomains (P < .05), achieving comparable absolute scores to OA patients. Overall, 86.1% of RA and 87.1% of OA patients were either somewhat or very satisfied with their TKA. Patient satisfaction correlated with VAS Pain and KOOS outcome scores in both groups. RA and OA patients had high rates of achieving MCID in SF-12 physical component scores and all 5 KOOS subdomains. A higher proportion of RA patients achieved MCID in KOOS Symptoms (98.4% vs 77.2%, P < .001).

Conclusion

RA patients had lower baseline expectations compared to OA patients. However, RA patients had greater improvements in KOOS and SF-12 subdomains, and there was no difference in satisfaction compared to OA patients after TKA.

Advanced Age Is Not a Barrier to Total Knee Arthroplasty: A Detailed Analysis of Outcomes and Complications in an Elderly Cohort Compared With Average Age Total Knee Arthroplasty Patients

04-06-2019 – Antonio Klasan, Sven Edward Putnis, Wai Weng Yeo, Brett Andrew Fritsch, Myles Raphael Coolican, David Anthony Parker

Journal Article

Background

Life expectancy and higher complication rates have made the routine use of total knee arthroplasty (TKA) in elderly patients disputed by some authors. The purpose of this study was to assess patient and implant survivorship, complication and revision rates, and patient-reported outcomes (PROMS) in a cohort of patients aged above 80 years undergoing TKA. A comparison with a propensity matched cohort of patients of average age within our database for TKA was performed.

Methods

A retrospective review of prospectively collected data identified 644 patients over the age of 80 years undergoing a TKA within a 14-year period. After calculating the average age of all TKA patients within the reviewed database, a cohort deemed average age was created within 1 standard deviation of the average age and matched using the following criteria: gender, surgeon, diagnosis, procedure type, and year. The primary outcomes were survivorship of the implant and the patient. The secondary outcomes were complications, transfusion rates, discharge destination, and PROMS.

Results

The revision rate was low for both groups (P = .051). Implant survivorship at 10 years was similar (P = .07). Mortality rate was higher in the elderly (P < .001). General complication rate was higher in the elderly (P = .031). Surgical complications rates were similar (P = .702). The PROMS at final follow-up were 4% lower in the elderly (P < .001).

Conclusion

TKA in the elderly is a safe procedure. With measures minimizing the perioperative complications and blood loss, the outcome can be expected to be similar to patients of average age. The projected implant and patient survivorship in the elderly cohort is long enough to suggest that TKA in the elderly could have a high impact on remaining quality of life.

Level III retrospective study.

Morphometric Assessment of Resected Femoral Cut Surface in Korean Knees and Its Fitting With Western-Designed Femoral Components

30-05-2019 – Teck S. Fong, Seong Chan Kim, Ji Eui Kim, Eui Soo Lee, Tae Woo Kim, Yong Seuk Lee

Journal Article

Background

This study aimed at assessing the morphometry of resected femurs in Korean patients during total knee arthroplasty (TKA) and comparing these measurements with current Western-designed femoral component dimensions.

Methods

This single-blind, prospective, randomized, controlled trial involved intraoperative measurements for 271 femoral component implantations from 3 contemporary TKA systems, with 2 systems offering narrow sizing options. The difference between femoral component dimensions and the resected surface of distal femur was measured in millimeters at 5 distinct zones.

Results

Overhang of standard femoral component was common in the anterior-medial condyle and anterior-lateral condyle ranging from 50.8% to 99.0% and 21.5% to 88.0%, respectively. With narrow femoral components, the rate of overhang reduced to 21.5%-30.2% and 9.2%-32.1%. Conversely, underhang rates were higher over the anterior flange width, middle medial-lateral and posterior medial-lateral zones. Standard components displayed higher underhang rates at these zones compared to narrow components. The good fit rate for femoral component was low among the 3 systems ranging from 1.0% to 56.0%. System with narrow option sizing increases the underhang rates in males, while improving the component fit among females at similar zones with rate ranging from 5.2% to 52.9%.

Conclusion

Currently available TKA implant designs may not provide a perfect match for the distal femoral shape of the Korean population. The availability of implants with standard and narrow options can substantially improve the optimal fitting of femoral components in the Korean population.

Increased Posterior Tibial Slope After Medial Open-Wedge High Tibial Osteotomy May Result in Degenerative Changes in Anterior Cruciate Ligament

20-05-2019 – Gi Beom Kim, Kang-Il Kim, Sang Jun Song, Sang Hak Lee

Journal Article

Background

This study aimed at evaluating changes in posterior tibial slope angle (PTSA) and the anterior cruciate ligament (ACL) before and after medial open-wedge high tibial osteotomy (MOWHTO) through 2-staged arthroscopic findings and verified whether the ACLs would be affected by the changed PTSA. We also evaluated which predisposing factors could influence ACL changes after MOWHTO.

Methods

From July 2010 to March 2016, 164 knees that could follow the second-look arthroscopy at the time of plate removal were enrolled. Radiologically, preoperative and postoperative hip-knee-ankle angle, femorotibial angle, medial proximal tibial angle, and PTSA were evaluated. Based on our previous study, we assessed the ACL using the macroscopic grading system (normal, abnormal degenerative, and partially ruptured ACL) by first- and second-look arthroscopy and compared it before and after HTO. The correlation between changes in PTSA (△PTSA) and ACL was evaluated. We also assessed predisposing factors that might affect ACL changes.

Results

Mean age at the time of osteotomy was 57.2 ± 5.1 years and time interval between the 2-stage arthroscopies was 26.3 ± 4.0 months. PTSA significantly increased after MOWHTO (P < .001). ACL stage at second-look arthroscopy was significantly progressed compared to first-look findings (P < .001). △PTSA was larger in the progressed group (2.1°; P < .001). Multivariate logistic regression indicated that greater body mass index (odds ratio, 1.2; P = .029) and larger △PTSA (odds ratio, 1.3; P = .008) were predisposing factors.

Conclusion

Increased posterior tibial slope following MOWHTO may result in degenerative ACL changes. Greater body mass index and larger △PTSA were predisposing factors for ACL degeneration after MOWHTO.

The Effect of Psychiatric Diagnosis and Psychotropic Medication on Outcomes Following Total Hip and Total Knee Arthroplasty

28-05-2019 – Andrea H. Stone, James H. MacDonald, Paul J. King

Journal Article

Background

Nearly 20% of the US adult population lives with mental illness, and less than 50% of these receive treatment. Preoperative mental health may affect postoperative outcomes in patients undergoing total joint arthroplasty (TJA), yet is rarely addressed; poor outcomes increase the cost of care and burden on the healthcare system. This study examines the influence of patients with psychiatric diagnosis (PD) and taking psychotropic medication (PM) on emergency room visits, readmissions, and discharge disposition following TJA.

Methods

Single institution retrospective analysis of a consecutive series of 3020 primary TJA performed between January 2017 and June 2018. Chi-squared, t-tests, and analysis of variance were used to quantify differences between groups.

Results

Nine hundred seventy-six (32.3%) patients had a PD, most had depression (10.1%), anxiety (8.6%), or both (8.4%); 808 (26.8%) patients were on PM. Patients with PD were more likely to experience emergency room visits (6.3% vs 10.0%, P = .034) and skilled nursing facility discharge (11.6% vs 17.9%, P = .005). Patients taking PM were more likely to experience skilled nursing facility discharge (12.4 vs 17.1, P = .047); those taking >2 PM had the highest rate (21.6%).

Conclusion

Patients with PD on or off PM may experience increased healthcare utilization in the postoperative period. Increased patient education and support may reduce these discrepancies. PD is not a deterrent for TJA, but targeted interventions should be developed to provide additional support where needed and avoid unnecessary utilization of resources.

Normal Pressure Hydrocephalus Is Associated With Increased Risks of Postoperative Complications Following Total Knee and Total Hip Arthroplasty

28-05-2019 – Dennis Q. Chen, Nicole D. Quinlan, Patrick K. Strotman, Brian C. Werner, James A. Browne

Journal Article

Background

Normal pressure hydrocephalus (NPH) has not been studied as a potential risk factor for postoperative complications after primary total knee (TKA) and total hip arthroplasty (THA).

Methods

Nearly 2000 patients with a diagnosis of NPH who underwent TKA or THA from 2005 to 2014 were identified in a national insurance database and compared to 10:1 matched controls using a logistic regression analysis.

Results

NPH was associated with an increased risk of hospital readmission, emergency room visit, and infection following TKA (odds ratio 1.48-2.70, all P < .01). NPH was associated with an increased risk of hospital readmission, emergency room visit, and dislocation following THA (odds ratio 2.40-2.50, all P < .01). NPH was also associated with significantly higher costs and hospital length of stay following both procedures.

Conclusion

The diagnosis of NPH is associated with an elevated risk of postoperative complications and increased resource utilization following TKA and THA.

Total Joint Arthroplasty Outcomes in Patients With a Previously Failed Toxicology Screen: A Propensity Score–Matched Analysis

24-06-2019 – Kavin Sundaram, George A. Yakubek, Nicolas S. Piuzzi, Juan Vargas, Alison K. Klika, Carlos A. Higuera, Trevor G. Murray

Journal Article

Background

The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge.

Methods

A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls.

Results

The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004).

Conclusion

These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.

Optimal Hospital and Surgeon Volume Thresholds to Improve 30-Day Readmission Rates, Costs, and Length of Stay for Total Hip Replacement

28-05-2019 – Ying-Yi Chou, Yu-Chi Tung

Journal Article

Background

Little is known about whether there are optimal hospital and surgeon volume thresholds to reduce readmission, costs, and length of stay (LOS) for total hip replacement (THR). Nationwide population-based data were applied to identify the optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on 30-day unplanned readmission, costs and LOS for THR.

Methods

A total of 6367 patients identified through Taiwan’s National Health Insurance Research Database received THR in 2012. Restricted cubic splines were used to identify the optimal hospital and surgeon volume needed to decrease the risk of 30-day unplanned readmission. Multilevel regression modeling and propensity score weighting were used to examine the impact of hospital and surgeon volume thresholds on 30-day unplanned readmission, costs, and LOS, after adjusting for patient, surgeon, and hospital characteristics.

Results

The volume thresholds for hospitals and surgeons were 65 cases and 15 cases a year, respectively. The overall mean LOS was 7.3 ± 4.3 days. Patients who received THR from surgeons who did not reach the volume threshold had higher 30-day unplanned readmission rates, costs, and LOS than those who received THR from surgeons who reached the volume threshold.

Conclusion

This is the first study to identify the surgeon volume threshold that can reduce 30-day unplanned readmission rates, costs, and LOS for THR. However, the results from Taiwan may not be applicable to other parts of the world. Identifying the threshold could help patients, providers, and policymakers to make decisions regarding optimal delivery of THR.

Monitoring Surgical Incision Sites in Orthopedic Patients Using an Online Physician-Patient Messaging Platform

13-06-2019 – Jenny Zhang, Kristina Dushaj, Vijay J. Rasquinha, Giles R. Scuderi, Matthew S. Hepinstall

Journal Article

Background

Prompt identification and treatment of wound complications is essential after joint arthroplasty, but emergency department and office visits for urgent evaluation of normal incisions are a source of unnecessary cost. The purpose of this study is to evaluate the use of an online image messaging platform for remote monitoring of surgical incision sites.

Methods

We conducted a retrospective review of 1434 hip and knee arthroplasty patients who registered for an online platform in the perioperative period. We reviewed images sent by patients to evaluate potential wound abnormalities. Medical records were reviewed to determine whether assessments based on wound photographs corresponded with subsequent in-person findings and ultimate disposition.

Results

Four hundred thirty patients (42%) sent at least one text or image message to their provider. Elimination of redundant images resulted in 104 image encounters, with 76 discrete encounters in 41 patients related to the surgical wound. Most showed normal wound appearance; patients were reassured and urgent visits were avoided. At scheduled in-person follow-up, none of these patients demonstrated unrecognized wound complications. Seventeen image encounters in 7 patients showed possible wound abnormalities. These prompted in-person follow-up on average less than 1 day later for 4 issues deemed urgent (2 patients received surgical treatment) and 5 days later for issues deemed nonurgent. Photos were also used to monitor abnormal wounds over time and to send information unrelated to wounds.

Conclusion

Utilization of an online physician-patient messaging platform can prevent unnecessary visits for normal appearing wounds, while facilitating rapid in-person treatment of wound complications.

Rapid Recovery After Total Joint Arthroplasty Using General Anesthesia

17-06-2019 – Jeffrey B. Stambough, G. Barnes Bloom, Paul K. Edwards, Gregory R. Mehaffey, C. Lowry Barnes, Simon C. Mears

Journal Article

Background

Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens used at high-volume joint replacement centers.

Methods

We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions.

Results

From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20).

Discussion

Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty.

Level of Evidence

IV– Case series.

Patient Attitudes Toward Resident and Fellow Participation in Orthopedic Surgery

28-05-2019 – Cindy R. Nahhas, Paul H. Yi, Chris Culvern, Michael B. Cross, Sina Akhavan, Staci R. Johnson, Ryan M. Nunley, Kevin J. Bozic, Craig J. Della Valle

Journal Article

Background

Residents and fellows’ participation in orthopedic surgery is a potential source of anxiety and concern for patients. The purpose of this study was to determine patients’ attitudes toward trainee involvement in orthopedic surgery, surgeons as educators, and disclosure of trainee involvement.

Methods

Three hundred two consecutive patients with preoperative and postoperative appointments at three arthroplasty practices in academic medical centers were surveyed with an anonymous, self-administered questionnaire. The questionnaire was developed in consultation with an expert in survey design.

Results

Two hundred thirty-four patients completed the questionnaire (response rate 77.5%). Respondents were 60.5% female, 79.6% white, 66.5% privately insured, and 82.8% had at least some college education. About 65.9% of the respondents felt that surgeons who teach are better surgeons. Nearly all felt residents and fellows should perform surgeries as part of their education (94.1% and 95.3%, respectively). However, 39.7% of the respondents were not satisfactory with a second-year resident assisting in their own surgery. Patients dissatisfied with their most recent orthopedic surgery were more likely to respond that they did not want residents helping with their surgery. Respondents agreed that resident or fellow involvement in surgery should be disclosed (92.2% and 90.1%, respectively).

Conclusions

Insured and educated patients in the United States overwhelmingly desire disclosure of trainee involvement in their surgery. To address the need for orthopedic training in the context of a patient population that is not fully comfortable with trainee involvement in their own surgery, an open discussion between patients and surgeons regarding trainees’ roles may be the best course of action.

Logistical and Economic Advantages of Sterile-Packed, Single-Use Instruments for Total Knee Arthroplasty

12-06-2019 – Tyler D. Goldberg, John A. Maltry, Mukesh Ahuja, Jason A. Inzana

Journal Article

Background

Total knee arthroplasty (TKA) is well established as a clinically successful and cost-effective procedure. The transition of the US healthcare system from a fee-for-service model to a value-based care model requires careful examination of patient care to ensure both quality and efficiency. Sterile-packed, single-use instruments have been introduced as a tool to help streamline the operating room (OR) logistics while reducing sterilization requirements. The aim of this study was to examine the potential logistic and economic benefits of single-use instruments compared to traditional, reusable instruments for TKA.

Methods

Four variables related to TKA costs and logistics were modeled in this study: OR turnover time tray sterilization, tray management time, and 90-day infection rates. Model input data for traditional instruments and single-use instruments were based on peer-reviewed literature. A total of 200 sites and 500 cases per site were simulated using the Monte-Carlo-Technique.

Results

The median total cost savings with single-use instruments was $994 per case. The largest driver for cost savings was tray sterilization. Sites with higher staff wages and sterilization costs had a larger probability of realizing greater cost savings with adoption of single-use instruments. In cases using single-use instruments, up to 51% of operating days could have accommodated an additional procedure due to the time savings in OR turnover.

Conclusion

This cost modeling study observed significant potential for logistical and economic improvements in TKA with single-use vs reusable instruments. Although few studies have been conducted to measure the impact of single-use instruments in practice, the results of these simulations motivate further investigation.

Value-Based Care Has Not Resulted in Biased Patient Selection: Analysis of a Single Center’s Experience in the Care for Joint Replacement Bundle

28-05-2019 – Sean P. Ryan, Johannes F. Plate, Collin S. Black, Claire B. Howell, William A. Jiranek, Michael P. Bolognesi, Thorsten M. Seyler

Journal Article

Background

Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center.

Methods

This is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care.

Results

A total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P < .001), prolonged length of stay (P < .001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients.

Conclusion

Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.

A Novel, Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems

19-05-2019 – Alexander J. Rondon, Yale A. Fillingham, David Janiec, Chris Vannello, Matthew S. Austin, P. Maxwell Courtney

Journal Article

Background

In 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA.

Methods

After institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs.

Results

Of the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001).

Conclusion

Even after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.

The Passing of David S. Hungerford

23-07-2019 – Michael A. Mont, Lynne C. Jones, Carlos J. Lavernia, John J. Callaghan

Editorial

Response to Letter to the Editor on “Unexplained Painful Hip Arthroplasty: What Should We Find? Diagnostic Approach and Results”

01-07-2019 – Roger Erivan, Guillaume Villatte, Matthieu Ollivier, Wayne Paprosky

Letter

Corrigendum to ‘Opioid Prescribers to Total Joint Arthroplasty Patients Before and After Surgery: The Majority Are Not Orthopedists’ The Journal of Arthroplasty 33 (2018) 3118-3124

20-08-2019 – Robert S. Namba, Elizabeth W. Paxton, Maria C. Inacio

Published Erratum