Abstract Background Developmental dysplasia of the hip (DDH) is a recognized cause of secondary arthritis, which may eventually lead to total hip arthroplasty (THA). An understanding of the common ...acetabular and femoral morphologic abnormalities will aid the surgeon in preparing for the complexity of the surgical case. Methods We present the challenges associated with acetabular and femoral morphologies that may be present in the dysplastic hip and discuss surgical options to consider when performing THA. In addition, common complications associated with this population are reviewed. Results The complexity of THA in the DDH patient is due to a broad range of pathomorphologic changes of the acetabulum and femur, as well as the diverse and often younger age of these patients. As such, THA in the DDH patient may offer a typical primary hip arthroplasty or be a highly complex reconstruction. It is important to be familiar with all the subtleties associated with DDH in the THA population. The surgeon must be prepared for bone deficiency when reconstructing the acetabulum and should place the component low and medial (at the anatomic hip center), and avoid oversizing the acetabular component. Femoral dysplasia is also complex and variable, and the surgeon must be prepared for different stem choices that allow for decoupling of the metaphyseal stem fit from the implanted stem version. In Crowe III and IV dysplasia, femoral derotation/shortening osteotomy may be required. Many complications associated with THA in the DDH patient may be mitigated with careful planning and surgical technique. Conclusion Performed correctly, THA can yield excellent results in this complex patient population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract We sought to determine if HbA1c and perioperative hyperglycemia were positively associated with the incidence of PJI. We retrospectively reviewed the VA VINCI database on patients who ...underwent primary joint arthroplasty between 2001 and 2011 and had HbA1c and perioperative blood glucose levels. Of 13,272 patients, 38% (n = 5035) had an elevated perioperative HbA1c ≥ 7%. While there was no increased risk of infection associated with elevated HbA1c (HR 0.86, P = 0.23), mortality was increased (HR 1.3, P = 0.01). Preoperative hyperglycemia was associated with an increased incidence of PJI (HR 1.44, P = 0.008). While HbA1c did not perfectly correlate with the risk of PJI, perioperative hyperglycemia did, and may be a target for optimization to decrease the burden of PJI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Advances in algorithms developed from sensor-based technology data allow for the passive collection of qualitative gait metrics beyond step counts. The purpose of this study was to evaluate pre- and ...post-operative gait quality data to assess recovery following primary total knee arthroplasty. This was a multicenter, prospective cohort study. From 6 weeks pre-operative through to 24 weeks post-operative, 686 patients used a digital care management application to collect gait metrics. Average weekly walking speed, step length, timing asymmetry, and double limb support percentage pre- and post-operative values were compared with a paired-samples
-test. Recovery was operationally defined as when the respective weekly average gait metric was no longer statistically different than pre-operative. Walking speed and step length were lowest, and timing asymmetry and double support percentage were greatest at week two post-operative (
< 0.0001). Walking speed recovered at 21 weeks (1.00 m/s,
= 0.063) and double support percentage recovered at week 24 (32%,
= 0.089). Asymmetry percentage was recovered at 13 weeks (14.0%,
= 0.23) and was consistently superior to pre-operative values at week 19 (11.1% vs. 12.5%,
< 0.001). Step length did not recover during the 24-week period (0.60 m vs. 0.59 m,
= 0.004); however, this difference is not likely clinically relevant. The data suggests that gait quality metrics are most negatively affected two weeks post-operatively, recover within the first 24-weeks following TKA, and follow a slower trajectory compared to previously reported step count recoveries. The ability to capture new objective measures of recovery is evident. As more gait quality data is accrued, physicians may be able to use passively collected gait quality data to help direct post-operative recovery using sensor-based care pathways.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Gait quality parameters have been used to measure recovery from total hip arthroplasty (THA) but are time-intensive and previously could only be performed in a lab. Smartphone sensor data and ...algorithmic advances presently allow for the passive collection of qualitative gait metrics. The purpose of this prospective study was to observe the recovery of physical function following THA by assessing passively collected pre- and post-operative gait quality metrics. This was a multicenter, prospective cohort study. From six weeks pre-operative through to a minimum 24 weeks post-operative, 612 patients used a digital care management application that collected gait metrics. Average weekly walking speed, step length, timing asymmetry, and double limb support percentage pre- and post-operative values were compared with a paired-sample
-test. Recovery was defined as the post-operative week when the respective gait metric was no longer statistically inferior to the pre-operative value. To control for multiple comparison error, significance was set at
< 0.002. Walking speeds and step length were lowest, and timing asymmetry and double support percentage were greatest at week two post-post-operative (
< 0.001). Walking speed (1.00 ± 0.14 m/s,
= 0.04), step length (0.58 ± 0.06 m/s,
= 0.02), asymmetry (14.5 ± 19.4%,
= 0.046), and double support percentage (31.6 ± 1.5%,
= 0.0089) recovered at 9, 8, 7, and 10 weeks post-operative, respectively. Walking speed, step length, asymmetry, and double support all recovered beyond pre-operative values at 13, 17, 10, and 18 weeks, respectively (
< 0.002). Functional recovery following THA can be measured via passively collected gait quality metrics using a digital care management platform. The data suggest that metrics of gait quality are most negatively affected two weeks post-operative; recovery to pre-operative levels occurs at approximately 10 weeks following primary THA, and follows a slower trajectory compared to previously reported step count recovery trajectories.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Abstract A femoral nerve catheter (FNC) is often used to minimize pain following total knee arthroplasty (TKA), but complications including inpatient falls, may increase as a result, despite fall ...prevention protocols. We evaluated the rate of falls in 707 primary TKAs performed with an FNC at a major academic center from May 2009 to September 2012. Despite a formalized fall prevention protocol, we found 19 falls (2.7%). Three patients required further operative intervention. At a rate of 2.7%, postoperative fall is one of the most common complications of TKA at our institution. While pain control may be good with the use of FNCs following primary TKA, improvements in fall prevention strategies or the use of alternative postoperative pain control modalities may need to be considered.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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.
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.
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.
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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
We sought to characterize the typical recovery in physical function (PF) and pain interference (PI) after TKA using Patient-Reported Outcomes Measurement Information System (PROMIS) patient-reported ...outcome (PRO) measures.
Ninety-one patients were enrolled into an institutional review board -approved prospective observational study. PROs were obtained preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 year. PROs included the PROMIS PF computerized adaptive test (CAT) and the PROMIS PI CAT. Generalized estimating equations were used to evaluate outcomes over time.
There was no difference in the preoperative and 6-week postoperative T-scores for the PF CAT (P = .410). However, all subsequent postoperative T-scores were greater than the preoperative T-score (all, P < 0.05). There was a significant reduction in PI CAT T-scores between the preoperative and all subsequent postoperative T-scores (all, P < .05). A clinically important difference in PF CAT T-scores (β = 5.44, 95% confidence interval 4.10-6.80; P < .001) and PI CAT T-scores (β = −7.46, 95% confidence interval −9.52 to −5.40; P < 0.001) was seen between the preoperative and 3-month postoperative visits. Sixty-three percent of the improvement in PF occurred by 3 months, and 89% had occurred by 6 months. The majority of reduction in PI (68%) occurred by 3 months and 90% had occurred by 6 months.
The greatest magnitude of improvement in both PF and PI occurred within the first 3 months. After 6 months, patients might expect modest improvements in PF and mild reductions of PI. Patients and surgeons should use this information for setting expectations, planning for recovery, and improving care.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Purpose
The purpose of this study was to determine the learning curve for total operative time using a novel cutting guide positioning robotic assistant for total knee arthroplasty (raTKA). ...Additionally, we compared complications and final limb alignment between raTKA and manual TKA (mTKA), as well as accuracy to plan for raTKA cases.
Methods
We performed a retrospective cohort study on a series of patients (
n
= 180) that underwent raTKA (
n
= 90) using the ROSA Total Knee System or mTKA (
n
= 90) by one of three high-volume (> 200 cases per year) orthopaedic surgeons between December 2019 and September 2020, with minimum three-month follow-up. To evaluate the learning curve surgical times and postoperative complications were reviewed.
Results
The cumulative summation analysis for total operative time revealed a change point of 10, 6, and 11 cases for each of three surgeons, suggesting a rapid learning curve. There was a significant difference in total operative times between the learning raTKA and both the mastered raTKA and mTKA groups (
p
= 0.001) for all three surgeons combined. Postoperative complications were minimal in all groups. The proportion of outliers for the final hip-knee-ankle angle compared to planned was 5.2% (3/58) for the mastered raTKA compared to 24.1% (19/79) for mTKA (
p
= 0.003). The absolute mean difference between the validated and planned resections for all angles evaluated was < 1 degree for the mastered raTKA cases.
Conclusion
As the digital age of medicine continues to develop, advanced technologies may disrupt the industry, but should not disrupt the care provided. This cutting guide positioning robotic system can be integrated relatively quickly with a rapid initial learning curve (6-11 cases) for operative times, similar 90-day complication rates, and improved component positioning compared to mTKA. Proficiency of the system requires additional analysis, but it can be expected to improve over time.
Level of evidence
Level III Retrospective Therapeutic Cohort Study.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Introduction
To our knowledge, no papers have reported the results of robotic-assisted surgery for sequential bilateral Total Knee Arthroplasty (TKA). Indeed, sequential bilateral TKA present several ...benefits, as one single anesthesia, surgical episode, hospitalization, and rehabilitation. The purpose of our study was to evaluate peri-operative outcomes and compare the complication rates, clinical outcomes, and implant positioning of sequential bilateral TKA performed with a robotic-assisted system versus a conventional technique.
Materials and methods
All patients who underwent a sequential bilateral robotic-assisted primary TKA (raTKA) in our institution between November 2019 and February 2021 were included. Twenty patients met the inclusion criteria and were matched with 20 sequential bilateral TKA performed with a conventional technique. The two groups were comparable for the demographic data and the preoperative parameters, including preoperative anticoagulation and ASA score. The minimum follow-up was 6 months.
Results
The operative time was significantly longer in the robotic group (< 0.0001), with a mean additional time of 29 min. There was no significant difference between both groups for postoperative blood loss, rate of blood transfusion, or postoperative pain. The average length of stay was 5 days. There was one early complication in the robotic group due to the tibial trackers. The functional outcomes were similar between both groups, except for the functional KSS score, which was better at 6 months in the robotic group (
p
< 0.0001). The restoration of the knee alignment and the distal femoral anatomy were significantly better in the robotic group than in the conventional group.
Conclusions
Despite a longer operative time, the peri-operative parameters of sequential bilateral TKA were similar between robotic and conventional techniques. Further, sequential bilateral raTKA was at least as safe as a conventional technique, without additional risk of medical complications.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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