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
Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, ...opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.
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
Background
Patient-specific instrumentation potentially improves surgical precision and decreases operative time in total knee arthroplasty (TKA) but there is little supporting data to confirm this ...presumption.
Questions/purposes
We asked whether patient-specific instrumentation would require infrequent intraoperative changes to replicate a single surgeon’s preferences during TKA and whether patient-specific instrumentation guides would fit securely.
Methods
We prospectively evaluated the plan and surgery in 60 patients treated with 66 TKAs performed with patient-specific instrumentation and recorded any changes. A subset of six postoperative radiographic changes to the femoral and tibial components (implant size, coronal and sagittal alignment) was analyzed to determine if surgeon intervention was beneficial. Each guide was evaluated to determine fit. We compared patient demographics and implant sizing in the patient-specific instrumentation group with a control group in which traditional instrumentation was used.
Results
We recorded 161 intraoperative changes in 66 knee arthroplasties (2.4 changes/knee) performed with patient-specific instrumentation. The predetermined implant size was changed intraoperatively in 77% of femurs and 53% of tibias. We identified a subset of 95 intraoperative changes that could be radiographically evaluated to determine if our changes were an improvement or detriment to reaching goal alignment. Eighty-two of the 95 changes (86%) made by the surgeon were an improvement to the recommended alignment or size of patient-specific instrumentation. The guide did not fit securely on eight femurs (12%) and three tibias (5%). Tourniquet time and blood loss were not improved with patient-specific instrumentation.
Conclusions
We caution surgeons against blind acceptance of patient-specific instrumentation technology without supportive data.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Polyethylene bearing design may influence the risk of revision after total knee arthroplasty (TKA). Previous investigations from outside of the United States have suggested the potential for an ...increased risk of all-cause revision and revision for infection with the use of posterior-stabilized bearings. We examine the risk of revision based on the polyethylene bearing design selection for primary TKA.
An analysis of the American Joint Replacement Registry (AJRR) data from 2012 to 2019 was performed. We identified all primary TKAs over the study period and linked cases to supplemental U.S. Centers for Medicare & Medicaid Services (CMS) data where available. Patient demographic characteristics, polyethylene characteristics, procedure dates, and cause for revision were recorded. Analysis was performed to compare minimally stabilized implants (cruciate-retaining, anterior-stabilized, or pivot bearing designs) with posterior-stabilized implants. Cumulative incidence function (CIF) curves and Cox proportional hazard ratios (HRs) were created for all-cause revision and revision for infection in each group.
We identified 305,279 cases with reported minimally stabilized or posterior-stabilized implant characteristics. There were 161,486 cases (52.9%) that utilized posterior-stabilized bearings compared with 143,793 cases (47.1%) with minimally stabilized bearings. For minimally stabilized bearings, 1,693 cases (1.18%) had all-cause revision and 334 cases (0.23%) had revision for infection. For posterior-stabilized bearings, 2,406 cases (1.49%) had all-cause revision and 446 cases (0.28%) had revision for infection. The use of posterior-stabilized bearings had HRs of 1.25 (95% confidence interval CI, 1.2 to 1.3; p < 0.0001) for all-cause revision and 1.18 (95% CI, 1.0 to 1.4; p = 0.02) for revision for infection.
Similar to investigations from international registries, we found an increased risk of all-cause revision and revision for infection when using posterior-stabilized bearings in TKA in the United States. Surgeons should consider this finding when considering bearing selection for primary TKA.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
IMPORTANCE: Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE: To measure the association ...of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS: Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES: Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES: Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS: From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median IQR, $113 $79-160; n = 2034 encounters) at baseline and $123 (median IQR, $99 $66-147; n = 4276 encounters) in the evaluation period (mean difference, −$15; 95% CI, −$19 to −$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median IQR, 3.4 0.8-7.8 hours; n = 29 encounters) at baseline and 3.6 hours (median IQR, 2.2 1.0-4.5 hours; n = 76 encounters) in the evaluation period (mean difference, −4.1 hours; 95% CI, −9.9 to −1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE: Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.
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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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
Advances in polyethylene bearing characteristics have led to various options for total knee arthroplasty. We examine trends in use of polyethylene in the United States.
An analysis of American Joint ...Replacement Registry data from 2012 to 2019 for primary total knee arthroplasty procedures was conducted. Design and manufacturing characteristics were obtained and validated in the American Joint Replacement Registry dataset. Polyethylene bearing design and manufacturing use characteristics were compared by year, gender, age group, and geographic region of the procedure. Descriptive analysis was performed.
We identified 993,292 cases over the study period. In total, 791,233 (80%) cases had complete device data available and were included in analysis. In addition, 366,280 (49.4%) cases utilized minimally stabilized bearings compared to 374,809 (50.6%) for posterior-stabilized bearings. Posterior-stabilized use was stable over the study period and highest in the Northeast (64.5%; P < .0001). Cruciate-retaining use decreased from 29.7% to 20.2% and anterior-stabilized use increased from 17.4% to 25.2%. Conventional polyethylene use decreased from 42.8% to 21.9%, and was highest in the 81+ age group (37.8%; P < .0001) and Northeast (43.0%; P < .0001). Highly cross-linked polyethylene (HXLPE) with antioxidant use increased from 9.08% to 31.8%, while HXLPE without antioxidant use remained constant.
There was an increase in use of anterior-stabilized and pivot bearings and an increase in use of HXLPE with antioxidant. Additionally, there were noted age group and regional differences in the use of various bearings. Further study should evaluate if these changing utilization trends are related to clinical outcomes, or due to regional training, preferences, or manufacturer pressures.
Level III, retrospective.
•This investigation used AJRR data to describe and compare trends in use of specific design and manufacturing characteristics for TKA.•Use of standard CR bearing designs has declined with concurrent increase in use of AS and pivot designs.•Use of conventional polyethylene has declined with increase in use of HXLPE with antioxidant.•All-polyethylene tibial components represent a small portion of TKA and their utilization is declining.•Rotating platform use remains stable and highest in younger age groups.•Use of PS bearings is greatest in the Northeast region.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Genicular nerve radiofrequency ablation (RFA) is increasingly being performed to treat chronic pain due to knee osteoarthritis (KOA). This narrative review provides a concise summary of the relevant ...neuroanatomy, randomized controlled trials, appropriate patient selection, and safety relating to genicular RFA. Cadaveric studies demonstrate significant variability in the location of the genicular nerves, which has stimulated debate about the ideal target locations for genicular RFA. Despite this, favorable outcomes have been observed in studies targeting only the superior medial genicular nerve, inferior medial genicular nerve, and superior lateral genicular nerve. Several randomized controlled trials demonstrate superiority of genicular RFA compared with intra-articular steroid, viscosupplementation, and oral analgesics. Genicular RFA of the superior medial genicular nerve, inferior medial genicular nerve, and superior lateral genicular nerve appears to be an effective treatment for painful KOA, but targeting additional sensory nerves may further improve treatment success. Although genicular RFA appears relatively safe on the basis of the available data, additional large-scale studies are needed to provide greater confidence.
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