Abstract Revision knee data from six joint arthroplasty centers were compiled for 2010 and 2011 to determine mechanism of failure and time to failure. Aseptic loosening was the predominant mechanism ...of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%), and malalignment (6.6%). Mean time to failure was 5.9 years (range 10 days to 31 years). 35.3% of all revisions occurred less than 2 years after the index arthroplasty, 60.2% in the first 5 years. In contrast to previous reports, polyethylene wear is not a leading failure mechanism and rarely presents before 15 years. Implant performance is not a predominant factor of knee failure. Early failure mechanisms are primarily surgeon-dependent.
Abstract Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, ...liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20 cc) liposomal bupivacaine mixed with 75 mg (30 cc) 0.25% bupivacaine, and 53 patients received 150 mg (60 cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 ( P = 0.73); Day 2: 4.4/4.8 ( P = 0.27); or Day 3: 3.5/3.7 ( P = 0.58). Narcotic use was similar during hospitalization, 51.8/54.2 ( P = 0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.
Risk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. ...The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care.
An electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m2), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared.
Mean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor.
Medical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.
Center for Medicare and Medicaid Services reimbursement is the same for hip arthroplasty performed electively for arthritis and urgently for femoral neck fracture.
An analytic report of hip ...arthroplasty for a 5-hospital network identified 2362 cases performed from January 2014 to May 2016. Resource utilization was determined using 90-day charges.
The fracture population (623 hips) was older (P < .01), had more medical comorbidities (28.3% vs 3.8%, P < .01), and was more likely to be anemic and malnourished (P < .01), and had longer hospital stay (5.7 vs 3.0 days, P < .0001), more frequent intensive care unit admission (4.5% vs 0.5%, P < .01), less frequent discharge to home (16.2% vs 83.6%, P < .01), more emergency department visits (26.5% vs 10.7%, P < .01), and more readmissions after hospital discharge (25.2% vs 12.2%, P < .01). Utilization of services ($50,875 vs $38,705, P < .0001) and the standard deviation of these services ($22,509 vs $9,847, P < .0001), from 90-day charges, were significantly greater in the fracture population.
This study supports exclusion of fracture care from the Comprehensive Care for Joint Replacement bundled payment program.
The opioid crisis has illuminated the risks of opioid use for pain management, with renewed interest in reducing opioid consumption after common orthopedic procedures. Anti-inflammatory medication is ...an important component of multimodal pain management for patients undergoing orthopedic surgery. The purpose of this study was to evaluate the effect of celecoxib on pain control and opioid use after shoulder surgery.
Patients scheduled for either total shoulder replacement (group 1) or rotator cuff repair (group 2) were candidates for the study. The exclusion criteria included allergy to celecoxib, coagulopathy, use of anticoagulants, baseline use of long-acting opioids, and a history of medical conditions such as myocardial infarction or stroke. Consenting patients were randomized by type of procedure using block randomization to receive either placebo or celecoxib 1 hour prior to the procedure and for 3 weeks postoperatively. The primary outcome measure assessed was opioid utilization as measured by morphine-equivalent dose (MED). Secondary outcome measures included pain scores at 3 and 6 weeks postoperatively. Data were analyzed using multiple linear regression.
Of 1081 patients scheduled for either total shoulder replacement or rotator cuff repair from February 2014 to February 2018, 78 were enrolled for arthroplasty (group 1, with 39 receiving celecoxib and 39 receiving placebo) and 79 were enrolled for rotator cuff repair (group 2, with 40 receiving celecoxib and 39 receiving placebo). Compared with the placebo arm, patients prescribed celecoxib took fewer MEDs by –168 (95% confidence interval CI, –272 to –64; P < .01) at 3 weeks in the total population and by –197.7 (95% CI, –358 to –38; P = .02) in the arthroplasty group. Similarly, at 6 weeks, total MEDs used was –199 (95% CI, –356 to –42; P < .01) in the total population and –270 (95% CI, –524 to –16; P = .04) in the arthroplasty group. No statistically significant differences in opioid consumption were found between study arms in the cuff repair group, at either 3 or 6 weeks. Of note, preoperative opioid use was statistically associated with higher levels of opioid use in the total population and group 1 at 3 and 6 weeks (P < .01 for all) but not in group 2 (P > .05 for both).
Use of morphine equivalents was statistically significantly less at 3 and 6 weeks in patients who took celecoxib in the total population and in the arthroplasty group. Patients prescribed celecoxib for 3 weeks after shoulder surgery took less opioid medication for pain at 3 and 6 weeks. Multimodal pain control using celecoxib is an effective way to reduce postoperative opioid use in shoulder arthroplasty patients. Preoperative opioid use is associated with higher levels of opioid use after shoulder arthroplasty.
Abstract Certain recreational, cultural, occupational, and religious practices may require knee flexion exceeding typical daily living activity needs. Some total knee prostheses mechanically ...accommodate high flexion to help meet such demands, e.g., the Vanguard knee (Biomet, Inc., Warsaw, IN) which can mechanically achieve 140°–145°. This multicenter, prospective clinical study of 957 Vanguard knees (865 patients) examined mid-term outcomes. The Kaplan-Meier survivorship estimate was 97.8% (95% CI: 96.5–98.7%) at 7.0 years. For patients with ≥ 2-year follow-up (n = 627), mean peak flexion increased from 116.8° to 124.8° ( P < 0.001). For knees with pre-operative flexion of < 95°, 95°–105°, and > 105°, the mean increases were 27.8°, 22.0°, and 3.6°, respectively. Mean Knee Society Knee and Function scores increased from 45.9 and 45.5 points to 92.0 and 73.8 points, respectively ( P < 0.001).
Abstract Background Despite pain resolution in most patients after total knee arthroplasty (TKA), poor function persists in approximately 20% of patients and frequently is associated with patient ...dissatisfaction. Lumbar spine problems are a leading cause of functional disability. This study sought to determine the association between lower knee function scores and history of spine disability. Methods Prospective demographic, health, and knee-specific data were collected for 1156 consecutive TKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score were obtained from 691 knees. Results Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. Oxford Knee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8; P = .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P = .10). Knee Society (KS) pain scores were similar regardless of spine history. KS function scores were lower in patients with vs without back problems preoperatively (42.3/47.0; P = .0005), postoperatively (69.0/79.8; P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with female gender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score (R = 0.57) and KS function score (R = 0.54). Conclusion Knee function scores were significantly worse in patients with a history of back problems and directly associated with ODI score. KS function scores indicated that TKA patients with back problems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissatisfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disability should guide patient expectations and evaluation of TKA outcomes.
Background
The Oxford knee is a unicompartmental implant featuring a mobile-bearing polyethylene component with excellent long-term survivorship results reported by the implant developers and early ...adopters. By contrast, other studies have reported higher revision rates in large academic practices and in national registries. Registry data have shown increased failure with this implant especially by lower-volume surgeons and institutions.
Questions/purposes
In the setting of a high-volume knee arthroplasty practice, we sought to determine (1) the failure rate of the Oxford unicompartmental knee implant using a failure definition for aseptic loosening that combined clinical features, plain radiographs, and scintigraphy, and (2) whether increased experience with this implant would decrease failure rate, if there is a learning curve effect.
Methods
Eighty-three Oxford knee prostheses were implanted between September 2005 and July 2008 by the principal investigator. Radiographic and clinical data were available for review for all cases. A failed knee was defined as having recurrent pain after an earlier period of recovery from surgery, progressive radiolucent lines compared with initial postoperative radiographs, and a bone scan showing an isolated area of uptake limited to the area of the replaced compartment.
Results
Eleven knees in this series failed (13%); Kaplan-Meier survivorship was 86.5% (95% CI, 78.0%–95.0%) at 5 years. Failure occurrences were distributed evenly over the course of the study period. No learning curve effect was identified.
Conclusions
Based on these findings, including a high failure rate of the Oxford knee implant and the absence of any discernible learning curve effect, the principal investigator no longer uses this implant.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Abstract Fifty patients underwent isokinetic muscle strength testing before surgery and at 6 weeks, 3 months, 6 months, and 1 year after unilateral total knee arthroplasty using the minisubvastus ...surgical technique. Quadriceps muscle strength returned to preoperative levels by 3 months postoperatively and was 17% stronger at 6 months and 30% stronger at 1 year than preoperative levels ( P < .05). At 1 year, the quadriceps strength of the involved knee was equivalent to that of the uninvolved knee ( P = .81). When the entire study population was subdivided by age, weight, sex, and the presence of arthritis in the uninvolved knee, each subgroup still had equivalent quadriceps strength between the involved and uninvolved knees. This prospective study demonstrated that the minisubvastus total knee arthroplasty technique led to a more rapid and more complete recovery of muscle strength than has been previously demonstrated after total knee arthroplasty with a medial parapatellar arthrotomy.
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