Robotic Arm–Assisted Total Knee Arthroplasty Khlopas, Anton; Sodhi, Nipun; Sultan, Assem A. ...
The Journal of arthroplasty,
July 2018, 2018-07-00, 20180701, Letnik:
33, Številka:
7
Journal Article
Recenzirano
Robotic arm–assisted total knee arthroplasty (RATKA) has a number of potential advantages. Therefore, in order to more comprehensively assess this technology, we reviewed the (1) accuracy and ...precision; (2) soft-tissue protection; (3) patient satisfaction; (4) learning curve; and (5) its other potential benefits.
A literature review was conducted using PubMed search database for studies reporting clinical outcomes, cadaver results, radiographic outcomes, surgeon experience, and robotic accuracy. Forty articles were included for the final analysis.
Advantages of RATKA may include greater component accuracy and precision, soft-tissue protection, increased patient satisfaction, a short learning curve, optimal ergonomic design, and less surgeon and surgical team fatigue. The aforementioned advantages might help improve clinical, surgical, and patient-reported outcomes.
Although there are a number of studies that highlight the potential advantages of RATKA, most of these studies report of short-term outcomes. It is hoped that longer term studies will continue to support the use of this technology in providing higher patient satisfaction and other clinical outcomes.
Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help ...alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.
A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively.
The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 23.8% vs 8 10.1%, P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 23.8% vs 16 20.3%, P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 12.5% vs 2 2.5%, P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68).
ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty.
It has been established by previous studies that longer operative times can lead to higher rates of complications and poorer outcomes after total hip arthroplasty (THA). However, these studies were ...heterogeneous, examined limited complications, and have not provided a clear time after which complications increase. The aims of this study were to (1) assess whether longer operative time increases risk of complications within 30 days of THA, (2) investigate the relationship between operative time and various complications after THA, and (3) identify possible operative times beyond which complication rates increase.
The National Surgical Quality Improvement Project database was queried to identify 89,802 procedures that were included in the final analysis. The effect of operative time on complications within 30 days was evaluated using multivariate logistic regression models. Spline regression models were created to investigate the relationship between operative time and complications.
Longer operative times were associated with higher risk of readmissions (P < .001), reoperations (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), renal or systemic complications (P < .001), and blood transfusion (P < .001). A linear relationship was observed between operative time and readmission, reoperation, surgical site infection, and transfusions with increased rate of these complications when the operative time exceeded 75 to 80 minutes. Venous thromboembolic complications had a U-shaped relationship with operative time with the trough around 90 to 100 minutes.
While our findings cannot establish a clear cause and effect relation, they do suggest strong correlation between increased operative time and perioperative complications. Additionally, this study suggests an optimal time of approximately 80 minutes, as a goal for surgeons, that may be associated with less risk of complications following THA.
New Technologies in Knee Arthroplasty Molloy, Robert M.
The Journal of arthroplasty,
July 2018, 2018-07-00, 20180701, Letnik:
33, Številka:
7
Journal Article
Proceedings of the 2017 AAHKS Meeting Molloy, Robert M.
The Journal of arthroplasty,
July 2018, 2018-07-00, 20180701, Letnik:
33, Številka:
7
Journal Article
Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of ...stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address.
The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes.
Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI.
In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 95% confidence interval (CI) 0.31 to 0.59; p < 0.001) and nonhome discharge (OR 0.39 95% CI 0.27 to 0.56; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 95% CI -0.063 to -0.026; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 95% CI 0.024 to 0.059; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 95% CI -0.13 to -0.024; p = 0.004; nonhome discharge: 0.060 95% CI 0.016 to 0.11; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 95% CI 0.32 to 0.54; p < 0.001), nonhome discharge (OR 0.44 95% CI 0.33 to 0.60; p < 0.001), 90-day readmission (OR 0.54 95% CI 0.39 to 0.77; p < 0.001), and 90-day ED admission (OR 0.60 95% CI 0.45 to 0.79; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 95% CI -0.035 to -0.007; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 95% CI -0.016 to 0.040; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 95% CI -0.13 to -0.049; p < 0.001; nonhome discharge: 0.046 95% CI 0.014 to 0.078; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group.
Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage.
Level III, therapeutic study.
An overall assessment of how patient demographic characteristics and comorbidities are improving or worsening can allow better understanding of the value of revision total joint arthroplasty (TJA). ...Therefore, the purpose of this study was to identify patient demographic characteristics and comorbidities trends and episode-of-care outcome trends from 2008 to 2018 in patients undergoing revision TJA.
The National Surgical Quality Improvement Program database was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes in patients undergoing revision TJA from 2008 to 2018 (n = 45,706). Pairwise t tests and pairwise chi-square tests were performed on consecutive years with Bonferroni correction. Trends were assessed using the 2-tailed Mann-Kendall test of the temporal trend.
Among patients undergoing revision TJA, there was no clinically important difference, from 2008 to 2018, in age, body mass index (BMI), percentages with >40 kg/m2 BMI, diabetes (18.8% to 19%), chronic obstructive pulmonary disease (4.1% to 5.4%), congestive heart failure within 30 days (0% to 1%), or acute renal failure (0% to 0.2%). However, modifiable comorbidities including smoking status (14.7% to 12.0%; p = 0.01), hypertension (66% to 26.0%; p = 0.02), anemia (34.5% to 26.3%; p < 0.001), malnutrition (10.4% to 9.3%; p = 0.004), and overall morbidity or mortality probability have improved, with a decrease in the hospital length of stay and 30-day readmission and a significant increase in home discharge (p < 0.001 for all).
Time-difference analysis demonstrated that the overall health status of patients undergoing revision TJA improved from 2008 to 2018. However, formal time-trend analysis demonstrated improvements to a lesser degree. The multidisciplinary effort to improve value-based metrics including patient comorbidity optimization and episode-of-care outcomes for primary TJA has been shown to potentially have an impact on revision TJA.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Abstract Background Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This ...study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS. Results Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday ( P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery ( P < .001). Conclusion Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.
The purpose of this study was to evaluate the associations of hospital volume with revision surgery for infection and superficial incisional infections.
A review of 12,541 primary total knee ...arthroplasties (TKAs) at a large integrated health system from 2014 to 2017 was conducted. Sixteen hospitals were classified as low-volume, medium-volume, or high-volume hospitals according to the mean number of TKAs/year (<250, 250-500, and >500, respectively). Thresholds were guided by percentiles and the literature on volume-outcome relationships. Medical records were reviewed for revision surgery for infection and superficial incisional infections during a mean 2-year review period. Multivariate analyses, adjusted for clinical and patient characteristics, were performed to evaluate the association between hospital volume and infection.
The overall rate of revision surgery for infection was 0.7% (n = 82), and the overall rate of superficial incisional infection was 2.6% (n = 324). After accounting for potential confounders, hospital volume was not found to have a significant association with revision surgery for infection when comparing high-volume and low-volume hospitals (odds ratio, 1.615; 95% confidence interval, 0.761-3.427; P = .212) as well as when comparing high-volume and medium-volume hospitals (odds ratio, 1.464; 95% confidence interval, 0.853-2.512; P = .166). Moreover, the risk of superficial incisional infection at high-volume hospitals was similar to that at low-volume (P = .107) and medium-volume (P = .491) hospitals.
Infection outcomes are quality metrics that are frequently used to compare hospitals including those of varying volumes. Using contemporary thresholds, this study found that infection rates after TKA at high-volume hospitals are comparable to low-volume and medium-volume hospitals.
The surgical management of complications surrounding patients who have undergone hip arthroplasty necessitates accurate identification of the femoral implant manufacturer and model. Failure to do so ...risks delays in care, increased morbidity, and further economic burden. Because few arthroplasty experts can confidently classify implants using plain radiographs, automated image processing using deep learning for implant identification may offer an opportunity to improve the value of care rendered.
We trained, validated, and externally tested a deep-learning system to classify total hip arthroplasty and hip resurfacing arthroplasty femoral implants as one of 18 different manufacturer models from 1972 retrospectively collected anterior-posterior (AP) plain radiographs from 4 sites in one quaternary referral health system. From these radiographs, 1559 were used for training, 207 for validation, and 206 for external testing. Performance was evaluated by calculating the area under the receiver-operating characteristic curve, sensitivity, specificity, and accuracy, as compared with a reference standard of implant model from operative reports with implant serial numbers.
The training and validation data sets from 1715 patients and 1766 AP radiographs included 18 different femoral components across four leading implant manufacturers and 10 fellowship-trained arthroplasty surgeons. After 1000 training epochs by the deep-learning system, the system discriminated 18 implant models with an area under the receiver-operating characteristic curve of 0.999, accuracy of 99.6%, sensitivity of 94.3%, and specificity of 99.8% in the external-testing data set of 206 AP radiographs.
A deep-learning system using AP plain radiographs accurately differentiated among 18 hip arthroplasty models from four industry leading manufacturers.
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