Abstract Introduction Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for patients, providers, and the United States healthcare system. Historically, ...leading causes for revision have included infection, osteolysis, loosening, stiffness, and instability. However, the predominant etiology of TKA failure has changed over time and may vary between reports based on many factors including study design, patient demographics and other regional factors. In order to effectively acknowledge modes of implant failure and maximize postoperative outcomes, it is essential to understand the present epidemiology of revision TKAs. This study aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: 1) etiologies for revision TKA; 2) frequencies of revision TKA procedures; 3) various demographics including payer type and region; and 4) the length of stay (LOS) and total charges based on type of revision TKA procedure. Methods The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between January 1, 2009 and December 31, 2013. The NIS is the largest publicly available all-payer inpatient healthcare database in the United States, yielding national estimates of hospital inpatient stays. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean length of stay and total charges were also calculated for each type of revision TKA procedure. Results Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revision procedures (57.7%). The South census region performed the most revision TKA procedures (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKA procedures was $75,028.07, with femoral component revisions demonstrating the highest charges ($90,065.11). Conclusion Infection and mechanical loosening are the leading indications for revision total knee arthroplasty in the United States. Additionally our analysis demonstrated higher rates of TKA revision in the South census region. Patients who underwent arthrotomy for removal of prosthesis without replacement procedures had the longest lengths of stay, and femoral component revisions incurred the highest charges. With the projected increase in primary TKAs performed annually, it is essential for orthopaedists to understand the factors contributing to implant failure and revision. Continued insight into the etiology and epidemiology of revision TKA procedures may be the principle step towards improving outcomes and mitigating the need for future revisions.
Abstract Introduction Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continues to burden the healthcare system. The most common ...causes of THA failure include osteolysis, loosening, dislocation, and infection. However, the predominant etiology of THA failure has evolved and displays variability throughout the literature depending on study design. In order to thoroughly understand how THAs are failing and how to reduce this burden, it is essential to assess modes of implant failure on a large-scale. This study aims to update the current literature on rates of revision THA in the US population. Specifically, we report on: 1) etiologies for revision THA; 2) frequencies of revision THA procedures; 3) patient demographics, payor type, and US Census Region of revision THA patients; and 4) the length of stay and total costs based on type of revision THA procedure. Methods The National Inpatient Sample (NIS) database was used to identify all revision THA procedures performed between January 1, 2009 and December 31, 2013. Demographic, clinical, and economic data were obtained for 258,461 revision THAs during this time period. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class in order to determine the prevalence of revision procedure performed. Results Dislocation was the main indication for revision THA (17.3%), closely followed by mechanical loosening (16.8%). The most common revision THA procedure performed was all-component revision (41.8%). Patients were most commonly white (77.4%), aged 75 years and older (31.6%), and resided in the South US census region (37.0%). The average length of stay for all procedures was 5.29 days, with arthrotomy procedures demonstrating the longest stays (10.31 days). The mean total charge for revision THA procedures was $77,851.24, with arthrotomy procedures accounting for the greatest costs ($107,371.65). Conclusion With nearly equal prevalence, dislocation and mechanical loosening make up the predominant indications for revision total hip arthroplasty in the United States. Our findings are concerning, given that these etiologies have persisted despite advancements in surgical technique and implant design. With the frequency of revision THAs projected to double in the next decade, orthopaedists must take steps to mitigate this potentially devastating complication.
Chronic opioid use prior to total knee arthroplasty Zywiel, Michael G; Stroh, D Alex; Lee, Seung Yong ...
Journal of bone and joint surgery. American volume,
2011-November-2, Letnik:
93, Številka:
21
Journal Article
Recenzirano
Chronic use of opioid medications may lead to dependence or hyperalgesia, both of which might adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes ...after total knee arthroplasty. The purpose of this study was to evaluate patients who underwent total knee arthroplasty following six or more weeks of chronic opioid use for pain control and to compare them with a matched group who did not use opioids preoperatively.
Forty-nine knees in patients who had a mean age of fifty-six years (range, thirty-seven to seventy-eight years) and who had regularly used opioid medications for pain control prior to total knee arthroplasty were compared with a group of patients who had not used them. Length of hospitalization, aseptic complications requiring reoperation, requirement for specialized pain management, and clinical outcomes were assessed for both groups.
Knee Society scores were significantly lower in the patients who regularly used opioid medications at the time of final follow-up (mean, three years; range, two to seven years); the opioid group had a mean of 79 points (range, 45 to 100 points) as compared with a mean of 92 points (range, 59 to 100 points) in the non-opioid group. A significantly higher prevalence of complications was seen in the opioid group, with five arthroscopic evaluations and eight revisions for persistent stiffness and/or pain, compared with none in the matched group. Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group.
Patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee.
Periprosthetic joint infection Kapadia, Bhaveen H, MD; Berg, Richard A, MD; Daley, Jacqueline A, BSc ...
The Lancet (British edition),
01/2016, Letnik:
387, Številka:
10016
Journal Article
Recenzirano
Summary Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these ...infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.
Hip arthroplasty Pivec, Robert, MD; Johnson, Aaron J, MD; Mears, Simon C, MD ...
The Lancet (British edition),
11/2012, Letnik:
380, Številka:
9855
Journal Article
Recenzirano
Summary Total hip arthroplasty is a cost-effective surgical procedure undertaken to relieve pain and restore function to the arthritic hip joint. More than 1 million arthroplasties are done every ...year worldwide, and this number is projected to double within the next two decades. Symptomatic osteoarthritis is the indication for surgery in more than 90% of patients, and its incidence is increasing because of an ageing population and the obesity epidemic. Excellent functional outcomes are reported; however, careful patient selection is needed to achieve best possible results. The present economic situation in many developed countries will place increased pressure on containment of costs. Future demand for hip arthroplasty, especially in patients younger than 65 years, emphasises the need for objective outcome measures and joint registries that can track lifetime implant survivorship. New generations of bearing surfaces such as metal-on-metal, ceramic-on-ceramic, and metal-on-ceramic, and techniques such as resurfacing arthroplasty have the potential to improve outcomes and survivorship, but findings from prospective trials are needed to show efficacy. With the recall of some metal-on-metal bearings, new bearing surfaces have to be monitored carefully before they can be assumed to be better than traditional bearings.
Recent technologic advances capable of measuring outcomes after total knee arthroplasty (TKA) are critical in quantifying value-based care. Traditionally accomplished through office assessments and ...surveys with variable follow-up, this strategy lacks continuous and complete data. The primary objective of this study was to validate the feasibility of a remote patient monitoring (RPM) system in terms of the frequency of data interruptions and patient acceptance. Second, we report pilot data for (1) mobility; (2) knee range of motion, (3) patient-reported outcome measures (PROMs); (4) opioid use; and (5) home exercise program (HEP) compliance.
A pilot cohort of 25 patients undergoing primary TKA for osteoarthritis was enrolled. Patients downloaded the RPM mobile application preoperatively to collect baseline activity and PROMs data, and the wearable knee sleeve was paired to the smartphone during admission. The following was collected up to 3 months postoperatively: mobility (step count), range of motion, PROMs, opioid consumption, and HEP compliance. Validation was determined by acquisition of continuous data and patient tolerance at semistructured interviews 3 months after operation.
Of the 25 enrolled patients, 100% had uninterrupted passive data collection. Of the 22 available for follow-up interviews, all found the system motivating and engaging. Mean mobility returned to baseline within 6 weeks and exceeded preoperative baseline by 30% at 3 months. Mean knee flexion achieved was 119°, which did not differ from clinic measurements (P = .31). Mean KOOS improvement was 39.3 after 3 months (range: 3-60). Opioid use typically stopped by postoperative day 5. HEP compliance was 62% (range: 0%-99%).
In this pilot study, we established the ability to remotely acquire continuous data for patients undergoing TKA, who found the application to be engaging. RPM offers the newfound ability to more completely evaluate the patients undergoing TKA in terms of mobility and rehabilitation compliance. Study with more patients is required to establish clinical significance.
Abstract To accompany the new clinical Knee Society Score, a committee was formed to develop an updated radiographic assessment and evaluation system. The purpose is to accumulate radiographic data ...in a standardized manner to facilitate more accurate interpretation, documentation and clinical correlation. We systematically reviewed the TKA radiographic evaluation literature as well as the original Knee Society Radiographic Evaluation and Scoring System. A modern system was developed, approved by the Knee Society membership, which ensured proper radiographic documentation of coronal and sagittal implant alignment, fixation interface integrity with respect to radiolucent lines and osteolysis, and a zonal classification system to document precise deficiency locations. It is hoped that data may be accumulated in a standardized manner with eventual formulation of implant risk “criteria” or “scores’.
Background
Aseptic loosening is the most common cause for revisions after lower-extremity total joint arthroplasties, however studies differ regarding the degree to which host factors influence ...loosening.
Questions/purpose
We performed a systematic review to determine which host factors play a role in the development of clinical and/or radiographic failure from aseptic loosening after (1) THA and (2) TKA.
Methods
Two searches on THA and TKA, respectively, using four electronic databases (EMBASE, CINAHL Plus, PubMed, and Scopus) were conducted. We identified a total of 209 reports that encompassed nine potential host factors affecting aseptic loosening. Inclusion criteria for consideration of scientific clinical reports were that 20 or more patients were involved, with more than 1-year followup, with at least three studies pertaining to each factor, and at least six of the Methodological Index for Non-randomized Studies criteria met, and with raw data for odds ratio (OR) calculations. Twenty-one studies (16 THA studies with 45,779 hips and five TKA studies with 288 knees, respectively) were used to calculate weighted OR and CIs (using the random effects theory) and study heterogeneity for four different host factors in THAs (male sex, high activity level, obesity defined as BMI ≥ 30 kg/m
2
, and current or former tobacco use) and one factor in TKA (BMI ≥ 30 kg/m
2
), which were placed in a forest plot.
Results
For THA, male sex (OR, 1.39; 95% CI, 1.22–1.58; p = 0.001) and high activity level (University of California Los Angeles UCLA activity score ≥ 8 points; OR, 4.24; 95% CI, 2.46–7.31; p = 0.001) were associated with aseptic loosening. However, obesity (OR, 1.01; 95% CI, 0.73–1.40; p = 0.96), and tobacco use (OR, 1.96; 95% CI, 0.43–8.97; p = 0.39) were not associated with an increased risk of aseptic loosening after THA with the numbers available. For TKA, we found no host factors associated with loosening. In particular, obesity (BMI ≥ 30 kg/m
2
) was not associated with aseptic loosening with the numbers available (OR, 2.28; 95% CI, 0.60–8.62; p = 0.22).
Conclusions
Patients undergoing a lower-extremity total joint arthroplasty who engage in impact sports should be counseled regarding their potential increased risk of aseptic loosening; however, given the weak evidence available, we believe that higher-level studies are necessary to clearly define the risk factors, particularly with newer-generation constructs.
Level of Evidence
Level IV, therapeutic study.
PDF
