Arthroplasty Today最新文献

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Background

Artificial intelligence (AI) in medicine has primarily focused on diagnosing and treating diseases and assisting in the development of academic scholarly work. This study aimed to evaluate a new use of AI in orthopaedics: content generation for professional medical education. Quality, accuracy, and time were compared between content created by ChatGPT and orthopaedic surgery clinical fellows.

Methods

ChatGPT and 3 orthopaedic adult reconstruction fellows were tasked with creating educational summaries of 5 total joint arthroplasty-related topics. Responses were evaluated across 5 domains by 4 blinded reviewers from different institutions who are all current or former total joint arthroplasty fellowship directors or national arthroplasty board review course directors.

Results

ChatGPT created better orthopaedic content than fellows when mean aggregate scores for all 5 topics and domains were compared (P ≤ .001). The only domain in which fellows outperformed ChatGPT was the integration of key points and references (P = .006). ChatGPT outperformed the fellows in response time, averaging 16.6 seconds vs the fellows' 94 minutes per prompt (P = .002).

Conclusions

With its efficient and accurate content generation, the current findings underscore ChatGPT's potential as an adjunctive tool to enhance orthopaedic arthroplasty graduate medical education. Future studies are warranted to explore AI's role further and optimize its utility in augmenting the educational development of arthroplasty trainees.

Background

Although there have been several studies describing risk factors for complications after outpatient total hip arthroplasty (THA), data describing the timing of such complications is lacking.

Methods

Patients who underwent outpatient or inpatient primary THA were identified in the 2012-2019 National Surgical Quality Improvement Program database. For 9 different 30-day complications, the median postoperative day of diagnosis was determined. Multivariable regressions were used to compare the risk of each complication between outpatient vs inpatient groups. Multivariable Cox proportional hazards modeling was used to evaluate the differences in the timing of each adverse event between the groups.

Results

After outpatient THA, the median day of diagnosis for readmission was 12.5 (interquartile range 5-22), surgical site infection 15 (2-21), urinary tract infection 13.5 (6-19.5), deep vein thrombosis 13 (8-21), myocardial infarction 4.5 (1-7), pulmonary embolism 15 (8-25), sepsis 16 (9-26), stroke 2 (0-7), and pneumonia 6.5 (3-10). On multivariable regressions, outpatients had a lower relative risk (RR) of readmission (RR = 0.73), surgical site infection (RR = 0.72), and pneumonia (RR = 0.1), all P < .05. On multivariable cox proportional hazards modeling, there were no statistically significant differences in the timing of each complication between outpatient vs inpatient procedures (P > .05).

Conclusions

The timing of complications after outpatient THA was similar to inpatient procedures. Consideration should be given to lowering thresholds for diagnostic testing after outpatient THA for each complication during the at-risk time periods identified here. Although extremely rare, this is especially important for catastrophic adverse events, which tend to occur early after discharge.

Background

This study aimed to investigate the relationship between 3-dimensional (3D) alignment and postoperative bone mineral density (BMD) changes with Accolade II tapered wedge stems, which have a different proximal shape from other tapered wedge stems, up to 5 years after primary total hip arthroplasty.

Methods

We retrospectively analyzed the hips of 89 patients who underwent total hip arthroplasty using the second-generation proximally coated cementless stem (Accolade II; Stryker Orthopedics, Mahwah, NJ) at our institution from 2014 to 2018 over a 5-year follow-up. We evaluated the relationship between stem alignment, measured using 3D-templating software, and BMD changes in the 7 Gruen zones and compared the data with those from a former study using other short taper-wedge stems.

Results

BMDs in zones 1 and 7 continued to decrease gradually every year after surgery, and BMD in zone 7 showed the largest decrease (21%) from baseline over 5 years. No correlation was found between stem alignment (varus/valgus, flexion/extension, and anteversion/retroversion) and changes in BMD in each zone over 5 years.

Conclusions

Our data showed no correlation between 3D stem alignment and changes in BMD in each Gruen zone over 5 years. This suggests that the Accolade II stem may fit better into any shape of the proximal medullary canal because of its unique characteristics.

Background

Following total knee arthroplasty (TKA), normal knee kinematics are rarely replicated. Retention of both cruciate ligaments (bicruciate retaining TKA) has helped this. Postoperative posterior tibial slope (PPTS) may further affect ligament tension and kinematics. The objective of this study is to determine how changes between the preoperative posterior tibial slope (PTS) and PPTS affect knee kinematics.

Methods

Twenty bicruciate retaining TKAs were performed using standard instrumentation. Fluoroscopic kinematic data were obtained during gait and a single knee bend. Differences (Δ) between radiographic measurements of preoperative and PPTS were correlated with in-vivo knee kinematics. Patients were separated into 2 groups based on their Δ values. Group I consisted of Δ values less than 0.7, indicating either a similar PPTS compared to preoperative PTS or a slightly flatter PPTS. Group II consisted of Δ values above 0.7, indicating a steepened PPTS.

Results

Preoperative PTS values ranged from −0.5° to 11.2°, with an average of 5.0° ± 3.4°. PPTS values ranged from 3.0° to 12.1°, with an average of 7.1° ± 3.1°. Weight-bearing range of motion (WBROM) measured from 94° to 139°, and femorotibial axial rotation ranged from −2.9° to 17.3°. A t-test revealed average values for WBROM in Group I_T (Δ < 0.7) to be significantly greater than those for Group II_T (Δ > 0.7) (P = .01).

Conclusions

These findings indicate that either a PPTS approximating the preoperative PTS or a slightly flattened PPTS in comparison (Δ < 0.7) is associated with WBROM greater than 130°. Values for axial rotation and anterior sliding were not significantly associated with changes to the PTS.

Purpose

Mild ligament imbalance is often encountered in the mediolateral plane during complex primary total knee arthroplasty. A constrained (CP) polyethylene insert compatible with the primary femur is useful to manage these cases without the need to fall back on revision implants. The aim of the study was to define the correct indications of the use of a CP insert based on objective data from computer assisted surgery and to compare the early results of a CP insert with a standard posterior stabilized (PS) insert through one-to-one propensity score matching.

Methods

This is a retrospective case study from a prospectively collected database. One-to-one matching without replacement was used with a caliper width of 0.2 to match the scores between CP (N = 64) and PS groups (N = 1624), resulting in equal covariate matching of PS (N = 64) and CP (N = 64) cohorts. Patients were assessed radiographically and functionally at a minimum follow-up of 3 years.

Result

Average coronal and sagittal plane deformities were similar in both the group CP (varus 13.1 ± 5.2 valgus 13 ± 7.9) and the group PS (varus 13.4 ± 4.6 valgus 10.9 ± 8.6). The average residual medial lateral gap difference was significantly higher in group CP (3.8 ± 1.8) in comparison to group PS (1.3 ± 1) (P < .05). A CP insert was chosen where mild ligament imbalance of 3-5 mm persisted after medial soft tissue releases in a varus knee and in cases with residual medial collateral ligament laxity in valgus knees.

Conclusions

Constrained insert used with the primary femoral component is a valuable option to handle mild ligamentous instability in complex primary total knee arthroplasty after mechanical alignment is achieved with computer navigation.

Level of Evidence

III.

Background

Trabecular metal augments (TMAs) have been extensively used in revision total hip arthroplasty (THA) to address acetabular bone defects. However, limited data exists regarding TMA utilization during primary THA. This study aims to assess the clinical and radiographic outcomes of TMAs used during primary THA.

Methods

A single-institution retrospective case series of primary THA patients treated with TMA between 2010 and 2019 was performed. Patient demographics, complications, and revisions were recorded. Cup position, center of rotation, leg length, and radiolucent lines were assessed radiographically. The Kaplan-Meier method was used to compute implant survivorship.

Results

Twenty-six patients (30 hips) were included with average age of 52.6 ± 15.3 years (range: 22-78) and mean follow-up of 4.1 ± 2.1 years (range: 2.0-8.9). Most TMAs were indicated for developmental dysplasia of the hip (n = 18; 60.0%). On average, hip center of rotation was lowered 1.5 ± 1.3 cm and lateralized 1.2 ± 1.5 cm, while leg length and global offset were increased by 2.4 ± 1.2 cm and 0.4 ± 1.0 cm, respectively. At final follow-up, 3 hips (10.0%) required revision: one (3.3%) for aseptic loosening and 2 (6.7%) for instability. No patients had progressive radiolucent lines at final follow-up. Five-year survival with aseptic loosening and all-cause revision as endpoints was 100% (95% confidence interval: 90.0%-100.0%) and 92.1% (95% confidence interval: 81.3%-100.0%), respectively. One patient required revision for aseptic loosening after the 5-year mark.

Conclusions

Trabecular metal augmentation during primary THA demonstrates satisfactory early to mid-term outcomes. TMA is a viable option for complex primary THA when bone loss is encountered or secondary support is required.

Level of Evidence

Level IV.

Bacground

The use of cemented fixation is widely recommended in hip arthroplasty for hip fractures, although it is not used universally.

Methods

We describe the trends in cementing prevalence in hemiarthroplasty for hip fractures in Canada for patients ≥55 years old between April 2017 and March 2022.

Results

The national prevalence of cemented fixation increased from 43% in 2017/18 to 58% in 2021/22, but there was a large variety of both the baseline prevalence and the trends across the country and between individual hospitals. The proportion of surgeons only performing cementless fixation fell from 30% to 21% between 2018/19 and 2021/22.

Conclusions

As cemented fixation is now universally recommended, more coordination is needed to track these trends and to help drive implementation of this evidence-based practice across Canada.

Background

The utilization of technology, including robotics and computer navigation, in total hip arthroplasty (THA) has been steadily increasing; however, conflicting data exists regarding its effect on short-term clinical and patient-reported outcomes. Therefore, this study sought to explore the association between different surgical technologies and postoperative outcomes following THA.

Methods

We retrospectively reviewed 9892 primary THA cases performed by 62 surgeons from a single institution from September 2017 to November 2022. Three cohorts were created based on the utilization of technology: conventional (no technology), navigation, or robotics. Patient demographics, clinical outcomes, and patient-reported outcome measures were collected over the first 90 days following surgery. This data was compared using analysis of variance and multivariate logistic regressions. In total, 4275 conventional, 4510 navigation, and 1107 robotic cases were included in our analyses.

Results

The robotic cohort achieved a perfect Activity Measure for Post-Acute Care (AM-PAC) score earliest (0.1 days, P < .001). After adjusting for potential confounding variables, use of robotic assistance was associated with greater odds of achieving a perfect AM-PAC score on postoperative day 0 (odds ratio 1.6, P < .001) and greater odds of having length of stay shorter than 24 hours (odds ratio 2.3, P < .001) compared to no technology use in THA. Hip dysfunction and Osteoarthritis Outcome Score, Joint Replacement and Patient-Reported Outcomes Measurement Information System Pain Interference scores showed the greatest improvement in the robotic cohort at both 6 weeks and 3 months following surgery.

Conclusions

The present study demonstrates favorable clinical and patient-reported outcomes in the first 90 days following surgery for patients undergoing robot-assisted THA compared to conventional and navigation-assisted THA.

During acetabular cup positioning, intraoperative measurements of cup anteversion were taken using both fluoroscopy and navigation system. With the C-arm introduced at 40°, an anteroposterior view of the pelvis is taken. The C-arm is then centered over the hip, showing an anteverted cup with an approximate inclination of 40°. The axial C-arm is tilted away until the cup opening is visualized as a straight line, indicating that the beam of the fluoroscopy is aligned with the cup’s anteversion. The tilt angle on the C-arm and anteversion reading on the navigation workstation were recorded. The high degree of agreement between fluoroscopic and navigation measurement of acetabular cup anteversion supports the use of fluoroscopy in settings with limited access to navigation systems in direct anterior total hip arthroplasty.