Journal of Arthroplasty最新文献

Background: High tibial osteotomy (HTO) is a joint-preserving treatment for younger patients who have unicompartmental knee osteoarthritis. Although effective, concerns persist that prior HTO may compromise subsequent total knee arthroplasty (TKA). This study aimed to assess the revision-free survival of TKA following ipsilateral HTO and identify factors associated with failure of both procedures in a U.S.

Population:

Methods: Patients who underwent TKA after prior ipsilateral HTO between 2000 and 2023 at a single academic institution were prospectively followed (n = 134), with a mean follow-up of 13.5 years (range, zero to 24.0) postoperative TKA and median ages at HTO and TKA of 52 and 63 years, respectively. Preoperative TKA radiographs were assessed using the Kellgren and Lawrence system. Kaplan-Meier analysis was performed to assess HTO and TKA survival. The mean HTO survival was 11.7 years (range, zero to 31.0), with a 10-year TKA conversion rate of 35.8%. Cox regressions identified factors associated with osteotomy survival.

Results: Older age (hazard ratio [HR]: 1.06; P < 0.001), higher body mass index (HR: 1.03; P = 0.033), and lower Charlson Comorbidity Index (CCI) (HR: 0.79; P < 0.001) were significantly associated with earlier conversion. Following TKA, 6.0% underwent revision surgery. Revisions were more common in younger patients (P = 0.01) and those who had lower CCI (P = 0.002). The infection rate for postoperative TKA was 2.2%.

Conclusions: In this U.S. cohort, TKA following prior ipsilateral HTO demonstrated a revision rate of 6.0%, with younger patients who have lower CCI scores more likely to require revision. The mean survival of HTO was approximately 12 years, with age, body mass index, and comorbidity index significantly influencing longevity. These findings support HTO as a durable joint-preserving treatment in younger patients, helping to guide clinical decision-making and may contribute to increased consideration of HTO as a treatment option in suitable people.

Background: Total hip arthroplasty (THA) and knee arthroplasty (TKA) are increasingly being performed on an outpatient basis. With this shift in site of service, the volume and complexity of work required for these procedures may be affected. The purpose of this study was to quantify the amount of perioperative work performed by the surgeon and advanced practice providers for same-day THA and TKA.

Methods: We prospectively timed preservice, immediate postservice, and discharge coordination activities for a consecutive series of 96 outpatient cases over a 4-week period. Timing data for activities performed in the operating room were obtained retrospectively from our institutional electronic medical record for 500 patients who underwent THA and 500 who underwent TKA. Results were compared with the current approved values reviewed by the Relative Value Scale Update Committee (RUC) in 2019. Cases were also separated into those performed in tertiary care hospitals, specialty hospitals, and ambulatory surgical centers to compare perioperative work by surgical setting.

Results: The average pre-evaluation time was 43.9 ± 7.3 minutes. The average time from the patient entering the operating room to incision was 39.0 ± 9.8 minutes. Immediate post-service tasks took 26.6 ± 7.2 minutes, and discharge coordination tasks took 122.1 ± 33.9 minutes. Overall, tasks measured took 231.6 minutes and were allotted only 208 minutes by the 2019 RUC. All phases of perioperative work took longer at ambulatory surgical centers relative to other settings, particularly discharge coordination, which took an average of 140.3 minutes (P = 0.043).

Conclusion: Outpatient arthroplasty requires at least the same amount of perioperative work as traditional inpatient arthroplasty. Further, our results suggest surgical teams are doing more work than is currently valued by the RUC. Policymakers should take this information into consideration while evaluating TKA and THA as these procedures continue to move to the outpatient setting.

Background: The purpose of this study was to compare the effect of spinal anesthesia (SA) versus general anesthesia (GA) on acute 90-day outcomes in same-day discharge (SDD) total hip (THA) and total knee arthroplasty (TKA) patients, including subgroup analysis of peripheral nerve block usage.

Methods: A retrospective review of 1,002 SDD patients (402 THAs, 600 TKAs) was performed, including 868 and 134 undergoing SA and GA, respectively. All patients received periarticular injections and multimodal analgesia; 80% of THAs received a paravertebral block (PVB), and 58% of TKAs received an adductor canal block (ACB). Intraoperative and postoperative narcotic usage (morphine milligram equivalents, MMEs) through SDD, numerical pain scores, first ambulation distance, hospital length of stay, and 90-day complications (readmissions or reoperations) were compared.

Results: The SA performed in SDD THA resulted in decreased intraoperative MME (0.1 versus 8.7, P < 0.01), postoperative MME (12.3 versus 16.1, P < 0.02), and pain scores (1.6 versus 3.8, P < 0.01). A similar result was found in TKA, as SA patients had decreased intraoperative MME (0.1 versus 13.1, respectively, P < 0.01), postoperative MME (9.7 versus 15.5, P < 0.01), and pain scores (1.5 versus 3.2, P < 0.01). There was no difference in hospital length of stay between groups, but THA patients undergoing GA showed an increased 90-day readmission rate (4.8 versus 0.3%, P < 0.01). For SA, the use of PVBs in THA reduced postoperative MMEs and pain scores, while there were minimal effects with ACBs in TKA.

Conclusions: For SDD THA and TKA patients, SA improved intraoperative and immediate postoperative pain control compared to GA without affecting acute recovery. The use of PVBs modestly improved acute pain for THA, while ACBs for TKA did not demonstrate the same effect in the setting of contemporary multimodal analgesia.

Level of evidence: Level 4, retrospective review.

Background: Perioperative glycemic control is considered a modifiable risk factor prior to primary total hip and total knee arthroplasty; however, it is still unknown whether preoperatively optimizing hemoglobin A1C values affects perioperative glucose control or postoperative complications. The purpose of this study was to compare patients who required preoperative diabetes mellitus (DM) optimization in the year prior to surgery (defined as hemoglobin A1C ≥ 8%) versus patients who had DM who did not require preoperative DM optimization to compare (1) postoperative glycemic control and (2) 90-day complications and incidence of revision arthroplasty.

Methods: This was a retrospective single-center analysis. Patients undergoing primary total joint arthroplasty who had a diagnosis of DM (hemoglobin A1C greater than 6.5%) were eligible for inclusion (N = 585). Patients who had previously uncontrolled DM requiring optimization (hemoglobin A1C ≥ 8.0%) in the year prior to surgery (N = 164) were compared to patients who had controlled DM (N = 421). All patients had hemoglobin A1C less than 8% preoperatively. Outcomes included median and peak perioperative glycemic control (postoperative day zero to two), 90-day complications, and incidence of revision arthroplasty at the final follow-up (mean 64 months). Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.

Results: Early postoperative median serum glucose and peak serum glucose were similar between patients who had controlled versus optimized DM. Higher preoperative hemoglobin A1C and peak hemoglobin A1C in the year prior to surgery were associated with worse median and peak serum glucose. The 90-day complication rates were similar in patients needing DM optimization versus controlled DM patients (odds ratio 1.67, 95% confidence interval 0.91 to 2.88; P = 0.10). Metformin use was independently associated with lower complication rates. Reoperations were similar between patients requiring preoperative DM optimization versus controlled DM (odds ratio 1.60, 95% confidence interval 0.59 to 4.36, P = 0.35).

Conclusions: This study suggests that the need for DM optimization does not affect perioperative glucose control, postoperative complications, or reoperations, suggesting that efforts to optimize hemoglobin A1C prior to total hip and total knee arthroplasty are warranted.

Background: Although multiple studies have examined the efficacy of muscle-sparing techniques in reducing dislocation after posterior approach THA, their findings are limited by small sample sizes and short follow-up durations, and to our knowledge, none have specifically evaluated outcomes in high-risk patients. This study compared the overall and 90-day dislocation risks of the previously described external rotator preservation (ERP) and standard posterior approach THA in high-risk patients.

Methods: We retrospectively reviewed patients who underwent THA between January 2008 and December 2022 at three tertiary centers, including those who had osteonecrosis of the femoral head (ONFH), inflammatory arthritis (IA), or a history of lumbar spinal fusion. Patients who underwent the ERP approach were identified from medical records and matched 1:1 to controls (standard posterior approach) by age, sex, body mass index, American Society of Anesthesiologists score, year of surgery, and surgical indication, yielding 501 patients per group. Binary logistic regressions were used to compare overall and 90-day dislocation risk. Kaplan-Meier analysis evaluated revision due to dislocation and all-cause revision. Surgical complications, Harris Hip Score (HHS), and postoperative radiographic parameters were compared. The mean follow-up was 10.7 years.

Results: The ERP group showed lower overall (odds ratio, 0.25; P < 0.001) and 90-day dislocation risks (odds ratio, 0.20; P = 0.002). Subgroup analyses revealed reduced dislocation risks in the ONFH and IA patients, with no difference in the lumbar spinal fusion subgroup. The estimated 10-year survivorship free from both revision for dislocation (P = 0.302) and any revision (P = 0.739) was similar. Other complications, the latest Harris Hip Score, and radiographic parameters were comparable.

Conclusions: The ERP approach for THA demonstrated lower overall and 90-day dislocation rates compared to the standard posterior approach in patients at high risk of dislocation without compromising long-term outcomes. The ERP may serve as an effective option for performing posterior approach THA in ONFH and IA patients.

Level of evidence: Level III, retrospective cohort study.

Background: The obesity epidemic has given rise to a growing number of patients who have a body mass index (BMI) exceeding 50. As BMI cutoffs are no longer recommended, arthroplasty surgeons continue to push the limits of surgical feasibility in total hip arthroplasty (THA) despite possible risks.

Methods: A retrospective cohort study of patients who underwent primary THA (N = 7,458) was developed, comparing outcomes between patients who had a BMI ≥ 50 (N = 147) and those of other weight classes. We used Cox proportional hazard models to estimate the association between patient BMI and revision risk using overweight patients (BMI 25 to 30) as the reference group. Patients entered the study cohort on their date of surgery and exited on the earliest of the date of revision, date of death, or the end of the study. Patient-reported outcome measures were compared pre- and postoperatively.

Results: Increased obesity class led to a gradient of elevated revision risk. In the first year after surgery, THA patients who had a BMI ≥ 50 demonstrated an adjusted hazard ratio (for revision of 11.8 (95% confidence interval [CI] 5.3 to 26.2). This risk was also elevated in patients who had a BMI of 40 to 50 (N = 635, hazard ratio = 3.8, 95% CI = 1.9 to 7.7). Although the patients who had a BMI ≥ 50 had a significantly worse preoperative Oxford-12 Hip score than other overweight patients, at five years, this difference was negligible.

Conclusions: There was an increased risk of early THA revision surgery in patients who had a BMI ≥ 50. This risk plateaued after the first year and was equivalent to other weight classes afterward. Despite worse preoperative function and greater failure rates, this population reports major benefits and high satisfaction with THA. The risk of THA appears to be worth it for most patients who have a BMI ≥ 50.

Background: Early postoperative pain control after total knee arthroplasty (TKA) plays a crucial role in patient satisfaction following surgery. Despite current multimodal pain management strategies, postoperative pain remains a concern for patients and can hinder the decision to undergo TKA. With the advent of intraosseous (IO) analgesic injections, the efficacy of IO multimodal analgesic cocktail administration compared to standard periarticular (PA) injections remains controversial.

Methods: A prospective randomized controlled trial was conducted comparing 45 patients who received an IO multimodal cocktail injection (five mg of morphine, 30 mg of ketorolac, 20 mL of 0.5% bupivacaine, and 0.6 mL of 1:1,000 epinephrine) with 45 patients who received a standard PA cocktail injection. A total of 43 patients in each group completed the study. Postoperative visual analog scale for pain at rest and during motion, morphine consumption, functional outcomes, and postoperative complications were recorded.

Results: In the IO group, visual analog scale for pain was significantly lower both at rest and during motion at four, six, and 12 hours, as well as two weeks postoperatively. The Timed Up and Go test was faster in the IO group at 48 hours, but not at two weeks. However, morphine consumption, time to start walking, time to discharge, postoperative range of motion, and complications showed no differences up to two weeks.

Conclusions: Intraosseous multimodal cocktail injection resulted in better pain control compared to PA injection during the early postoperative period, as well as improved function in the Timed Up and Go test at 48 hours after TKA, without increasing postoperative complications.

Level of evidence: Therapeutic Level I.