Faculty Bibliography

As perioperative protocols have improved, there has been a reduction in the rates of key complications after hip and knee arthroplasty. Likewise, as we have been able to make patients more comfortable postoperatively, hospital length of stay has decreased and in some centers, hip and knee arthroplasty is now routinely performed as an outpatient. While the number of surgeons offering this option and patients choosing to have procedures performed as an outpatient grows, many questions revolve around this movement. This article will review the data supporting outpatient arthroplasty, the business and legal aspects involved, if surgeons can align with their hospital to offer these services, and how tightly knit and highly organized teams are key to the success of safely offering hip and knee arthroplasty on an outpatient basis.

BACKGROUND:Patellar maltracking is a potential surgical complication following total knee arthroplasty (TKA) and can result in anterior knee pain, recurrent patellar dislocation, and damage to the medial patellar soft tissue stabilizers. Data remain unclear as to whether the patellar button should be revised during a revision TKA (rTKA) if changing the component implant system. Our study examines whether retaining the original patellar button during an rTKA using a different implant system affects patellar tracking. METHODS:A retrospective cohort study of rTKA patients between August 2011 and June 2019 was performed at an urban, tertiary referral center. Patients were divided into 2 cohorts depending on whether their retained patella from their primary TKA was of the same (SIM) or different implant manufacturer (DIM) as the revision system used. Radiographic measurements were performed on preoperative and postoperative knee radiographs and differences were compared between the 2 groups. Baseline demographic data were also collected. RESULTS:Of the 293 consecutive, aseptic rTKA cases identified, 122 underwent revision in the SIM cohort and 171 in the DIM cohort. There were no demographic differences between the groups. No statistical significance was calculated for differences in preoperative and postoperative patellar tilt or Insall-Salvati ratio between the groups. The DIM group was found to have more lateral patellar translation (-0.01 ± 6.09 vs 2.68 ± 7.61 mm, P = .001). However, when calculating differences in the magnitude of the translation (thereby removing differences due to laterality), no difference was observed (0.06 ± 3.69 vs 0.52 ± 4.95 mm, P = .394). CONCLUSION/CONCLUSIONS:No clinically significant differences in patellar tracking were observed when the original patellar component was retained and a different revision implant system was used. Given the inherent risks of bone loss and fracture with patellar component revision, surgeons performing rTKA may retain the primary patella if it is well fixed and can still expect appropriate patellar tracking regardless of the revision implant system used. LEVEL OF EVIDENCE/METHODS:III, Retrospective cohort study.

BACKGROUND:Tranexamic acid (TXA) is increasingly used to minimize blood loss during total joint arthroplasty (TJA). Although TXA has been shown to be highly effective in reducing operative blood loss, many surgeons believe that it places patients with coronary artery disease (CAD) or a history of coronary stents at an increased risk for myocardial infarction. The purpose of this study was to determine if TXA is safe to use in patients with a history of CAD or coronary stents. METHODS:We performed a retrospective analysis at a single, tertiary academic medical center identifying consecutive total hip and knee arthroplasty cases over an 8-year period. From this cohort who received TXA intraoperatively, we identified patients with a history of CAD or coronary stents and determined the total myocardial infarction and venous thromboembolism (VTE) rates within a 90-day postoperative period. Chi-square analyses were used to identify differences in VTE rates between cohorts. A post hoc power analysis was also performed to determine whether our results were powered to detect a difference in VTE rates. RESULTS:In the 26,808 identified at-risk patients, there were no postoperative myocardial infarctions. No significant differences were observed for VTE rates compared with the control cohort using either topical or intravenous TXA, with regard to CAD (0.29% compared with 0.76%; p = 0.09) or coronary stents (0% compared with 0.76%; p = 0.14). Moreover, there was no significant difference observed in VTE rates when administration was subcategorized into intravenous and topical methods with regard to CAD (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0). CONCLUSIONS:In our series, topical and intravenous TXA were equally safe when used in patients with a history of CAD and coronary stents in comparison with the control cohort. With equal efficacy and risk of adverse events, we recommend intravenous TXA, which may enable easier institutional implementation. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:As the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department. METHODS:A retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution's average payment for Medicare readmissions and observations, actual and potential savings were calculated. RESULTS:Sixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status. CONCLUSION/CONCLUSIONS:At our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.

The purpose of this study was to investigate whether preoperative opioid use had any effect on clinical outcomes and patient-reported outcome measures (PROMs) before and after primary, elective total hip arthroplasty (THA). The authors retrospectively reviewed 793 patients who underwent primary THA from November 2018 to March 2020 with available PROMs. Patients were stratified into two groups based on whether or not they were taking opioids preoperatively. Demographics, clinical data, and PROMs (Forgotten Joint Score-12 [FJS-12], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Veterans RAND 12 [VR-12] Physical Component Score [PCS] and Mental Component Score [MCS]) were collected at various time periods. Demographic differences were assessed with chi-square and independent sample t tests. Clinical data and PROMs were compared using multilinear regressions. Seventy-five (10%) patients were preoperative opioid users and 718 (90%) were not. Preoperative opioid users had a longer stay (1.37 vs 1.07 days; P=.030), a longer surgical time (102.44 vs 90.20 minutes; P=.001), and higher all-cause postoperative emergency department visits (6.7% vs 2.1%; P=.033) compared with patients not taking opioids preoperatively. Preoperative HOOS, JR (46.63 vs 51.26; P=.009), VR-12 PCS (27.79 vs 31.53; P<.001), and VR-12 MCS (46.24 vs 49.33; P=.044) were significantly lower for preoperative opioid users, but 3-month and 1-year postoperative scores were not statistically different. At 3 months and 1 year, FJS-12 scores did not differ significantly. Mean improvement preoperatively to 1 year in HOOS, JR values exceeded the minimal clinically important difference, with preoperative opioid users experiencing a greater improvement (36.50 vs 33.11; P=.008). Preoperative opioid users had a longer stay, a longer surgical time, and higher all-cause emergency department visits compared with preoperatively opioid naïve patients. Although preoperative opioid users reported significantly lower preoperative PROMs, they did not statistically differ postoperatively, which indicates a larger delta improvement and similar benefits following THA. [Orthopedics. 2021;44(2):77-84.].

Limb alignment is a critically important factor to consider in the management of the patient with knee arthritis. Abnormal alignment is associated with the accelerated progression of osteoarthritis and, if not addressed at the time of surgery, may contribute to early failure of knee replacement implants. The contribution of the hindfoot to overall limb alignment has received limited attention in the context of deformity correction in total knee arthroplasty (TKA). In this review, we present evidence supporting the inclusion of the hindfoot in the consideration of overall limb alignment for TKA and propose a management algorithm.

A critical component in the evaluation of a patient with a periprosthetic hip fracture is determination of stem stability. Failure to critically evaluate preoperative radiographs and subsequently intraoperative stem position may result in an incorrect treatment algorithm and early catastrophic failure of the implant construct. In 2018, this is becoming a larger issue as demand for revision total hip arthroplasty increases. Several factors contribute to the type of implant used in these fractures and depend on age, activity level, comorbidities, and available bone stock. The purpose of this article is to review the evaluation of periprosthetic hip fractures around a loose stem and provide tips and tricks for their management to allow for a successful, long-lasting outcome.

As the demand for total hip arthroplasty (THA) continues to increase, the burden of revision THA is also expected to increase. Although the quality of polyethylene has improved markedly, osteolysis continues to be a risk for older designs and younger, active patients. Although progressive but typically asymptomatic in early stages, osteolysis can result in component failure and complicate revision surgery. Serial radiographs are paramount for monitoring progression. Although select cases may be treated with observation, surgery should be considered based on age, activity level, and projected life span. Well-fixed, noncemented modular acetabular components may be treated with curettage and bone grafting, as well as having to bear liner exchange with retention of the acetabular shell. However, in the setting of osteolysis, it is controversial whether bone grafting and component retention is superior to cup revision. This review explores the pathophysiology of osteolysis after THA and provides a comprehensive analysis of the evaluation and treatment of patients with osteolysis.

Interprosthetic femur fractures are a rare but serious complication following total hip and knee arthroplasty. Classification systems have focused not only on diagnosis but also on treatment algorithm. Critical to the evaluation of patients with these fractures are an assessment of fracture location, bone quality, and the presence of stemmed implants. The gold standard for fracture fixation is locked plating with bicortical and unicortical screws, supplemented with wires or cables as needed. For patients with compromised bone stock or insufficient bony area for fixation, allograft augmentation with struts or interprosthetic sleeves may be used. For fractures with severe bone loss, conversion to a megaprosthesis or total femur replacement may be warranted.

There currently exists an array of operative strategies to manage Lisfranc injuries. Modular fixation systems present surgeons with a choice between fully threaded solid cortical (FSC) and partially threaded cannulated cancellous (PCC) bone screws when using a transarticular screw approach. It is currently unknown how screw design influences fixation strength in Lisfranc reconstructions. The purpose of this study was to evaluate the biomechanical differences of FSC and PCC screws using a cadaveric model of a simulated Lisfranc injury and controlled benchtop experiments. Ten matched pairs of cadaveric feet received an acute Lisfranc injury and were repaired with FSC or PCC screws. Diastasis was measured between the medial and intermediate cuneiforms and the first and second metatarsals during simulations of partial weight bearing. Three-point bending and axial pull-out tests were performed to characterize screw mechanics that could not be measured within the cadaveric model. Screw design did not affect cuneiform or metatarsal diastasis. Neither screw loosening nor deformation was observed following cadaveric testing. Bending tests indicated FSC screws had higher ultimate strength, but there was no significant difference in yield load. Partially threaded cannulated cancellous bone screws exhibited superior axial pull-out strength. Fully threaded solid cortical and PCC screws provide equal amounts of fixation strength during partial weight bearing and similar resistance to deformation under bending loads. Partially threaded cannulated cancellous screws may simplify the operative procedure and minimize nonoptimal screw placement. If a clinician so desires, PCC screws may be used in lieu of FSC screws without sacrificing fixation strength. [Orthopedics. 2018; 41(2):e222-e227.].