Faculty Bibliography

BACKGROUND:Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients. METHODS:A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications. RESULTS:The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION/CONCLUSIONS:Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

BACKGROUND:Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. METHOD/METHODS:This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. RESULTS:Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). CONCLUSIONS:Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III. CLINICAL RELEVANCE/CONCLUSIONS:This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Larsen syndrome is a rare genetic disorder characterized by weak connective tissues and various musculoskeletal abnormalities. This is a case report of a 39-year-old patient with Larsen syndrome who presented with over a decade of bilateral hip pain and difficulty ambulating. This patient has a prior history of bilateral congenital hip dislocations that were treated with open reduction and spica casting as a child with good result. Years later, she went on to develop bilateral hip osteoarthritis with significant remodeling of the proximal femur. The goal of this case presentation is to demonstrate the utility of total hip arthroplasty for this patient and discuss surgical challenges and considerations.

INTRODUCTION/BACKGROUND:The term "spinopelvic mobility" is most often applied to motion within the spinopelvic segment. It has also been used to describe changes in pelvic tilt between various functional positions, which is influenced by motion at the hip, knee, ankle and spinopelvic segment. In the interest of establishing a consistent language for spinopelvic mobility, we sought to clarify and simplify its definition to create consensus, improve communication, and increase consistency with research into the hip-spine relationship. METHODS:A literature search was performed using the Medline (PubMed) library to identify all existing articles pertaining to spinopelvic mobility. We reported on the varying definitions of spinopelvic mobility including how different radiographic imaging techniques are used to define mobility. RESULTS:The search term "spinopelvic mobility" returned a total of 72 articles. The frequency and context for the varying definitions of mobility were reported. 41 papers used standing and upright relaxed-seated radiographs without the use of extreme positioning, and 17 papers discussed the use of extreme positioning to define spinopelvic mobility. DISCUSSION/CONCLUSIONS:Our review suggests that the definitions of spinopelvic mobility is not consistent in the majority of published literature. We suggest descriptions of spinopelvic mobility independently consider spinal motion, hip motion, and pelvic position, while recognizing and describing their interdependence.

INTRODUCTION/BACKGROUND:High body mass index (BMI) and wound drainage following total joint arthroplasty (TJA) can lead to wound healing complications and periprosthetic joint infection. Silver-embedded occlusive dressings and negative pressure wound therapy (NPWT) have been shown to reduce these complications. The purpose of this prospective trial was to compare the effect of silver-embedded dressings and NPWT on wound complications in patients with BMI ≥ 35 m/kg2 undergoing TJA. METHODS:and were undergoing primary TJA between October 2017 and February 2020. Patients who underwent revision surgery, or those with an active infection, previous scar, history of wound healing complications, post-traumatic degenerative joint disease with hardware, or inflammatory arthritis were excluded. Patients were randomized to receive either a silver-embedded occlusive dressing (control) or NPWT. Frequency distributions, means, and standard deviations were used to describe patient demographics, postoperative complications, 90-day readmissions, and reoperations. T-test and chi-squared tests were used to test for significant differences between continuous and categorical variables, respectively. RESULTS:Two hundred-thirty patients with 3-month follow-up were included. One-hundred-fifteen patients received the control and 115 patients received NPWT. There were six patients (5.2%) in the control group with wound complications (drainage: n = 5, non-healing wound: n = 1) and two patients (1.7%) in the NPWT with complications (drainage: n = 2). There were no 90-day readmissions in the control group versus two (1.8%) 90-day readmissions in the NPWT group. Finally, three patients (2.6%) in the control group underwent reoperations (irrigation and debridement [I&D], I&D with modular implant exchange, and implant revision), while none in the NPWT group had undergone reoperation. The two groups showed insignificant differences in wound complications (p = 0.28), 90-day readmissions (p = 0.50), and reoperations (p = 0.25). CONCLUSION/CONCLUSIONS:Patients with BMI ≥ 35 m/kg2 undergoing TJA have no statistical difference in early wound complications, readmissions, or reoperations when treated with either silver-embedded dressings or NPWT.

BACKGROUND:Metabolic syndrome (MetS) includes interrelated conditions such as insulin resistance, abdominal obesity, hypertension, and dyslipidemia. This study sought to determine the association of MetS in morbidly obese patients (body mass index >40) on complications and clinical outcomes after primary total knee arthroplasty (TKA). METHODS:A retrospective review was performed to include all morbidly obese patients who underwent primary elective TKA for osteoarthritis at a single academic institution. Patients who did and did not have MetS were propensity-matched 1:1 based on baseline characteristics. A total of 391 patients who did and 935 who did not have MetS were included having a mean body mass index of 44.2 (range, 40.0 to 68.9). RESULTS:The MetS patients had longer lengths of stay (LOS) (3.5 ± 2.4 versus 3.0 ± 1.5 days, P = .001) and were more likely to be discharged to skilled nursing facilities (23.8 versus 15.3%, P = .007). At 90 days postoperatively, major (P = .756) and minor (P = .652) complication rates and readmissions (P = .359) were similar. Revision rates as well as improvements in KOOS-JR, and VR-12 mental and physical component scores from preoperative to 1 year (P = .856, P = .524, and P = .727, respectively) postoperatively did not significantly differ between groups. MetS and non-MetS patients had similar 5-year freedom from all-cause revision (90.2 versus 94.2%, P = .791). CONCLUSION/CONCLUSIONS:Morbidly obese patients who have MetS had longer LOS and higher discharges to skilled nursing facilities. The 90-day complications, readmissions, revision rates, and patient-reported outcomes were similar, suggesting that resource allocation should be focused on perioperative protocols that can help optimize LOS and discharge dispositions in morbidly obese MetS patients undergoing TKA. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS:A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS:A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION/CONCLUSIONS:Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

Background: National projections of future joint arthroplasties are useful in understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for revision total joint arthroplasty procedures from 2040 through 2060.
Method(s): The study uses 2000-2019 data from the CMS Medicare Part-B National Summary and combines procedure counts using CPT codes for revision total joint arthroplasty procedures. In 2019, revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) procedures totaled 53,217 and 30,541, respectively, forming a baseline from which we generated point forecasts between 2020 and 2060 and 95% forecast intervals (FI).
Result(s): On average, the model projects an annual growth rate of 1.77% for rTHAs and 4.67% for rTKAs. By 2040, rTHAs were projected to be 43,514 (95% FI = 37,429-50,589) and rTKAs were projected to be 115,147 (95% FI = 105,640-125,510). By 2060, rTHAs was projected to be 61,764 (95% FI = 49,927-76,408) and rTKAs were projected to be 286,740 (95% FI = 253,882-323,852).
Conclusion(s): Based on 2019 total volume counts, the log-linear exponential model forecasts an increase in rTHA procedures of 42% by 2040 and 101% by 2060. Similarly, the estimated increase for rTKA is projected to be 149% by 2040 and 520% by 2060. An accurate projection of future revision procedure demands is important to understand future healthcare utilization and surgeon demand. This finding is only applicable to the Medicare population and demands further analysis for other population groups.
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BACKGROUND:Intra-articular hyaluronic acid (IAHA) has been commonly used in the management of knee osteoarthritis (OA). This study sought to assess patient-reported outcomes (PRO) following different formulations of hyaluronic acid injections for patients who have knee OA. METHODS:A retrospective analysis was performed on patients who have knee OA and received IAHA knee injections from October 2018 to May 2022 in sports medicine (SM) and adult reconstructive (AR) clinics. Patients completed PRO measures including the Patient-Reported Outcome Measurement Information System (PROMIS) Mobility, Pain Interference, and Pain Intensity at baseline, 6-week, 6-month, and 12-month follow-up. Univariate and multivariate analyses were used to evaluate changes in PRO measures between baseline and follow-up periods and to evaluate differences between the SM and AR divisions. A total of 995 patients received IAHA for knee OA and completed PRO assessments. RESULTS:There was no difference in the PROMIS measures based on molecular weight at 6 weeks, 6 months, and 12 months. Except for 6-month Mobility scores between the SM and AR patients (-0.52 ± 5.46 versus 2.03 ± 6.95; P = .02), all other PROMIS scores were similar. Mobility scores at 6 months were significantly different based on Kellgren and Lawrence grade (P = .005), but all other PROMIS scores were similar. CONCLUSION/CONCLUSIONS:Average change in PROMIS scores were significantly different only for 6-month Mobility scores based on divisions and Kellgren and Lawrence grade but did not achieve minimally clinical important difference at most timepoints. Further studies are needed to investigate whether improvement is observed in specific patient populations.