Faculty Bibliography

BACKGROUND:The use of perioperative adductor canal blocks (PABs) continues to be a highly debated topic for total knee arthroplasty (TKA). Here, we evaluate the effect of PABs on immediate postoperative subjective pain scores, opioid consumption, and objective functional outcomes. METHODS:On December 1, 2019, an institution-wide policy change was begun to use PABs in primary elective TKAs. Patient demographics, immediate postoperative nursing documented pain scores, opioid administration events, and validated physical therapy functional scores were prospectively collected as part of the standard of care and retrospectively queried through our electronic data warehouse. A historical comparison cohort was derived from consecutive patients undergoing TKA between July 1, 2019 and November 30, 2019. RESULTS:405 primary TKAs received PABs, while 789 patients were in the control cohort. Compared with controls, average verbal rating scale pain scores were lower among PAB recipients from 0-12 hours (2.42 ± 1.60 vs 2.05 ± 1.60; <.001) and 24-36 hours (4.92 ± 2.00 vs 4.47 ± 2.27; <.01). PAB recipients demonstrated significantly lower opioid consumption within the first 24 hours (44.34 ± 40.98 vs 36.83 ± 48.13; P < .01) and during their total inpatient stay (92.27 ± 109.81 vs 77.52 ± 123.11; <.05). AM-PAC scores within the first 24 hours were also higher for PABs (total scores: 20.28 ± 3.06 vs 20.71 ± 3.12; <.05). CONCLUSION/CONCLUSIONS:While the minimal clinically important differences in pain scores and functional status were comparable between both cohorts, patients demonstrated a significant reduction in overall inpatient opiate consumption after the introduction of PABs. Surgeons should consider these findings when evaluating for perioperative pain management, opioid-sparing, and rapid discharge protocols.

BACKGROUND:Use of computer-assisted navigation (CAN) and robotic-assisted (RA) surgery in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) both necessitate the use of tracking pins rigidly fixed to the femur and tibia. Although periprosthetic fractures through tracking pin sites are rare, there is a paucity of literature on this potential complication. Therefore, the purpose of this study was to perform a systematic review of the current literature to assess the incidence and clinical outcomes of periprosthetic fractures through tracking pin sites following CAN and RA TKA and UKA. METHODS:A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using the PubMed, MEDLINE, and Cochrane databases in April 2020. Studies were assessed for the presence of pin site fractures, fracture characteristics, and clinical outcomes. RESULTS:Seventeen clinical studies (5 case series, 1 cohort study, and 11 case reports) involving 29 pin-related fractures were included for review. The overall incidence ranged from 0.06% to 4.8%. The mean time from index arthroplasty to fracture was 9.5 weeks (range, 0 to 40 weeks). The majority of fractures occurred in the femoral diaphysis (59%). Nineteen fractures (66%) were displaced and 10 (34%) were nondisplaced or occult. The majority of cases were atraumatic in nature or involved minor trauma and were typically preceded by persistent leg pain. A transcortical pin trajectory, large pin diameter (>4 mm), diaphyseal fixation, multiple placement attempts, and the use of non-self-drilling, non-self-tapping pins were the most commonly reported risk factors for pin-related periprosthetic fractures following CAN or RA TKA. CONCLUSIONS:Surgeons should maintain a high index of suspicion for pin-related fractures in patients with ongoing leg or thigh pain after CAN or RA TKA in order to avoid fracture displacement and additional morbidity. As CAN and RA TKA have unique complication risks, the debate regarding the value of technology-assisted TKA and its cost-effectiveness continues. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years. METHODS:A retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences. RESULTS:Elective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort's (n = 554) (P < .0001). For nonelective THA cases, the older cohort's (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001). CONCLUSION/CONCLUSIONS:Although primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.

INTRODUCTION/BACKGROUND:There is debate regarding whether the use of computer-assisted technology, such as navigation and robotics, has any benefit on outcomes or patient-reported outcome measures (PROMs) following total knee arthroplasty (TKA). This study aims to report on the association between intraoperative use of technology and outcomes in patients who underwent primary TKA. METHODS:We retrospectively reviewed 7096 patients who underwent primary TKA from 2016-2020. Patients were stratified depending on the technology utilized: navigation, robotics, or no technology. Patient demographics, clinical data, Forgotten Joint Score-12 (FJS), and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) were collected at various time points up to 1-year follow-up. Demographic differences were assessed with chi-square and ANOVA. Clinical data and PROMs were compared using univariate ANCOVA, controlling for demographic differences. RESULTS:A total of 287(4%) navigation, 367(5%) robotics, and 6442(91%) manual cases were included. Surgical-time significantly differed between the three groups (113.33 vs 117.44 vs 102.11; P < .001). Discharge disposition significantly differed between the three groups (P < .001), with more manual TKA patients discharged to a skilled nursing facility (12% vs 8% vs 15%; P < .001) than those who had technology utilized. FJS scores did not statistically differ at three-months (P = .067) and one-year (P = .221). We found significant statistical differences in three-month KOOS, JR scores (59.48 vs 60.10 vs 63.64; P = .001); however, one-year scores did not statistically differ between all groups (P = .320). CONCLUSION/CONCLUSIONS:This study demonstrates shorter operative-time in cases with no utilization of technology and clinically similar PROMs associated with TKAs performed between all modalities. While the use of technology may aid surgeons, it has not currently translated to better short-term outcomes. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort.

BACKGROUND:Obesity is a growing public health concern. This study aims to identify the association of body mass index (BMI) on postoperative Forgotten Joint Score-12 (FJS-12) in patients undergoing primary total hip arthroplasty (THA). METHODS:):<30 (nonobese) and ≥30 (obese). FJS-12 scores were collected postoperatively at 3 months, 1 year, and 2 years. Demographic differences were assessed with chi-square and independent sample t-tests. Mean scores between the groups were compared using multilinear regression analysis, controlling for demographic differences. RESULTS:Of the 2130 patients included, 1378 were nonobese, and 752 were obese. Although obese patients reported lower FJS-12 scores all time periods, there were no statistical differences between the two groups at 3 months (53.61 vs 49.62;P = .689), 1 year (68.11 vs 62.45; P = .349), and 2 years (73.60 vs 65.58; P = .102). A subanalysis comparing patients who were of normal BMI (<25), overweight (25.0-29.9), and obese (≥30) followed a similar inverse trend in scores but showed no statistical differences at all postoperative time points (3m:P = .612,1y:P = .607,2y:P = .253). Mean improvement in FJS-12 scores from 3 months to 1 year (14.50 vs 12.83; P = .041), 1 year to 2 years (5.49 vs 3.13; P = .004), and from 3 months to 2 years (20.00 vs15.96; P < .001) were significantly greater for nonobese patients compared to obese patients. CONCLUSION/CONCLUSIONS:While obesity trended toward lower FJS-12 scores, the differences in scores were not statistically significant compared to nonobese patients. BMI did not influence overall FJS-12 scores; however, obese patients achieved a slightly smaller statistical improvement during the first 2 years, though this may not be clinically significant. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

PURPOSE/OBJECTIVE:Blood loss during and following elective total hip arthroplasty (THA) can be substantial and may require allogeneic blood transfusions which carries significant risks and morbidity for patients. Intraoperative use of tranexamic acid (TXA) has been proven to reduce the need for allogeneic blood transfusion in elective THA patients. Data regarding TXA efficacy in reducing blood loss in trauma patients undergoing non-elective primary THA is sparse, and its routine use is not well established. METHODS:This is a retrospective analysis of a consecutive cohort of patients who underwent non-elective primary THA in a tertiary medical center between January 1st 2011- December 31st 2019. The cohort was divided into two groups; one received perioperative TXA treatment while the other did not. Blood loss, blood product administration, peri and postoperative complications, readmissions and 1-year mortality were compared between groups. RESULTS:A total of 419 patients (146 males, 273 females) who underwent THA were included in this study. The "TXA" group consisted 315 patients compared to 104 patients in the "no TXA" group. TXA use reduced postoperative bleeding, as indicated by changes in hemoglobin levels before and after surgery (ΔHb= -2.75 gr/dL vs. ΔHb= -3.34 gr/dL, p<0.001) and by administration of allogeneic blood transfusions (7.0% vs. 16.3%, p = 0.004). CONCLUSION/CONCLUSIONS:Similar to the known effect of TXA in elective THA patients, the use of TXA treatment in patients undergoing non-elective THA led to a significant reduction in postoperative blood loss and in the proportion of patients requiring allogeneic blood transfusions.

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%.

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

BACKGROUND:The effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA. METHODS:A search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (ΔKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for ΔKSS (⍺ = 0.05; power = 80%). Differences between cohorts were assessed. RESULTS:About 195 TKAs were identified for each cohort. ΔKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P = .86) and 11.1° vs 10.0° (P = .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P = .59), aseptic loosening (0.5%, 0.5%; P = 1.0), instability (0.5%, 0.5%; P = 1.0), all-cause revision for stiffness (3.1%, 2.1%; P = .52), manipulation under anesthesia (2.1%, 2.1%; P = 1.0), and liner exchange (0.5%, 0%; P = .32). CONCLUSION:The results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique.