Faculty Bibliography

Past studies have shown successful outcomes regarding the use of various interventional education methods in improving patient compliance. At our institution, different educational resources are offered and encouraged, including a 2-hour-long educational class, to prepare patients who are undergoing total joint arthroplasty procedures. Given the significant impact that patient compliance with preoperative instruction can have on overall outcomes of these procedures, this study was intended to assess the effects that the educational classes can have on patient compliance with this institution's 6-point preoperative total joint arthroplasty protocol. The study analyzed 2 groups, those who did and did not attend the preoperative classes, and compliance rates were compared between the 2. It was hypothesized that patients who did attend the classes would be more compliant to the protocol compared to those who did not. Although results from the study showed that there were no significant differences in adherence between the 2 groups, future quality assessment studies can build off this in order to move toward achieving optimal patient compliance with preoperative instructions.

Total knee arthroplasty (TKA) is associated with improved patient-reported pain levels, function, and quality of life; however, it is poorly understood whether there is increased physical activity following TKA. Using data from the Osteoarthritis Initiative (OAI), we compare physical activity, as measured using an accelerometer, and patient-reported outcome measures of 60 patients who had already received a TKA with 63 patients who eventually received a TKA during the OAI study. There was no significant difference in activity levels between the two groups as measured by the accelerometer. Total WOMAC, KOOS Quality of Life, KOOS Knee Pain, and KOOS Function scores improved in the post-TKA compared to the pre-TKA group. In both pre-TKA and post-TKA groups, physical activity guidelines were met in only 5% or less.

INTRODUCTION: With this growing demand, the length of stay for total hip arthroplasty (THA) procedures has decreased, and as a trade-off, we have seen a higher utilization of extended care facilities (ECFs). Both trends have significant economic implications on the health care system, and predicting the discharge destinations of THA patients would help policy makers plan for future health expenditures. We performed a retrospective data analysis of a large patient database to determine which variables are significant in predicting discharge destinations of THA patients. METHODS: We used the California Hospital Discharge data set of the year 2010, collected and provided by the Office of Statewide Health Planning and Development. The data set includes information about patient demographics, insurance type, diagnoses and procedures, and patient disposition. The study cohort included 14 326 patients. Discharge to home was the reference category. Discharge to ECF and discharge to home with home care were the 2 additional alternatives. RESULTS: In all, 46.9% of patients were discharged home with home health care, followed by 29.6% to ECF, and 23.5% to home without care. Discharge to ECF was more likely for patients with more comorbidities and a higher age. The strongest predictors were Medicaid and black or Asian race. Medicare relative to private payer was a strong predictor of ECF discharge. Male gender was the only factor that lowered the risk of discharge to ECF. The strongest predictor for discharge to home with home care was black race relative to whites. Medicaid lowered the risk of home care, and gender did not matter. CONCLUSION: This study serves to provide insight on which patient characteristics influence discharge destination after THA. Race, insurance, and morbidity were highly significant factors on patient discharge destination to a subacute nursing facility.

AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA). METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups. RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 +/- 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 +/- 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 +/- 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 +/- 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001). CONCLUSION: TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.

BACKGROUND: Metal hypersensitivity is an uncommon complication after total knee arthroplasty (TKA) that can lead to significant functional impairment and aseptic prosthesis failure. CASE REPORT: We describe a 70-year-old patient who presented with persistent pain, swelling, and instability 2 years after a primary TKA. The patient had a history of metal hypersensitivity following bilateral metal-on-metal total hip arthroplasty (THA) that was revised to ceramic-on-polyethylene implants. Knee radiographs showed severe osteolysis with implant loosening. Serum cobalt was elevated and serum chromium was significantly elevated, while joint aspiration and inflammatory marker levels ruled out a periprosthetic infection. Revision TKA was performed, with intraoperative tissue pathology and postoperative leukocyte transformation testing confirming metal hypersensitivity as the cause for aseptic implant failure. CONCLUSIONS: This case report demonstrates the clinical and laboratory signs that suggest metal hypersensitivity in total knee arthroplasty and the potential for joint function restoration with revision surgery.

The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.

PURPOSE: To investigate the difference in T1rho profiles of the entire femoral cartilage between SPGR and b-FFE sequences at 3.0T. MATERIALS AND METHODS: 20 healthy volunteers were enrolled in this study. T1rho images of each subject were acquired with two types of pulse sequences: SPGR and b-FFE. Femoral cartilage segmentation was performed by two independent raters slice-by-slice using Matlab. Inter- and intra-observer reproducibility between the two imaging protocols was calculated. The relative signal intensity (SI) of cartilage, subchondral bone marrow, joint effusion, and the relative signal contrast between structures of the knee were quantitatively measured. The difference in T1rho values between SPGR and b-FFE sequences was statistically analyzed using the Wilcoxon signed-rank test. RESULTS: The average T1rho value of the entire femoral cartilage with b-FFE was significantly higher compared to SPGR (p<0.05). The reproducibility of the segmented area and T1rho values was superior with SPGR compared to b-FFE. The inter-class correlation coefficient was 0.846 on SPGR and 0.824 on b-FFE. The intra-class correlation coefficient of T1rho values was 0.878 on SPGR and 0.836 on b-FFE. The two imaging techniques demonstrated different signal and contrast characteristics. The relative SI of fluid was significantly higher on SPGR, while the relative SI of subchondral bone was significantly higher on b-FFE (p<0.001). There were also significant differences in the relative contrast between fluid-cartilage, fluid-subchondral bone, and cartilage-subchondral bone between the two sequences (all p<0.001). CONCLUSION: We need to pay attention to differences in T1rho values between SPGR and b-FFE in clinical applications.

BACKGROUND: Total knee arthroplasty (TKA) instrumentation and implant designs have been evolving, with one of the current innovations being patient-specific implants (PSIs). PURPOSE: To evaluate whether there is a significant difference in surgical time, intraoperative blood loss, postoperative range of motion, and length of stay between PSI and conventional TKA. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive series of 621 TKA patients, 307 with PSIs and 314 with conventional implants, was reviewed. Differences in estimated blood loss, length of stay, range of motion, and surgical time/tourniquet time between the 2 cohorts were analyzed. RESULTS: Linear regression analysis demonstrated that PSI decreased estimated blood loss by 44.72 mL (P < .01), decreased length of stay by 0.39 days (P < .01), decreased postoperative range of motion by 3.90 degrees (P < .01), and had a negligible difference on surgical and tourniquet time. CONCLUSION: The use of PSI is associated with decreased estimated blood loss, decreased length of stay, decreased range of motion, and no discernible difference in surgical or tourniquet time, all of which are unlikely to be clinically significant.

Pelvic discontinuity is an uncommon condition that usually presents in the revision total hip arthroplasty population. However, its incidence will most likely increase due to the increasing number of primary and revision total hip arthroplasties (THA) done in recent years. Pelvic discontinuity (acetabular disassociation) is perhaps one of the more challenging cases for the hip arthroplasty surgeon to manage. Historically, the management of pelvic discontinuity has been wrought with many challenges. What follows is a review of the current techniques and outcomes for acetabular reconstruction in patients with acetabular disassociation including: porous metal components, internal fixation with acetabular reconstruction, acetabular distraction with jumbo cups, cup and cage construct, and the use of custom triflange.The complexity of pelvic discontinuity and with the myriad of options available to the hip arthroplasty surgeon to address this particular issue, preoperative planning becomes all the more essential.

This meta-analysis reviewed 12 studies comparing patient-specific instrumentation (PSI) with standard instrumentation (SI) for total knee arthroplasty in terms of postoperative coronal alignment and operation time. There is no significant difference between PSI and SI in terms of hip-knee-ankle angle (overall coronal alignment or mechanical axis), tibial coronal alignment, and operation time.