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Analysis of perioperative outcomes in hip resection arthroplasty

Nazemi, Alireza K; Upfill-Brown, Alexander; Arshi, Armin; Sekimura, Troy; Zeegen, Erik N; McPherson, Edward J; Stavrakis, Alexandra I
BACKGROUND:Hip resection arthroplasty (HRA) is a salvage surgical technique for the management of complex hip conditions wherein arthroplasty may be contraindicated. The purpose of this study was to review modern-day indications for HRA and compare outcomes between patients undergoing HRA and revision total hip arthroplasty (RTHA). METHODS:The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients undergoing HRA or RTHA between 2012 and 2017. Patient demographics, risk factors, and perioperative complications were analyzed. Multivariate regression was used to determine predictors of early postoperative complications. Propensity score matching (PSM) was performed to compare relative risks (RR) of complications in HRA compared to RTHA. RESULTS:290 patients underwent HRA between 2012 and 2017. Infection was the most common indication for HRA (39.8%), followed by femoral neck fracture or malunion/nonunion (26%) and prosthetic instability (12.2%). Increased body mass index (BMI) (p = 0.012) and chronic obstructive pulmonary disease (COPD) (p = 0.007) were associated with increased risk of complication in HRA. There were no significant differences in short-term complication risks between RTHA and HRA. CONCLUSIONS:HRA was associated with short-term complication rates comparable to RTHA. These findings may help in surgical decision-making and appropriate indications in the present day. LEVEL OF EVIDENCE/METHODS:III.
PMID: 33625542
ISSN: 1434-3916
CID: 5233922

The Changing Economic Value and Leverage of Arthroplasty Surgeons: How the Shift in Arthroplasty Surgery Location Impacts the Relationship of Private Surgeons, Hospitals, and Ambulatory Surgery Centers

Arshi, Armin; Wellens, Bryan; Krueger, Chad A
The recent removal of total hip and knee arthroplasty from the Medicare inpatient-only list, COVID-19 pandemic, decreasing reimbursements, and bundled payment programs have all had tremendous impact on the practice of arthroplasty. Surgeons and practices must adapt to these challenges to achieve the ideal triad of quality patient care, low cost to payors, and sustainable financial margins for stakeholders. Here, we review institutional data and present our experience with the changing arthroplasty practice landscape. With the principle of demand matching, arthroplasty surgeons and practices can risk-stratify and shuttle patients in the appropriate operative and rehabilitation setting to optimize quality and efficiency.
PMID: 34942346
ISSN: 1532-8406
CID: 5233972

Navigated and Robot-Assisted Technology in Total Knee Arthroplasty: Do Outcome Differences Achieve Minimal Clinically Important Difference?

Arshi, Armin; Sekimura, Troy; Kelley, Benjamin V; Zeegen, Erik N; Lonner, Jess H; Stavrakis, Alexandra I
BACKGROUND:In total knee arthroplasty (TKA), computer-assisted navigation (N-TKA) and robotic-assisted methods (RA-TKA) are intended to increase precision of mechanical and component alignment. However, the clinical significance of published patient-reported outcome measure (PROM) differences in comparison to conventional TKA (C-TKA) is unknown. METHODS:A systematic review was performed to identify all studies reporting perioperative PROMs for either primary N-TKA or RA-TKA with a C-TKA comparison cohort with a minimum 1-year follow-up. Relative improvements in PROMs for the two cohorts were compared to published minimal clinically important difference (MCID) values. RESULTS:After systematic review, 21 studies (N = 3,214) reporting on N-TKA and eight studies (N = 1,529) reporting on RA-TKA met inclusion criteria. Eighteen of 20 studies (90%) reported improved radiographic outcomes with N-TKA relative to C-TKA; five of five studies reported improved radiographic outcomes with RA-TKA relative to C-TKA. Five of 21 studies (24%) reported statistically significant greater improvements in clinical PROMs for N-TKA relative to C-TKA, whereas only two (10%) achieved clinical significance relative to MCID on a secondary analysis. One of 8 studies (13%) reported statistically significant greater improvements in PROMs for RA-TKA relative to C-TKA, whereas none achieved clinical significance relative to MCID on a secondary analysis. No studies reported a significant difference in revision rates. CONCLUSION/CONCLUSIONS:While most studies comparing RA-TKA and N-TKA with C-TKA demonstrate improved radiographic alignment outcomes, a minority of studies reported PROM differences that achieve clinical significance. Future studies should report data and be interpreted in the context of clinical significance to establish patient and surgeon expectations for emerging technologies.
PMID: 35367335
ISSN: 1532-8406
CID: 5234012

Cemented Versus Noncemented Total Knee Arthroplasty Outcomes

Stavrakis, Alexandra; Arshi, Armin; Chiou, Daniel; Hsiue, Peter; Horneff, John Gabriel; Photopoulos, Christos
INTRODUCTION/BACKGROUND:Aseptic loosening remains one of the most common indications for revision total knee arthroplasty (TKA). Given the demographic shift to a younger and more active TKA patient population, some surgeons have revisited noncemented fixation given its potential for lower rates of long-term aseptic loosening. The purpose of this study was to compare the demographics and complications between patients undergoing noncemented and cemented TKA. METHODS:Using the MKnee subset of the PearlDiver database, diagnosis and procedure codes were used to identify patients who had undergone cemented or noncemented TKA for osteoarthritis with a minimum 2-year follow-up. Propensity score matching was done to compare risk-adjusted medical and surgical complication profiles at 90 days, 1 year, and 2 years. RESULTS:Of 203,574 patients identified, 3.2% underwent noncemented TKA and 96.8% underwent cemented TKA. Using propensity-matched analysis, there was no difference in 90-day medical complications. Noncemented TKA was associated with a greater risk of periprosthetic joint infection throughout the study (90-day odds ratio [OR] 1.34, 1-year OR 1.27, 2-year OR 1.27, P < 0.05). Noncemented TKA was associated with a greater risk of periprosthetic fracture at 1 year and 2 years (1 year OR 2.19, 2 years OR 1.89, P < 0.05). No notable difference was observed in risk of aseptic loosening between the two groups. DISCUSSION/CONCLUSIONS:Noncemented TKA is associated with a higher rate of periprosthetic joint infection and periprosthetic fracture. Additional studies are needed to compare long-term rates of aseptic loosening between noncemented and cemented TKA. LEVEL OF EVIDENCE/METHODS:Level III.
PMID: 35167508
ISSN: 1940-5480
CID: 5233982

Clinical and Radiographic Outcomes of Novel 3D-Printed Highly Porous Knee Cone Design

Tarabichi, Saad; Grau, Luis; Arshi, Armin; Post, Zachary; Ong, Alvin; Hozack, William J
INTRODUCTION:Metaphyseal bone defects seen at revision total knee replacement (TKA) have traditionally been treated with bone graft or cement. Recently, metal augments have surfaced as viable alternatives to conventional methods previously used in these patients. Newer 3D-printed metal cones offer better biological fixation as a means of improving construct stability. This study aimed to determine clinical and radiographic outcomes of the novel 3D-printed titanium cone augments for femoral and tibial metaphyseal bone defects. MATERIALS AND METHODS:A retrospective review was undertaken of 72 patients who underwent revision TKA with metaphyseal cones (Stryker) and stemmed implants from 2015-2017. Knee Injury and Osteoarthritis Outcome Scores (KOOS Jr) and VR/SF-12 scores were recorded. Knee Society radiographic scores were calculated at latest follow up to evaluate for radiolucency and biological fixation. Loosening noted on radiographs and reoperation for any reason were the endpoints to determine survivorship. RESULTS:A total of 68 patients with 78 cones (58 tibial, 20 femoral) met inclusion criteria. Mean follow up was 3.4 years (range 2-5.4 years). The average KOOS Jr score increased from 38 preoperatively to 66 at two years. The average VR/SF-12 PH score increased from 33 preoperatively to 37 at two years. The average VR/SF-12 MH score increased from 46 preoperatively to 54 at two years. Twelve percent of tibial implants and 10% of femoral implants with cones were found to have lucency in at least one radiographic zone. Overall survivorship at latest follow up was 93% with two patients requiring revision for infection, two revised following mechanical complications, and one patient who underwent polyethylene exchange after experiencing mechanical complications. When considering only aseptic loosening, survivorship was 100%. CONCLUSION:This 3D-printed titanium femoral and tibial cone augment system showed excellent survivorship, biological fixation, clinical outcomes, and radiographic outcomes in the setting of TKA. Further studies are needed for assessment of long-term survivorship.
PMID: 35196742
ISSN: 1090-3941
CID: 5233992

Rates and timing of short-term complications following operative treatment of tibial shaft fractures

Upfill-Brown, Alex; Hwang, Richard; Clarkson, Sam; Brodke, Dane; Devana, Sai; Mayer, Erik; Kelley, Benjamin; Arshi, Armin; Lee, Christopher
INTRODUCTION/BACKGROUND:Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures. METHODS:The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications. RESULTS: < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications. CONCLUSIONS:Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.
PMID: 34765906
ISSN: 2574-2167
CID: 5233962

Clinical Outcomes of Meniscal Allograft Transplantation With Respect to the Minimal Clinically Important Difference

Su, Lisa; Garcia-Mansilla, Ignacio; Kelley, Benjamin; Arshi, Armin; Fabricant, Peter D; Sherman, Seth L; Jones, Kristofer J
BACKGROUND:Arthroscopic-assisted meniscal allograft transplantation (MAT) has become a viable and effective treatment option for young active patients with postmeniscectomy pain. The minimal clinically important difference (MCID) of patient-reported outcome measures (PROMs) is imperative to evaluate the clinical significance of surgical interventions and inform clinical practice guidelines in orthopaedic surgery. PURPOSE/OBJECTIVE:To perform a systematic review of clinical outcome studies of patients undergoing MAT and compare postoperative improvement with established MCID thresholds. STUDY DESIGN/METHODS:Systematic review and meta-analysis; Level of evidence, 4. METHODS:A systematic review was performed using the PubMed, Web of Science, and Cochrane Library databases. A meta-analysis was performed using data obtained from studies reporting patient-reported outcomes. Subgroup analysis was performed on patients undergoing isolated lateral MAT using fresh-frozen grafts. Weighted mean postoperative improvements in the International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) were calculated and compared with MCID values to determine if they met the MCID threshold. RESULTS:A total of 35 studies were identified, including 1658 unique patients. Weighted mean postoperative score improvements exceeded MCID thresholds for the VAS pain, IKDC, and Lysholm. Subgroup analysis of patients undergoing isolated lateral fresh-frozen MAT demonstrated postoperative improvements exceeding the MCID for the Lysholm and VAS pain. CONCLUSION/CONCLUSIONS:Evaluating postoperative PROMs with respect to the MCID is crucial to evaluate the effect of MAT on functional improvement. The results of the present meta-analysis suggest that postoperative improvements after MAT are clinically meaningful as reflected by PROMs exceeding the MCID threshold for the IKDC, Lysholm, and VAS pain.
PMID: 34495780
ISSN: 1552-3365
CID: 5233952

Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration

Sheppard, William L; Hinckel, Betina B; Arshi, Armin; Sherman, Seth L; Jones, Kristofer J
OBJECTIVE:Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair. DESIGN:A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery. RESULTS:All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively. CONCLUSIONS:In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.
PMID: 30971096
ISSN: 1947-6043
CID: 5233782

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study

Upfill-Brown, Alex; Arshi, Armin; Sekimura, Troy; Lee, Christopher; Stavrakis, Alexandra; Sassoon, Adam
BACKGROUND:Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx). METHODS:The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA). RESULTS:563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001). CONCLUSIONS:In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.
PMID: 34185154
ISSN: 1434-3916
CID: 5233942

Comparison of complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures

Arshi, Armin; Su, Lisa; Lee, Christopher; Sassoon, Adam A; Zeegen, Erik N; Stavrakis, Alexandra I
INTRODUCTION/BACKGROUND:Most geriatric hip fractures occur in the femoral neck (FN) and intertrochanteric (IT) regions of the femur, while a minority occur in the subtrochanteric (ST) region. Relative outcomes based on the anatomical subtype of fracture are not well studied. This study characterizes postoperative complications and outcomes of hip fractures distinguished by anatomic region. MATERIALS AND METHODS/METHODS:The targeted hip fracture series of the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify geriatric (≥ 65 years) patients who sustained operative FN, IT, and ST hip fractures. Primary patient demographic and perioperative data were collected and correlated with 30-day postoperative complications and outcomes. Multivariate regression was used to calculate relative risks of adverse events (AEs) between groups. RESULTS:In total, 8220 geriatric hip fracture patients were identified. Risk-adjusted 30-day mortality was not significantly different between patients with ST (5.8%, p = 0.735) and IT (7.3%, p = 0.169) femur fractures relative to those with FN fractures (6.6%). The overall risk-adjusted rate of minor and major medical AEs within 30 days and risk-adjusted rate of wound complications was not significantly different between FN, IT, and ST fractures. Patients with IT [34.4%, OR 2.35 (2.35-3.08), p < 0.001] and ST fractures [49.8%, OR 5.94 (4.58-7.70), p < 0.00] had higher risk-adjusted incidence of postoperative blood transfusion relative to FN fractures (18.5%). Furthermore, patients with IT fractures had a slightly lower risk-adjusted incidence of unplanned reoperation [2.1 vs. 2.7%, OR 0.69 (0.47-0.99), p = 0.046] and hospital readmission (7.8 vs. 9.2%, OR 0.76 [0.63-0.91], p = 0.003) than patients with FN fractures. CONCLUSIONS:With respect to anatomic region, geriatric hip fractures have similar short-term mortality and medical AE profiles with differences in transfusion, reoperation, and readmission rates. Knowledge of these short-term outcomes may guide surgeons in counseling hip fracture patients peri-operatively.
PMID: 34110476
ISSN: 1434-3916
CID: 5233932