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Total knee arthroplasty in patients with lumbar spinal fusion leads to significant changes in pelvic tilt and sacral slope

Shichman, Ittai; Ben-Ari, Erel; Sissman, Ethan; Singh, Vivek; Hepinstall, Matthew; Shwarzkopf, Ran
BACKGROUND:The knee-hip-spine syndrome has been well elucidated in the literature in recent years. The aim of this study was to evaluate the effect of total knee arthroplasty (TKA) on spinopelvic sagittal alignment in patients with and without pre-TKA lumber spinal fusion. METHODS:This is a retrospective cohort study of 113 patients who underwent TKA for primary osteoarthritis. Patients were stratified into the following three groups: (1) patients who had pre-TKA spinal fusion (SF, n = 19), (2) patients who had no spinal fusion but experienced pre-TKA flexion contracture (FC, n = 20), and (3) patients without flexion contracture or spinal fusion before TKA (no SF/FC, n = 74). Spinopelvic sagittal alignment parameters, including pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and plumb line-sacrum distance (SVA) were measured preoperatively and 3 months postoperatively on lateral standing full-body low-dose images. RESULTS:TKA resulted in significant pre- to postoperative changes in pelvic tilt (average ∆ PT = - 8.6°, p = 0.018) and sacral slope (average ∆ SS = 8.6°, p = 0.037) in the spinal fusion (SF) group. Non-significant changes in spinopelvic sagittal alignment parameters (PT, SS, LL, TK, SVA) were noted postoperatively in all patients in the FC and the no SF/FC groups. CONCLUSIONS:TKA can lead to meaningful changes in spinopelvic alignment in patients with prior lumbar fusion compared to those without spinal fusion. Patients with spinal fusion who are candidates for both hip and knee replacements should consider undergoing TKA first since changes in spinopelvic sagittal alignment can increase the risk of future complications. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.
PMID: 35536355
ISSN: 1434-3916
CID: 5214272

Correction to: Total knee arthroplasty in patients with lumbar spinal fusion leads to significant changes in pelvic tilt and sacral slope

Shichman, Ittai; Ben-Ari, Erel; Sissman, Ethan; Singh, Vivek; Hepinstall, Matthew; Schwarzkopf, Ran
PMID: 35674822
ISSN: 1434-3916
CID: 5248422

A New Classification System for Cementless Femoral Stems in Total Hip Arthroplasty

Radaelli, Marco; Buchalter, Daniel B; Mont, Michael A; Schwarzkopf, Ran; Hepinstall, Matthew S
BACKGROUND:The growing variety of total hip arthroplasty implants necessitates a standardized, simple, and brand-neutral language to precisely classify femoral components. Although previous classifications have been useful, they need updating to include stems that have current surface treatment technologies, modularity, collar features, and other geometric characteristics. METHODS:To accomplish this, we propose a new classification system for stems based on 3 distinguishing stem features: (1) geometry, (2) location of modularity, and (3) length. RESULTS:Our system allows for the easy classification of all currently used stem types. CONCLUSIONS:One goal of this endeavor is to improve clinical record keeping to facilitate study comparisons as well as literature reviews.
PMID: 36122690
ISSN: 1532-8406
CID: 5335302

Impact of revision TKA indications on resource utilization

Christensen, Thomas H; Roof, Mackenzie A; Shichman, Ittai; Lygrisse, Katherine A; Aggarwal, Vinay K; Hepinstall, Matthew; Schwarzkopf, Ran
BACKGROUND:Indications for surgery may impact resource utilization in aseptic revision total knee arthroplasty (rTKA), and understanding these relationships would facilitate risk-stratification preoperatively. The purpose of this study was to investigate the impact of rTKA indications on readmission, reoperation, length of stay (LOS), and cost. METHODS:We reviewed all 962 patients who underwent aseptic rTKA at an academic orthopedic specialty hospital between June 2011-April 2020 with at least 90 days of follow-up. Patients were categorized based on their indication for aseptic rTKA as listed in the operative report. Demographics, surgical factors, LOS, readmission, reoperation and cost were compared between cohorts. RESULTS:There were significant differences in operative time among cohorts (p < 0.001), highest among the periprosthetic fracture group (164.2 ± 59.8 min). Reoperation rate was greatest in the extensor mechanism disruption cohort (50.0 %, p = 0.009). Total cost differed significantly among groups (p < 0.001), which was highest among the implant failure cohort (134.6 % of mean) and lowest for component malpositioning cohort (90.2 % of mean). Similarly, there were significant differences in direct cost (p < 0.001) which was highest in the periprosthetic fracture cohort (138.5 % of mean), and lowest in the implant failure cohort (90.5 % of mean). There were no differences in discharge disposition, or number of re-revisions among all groups. CONCLUSIONS:Operative time, components revised, LOS, readmissions, reoperation rate, total cost and direct cost following aseptic rTKA varied significantly between different revision indications. These differences should be noted for preoperative planning, resource allocation, scheduling, and risk-stratification. LEVEL OF EVIDENCE/METHODS:III, retrospective observational analysis.
PMID: 36812749
ISSN: 1873-5800
CID: 5433912

Effect of Pelvic Sagittal Tilt and Axial Rotation on Functional Acetabular Orientation

Schwarz, Julia; Yeroushalmi, David; Hepinstall, Matthew; Buckland, Aaron J; Schwarzkopf, Ran; Meftah, Morteza
Accurate and reproducible acetabular component positioning is among the most important technical factors affecting outcomes of total hip arthroplasty. Although several studies have investigated the influence of pelvic tilt and obliquity on functional acetabular anteversion, the effect of pelvic axial rotation has not yet been established. We analyzed a generic simulated pelvis created using preoperative full-body standing and sitting radiographs. A virtual acetabulum was placed in 144 different scenarios of acetabular anteversion and abduction angles. In each scenario, the effects of pelvic tilt and pelvic axial rotation on different combinations of acetabular orientations were assessed. The change in acetabular anteversion was 0.75° for each 1° of pelvic tilt and was most linear in abduction angles of 40°±45°. The change in acetabular anteversion was 0.8° for each 1° of pelvic axial rotation. Surgeons may consider adjusting acetabular anteversion in fixed axial pelvic deformities when the degree of deformity affects functional acetabular positioning, assessed from preoperative standing and sitting weight-bearing radiographs. [Orthopedics. 2023;46(1):e27-e30.].
PMID: 36206512
ISSN: 1938-2367
CID: 5418752

CORR Insights®: A Radiographic Abdominal Pannus Sign is Associated With Postoperative Complications in Anterior THA

Hepinstall, Matthew S
PMID: 36480064
ISSN: 1528-1132
CID: 5378752

Muscle recovery after total hip arthroplasty: prospective MRI comparison of anterior and posterior approaches

Robinson, Jonathan; Bas, Marcel; Deyer, Timothy; Cooper, H John; Hepinstall, Mathew; Ranawat, Amar; Rodriguez, Jose A
INTRODUCTION/UNASSIGNED:The direct anterior approach (DAA) and the posterior approach (PA) are 2 common total hip arthroplasty (THA) exposures. This prospective study quantitatively compared changes in periarticular muscle volume after DAA and PA THA. MATERIALS/UNASSIGNED:19 patients undergoing THA were recruited prospectively from the practices of 3 fellowship-trained hip surgeons. Each surgeon performed a single approach, DAA or PA. Enrolled patients underwent a preoperative MRI of the affected hip and two subsequent postoperative MRIs at around 6 weeks and 6 months after surgery. Clinical evaluations were done by Harris Hip Score at each follow-up interval. RESULTS/UNASSIGNED:MRIs or 10 DAA and 9 PA patients were analysed. Groups did not differ significantly with regard to BMI, age, or preoperative muscle volume. 1 DAA patient suffered a periprosthetic fracture and was excluded from the study. DAA hips showed significant atrophy in the obturator internus (-37.3%) muscle at early follow-up, with persistent atrophy of this muscle at the final follow-up. PA hips showed significant atrophy in the obturator internus (-46.8%) and externus (-16.0%), piriformis (-8.12%), and quadratus femoris muscles (-13.1%) at early follow-up, with persistent atrophy of these muscles at final follow-up. Loss of anterior capsular integrity was present at final follow-up in 2/10 DAA hips while loss of posterior capsular integrity was present in 5/9 PA hips. There was no difference in clinical outcomes. DISCUSSION/UNASSIGNED:This study demonstrates that DAA showed less persistent muscular atrophy than PA. Regardless of surgical approach, a muscle whose tendon is detached from its insertion is likely to demonstrate persistent atrophy 6 months following THA. Although the study was not powered to compare clinical outcomes, it should be noted that no significant difference in patient outcomes was observed.
PMID: 36192819
ISSN: 1724-6067
CID: 5351512

Adoption of Robotic-Arm-Assisted Total Knee Arthroplasty Is Associated with Decreased Use of Articular Constraint and Manipulation under Anesthesia Compared to a Manual Approach

Zhang, Jenny; Matzko, Chelsea N; Sawires, Andrew; Ehiorobo, Joseph O; Mont, Michael A; Hepinstall, Matthew S
Haptic robotic-arm-assisted total knee arthroplasty (RATKA) seeks to leverage three-dimensional planning, intraoperative assessment of ligament laxity, and guided bone preparation to establish and achieve patient-specific targets for implant position. We sought to compare (1) operative details, (2) knee alignment, (3) recovery of knee function, and (4) complications during adoption of this technique to our experience with manual TKA. We compared 120 RATKAs performed between December 2016 and July 2018 to 120 consecutive manual TKAs performed between May 2015 and January 2017. Operative details, lengths of stay (LOS), and discharge dispositions were collected. Tibiofemoral angles, Knee Society Scores (KSS), and ranges of motion were assessed until 3 months postoperatively. Manipulations under anesthesia, complications, and reoperations were tabulated. Mean operative times were 22 minutes longer in RATKA (p < 0.001) for this early cohort, but decreased by 27 minutes (p < 0.001) from the first 25 RATKA cases to the last 25 RATKA cases. Less articular constraint was used to achieve stability in RATKA (93 vs. 55% cruciate-retaining, p < 0.001; 3 vs. 35% posterior stabilized (PS), p < 0.001; and 4 vs. 10% varus-valgus constrained, p_ = _0.127). RATKA had lower LOS (2.7 vs. 3.4 days, p < 0.001). Discharge dispositions, tibiofemoral angles, KSS, and knee flexion angles did not differ, but manipulations were less common in RATKAs (4 vs. 17%, p = 0.013). We observed less use of constraint, shorter LOS, and fewer manipulations under anesthesia in RATKA, with no increase in complications. Operative times were longer, particularly early in the learning curve, but improved with experience. All measured patient-centered outcomes were equivalent or favored the newer technique, suggesting that RATKA with patient-specific alignment targets does not compromise initial quality. Observed differences may relate to improved ligament balance or diminished need for ligament release.
PMID: 33389735
ISSN: 1938-2480
CID: 4764862

Dual-mobility versus Fixed-bearing in Primary Total Hip Arthroplasty: Outcome Comparison

Singh, Vivek; Loloi, Jeremy; Macaulay, William; Hepinstall, Matthew S; Schwarzkopf, Ran; Aggarwal, Vinay K
Purpose/UNASSIGNED:Use of dual mobility (DM) articulations can reduce the risk of instability in both primary and revision total hip arthroplasty (THA). Knowledge regarding the impact of this design on patient-reported outcome measures (PROMs) is limited. This study aims to compare clinical outcomes between DM and fixed bearing (FB) prostheses following primary THA. Materials and Methods/UNASSIGNED:All patients who underwent primary THA between 2011-2021 were reviewed retrospectively. Patients were separated into three cohorts: FB vs monoblock-D vs modular-DM. An evaluation of PROMs including HOOS, JR, and FJS-12, as well as discharge-disposition, 90-day readmissions, and revisions rates was performed. Propensity-score matching was performed to limit significant demographic differences, while ANOVA and chi-squared test were used for comparison of outcomes. Results/UNASSIGNED:=0.608) between the groups. Conclusion/UNASSIGNED:DM bearings yield PROMs similar to those of FB implants in patients undergoing primary THA. Although DM implants are utilized more often in patients at higher-risk for instability, we suggest that similar patient satisfaction may be attained while achieving similar dislocation rates.
PMID: 35800126
ISSN: 2287-3260
CID: 5280612

Presence of back pain prior total knee arthroplasty and its effects on short-term patient-reported outcome measures

Singh, Vivek; Zak, Stephen; Robin, Joseph X; Kugelman, David N; Hepinstall, Matthew S; Long, William J; Schwarzkopf, Ran
PURPOSE/OBJECTIVE:Back pain may both decrease patient satisfaction after TKA and confound outcome assessment in satisfied patients. Our primary objective was to determine whether preoperative back pain is associated with differences in postoperative patient-reported outcome measures (PROMs). METHODS:We retrospectively reviewed 234 primary TKA patients who completed PROMs preoperatively and 12 weeks postoperatively, which included a back pain questionnaire, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the Forgotten Joint Score-12 (FJS-12). Cohorts were defined based on the severity of preoperative back pain (none, mild, moderate and severe) and compared. Demographics were compared using ANOVA and Chi-square analysis. Univariate ANCOVA analysis was utilized to compare PROMs while accounting for significant demographic differences. RESULTS:Both preoperative KOOS JR scores (none: 47.90, mild: 47.61, moderate: 44.61 and severe: 38.70; p = 0.013) and 12-week postoperative KOOS JR scores (none: 61.24, mild: 64.94, moderate: 57.48 and severe: 57.01; p = 0.012) had a statistically significant inverse relationship with regard to the intensity of preoperative back pain. Although FJS-12 scores at the 12-week postoperative period trended lower with increasing levels of preoperative back pain (p = 0.362), it did not reach statistical significance. Patients who reported severe back pain preoperatively achieved the largest delta improvement from baseline compared to those with lesser pain intensity (p = 0.003). Patients who had a 2-grade improvement in their back pain achieved significantly higher KOOS JR scores 12 weeks postoperatively compared to patients with either 1-grade or no improvement (63.53 vs. 55.98; p = 0.042). Both preoperative (47.99 vs. 41.11; p = 0.003) and 12-week postoperative (64.06 vs. 55.73; p < 0.001) KOOS JR scores were statistically higher for those who reported mild or no back pain pre-and postoperatively than those who reported moderate or severe back pain pre-and postoperatively. CONCLUSION/CONCLUSIONS:Knee pain and back pain both exert negative effects on outcome instruments designed to measure pain and function. Although mean improvement from pre- to postoperative KOOS JR scores for patients with severe pre-existing back pain was higher than their counterparts, this statistical difference is likely not clinically significant. This implies that all patients may experience similar benefits from TKA despite the presence or absence of back pain. Attempts to measure TKA outcomes using PROMs should seek to control for lumbago and other sources of body pain. Level of Evidence IIIRetrospective Cohort Study.
PMID: 34037858
ISSN: 1633-8065
CID: 4904962