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Prior Instability is Strongly Associated With Dislocation After Isolated Head and Liner Exchange

Berlinberg, Elyse J; Roof, Mackenzie A; Shichman, Ittai; Meftah, Morteza; Schwarzkopf, Ran
BACKGROUND:Isolated head and liner exchange is an appealing alternative to a more extensive revision total hip arthroplasty in patients who have well-fixed components. Despite efforts to increase femoral offset and restore soft tissue tensioning, limited component revision may be associated with higher rates of postoperative instability. METHODS:(range, 18.2-46.7). The most common indications for surgery included acetabular liner wear in 86 hips (41%), instability in 40 hips (19%), and infection in 36 hips (17%). RESULTS:increase, 95% CI 0.80-0.99, P = .046). CONCLUSION/CONCLUSIONS:In a large cohort of patients who had isolated head and liner exchange, patients who had prior instability had 7-fold elevated odds of postoperative dislocation. This risk remains significant after controlling for cup positioning outside the Lewinnek safe zone, liner type, head size, neck length, soft tissue compromise, neuromuscular disease, and dual mobility constructs. LEVEL OF EVIDENCE/METHODS:III, retrospective cohort study.
PMID: 35780950
ISSN: 1532-8406
CID: 5280092

Discontinued Use of Outpatient Portable Intermittent Pneumatic Compression Devices May Be Safe for Venous Thromboembolism Prophylaxis in Primary Total Knee Arthroplasty Using Low-Dose Aspirin

Tang, Alex; Zak, Stephen; Lygrisse, Katherine; Slover, James; Meftah, Morteza; Lajam, Claudette; Schwarzkopf, Ran; Macaulay, William
Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.
PMID: 33241544
ISSN: 1938-2480
CID: 4680922

Trends in Complications and Outcomes in Patients Aged 65 Years and Younger Undergoing Total Knee Arthroplasty: Data From the American Joint Replacement Registry

Shah, Akash; Cieremans, David; Slover, James; Schwarzkopf, Ran; Meftah, Morteza
INTRODUCTION/BACKGROUND:The purpose of this study was to identify common complications and the rates of readmission and revision in total knee arthroplasty (TKA) patients younger than 65 years. METHODS:Using the American Joint Replacement Registry, we conducted a retrospective review of all TKAs done in patients aged 18 to 65 years from 2012 to 2020. Demographic factors such as age, sex, Charlson Comorbidity Index (CCI), and preoperative Veterans RAND 12-Item Health Survey Physical Component Summary (VR-12 PCS) scores were collected. We excluded patients older than 65 years and revision, oncologic, and nonelective cases. Primary outcomes included cumulative revision rate, 90-day readmission rate, and reason for revision. Univariate analysis and the Kaplan-Meier method were used. RESULTS:Six thousand one hundred seventy-nine patients were included. The average age was 58.8 years (SD 5.5 years), 61% were female, 82% were White, and 88% had a CCI of 0 (1 = 8% and ≥2 = 4%). The mean follow-up was 42.51 months. Seventy-four patients (1.2%) underwent revision. Sixty-nine patients (1.1%) were readmitted within 90 days. No factors assessed increased revision rates. Revision-free survivorship was 98.7% (95% CI 98.4 to 99.0) and 98.6% (95% CI 98.2 to 99.0) at 5 and 8 years, respectively. Infection (15%), aseptic loosening (14%), and instability (12%) were the most common indications for revision. CONCLUSION/CONCLUSIONS:TKA done in young and presumed active patients has excellent survivorship. Long-term follow-up is needed to assess survival trends in this growing population.
PMID: 35704921
ISSN: 2474-7661
CID: 5277862

The effects of tourniquet on cement penetration in total knee arthroplasty

Zak, Stephen G; Tang, Alex; Pivec, Robert; Meftah, Morteza; Austin, Matthew S; Schnaser, Erik; Schwarzkopf, Ran
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.
PMID: 35552801
ISSN: 1434-3916
CID: 5214852

Outcomes of isolated head-liner exchange versus full acetabular component revision in aseptic revision total hip arthroplasty

Berlinberg, Elyse J; Roof, Mackenzie A; Meftah, Morteza; Long, William J; Schwarzkopf, Ran
INTRODUCTION/UNASSIGNED:Isolated head and liner exchange in aseptic revision total hip arthroplasty (rTHA) is an appealing option rather than full acetabular component revision; however, early outcome reports suggest high rates of complications requiring re-revision. This study seeks to compare the outcomes of these procedures. METHODS/UNASSIGNED:This retrospective study assessed 124 head and liner exchanges and 59 full acetabular cup revisions conducted at a single center between 2011 and 2019 with at least 2 years of follow-up. Baseline demographics did not vary by group. Mean follow-up was 3.7 (range 2.0-8.6) years. RESULTS/UNASSIGNED:0.22) were associated with failure within 2 years. CONCLUSIONS/UNASSIGNED:In this analysis, 2-year outcomes for isolated head and liner exchange were non-inferior to full acetabular component revision. A future randomised prospective study should be conducted to better assess the optimal approach to revision in an aseptic failed hip arthroplasty.
PMID: 35438018
ISSN: 1724-6067
CID: 5218232

The learning curve associated with imageless navigation in total knee arthroplasty

Zabat, Michelle A; Oakley, Christian T; Marwin, Scott E; Meftah, Morteza; Schwarzkopf, Ran
INTRODUCTION/BACKGROUND:Computer-assisted navigation systems (CAS) are increasingly being integrated into total knee arthroplasty (TKA) procedures, but perceptions of associated learning curve and increased operative time continue to curtail uptake. Newer-generation navigational systems aim to streamline integration into surgical workflow to mitigate increases in operative time. Here, we assess the impact of a novel imageless CAS on operative time for TKA. METHODS:A retrospective analysis of prospectively collected data of a cohort of patients undergoing primary unilateral TKA with one of three surgeons between October 2019 and March 2020 was conducted. Consecutive cases using a novel imageless CAS were included in analysis. For each surgeon, average operative time was recorded and compared in sequential five-case cohorts to average operative time for the same procedure performed conventionally using a two-tailed t test. RESULTS:Average conventional operative times were 95.9 ± 15.0, 86.6 ± 13.7, and 116.9 ± 25.1 min for the three surgeons. Initial CAS-assisted operative times increased to 107.0 ± 9.8 (p = 0.07) and 102.4 ± 13.2 (p = 0.06) min for Surgeons 1 and 2 and decreased to 113.2 ± 9.8 min (p = 0.52) for Surgeon 3. Most recent CAS-assisted operative times were 94.8 ± 13.9 (p = 0.88), 88.7 ± 15.3 (p = 0.84), and 104.8 ± 13.2 (p = 0.12) min as compared to pre-CAS. Absolute differences for the most recent navigated procedures ranged from 12.1 min faster to 2.0 min slower. CONCLUSION/CONCLUSIONS:The learning curve for TKA navigation may be as few as 10 cases, and any associated increases in operative time may be transient and non-significant. Moreover, navigation may ultimately speed operative time, perhaps as the result of enhanced intraoperative assessment of alignment.
PMID: 35226121
ISSN: 1434-3916
CID: 5174132

The use of imageless navigation to quantify cutting error in total knee arthroplasty

Schwarzkopf, Ran; Meftah, Morteza; Marwin, Scott E; Zabat, Michelle A; Muir, Jeffrey M; Lamb, Iain R
PURPOSE/OBJECTIVE:Navigated total knee arthroplasty (TKA) improves implant alignment by providing feedback on resection parameters based on femoral and tibial cutting guide positions. However, saw blade thickness, deflection, and cutting guide motion may lead to final bone cuts differing from planned resections, potentially contributing to suboptimal component alignment. We used an imageless navigation device to intraoperatively quantify the magnitude of error between planned and actual resections, hypothesizing final bone cuts will differ from planned alignment. MATERIALS AND METHODS/METHODS:A retrospective study including 60 consecutive patients undergoing primary TKA using a novel imageless navigation device was conducted. Device measurements of resection parameters were obtained via attachment of optical trackers to femoral and tibial cutting guides prior to resection. Following resection, optical trackers were placed directly on the bone cut surface and measurements were recorded. Cutting guide and bone resection measurements of both femoral and tibial varus/valgus, femoral flexion, tibial slope angles, and both femoral and tibial medial and lateral resection depths were compared using a Student's t-test. RESULTS:Femoral cutting guide position differed from the actual cut by an average 0.6 ± 0.5° (p = 0.85) in the varus/valgus angle and 1.0 ± 1.0° (p = 0.003) in the flexion/extension angle. The difference between planned and actual cut measurements for medial and lateral femoral resection depth was 1.1 ± 1.1 mm (p = 0.32) and 1.2 ± 1.0 mm (p = 0.067), respectively. Planned cut measurements based on tibial guide position differed from the actual cut by an average of 0.9 ± 0.8° (p = 0.63) in the varus/valgus angle and 1.1 ± 1.0° (p = 0.95) in slope angle. Measurement of medial and lateral tibial resection depth differed by an average of 0.1 ± 1.8 mm (p = 0.78) and 0.2 ± 2.1 mm (p = 0.85), respectively. CONCLUSIONS:Significant discrepancies between planned and actual femoral bone resection were demonstrated for flexion/extension angle, likely the result of cutting error. Our data highlights the importance of cut verification postresection to confirm planned resections are achieved, and suggests imageless navigation may be a source of feedback that would allow surgeons to intraoperatively adjust resections to achieve optimal implant alignment.
PMID: 34863317
ISSN: 2234-0726
CID: 5074992

The Use of Navigation or Robotic-Assisted Technology in Total Knee Arthroplasty Does Not Reduce Postoperative Pain

Zak, Stephen Gerard; Yeroushalmi, David; Tang, Alex; Meftah, Morteza; Schnaser, Erik; Schwarzkopf, Ran
The use of intraoperative technology (IT), such as computer-assisted navigation (CAN) and robot-assisted surgery (RA), in total knee arthroplasty (TKA) is increasingly popular due to its ability to enhance surgical precision and reduce radiographic outliers. There is disputing evidence as to whether IT leads to better clinical outcomes and reduced postoperative pain. The purpose of this study was to determine if use of CAN or RA in TKA improves pain outcomes. This is a retrospective review of a multicenter randomized control trial of 327 primary TKAs. Demographics, surgical time, IT use (CAN/RA), length of stay (LOS), and opioid consumption (in morphine milligram equivalents) were collected. Analysis was done by comparing IT (n = 110) to a conventional TKA cohort (n = 217). When accounting for demographic differences and the use of a tourniquet, the IT cohort had shorter surgical time (88.77 ± 18.57 vs. 98.12 ± 22.53 minutes; p = 0.005). While postoperative day 1 pain scores were similar (p = 0.316), the IT cohort has less opioid consumption at 2 weeks (p = 0.006) and 1 month (p = 0.005) postoperatively, but not at 3 months (p = 0.058). When comparing different types of IT, CAN, and RA, we found that they had similar surgical times (p = 0.610) and pain scores (p = 0.813). Both cohorts had similar opioid consumption at 2 weeks (p = 0.092), 1 month (p = 0.058), and 3 months (p = 0.064) postoperatively. The use of IT in TKA does not yield a clinically significant reduction in pain outcomes. There was also no difference in pain or perioperative outcomes between CAN and RA technology used in TKA.
PMID: 34530477
ISSN: 1938-2480
CID: 5067272

Does the Use of Intraoperative Technology Yield Superior Patient Outcomes Following Total Knee Arthroplasty?

Singh, Vivek; Fiedler, Benjamin; Simcox, Trevor; Aggarwal, Vinay K; Schwarzkopf, Ran; Meftah, Morteza
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.
PMID: 33277145
ISSN: 1532-8406
CID: 4708272

Does the Use of a Tourniquet Influence Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial

Zak, Stephen G; Yeroushalmi, David; Long, William J; Meftah, Morteza; Schnaser, Erik; Schwarzkopf, Ran
BACKGROUND:Intraoperative tourniquet use in total knee arthroplasty (TKA) is a common practice which may improve visualization of the surgical field and reduce blood loss. However, the safety and efficacy associated with tourniquet use continues to be a subject of debate among orthopedic surgeons. The primary purpose of this study is to evaluate the effects of tourniquet use on pain and opioid consumption after TKA. METHODS:This is a multicenter randomized controlled trial among patients undergoing TKA. Patients were preoperatively randomized to undergo TKA with or without the use of an intraoperative tourniquet. Frequency distributions, means, and standard deviations were used to describe baseline patient demographics (age, gender, race, body mass index, smoking status), length of stay, surgical factors, visual analog scale pain scores, and opioid consumption in morphine milligram equivalents. RESULTS:A total of 327 patients were included in this study, with 166 patients undergoing TKA without a tourniquet and 161 patients with a tourniquet. A statistically significant difference was found in surgical time (97.87 vs 92.98 minutes; P = .05), whereas none was found for length of stay (1.73 vs 1.70 days; P = .87), postop visual analog scale pain scores (1.73 vs 1.70; P = .87), inpatient opioid consumption (19.84 vs 19.27 morphine milligram equivalents; P = .74), or outpatient opioid consumption between the tourniquet-less and tourniquet cohorts, respectively. There were no readmissions in either cohort during the 90-day episode of care. CONCLUSION/CONCLUSIONS:Utilization of a tourniquet during TKA has minimal impact on postoperative pain scores and opioid consumption when compared with patients who underwent TKA without a tourniquet.
PMID: 33795174
ISSN: 1532-8406
CID: 4838372