Background: There have been multiple ways to measure outcomes post total knee arthroplasty. Ultimate goal is to replicate a natural joint to allow patients to perform most activities of daily living and give high satisfaction rates. Patient reported outcome measures (PROM) like Forgotten Joint Score (FJS), Oxford Knee Score (OKS)and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) have been validated and used for evaluation of TKA patients. FJS helps to evaluate how natural a prosthesis feels post surgery. Our aim was to study how natural a joint felt or was forgotten 2 year after surgery and how FJS correlates with OKS and WOMAC scores. Materials and Methods : We evaluated 254 total knee replacements with minimum 2 year post TKA. All the patients who were at least 2 year post operative, completed FJS questionnaire where scores are ranged from 0-100; OKS questionnaire where scores are ranged between 0-48; Short – form WOMAC questionnaire where scores are ranged between 0-28. Correlation analysis was performed for FJS with OKS and short - form WOMAC scores. Results: 254 patients with mean age of 65.01 years of which 83 males and 171 females were evaluated with minimum of 24 months follow up and average follow-up of 30.85 months. Average FJS, OKS and SF WOMAC were 77.24, 38.75 & 79.97 respectively. FJS showed good correlation with OKS and SF WOMAC scores. Conclusion : FJS is an easy and equally effective outcome measure, which is valid and reliable like the other common well know measures like OKS and WOMAC. Patients experience a marked improvement in the FJS over the first two years. Patients in our series had good outcomes who had more natural feel of knees or a feeling of “forgotten knees” in their day to day activity after 2 years of surgery.
Keywords Total Knee Arthroplasty, robotic-assisted, opioid use Background With the rise of robotic arm-assisted total knee arthroplasty (TKA) cases, there is a need to determine if there are clinical benefits associated with this technology. The purpose of this study was to further evaluate if robotic-assisted TKAs result in improved inpatient post-operative outcomes compared to conventional TKAs. Materials and Methods After IRB approval, a retrospective chart review of 100 robotic-assisted primary TKAs and 100 matched controls undergoing conventional TKA was performed. Patients underwent primary TKA from 2016 to 2018 with minimum 6-month postoperative follow-up by a single fellowship-trained arthroplasty surgeon at a high-volume joint center. Exclusion criteria included <6 month postoperative follow-up, incomplete chart information, inflammatory arthritis, and BMI >40. Demographics and post-operative outcomes, including length of stay (LOS), opioid consumption, duration of opioid use, and discharge status, were recorded. Results There were no significant differences in pre-operative demographics between the two groups. A decrease in LOS (1.58 vs. 2.18 days, p < 0.001) and morphine equivalents (73.52 vs. 102.50, p = 0.017) was reported for the robotic TKA group compared to the control group. The robotic group also reported fewer patients at six weeks postoperatively requiring opioids compared to the control group (37 vs. 61, p = 0.001). Average KOOS Jr at 6-months postoperatively was 81.73 for the control group and 78.22 in the robotic group (p = 0.039). Conclusion Robotic-assisted TKA patients experienced significantly decreased LOS, morphine equivalents, and opioid usage at 6-week postoperatively, indicating that there are early clinical benefits of robotic-assisted TKA. No significant differences between the robotic and control groups were reported in pre-operative KOOS Jr. Although average 6-month postoperative KOOS Jr was slightly higher for the control group, the difference was clinically insignificant. Our average KOOS Jr for both cohorts was higher than the national 1-year postoperative average, 76.8.
Background Tranexamic acid significantly reduces blood loss and transfusion requirements in arthroplasty patients. However, it is often avoided in patients who have had previous arterial and thromboembolic disease despite the absence of evidence of hazard in this group of patients. We examined the use of tranexamic acid in unselected hip and knee arthroplasty patients including those considered to be ‘high risk’. Methods A 2-year retrospective multicentre study was performed with patients who underwent hip or knee arthroplasty surgery. A blood management protocol included universal tranexamic acid use for all patients. Blood loss, transfusion volumes and complications were analysed. Results A total of 958 patients were included in the study, 130 patients were considered ‘high risk’ of thromboembolic complications and 828 patients were considered ‘low risk’. 879 patients received tranexamic acid with a significant reduction in blood loss (p<0.001) in these patients. Two of 130 (1.5%) ‘high risk’ patients and 14 of 828 (1.7%) ‘low risk’ patients had post-operative VTE. There was no significant difference in rate of VTE between the ‘high risk’ and ‘low risk’ patients (p=0.6) or in the subgroup of ‘high risk’ patients who had received TXA (p=1). Conclusions The efficacy of tranexamic acid is overwhelming and outweighs any potential risks. Tranexamic acid should be considered for use in all arthroplasty patients including those with prior history of venous or arterial thrombosis.
We report a case of a 23-year-old female with a history of congenital proximal femoral deformity and malunion of a prior proximal femoral corrective osteotomy, who presented seeking treatment for debilitating end-stage arthritis of her hip. Consideration for total hip arthroplasty (THA) for this patient was complicated by her young age and the complexity of her proximal femoral deformity. A 3-dimensional bone model of the patient’s femur was created using digital reconstructive software based on preoperative CT-imaging and used to plan our corrective osteotomy and arthroplasty component specifications. Using the detailed characterization of the femoral morphology, custom cutting guides were designed to fit uniquely into the correct position and ensure a high degree of accuracy with our osteotomy cuts. This unique case highlights the use of 3D-modeling software and printing technology for detailed surgical planning and precise execution in patients with complex deformities or otherwise abnormal anatomy.
Total joint arthroplasty (TJA) is moving towards the outpatient setting. Teams must develop patient selection criteria to ensure appropriate candidates are treated at the optimal site of care. Protocols and recommendations have been developed to aid care teams in developing patient selection criteria, but these come from multiple disparate sources. We review the available literature on patient selection criteria and optimization in the outpatient TJA population, and synthesize this information into a workable format for care design. We hope to provide a resource to stakeholders that can be tailored to their unique outpatient facility. Keywords: Total joint arthroplasty, outpatient, same day discharge, selection criteria, patient optimization.
Background: Transfusion is a known risk of total hip arthroplasty (THA). It has been associated with a multitude of medical complications and increased cost. Prior studies report transfusion rates associated with THA, with wide variation, but most cannot differentiate the surgical approach utilized. The anterior approach (AA) for THA has been associated with increased operative time, complications, and blood loss, but little data exists regarding the actual transfusion rate associated with the approach. Methods: We performed a retrospective review of 390 consecutive, elective, primary unilateral AA THA procedures. Patient demographic, clinical and perioperative data was analyzed. A modern perioperative pathway, including a simple protocol to limit blood loss, is defined. Results: The group consisted of a typical inpatient arthroplasty population, with wide ranges of age, body mass index (BMI), and health status. The average age was 64.05 years (+ 10.67, range 27-94). BMI averaged 29.76 kg/m2 (+ 5.98, range 16-47). The majority of patients were American Society of Anesthesiologists (ASA) class 2 (45.6%) or 3 (50.3%), with 10 patients ASA 4 (2.6%). Average preoperative hemoglobin was 13.48 g/dL (+ 1.47, range 9.1-18.2). Operative time averaged 91.22 minutes (+ 14.2). 83.3% of patients received a spinal anesthetic. Most patients were discharged on postoperative day one (93.1%) to home (99%). Estimated blood loss averaged 264mL (+ 95.19, range 100-1000). No patient required perioperative transfusion or readmission for symptomatic anemia within 30 days postoperative. Conclusion: A modern protocol we utilize and define is capable of limiting blood loss and transfusion risk in anterior approach total hip arthroplasty.
Background: Despite significant evaluation, no consensus has been reach for best clinical practice for resurfacing the patella during total knee arthroplasty. Further complicating the ability to reach a conclusion is the inclusion of several different implant types used in previous research. Questions/Purpose: The purpose of this study was to compare post-TKA outcomes between two cruciate retaining implants with or without patella resurfacing. Methods: This retrospective review included 289 patients (380 knees) with a minimum six-month follow-up. All patients received a CR implant, with either a symmetric or an asymmetric tibial baseplate. Post-TKA knee flexion was categorized as <120° and ≥120° and knee extension classified as 0° or >0° and required knee manipulations were noted. Descriptive, nonparametric statistics were performed and a multivariate logistic regression was performed to determine risk of poor range of motion and manipulations. Results: Age was significantly lower in the resurfaced group (p=0.001) and the resurfaced group had longer tourniquet time (p=0.003). The symmetric-resurfaced group had ≥120° of flexion and full extension in 72% and 98.7% of patients, respectively. Compared to symmetric-resurfaced, all other groups had a significantly greater risk of not reaching 120° of knee flexion (p<0.05). There were no significant differences in the risk of requiring a MUA between groups (p>0.06). Conclusions: The effect of resurfacing the patella on post-TKA outcomes may be influenced by tibial implant design. Compared to all other combinations, a symmetric tibial baseplate and resurfaced patella resulted in the highest percentage of patients reaching ≥120°, with a low incidence of manipulations.
Background:There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood.Methods:We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention.Results:Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films.Discussion and Conclusion: This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.
INTRODUCTION: The purpose of this study was to evaluate the two year clinical and radiographic outcomes of patients undergoing a primary total hip arthroplasty (THA) using the Trident Tritanium primary Cup. METHODS: 197 patients who underwent a direct anterior THA using a Tritanium acetabular component between 2011 and 2015 were retrospectively reviewed by two surgeons from a single institution. The investigators, along with an independent physician, separately reviewed radiographs blinded to clinical data looking for radiolucent lines adjacent to the acetabular cup using the Charnley-DeLee zones. Clinical results were measured using acetabular revision surgery as an end point for failure. According to the American Academy of Orthopaedic Surgeons Levels of Evidence, this study was consistent with a Level III Therapeutic study. RESULTS: 101 (48.73%) subjects did not exhibit any radiolucent lines around the acetabular component. 53 (26.90%) subjects displayed radiolucency in only one zone. 27 (13.71%) subjects displayed radiolucency in two zones, and 16 (8.12%) displayed radiolucency in all three zones. Radiolucency was most prevalent in zone 1 at 2 years with 83 (42.13%) subjects displaying radiolucency. There were five (2.54%) acetabular failures within two years of the index surgery. Of those 5 subjects, 3 displayed radiolucency in 1 zone, 2 displayed radiolucency in >1 zone, and 2 displayed radiolucencies >1 mm. CONCLUSION: In our study, the Tritanium Cup demonstrated a 2.54% failure rate for aseptic loosening at 2 year follow-up. In addition, 48.73% of patients displayed a radiolucent line in at least one Charnley-DeLee zone. We also observed a progression of radiolucencies between the 6 month radiographs and the 2 year radiographs.
Metal-on-metal (MoM) hip arthroplasty was re-popularized in the 1990s to resolve osteolysis and wear associated with metal-on-polyethylene products. Despite early success, registries began reporting high failure rates due to adverse reactions to metal debris (ARMD), manifesting as pseudotumors, hip effusions and osteolysis. Evaluation includes clinical exam, advanced imaging, and blood metal ions and infectious markers. This review provides physicians with an evidence-based update on the 1) clinical workup and management of patients with existing MoM implants, 2) risk and prognostic factors associated with suboptimal results and 3) the precipitating events and lessons learned applicable to future orthopedic prosthesis.
Navy Corpsman Maxton “Max” W. Soviak, HM3 (22 years old) of Berlin Heights, Ohio, was one of the 13 U.S. service members killed while supporting non-combatant evacuation operation in Kabul, Afghanistan. Max was advanced to the rank of Hospital Corpsman Third Class “as a result of his brave actions in support of fellow service members,” according to a Navy statement. He was also posthumously awarded the Purple Heart and Fleet Marine Force Corpsman warfare badge.
Introduction: In today’s post COVID 19 world, many healthcare systems have been pushed past the brink of economic sustainability. With Total Hip (THR) and Knee Replacements (TKR) being a few of the biggest ticket items, the need to adopt methods that improve quality of care & reduce unnecessary costs, is imperative. In this context, we report our experience with a Short Stay / Overnight joint replacement model using an ERAS (Enhanced Recovery After Surgery) Protocol which promotes rapid post-operative recovery and a decreased LOS without an increase in complications or readmission rates. Method: Retrospective collection of clinical & demographic data was undertaken for 114 consecutive patients undergoing primary THR or TKR by a single surgeon between 1 January 2018 and 19 March 2020 at 2 hospitals (1 public, 1 private). The data was analyzed for LOS, complications & readmission rates within 90 days after surgery. Results: In THR (n=93) and TKR (n=21), mean LOS was1.54 nights (range 0 - 4). 8 patients were discharged to a rehabilitation facility, the remaining 106 were discharged home. 2 patients were readmitted within 90 days of surgery - one with a periprosthetic fracture and the other for an unrelated respiratory illness. Conclusion: The implementation of a Short Stay model and associated ERAS protocols in both the public and private hospital settings reduced LOS without a concomitant increase in postoperative complications or readmission rates.
Background: Cementless implants were introduced approximately three decades ago in order to address aseptic loosening of cemented hip prostheses with the aim of early mobilisation, better functional result and bone stock preservation. The primary objective of this study is to introduce a new cementless HA coated implant and report its minimum 2 year follow up results.Material & method: This is a prospective, multi-centre, consecutive series, clinical outcomes study with 75 patients. Inclusion criteria for the study were age 21- 85 years, BMI <40, osteoarthritis of the hip.Patients were operated using a standard posterolateral approach. The Paragon stem and the Global cup were implanted in a cementless method. Patients were reviewed at 6 weeks, 6 months and two years postoperative. At each visit AQoL 6D, VAS Pain, Oxford Hip Score were recorded. Post-operative X-Rays were reviewed at immediate post-operative, 6 months and two years.Results: Mean duration of surgery was 63.1 min with range of 40-120 min. AQoL over time changed from pre-op mean 50.51, at 6 weeks and at 2 years mean 35.06. Oxford hip score had upward trend from pre-op to post-op 6wks assessments and a plateau in following assessments. VAS pain trajectories, showing a clear downward trend from pre-op to post-op 6wks and a plateau in the following postoperative assessments.Discussion & conclusion: The combination of Paragon stem and Global cup incorporates proven features of successful implants. The unique feature of lateral tension grooves and progressive neck dimension with dual offset options. This combination has shown promising early results with early follow up of a minimum of 2 years, with a 100% survivorship of the stem and 98.7% survivorship overall for any reason and is a good cementless option in THA.
Introduction Tranexamic acid (TXA) has been shown to be effective in reducing post-operative blood loss after hip replacement surgery. Clinicians can be reluctant to administer intravenous (IV) TXA to high risk patients and intra-articular (IA) administration has been proposed as an alternative mode of delivery. This study was conducted to compare the efficacy of IV versus IA administration of TXA. Methods This prospective, double blinded, randomised non-inferiority trial, compared 69 patients undergoing primary total hip arthroplasty (THA) who received either 3 doses of 15mg/kg of IV TXA or 3 g of IA TXA after capsular closure. The primary outcomes were change in Hb and the rate of blood transfusion. The secondary outcome was the rate of VTE. Results The mean haemoglobin level change from pre-operative to day 1 post-operative for the IV group was 26.7g/L and for IA group was 27.3g/L. No statistically significant difference was detected between the two groups (p=0.82). No patients required a transfusion or developed a VTE. Conclusions IA administration of TXA can be equally effective as IV in the reduction of blood loss and the prevention of post-operative anaemia in primary THA.
Introduction & Aims TKA in more active and young patients has prompted the interest in more durable and biological methods of Osteo-integration with cementless components. With the emergence of improved biomaterials like porous titanium and the success, search for a cementless TKA with long-term durability and survivorship may have ended. This is a retrospective study of 492 consecutive TKAs using Cementless tibial fixation, reporting on the early 4 years clinical and radiological outcomes. Method We studied 492 TKAs performed consecutively by a single surgeon between 1stJan. 2010 and 31stDec. 2015 using a cementless, fixed bearing tibial tray (porous–Regenerex, Vanguard, Zimmer-Biomet) and a cementless femoral component (Vanguard) with no exclusion criteria. Clinical and radiological follow-up was done on these patients and in addition a comprehensive joint registry review was performed on the whole cohort (Level II evidence). Results The average Knee Society Score at final follow-up was 89.33, average pre-op being 42.06. Average post-op WOMAC score was 43.45 and average pre-op was 77.78. On radiological examination, no patients had osteolysis around tibial base plate. In our series 9 patients were revised, out of which only 4 patients had the tibial tray and femoral component revised and 5 patients had patella resurfacing or liner exchange. Overall survivorship of the cementless tibial component is excellent with a survivorship of 99.4% at 5.9 years based on a comprehensive AOANJRR data. Conclusions Cementless tibial fixation using a porous titanium construct can provide stable bone ingrowth fixation on the tibial side with excellent and predictable early 4 to 5 year clinical and radiological outcomes.
Introduction While total knee arthroplasty (TKA) is a successful treatment for debilitating arthritis, up to 20% of patients may be dissatisfied with their outcome. One hypothesis for dissatisfaction is the distortion of native knee kinematics following sacrifice of the anterior cruciate ligament (ACL) during TKA. The purpose of this study was to determine the impact of ACL status at the time of surgery in patients undergoing Posterior Stabilized (PS) TKA for osteoarthritis (OA). Methods A consecutive prospective series of patients undergoing TKA by a single surgeon underwent prospective intraoperative assessment of their ACL status divided into three different groups:1) intact, 2) attenuated, or 3) deficient. Demographic, preoperative, intraoperative, and postoperative data were collected for each patient by two blinded, independent observers. Outcomes included patient satisfaction and Knee Society Score for Pain (KSS) and Function (KSF), Kellgren and Lawrence (K&L), UCLA Activity Score (UCLA), Short Form-12 (SF12), EuroQol (EQ5D) and patient satisfaction. Results: Of 116 patients, 33 (28.4%) patients had an ACL deficient knee, 40 (34.5%) patients had an attenuated ACL, and 43 (37.1%) patients had an intact ACL. Those with absent ACL were significantly more likely to have a higher BMI (p=.007) and be male (p=.003). Patient with a deficient ACL had significantly lower preoperative KSF and higher K&L scores (p=.009, p=1.26 x 10-7). Attenuated and deficient groups had the greatest change in SF12PCS scores at their one-year follow-up with increases of 9.9 (±10.0) and 10.8 (±8.0), respectively (p=.037). No significant differences in overall postoperative KSS, KSF and satisfaction scores based on ACL status (p=.574 and p=.529, respectively) were found. Conclusion In a relatively large series, patient with ACL deficiency were more likely to have worse pre-operative outcome scores and similar or better post-operative outcome scores. This suggests that those with ACL insufficiency may experience more subjective improvement from TKA. ACL status can be used as an additional surgical marker to help orthopaedic surgeons identify which patients would most benefit from TKA.
The worldwide orthopaedic industry lost one of our true giants, as Nik Nikolaev passed away in December of last year. Nik is survived by Sandy, his wife of nearly 60 years, daughter Kimberly and son Cort, of whom he was immensely proud. He is also survived by all of us who had the privilege of knowing and working with him, and by the millions of patients who received the gift of a new prosthesis that Nik was responsible for commercializing.
Background: Serum Cobalt (Co) and Chromium (Cr) forms part of the diagnostic process for metallosis following Total Hip Arthroplasty (THA). While knowledge exists on longer term metal ion levels, expected early post-operative rises in serum Co and Cr in Metal-on-Polyethylene (MoP) THAs are currently unknown. This study aims to describe early rises in serum Co and Cr at 6 months post-operatively. Methods: A prospective cohort study of 100 consecutive patients with an uncemented titanium stem from a single THA manufacturer was performed. Patients had either a metal (n=50) or ceramic (n=50) head articulating with a highly cross-linked polyethylene. Serum Co and Cr levels were measured 6 months post-operatively. Analysis compared mean values between groups and to determined baseline levels. Subgroup analysis investigated the effect of femoral head size and offset on metal ion levels. Results: A mean difference of 2.259 nmol/L (95% CI 0.449-4.069; p=0.015) was found when comparing 6-month serum Co in the metal head group compared to baseline. No significant differences were found in serum Cr (p=0.943). Mean serum Co levels were higher in the MoP group compared to the CoP (Ceramic-on-Polyethylene) comparator group (p=0.012). There were no differences in serum Cr (p=0.976). Variations in femoral head size and offset did not impact metal ion levels. Conclusion: At six months, a higher magnitude of serum Co exists in metal heads when compared to baseline (p=0.015) and to ceramic heads (p=0.012). Further study is required to determine whether serum concentrations of metal ions will continue to increase over time.
Trauma centers in the United States focus on providing care to patients who have suffered injuries and may require critical care. These trauma centers are classified into five different levels: Level I to Level V. Level V trauma centers are the least comprehensive, providing minimal 24-hour care and resuscitation, and Level I trauma centers are the most comprehensive, accepting the most severely injured patients and always delivering care through the use of an attending surgeon. However, there is a major inequity in access to trauma centers across the United States, especially amongst rural residents. Level III to Level V trauma centers tend to be dominantly situated in rural and underserved areas. Furthermore, trauma centers tend to be widely dispersed with respect to rural areas. Therefore, these areas tend to have a greater mortality rate in relation to traumatic injuries. Improvements in access to high-tier traumatic care must occur in order to reduce mortality due to traumatic injuries in underserved rural areas. Possible improvements to rural trauma care include bolstering the quality of care in Level III trauma centers, increasing Level II center efficiency through the involvement of orthopedic traumatologists, placing medical helicopter bases in more strategic locations that enable transport teams to reach other trauma centers faster, building more Level I and Level II trauma centers, and converting Level III centers into either Level I or Level II centers.
As a response to the viral pneumonias and severe illnesses that were emerging in patients, an ophthalmologist November 2019 a novel coronavirus emerged in Wuhan, Hubei, China Dr Li Wenliang, working at Wuhan Central Hospital, voiced his concerns only to be severely admonished by the authorities. The accelerated spread of the Severe Acute Respiratory Syndrome (SARS) in Wuhan, and then globally, as a result of the novel coronavirus was acute and pronounced. China alerted the World Health Organisation to several pneumonia cases at the end of December 2019 and the first death was recorded in early January 2020. The respiratory physician Dr Nanshan Zhong, announced human-to-human spread and a few days later on the 23 January 2020, Wuhan was placed under quarantine. The virus spread outside China and the WHO declared the outbreak a global health emergency on 30 January 2020. Tragically Dr Li Wenliang died on 7 February 2020 as a result of exposure to the virus, leaving a five-year-old son and a pregnant wife.
