Showing papers in "Journal of Arthroplasty in 2017"

Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature.

Abstract: Background Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. Methods Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. Results This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. Conclusion Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them.

Current Epidemiology of Revision Total Hip Arthroplasty in the United States: National Inpatient Sample 2009 to 2013

Abstract: Background Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continues to burden the healthcare system. THA failure has evolved and displays variability throughout the literature. In order to understand how THAs are failing and how to reduce this burden, it is essential to assess modes of implant failure on a large scale. Thus, we report: (1) etiologies for revision THA; (2) frequencies of revision THA procedures; (3) patient demographics, payor type, and US Census region of revision THA patients; and (4) the length of stay and total costs based on the type of revision THA procedure. Methods We queried the National Inpatient Sample database for all revision THA procedures performed between January 1, 2009 and December 31, 2013. This yielded 258,461 revision THAs. Patients specific demographics were identified in order to determine the prevalence of revision procedure performed. Results Dislocation was the main indication for revision THA (17.3%), followed by mechanical loosening (16.8%). All-component revision was the most common procedure performed (41.8%). Patients were most commonly white (77.4%), aged 75 years and older (31.6%), and resided in the South US Census region (37.0%). The average length of stay for all procedures was 5.29 days. The mean total charge for revision THA procedures was $77,851.24. Conclusion Dislocation and mechanical loosening is the predominant indication for revision THA in the United States. With the frequency of revision THAs projected to double in the next decade, orthopedists must take steps to mitigate this potentially devastating complication.

Current Epidemiology of Revision Total Knee Arthroplasty in the United States

Abstract: Background Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for the United States healthcare system. The predominant etiology of TKA failure has changed over time and may vary between studies. This report aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: (1) etiologies for revision TKA; (2) frequencies of revision TKA procedures; (3) various demographics including payer type and region; and (4) the length of stay (LOS) and total charges based on type of revision TKA procedure. Methods The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between 2009 and 2013. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean LOS and total charges were also calculated. Results Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revisions (57.7%). The South census region performed the most revision TKAs (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKAs was $75,028.07. Conclusion Without appropriate measures in place, the burden of revision TKAs may become overwhelming and pose a strain on providers and institutions. Continued insight into the etiology and epidemiology of revision TKAs may be the principle step towards improving outcomes and mitigating the need for future revisions.

Effect of Bundled Payments and Health Care Reform as Alternative Payment Models in Total Joint Arthroplasty: A Clinical Review

Abstract: Background In an effort to control rising healthcare costs, healthcare reforms have developed initiatives to evaluate the efficacy of alternative payment models (APMs) for Medicare reimbursements. The Center for Medicare and Medicaid Services Innovation Center (CMMSIC) introduced the voluntary Bundled Payments for Care Improvement (BPCI) model experiment as a means to curtail Medicare cost by allotting a fixed payment for an episode of care. The purpose of this review is to (1) summarize the preliminary clinical results of the BPCI and (2) discuss how it has led to other healthcare reforms and alternative payment models. Methods A literature search was performed using PubMed and the CMMSIC to explore different APMs and clinical results after implementation. All studies that were not in English or unrelated to the topic were excluded. Results Preliminary results of bundled payment models have shown reduced costs in total joint arthroplasty largely by reducing hospital length of stay, decreasing readmission rates, as well as reducing the number of patients sent to in-patient rehabilitation facilities. In order to refine episode of care bundles, CMMSIC has also developed other initiatives such as the Comprehensive Care for Joint Replacement (CJR) pathway and Surgical Hip and Femur Fracture (SHFFT). Conclusion Despite the unknown future of the Affordable Care Act, BPCI, and CJR, preliminary results of alternative models have shown promise to reduce costs and improve quality of care. Moving into the future, surgeon control of the BPCI and CJR bundle should be investigated to further improve patient care and maximize financial compensation.

Opioid Use After Total Knee Arthroplasty: Trends and Risk Factors for Prolonged Use

Abstract: Background The United States is in the midst of an opioid epidemic. Little is known about perioperative opioid use for total knee arthroplasty (TKA). The purpose of this study was to identify rates of preoperative opioid use, evaluate postoperative trends and identify risk factors for prolonged use after TKA. Methods Patients who underwent primary TKA from 2007-2014 were identified within the Humana database. Postoperative opioid use was measured by monthly prescription refill rates. A preoperative opioid user (OU) was defined by history of opioid prescription within 3 months prior to TKA and a non-opioid user (NOU) was defined by no history of prior opioid use. Rates of opioid use were trended monthly for one year postoperatively for all cohorts. Results 73,959 TKA patients were analyzed and 23,532 patients (31.2%) were OU. OU increased from 30.1% in 2007 to 39.3% in 2014 (P Conclusion Approximately one-third of TKA patients use opioids within 3 months prior to surgery and this percentage has increased over 9% during the years included in this study. Preoperative opioid use was most predictive of increased refills of opioids following TKA. However, other intrinsic patient characteristics were also predictive of prolonged opioid use.

Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.

Abstract: Background As outpatient total hip (THA) and knee arthroplasties (TKA) increase in popularity, concerns exist about the safety of discharging patients home the same day. The purpose of this study is to determine the complications associated with outpatient total joint arthroplasty (TJA) and to identify high-risk patients who should be excluded from these protocols. Methods We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary TKA or THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between outpatient and traditional inpatient procedures. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes. Results Of the total 169,406 patients who underwent TJA, 1220 were outpatient (0.7%). The outpatient and inpatient groups had an overall complication rate of 8% and 16%, respectively. Patients aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications after THA and TKA (all P P = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651, P = .789), and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567, P Conclusion With the resources available in a hospital setting, outpatient TJA may be a safe option, but only in select, healthier patients. Care should be taken to extrapolate these results to an outpatient facility, where complications may be more difficult to manage.

Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013.

Abstract: Background The utilization of hip arthroscopy continues to increase in the United States. The purpose of this study was to examine trends in hip arthroscopy procedures and outcomes. Methods We performed a retrospective cohort study using Optum Labs Data Warehouse administrative claims data. The cohort comprised 10,042 privately insured enrollees aged 18-64 years who underwent a hip arthroscopy procedure between 2005 and 2013. Utilization trends were examined using age-specific, sex-specific, and calendar-year-specific hip arthroscopy rates. Outcomes were examined using the survival analysis methods and included subsequent hip arthroscopy and total hip arthroplasty (THA). Results Hip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. The overall 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In the subset of patients in whom laterality of the subsequent procedure could be determined, about half of the subsequent hip arthroscopy procedures (46%) and almost all of the THA procedures (94%) were on the same side. Decreasing age was significantly associated with the risk of subsequent arthroscopy ( P P Conclusion The utilization of hip arthroscopy procedures increased dramatically over the last decade in the 18-64-year-old privately insured population, with the largest increase in younger age-groups. Future studies are warranted to understand the determinants of the large increase in utilization of hip arthroscopy and outcomes.

The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review

Abstract: Background Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty. Methods We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation. Results Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again. Conclusion For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Total Hip Arthroplasty Patients With Fixed Spinopelvic Alignment Are at Higher Risk of Hip Dislocation.

Abstract: Background Sitting radiographs have been used as a pre-operative tool to plan patient-specific total hip arthroplasty (THA) component position that would improve hip stability. Previous work has demonstrated that spinal mobility may impact functional acetabular position when seated. We sought to determine whether patients who dislocate following THA have different sitting spinopelvic alignment or acetabular component orientation compared to patients who did not dislocate. Methods A consecutive series of 1000 patients underwent post-operative low-dose biplanar spine-to-ankle lateral radiographs in standing and sitting positions 1 year following THA. Twelve patients (1% of all patients) experienced hip dislocation. Patients were categorized as having normal lumbar spines (without radiographic arthrosis) or as having lumbar multi-level degenerative disc disease. Measurements of spinopelvic alignment parameters (including sacral slope, lumbar lordosis, and proximal femur angles) and acetabular component orientation in sitting position (functional inclination and functional anteversion) were performed. Results Patients who dislocated had significantly less spine flexion, less change in pelvic tilt, and more hip flexion from standing to sitting positions compared to patients with normal spines. In sitting position, dislocators had acetabular components with less functional inclination and less functional anteversion. Conclusion This study demonstrates that patients with fixed spinopelvic alignment from standing to sitting position are at higher risk of hip dislocation. Imaging patients from standing to sitting position using this technique can provide valuable information on whether a patient has fixed spinopelvic alignment with postural changes and is therefore at higher risk of dislocation.

Total Hip Arthroplasty in the Spinal Deformity Population: Does Degree of Sagittal Deformity Affect Rates of Safe Zone Placement, Instability, or Revision?

Abstract: Background Changes in spinal alignment and pelvic tilt alter acetabular orientation in predictable ways, which may have implications on stability of total hip arthroplasty (THA). Patients with sagittal spinal deformity represent a subset of patients who may be at particularly high risk of THA instability because of postural compensation for abnormal spinal alignment. Methods Using standing stereoradiography, we evaluated the spinopelvic parameters, acetabular cup anteversion, and inclination of 139 THAs in 107 patients with sagittal spinal deformity. Standing images were compared with supine pelvic radiographs to evaluate dynamic changes in acetabular cup position. Dislocation and revision rates were procured through retrospective chart review. The spinal parameters and acetabular cup positions among dislocators were compared with those who did not dislocate. Results The rate of THA dislocation in this cohort was 8.0%, with a revision rate of 5.8% for instability. Patients who sustained dislocations had significantly higher spinopelvic tilt, T1-pelvic angle, and mismatch of lumbar lordosis and pelvic incidence. Among all patients, 78% had safe anteversion while supine, which decreased significantly to 58% when standing due to increases in spinopelvic tilt. Among dislocating THA, 80% had safe anteversion, 80% had safe inclination, and 60% had both parameters within the safe zone. Conclusion In this cohort, patients with THA and concomitant spinal deformity have a particularly high rate of THA instability despite having an acetabular cup position traditionally thought of as within acceptable alignment. This dislocation risk may be driven by the degree of spinal deformity and by spinopelvic compensation. Surgeons should anticipate potential instability after hip arthroplasty and adjust their surgical plan accordingly.

Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the “Outpatient Arthroplasty Risk Assessment Score”

Abstract: Background Current patient selection criteria and medical risk stratification methods for outpatient primary total joint arthroplasty (TJA) surgery are unproven. This study assessed the predictive ability of a medically based risk assessment score in selecting patients for outpatient and short stay surgery. Methods A retrospective review of 1120 consecutive primary TJAs in an early discharge program was performed. An Outpatient Arthroplasty Risk Assessment ("OARA") score was developed by a high-volume arthroplasty surgeon and perioperative internal medicine specialist to stratify patients as "low-moderate risk (≤59)" and "not appropriate" (≥60) for early discharge. OARA, American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and Charlson comorbidity index (CCI) scores were analyzed with respect to length of stay. Results The positive predictive value of the OARA score was 81.6% for the same or the next day discharge, compared with that of 56.4% for ASA-PS ( P P = .002) scores. Patients with OARA scores ≤59 were 2.0 (95% confidence interval [CI], 1.4-2.8) times more likely to be discharged early than those with scores ≥60 ( P P = .001). CCI did not predict early discharge ( P ≥ .301). With deliberate patient education and expectations for outpatient discharge, the odds of early discharge predicted by the OARA score, but not the ASA-PS score, increased to 2.7 (95% CI, 1.7-4.2). Conclusion The OARA score for primary TJA has more precise predictive ability than the ASA-PS and CCI scores for the same or next day discharge and is enhanced with a robust patient education program to establish appropriate expectations for early discharge. Early results suggest that the OARA score can successfully facilitate appropriate patient selection for outpatient TJA, although consideration of clinical program maturity before adoption of the score is advised.

Arthrofibrosis Associated With Total Knee Arthroplasty

Abstract: Background Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. Methods In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. Results Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. Conclusion Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Failure After Modern Total Knee Arthroplasty: A Prospective Study of 18,065 Knees.

Abstract: Background We sought is to determine the mechanism of failure among primary total knee arthroplasties (TKAs) performed at a single high-volume institution by asking the following research questions: (1) What are the most common failure modes for modern TKA designs? and (2) What are the preoperative risk factors for failure following primary TKA? Methods From May 2007 to December 2012, 18,065 primary TKAs performed on 16,083 patients at a single institution were recorded in a prospective total joint arthroplasty registry with a minimum of 5-year follow-up We retrospectively reviewed patient charts to determine a cause of failure for primary TKAs A cox proportional hazard model was used to determine the risk of revision surgery following primary TKA Results The most common reasons for failure within 2 years after TKA were infection and stiffness The multivariable regression identified the following preoperative risk factors for TKA failure: history of drug abuse (hazard ratio [HR] 468; P = 003), deformity/mechanical preoperative diagnosis (HR 352; P Conclusion These findings add to the growing data that primary TKAs are no longer failing from polyethylene wear-related issues This study identified preoperative risk factors for failure of primary TKAs, which may be useful information for developing strategies to improve outcomes following TKA

Preoperative Opiate Use Independently Predicts Narcotic Consumption and Complications After Total Joint Arthroplasty

Abstract: Background Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA. Methods We prospectively evaluated a consecutive series of 802 patients undergoing elective primary THA and TKA over a 9-month period. All patients were managed using a multimodal pain protocol. Data on medical comorbidities and history of preoperative narcotic use were collected and correlated with deviations from the protocol. Results Of the 802 patients, 266 (33%) required intravenous narcotic rescue. Patients aged P = .019) and with preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P P P P = .025) and a 2.5-times risk of requiring oral narcotics at 3 months postoperatively (OR, 2.48; 95% CI, 1.61-3.82; P Conclusion Despite the effectiveness of multimodal postoperative pain protocols, younger patients with preoperative history of narcotic use require additional opioids and are at a higher risk for complications and a greater length of stay.

The Impact of Mechanical and Restricted Kinematic Alignment on Knee Anatomy in Total Knee Arthroplasty

Abstract: Background Total knee arthroplasty (TKA), aiming at neutral mechanical alignment (MA), inevitably modifies the patient's native knee anatomy. Another option is kinematic alignment (KA), which aims to restore the original anatomy of the knee. The aim of this study was to evaluate the variations in lower limb anatomy of a patient population scheduled for TKA, and to assess the use of a restricted KA TKA protocol and compare the resulting anatomic modifications with the standard MA technique. Methods A total of 4884 knee computed tomography scans were analyzed from a database of patients undergoing TKA with patient-specific instrumentation. The lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and hip-knee-ankle angle (HKA) were measured. Bone resections were compared using a standard MA and a restricted KA aiming for independent tibial and femoral cuts of maximum ±5° deviation from the coronal mechanical axis and a resulting overall coronal HKA within ±3° of neutral. Results The mean preoperative MPTA was 2.9° varus, LDFA was 2.7° valgus, and overall HKA was 0.1° varus. Using our protocol, 2475 knees (51%) could have undergone KA without adjustment. To include 4062 cases (83%), mean corrections of 0.5° for MPTA and 0.3° for LDFA were needed, significantly less than with MA (3.3° for MPTA and 3.2° for LDFA; P Conclusion The range of knee anatomy in patients scheduled for TKA is wide. MA leads to greater modifications of knee joint anatomy. To avoid reproducing extreme anatomy, the proposed restricted KA protocol provides an interesting hybrid option between MA and true KA.

Allogeneic Blood Transfusion Is a Significant Risk Factor for Surgical-Site Infection Following Total Hip and Knee Arthroplasty: A Meta-Analysis

Abstract: Background Blood loss occurs significantly more frequently during total hip and knee arthroplasty than among any other type of orthopedic operation, which can sometimes lead to requiring a blood transfusion. Although allogeneic blood transfusion has been identified as a risk factor for postoperative surgical-site infection following arthroplasty, results are inconclusive. The purpose of this study was to conduct a systematic meta-analysis to investigate whether having an allogeneic blood transfusion significantly increases the risk for surgical-site infection, particularly after total hip and knee arthroplasty. Methods We performed a systematic review and meta-analysis using random-effect models. Using an electronic database search, we selected 6 studies that included data on 21,770 patients and among these studies compared the postoperative infection rate between an allogeneic blood-transfusion exposure group and a nonexposure group. We calculated the pooled odds ratios and 95% confidence intervals for the groups. Results The prevalences of surgical-site infections in our pooled analyses were 2.88% and 1.74% for the transfusion and nontransfusion groups, respectively. The allogeneic blood transfusion group had a significantly higher frequency of surgical-site infections based on pooled analysis using a random-effect model (pooled odds ratio = 1.71, 95% confidence interval: 1.23-2.40, P = .002). Conclusion Allogeneic blood transfusion is a significant risk factor for increasing the surgical-site infection rate after total hip and knee arthroplasty.

Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty for Medial Compartment Arthritis in Patients Older Than 75 Years: Comparable Reoperation, Revision, and Complication Rates

Abstract: Background Prior studies comparing unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) in the elderly are limited by heterogeneity in arthritic disease patterns and patient selection. We report the results of UKA and TKA in patients 75 years and older with isolated medial compartmental arthritis, with special emphasis on immediate postoperative recovery, complications, reoperation rates, and implant survivorship at midterm follow-up. Methods A retrospective review was performed of all patients 75 years and older who underwent UKA or TKA at our institution between 2002 and 2012. All TKA preoperative X-rays were reviewed by a blind observer to identify knees with isolated medial compartmental arthritis considered acceptable candidates for UKA. Patients with less than 2 years of follow-up, flexion contracture greater than 10°, and rheumatoid arthritis were excluded. The final sample included 120 UKA (106 patients) and 188 TKA (170 patients) procedures. Patient records were reviewed to determine early postoperative recovery, complications, reoperations for any reason, and implant survivorship. Results UKA patients experienced significantly shorter operative time, shorter hospital stay, lower intraoperative estimated blood loss, lower postoperative transfusions, greater postoperative range of motion, and higher level of activity at time of discharge. Two UKA and 2 TKA patients required revision surgery. There was no statistically significant difference in postoperative Knee Society Scores. There were no differences in 5-year survivorship estimates. Conclusion Due to its less invasive nature, patients older than 75 undergoing UKA demonstrated faster initial recovery when compared to TKA, while maintaining comparable complications and midterm survivorship. UKA should be offered as an option in the elderly patient who fits the selection criteria for UKA.

Revision Total Knee Arthroplasty for Periprosthetic Joint Infection Is Associated With Increased Postoperative Morbidity and Mortality Relative to Noninfectious Revisions

Abstract: Background Periprosthetic joint infection (PJI) after primary total knee arthroplasty (TKA) is a devastating complication. The short-term morbidity profile of revision TKA performed for PJI relative to non-PJI revisions is poorly characterized. The purpose of this study is to determine 30-day postoperative outcomes after revision TKA for PJI, relative to primary TKA and aseptic revision TKA. Methods The American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2015 was queried for primary and revision TKA cases. Revision TKA cases were categorized into PJI and non-PJI cohorts. Differences in 30-day outcomes including postoperative complications, readmissions, operative time, and length of stay were compared using bivariate and multivariate analyses. Results In total, 175,761 TKAs were included in this study, with 162,981 (92.7%) primary TKAs and 12,780 (7.3%) revision TKAs, of which 2196 (17.2%) revisions were performed for PJI. When compared to aseptic revision TKA, multivariate analysis demonstrated that PJI revisions had a significantly higher risk of major early postoperative complications including death (adjusted odds ratio [OR] 3.25) and sepsis (OR 8.73). In addition, nonhome discharge (OR 1.75), readmissions (OR 1.67), and length of stay (+2.1 days) were all greater relative to non-PJI revisions. Conclusion Utilizing a large, prospectively collected, national database, we found that revision TKA for PJI has a greater risk of short-term morbidity and mortality and requires a higher utilization of healthcare resources. These results have implications for patient counseling and alternative payment models that may eventually include revision TKA.

Prosthetic Dislocation and Revision After Primary Total Hip Arthroplasty in Lumbar Fusion Patients: A Propensity Score Matched-Pair Analysis

Abstract: Background Lumbar-pelvic fusion reduces the variation in pelvic tilt in functional situations by reducing lumbar spine flexibility, which is thought to be important in maintaining stability of a total hip arthroplasty (THA). We compared dislocation and revision rates for patients with lumbar fusion and subsequent THA to a matched comparison cohort with hip and spine degenerative changes undergoing only THA. Methods We identified patients in New York State who underwent primary elective lumbar fusion for degenerative disc disease pathology and subsequent THA between January 2005 and December 2012. A propensity score match was performed to compare 934 patients with prior lumbar fusion to 934 patients with only THA according to age, gender, race, Deyo comorbidity score, year of surgery, and surgeon volume. Revision and dislocation rates were assessed at 3, 6, and 12 months post-THA. Results At 12 months, patients with prior lumbar fusion had significantly increased rates of THA dislocation (control: 0.4%; fusion: 3.0%; P P P P Conclusion Patients undergoing lumbar fusion and subsequent THA have significantly higher risks of dislocation and revision of their hip arthroplasty than a matched cohort of patients with similar hip and spine pathology but only undergoing THA. During preoperative consultation for patients with prior lumbar fusion, orthopedic surgeons must educate the patient and family about the increased risk of dislocation and revision.

Comparison of Outpatient vs Inpatient Total Knee Arthroplasty: An ACS-NSQIP Analysis.

Abstract: Background There has been a recent surge of interest in performing primary total knee arthroplasty (TKA) in the outpatient setting to reduce cost and increase patient satisfaction. Detailed information on the safety of outpatient TKA in large sample sizes is scarce. Methods Patients who underwent primary, elective TKA were identified in the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days, whereas inpatient procedure was defined as having a length of stay ≥1 days. To reduce the effect of confounding factors and nonrandom assignment of treatment, propensity score matching was used. Multivariate analyses on the matched samples were used to compare the rates of adverse events that happened any time during the 30-day postoperative period, postdischarge adverse events, and readmissions between the outpatient and inpatient cohorts. Results A total of 112,922 TKA patients met the inclusion criteria. Of these, only 642 (0.57%) were outpatient procedures. Outpatients tended to be men, slightly younger, and have less comorbidity. After propensity matching, multivariate analysis revealed a higher rate of postdischarge blood transfusions ( P Conclusion Based on the perioperative outcome measures studied here, outpatient TKA can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients postdischarge may be warranted.

Preoperative Anxiety and Depression Correlate With Dissatisfaction After Total Knee Arthroplasty : A Prospective Longitudinal Cohort Study of 186 Patients, With 4-Year Follow-Up

Abstract: Background After more than 4 decades experience of total knee arthroplasty (TKA), there is still a group of patients who are not satisfied with the outcome. In spite of the improvement of many aspects around the procedure, for unexplainable reasons, patient dissatisfaction is still approximately the same. We conducted this study to analyze correlations between preoperative psychological aspects and dissatisfaction after TKA. Methods A total of 186 patients were operated with a primary TKA. Patients filled out the Hospital Anxiety and Depression Scale, Visual Analog Pain Scale (0-100), and Knee injury and Osteoarthritis Outcome Score preoperatively and 4 years postoperatively. Four years postoperatively, the patients also scored their satisfaction degree with the outcome of the surgery. Results Of 186 patients, 27 (15%) reported that they were dissatisfied or uncertain with the result of their TKA 4 years postoperatively. Sixteen of those 27 patients had reported anxiety/depression preoperatively compared with 11 of 159 (7%) in the satisfied or very satisfied groups. Patients with preoperative anxiety or depression had more than 6 times higher risk to be dissatisfied compared with patients with no anxiety or depression ( P P = .03). Dissatisfied patients had 1-day longer hospital stay compared with the satisfied group ( P Conclusion Preoperative anxiety and/or depression is an import predictor for dissatisfaction after TKA. Psychological assessment and treatment preoperatively might improve degree of satisfaction.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis.

Abstract: Background The choice between anterior approach (AA) and posterior approach (PA) in primary total hip arthroplasty (THA) is controversial. Previous reviews have predominantly relied on data from retrospective studies. Methods This systematic review included prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA. Outcomes were pain severity, narcotic usage, hip function using Harris Hip Score, and complications. Random effects meta-analysis was performed for all outcomes. Efficacy data were reported as standardized mean difference (SMD) where values of 0.2, 0.5, 0.8, and 1.0 were defined as small, medium, large, and very large effect sizes, respectively. Complications were reported as the absolute risk difference (RD) where a positive value implied higher risk with AA and a lower value implied lower risk with AA. Results A total of 13 prospective comparative studies (7 randomized) with patients treated with AA (n = 524) or PA (n = 520) were included. The AA was associated with lower pain severity (SMD = −0.37, P Conclusion In this systematic review and meta-analysis of prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA, patients treated with AA reported less pain, consumed fewer narcotics, and reported better hip function. No statistical differences in complication rates were detected between AA and PA. Ultimately, the choice of surgical approach in primary THA should consider preference and experience of the surgeon as well as preference and anatomy of the patient.

Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial

Abstract: Background Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA). Methods One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach. Group A included patients who had a total hip arthroplasty with a DAA, whereas group B included those with a PLA. Patients were randomized into the DAA or PLA groups (n = 60), and perioperative and postoperative outcomes were recorded. Results When compared with the PLA, the DAA had a shorter incision length (9.1 vs 13.1 cm; P Conclusion We found functional advantages in early recovery after the DAA compared with the PLA. The DAA can offer rapid functional recovery with less muscle damage, greater pain relief, and lower variance in cup inclination and anteversion. However, no functional difference was found at 6 months follow-up.

A Prospective Randomized Clinical Trial in Total Hip Arthroplasty-Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach.

Abstract: Background We report a prospective randomized study comparing early clinical results between the direct anterior approach (DAA) and posterior approach (PA) in primary hip arthroplasty. Methods Surgeries were performed by 2 senior hip arthroplasty surgeons. Seventy-two patients with complete data were assessed preoperatively 2, 6, and 12 weeks postoperatively. The primary outcomes were the Western Ontario McMasters Arthritis Index and Oxford Hip Scores. Secondary outcome measures included the EuroQoL, 10-meter walk test, and clinical and radiographic parameters. Results Data analyses showed no difference between DAA (n = 35) and PA (n = 37) groups when comparing total scores for primary outcomes. No significant differences were observed for 10-meter walk test, EuroQoL, and radiographic analyses. Subgroup analysis for surgeon 1 identified that the DAA group had shorter acute hospital stay, less postoperative opiate requirements, and smaller wounds. However, this was offset by increased operative time, higher intraoperative blood loss, and weaker hip flexion at 2 and 6 weeks. Subgroup analysis of items on the Western Ontario McMasters Arthritis Index and Oxford Hip Score identified that hip flexion activity favored the DAA group up to 6 weeks postoperatively. There was an 83% incidence of lateral cutaneous nerve of thigh neuropraxia at the 12-week mark in the DAA group. No neuropraxias occurred in the PA group. One dislocation occurred in each group. A single patient from the DAA group required reoperation for leg-length discrepancy. Conclusion DAA total hip arthroplasty (THA) has comparable results with PA THA. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience.

Challenges in Total Hip Arthroplasty in the Setting of Developmental Dysplasia of the Hip

Abstract: Background Developmental dysplasia of the hip (DDH) is a recognized cause of secondary arthritis, which may eventually lead to total hip arthroplasty (THA). An understanding of the common acetabular and femoral morphologic abnormalities will aid the surgeon in preparing for the complexity of the surgical case. Methods We present the challenges associated with acetabular and femoral morphologies that may be present in the dysplastic hip and discuss surgical options to consider when performing THA. In addition, common complications associated with this population are reviewed. Results The complexity of THA in the DDH patient is due to a broad range of pathomorphologic changes of the acetabulum and femur, as well as the diverse and often younger age of these patients. As such, THA in the DDH patient may offer a typical primary hip arthroplasty or be a highly complex reconstruction. It is important to be familiar with all the subtleties associated with DDH in the THA population. The surgeon must be prepared for bone deficiency when reconstructing the acetabulum and should place the component low and medial (at the anatomic hip center), and avoid oversizing the acetabular component. Femoral dysplasia is also complex and variable, and the surgeon must be prepared for different stem choices that allow for decoupling of the metaphyseal stem fit from the implanted stem version. In Crowe III and IV dysplasia, femoral derotation/shortening osteotomy may be required. Many complications associated with THA in the DDH patient may be mitigated with careful planning and surgical technique. Conclusion Performed correctly, THA can yield excellent results in this complex patient population.

Complications After Revision Total Hip Arthroplasty in the Medicare Population.

Abstract: Background The purpose of this study was to identify the incidence and types of complications after revision total hip arthroplasty (THA) within the first year, and determine the relative risk factors for these complications and of re-revision. Methods The sample size of 5% Medicare claims data from 1998-2011 was studied. Primary THA patients who underwent subsequent revision were identified using ICD-9-CM codes. Outcomes and complications after revision THA were assessed. Multivariate Cox regression was used to evaluate the effect of patient demographic characteristics on the adjusted complication risk for revision THA patients. Results Of the 64,260 primary THA patients identified between 1998 and 2011, 3555 patients (5.71%) underwent revision THA. Etiology of primary hip failure included mechanical complications such as loosening and wear (40.7%), dislocation (14.0%), and infection (11.3%). Complications after revision THA included infection and redo revision, 17.3% and 15.8% followed by venous thromboembolic disease (VTE) at 11.1%, dislocation at 5.43%, PE at 3.24%, and death at 2.11%. The rate of "new" infections after an aseptic revision was 8.13%. Patients in the 85+-year-old age group had a 100% greater adjusted risk of VTE ( P P P P P = .002), and re-revision THA ( P = .011). Conclusion Advanced age is a clear risk factor for VTE and mortality, but not for dislocation, infection, or re-revision. Higher Charlson index was found to be a risk factor for every complication after revision except dislocation. Greater attention is required to address the high rate of infection and re-do revision after revision THA (17.3% and 15.8%).

Association Between Body Mass Index and Thirty-Day Complications After Total Knee Arthroplasty.

Abstract: Background Although previous studies have evaluated the effect of obesity on the outcomes of total knee arthroplasty (TKA), most considered obesity as a binary variable. It is important to compare different weight categories and consider body mass index (BMI) as a continuous variable to understand the effects of obesity across the entire range of BMI. Therefore, the objective of this study is to analyze the effect of BMI on 30-day readmissions and complications after TKA, considering BMI as both a categorical and a continuous variable. Methods The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 150,934 primary TKAs. Thirty-day rates of readmissions, reoperations, and medical/surgical complications were compared between different weight categories (overweight: BMI >25 and ≤30 kg/m2; obese: BMI >30 and ≤40 kg/m2; morbidly obese: BMI >40 kg/m2) and the normal weight category (BMI >18.5 and ≤25 kg/m2) using multivariate regression models. Spline regression models were created to study BMI as a continuous variable. Results Obese patients were at increased risk of pulmonary embolism (PE) (P Conclusion Obesity increased the risk of readmission and various complications after TKA, with the risk being dependent on the severity of obesity. Relationships between BMI and complications showed considerable variations with some outcomes like readmission and reoperation showing a U-shaped relationship. Based on our findings, a potential BMI goal in weight management for obese patients could be established around 29-30 kg/m2, in order to decrease the risk of most TKA postoperative complications.

Early Outcomes of Kinematic Alignment in Primary Total Knee Arthroplasty: A Meta-Analysis of the Literature.

Abstract: Background Kinematic alignment in total knee arthroplasty (TKA) seeks to more anatomically align the knee prosthesis to promote more physiological kinematics. However, there are questions about the durability, function, and complication rate of a non–mechanically aligned TKA. Therefore, the purpose of this study is to perform a systematic review and meta-analysis to evaluate early outcomes after kinematic alignment. Methods Two independent reviewers performed a systematic review of the English literature using both the MEDLINE and Embase databases searching for studies on kinematic TKA. Of the initial 839 published reports, 9 studies were included in the review. Four randomized, controlled trials comparing outcomes of kinematic and conventional alignment TKA were identified. Data were extracted and aggregated using inverse variance and Mantel-Haenszel fixed effects meta-analysis. Results Of an aggregated 877 kinematic TKAs, the cumulative survivorship was 97.4% at a weighted mean follow-up of 37.9 months. The most common reasons for revision were patellofemoral problems in 8 patients (1.2%). We found no difference in the complication rate between the 229 kinematic and 229 conventional TKA patients (3.9% vs 4.4%; P = .83). The kinematic TKA group had a higher combined postoperative Knee Society Score than the conventional TKA group (mean difference, 9.1 points; 95% confidence interval, 5.2-13.0 points; P Conclusion Small deviations from the traditional mechanical axis alignment in TKA do not appear to impact overall survivorship or complication rates at short-term follow-up. Functional outcome as measured by the Knee Society Score favored kinematic alignment. These preliminary results illustrate the concept that there may be more than a single alignment target for all patients undergoing primary TKA.

Operative Time Affects Short-Term Complications in Total Joint Arthroplasty

Abstract: Background Increased operative time has been associated with increased complications after total joint arthroplasty (TJA). The purpose of the present study was to investigate the effect of operative time on short-term complications after TJA while also identifying patient and operative factors associated with prolonged operative times. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011-2013 to identify all patients who underwent primary total hip or knee arthroplasty. Patients were stratified by operative time, and 30-day morbidity and mortality data compared using univariate and multivariable analyses. Results We identified 99,444 patients who underwent primary TJA. The overall incidence of complications after TJA was 4.9%. Overall complications were increased in patients with operative times >120 minutes (5.9%) as compared to patients with operative times P 120 minutes. In a multivariable analysis, operative time exceeding 120 minutes remained an independent predictor of any complication and wound complication, with each 30-minute increase in operative time beyond 120 minutes further increasing risk. Patient age ≤65 years, male sex, black race, body mass index ≥30 kg/m 2 , and an American Society of Anesthesiologists classification of 3 or 4, predicted operative times >120 minutes. Conclusion We found that operative time >120 minutes was associated with increased short-term morbidity and mortality after primary TJA. Younger age, male sex, black race, obesity, and increased comorbidity were risk factors for operative time exceeding 120 minutes.

Technology-Assisted Hip and Knee Arthroplasties: An Analysis of Utilization Trends

Abstract: Background Robotic and computer navigation technology is available to surgeons for use in hip and knee arthroplasties to increase the precision of component placement. However, they do add significant costs to these procedures, and the long-term clinical outcomes and value of technology assistance for joint replacement remain unclear. Methods We identified 321,522 patients in Medicare Severity Diagnosis Related Groups 469 and 470 who underwent primary total hip arthroplasty (N = 133,472) or primary total or unicompartmental knee arthroplasty (N = 188,050) between 2008 and 2015 in the New York Statewide Planning and Research Cooperative System (SPARCS). Results Among all total joint arthroplasties performed during this period, technology assistance was used in 5.1% of cases. Technology assistance was more common for knee (7.3%) than hip (1.9%) arthroplasty (P Conclusion Technology assistance has become increasingly used by orthopedic surgeons for hip and knee arthroplasties, however, adoption has not been uniform.