Factors Associated with Reoperation after Pyrocarbon Proximal Interphalangeal Joint Arthroplasty for the Arthritic Joint: A Retrospective Cohort Study

Introduction  The rate of reoperation after pyrocarbon proximal interphalangeal (PIP) joint arthroplasty ranges from 5.9 to 37% and complications such as radiographic loosening, deformity, dislocation, and stiffness are common. Because of the limited amount of knowledge around these problems, we evaluated factors associated with reoperation after pyrocarbon PIP arthroplasty. Materials and Methods  We retrospectively included all adult patients that underwent primary PIP pyrocarbon implant arthroplasty between 2002 and 2016 at one institutional system. A total of 45 patients, with a mean age of 55 (standard deviation: 14), underwent 66 PIP arthroplasties. To address for within individual correlations, we only included fingers treated at patients’ initial surgery ( n = 54) in our statistical analysis. These patients were predominantly diagnosed with noninflammatory arthritis 73% ( n = 33). Arthroplasty was performed upon 10 index, 22 middle, 20 ring, and 2 small fingers. Results  The reoperation rate after pyrocarbon PIP arthroplasty was 30% over a median follow-up of 25 months (interquartile range: 8.7–54). Indications for reoperation consisted of subluxation ( n = 6), stiffness ( n = 5), swan-neck deformity ( n = 3), and soft tissue complications ( n = 2). Younger age ( p = 0.025), male sex ( p = 0.017), and noninflammatory arthritis ( p = 0.038) were associated with a higher reoperation rate. Conclusion  In this study, our reoperation rate after pyrocarbon PIP arthroplasty was 30%. This study suggested that younger patients, males, and patients with noninflammatory arthritis are at higher risk of reoperation. We recommend considering these factors when selecting candidates for pyrocarbon arthroplasty. Future studies should focus on prospectively researching these factors in comparison with other implants.     

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BackgroundIt is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.MethodsPatient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).ResultsOne hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.ConclusionThese results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.     

Joint Replacement Access in 2016 : A Supply Side Crisis

Demand for primary and revision arthroplasty is expected to double in 10 years. Coincident with this is a decreased interest in arthroplasty by residents. Retirement of arthroplasty surgeons further threatens access. This study determines if supply will meet demand. Survey data were used to calculate the 2016 workforce. Demand in 2016 was estimated using the Nationwide Inpatients Sample. Between 2008 and 2016, 400 arthroplasty specialists and 1584 generalists will enter the workforce. By 2016, 1896 arthroplasty surgeons will retire using 65 years as a conservative retirement age, whereas 4239 will retire using 59 years as a baseline retirement age. In 2016, the model estimated a procedural shortfall ranging from 174?409 (↓18.6%) using conservative retirement assumptions (age, 65 years) to 1?177?761 (↓69.4%) using baseline retirement assumptions (age, 59 years). This economic model predicts a supply side crisis that threatens patient access to specialty care. Immediate steps to stimulate supply must be taken.     

Financial Distress and Discussing the Cost of Total Joint Arthroplasty

Background

Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.

Disease Progression After Unicompartmental Arthroplasty: Add a Compartment or Revise to Total Knee Arthroplasty?

BackgroundFive percent to 7% of unicompartmental knee arthroplasties (UKA) require revision for disease progression in untreated compartment(s), most commonly to total knee arthroplasty (TKA). TKA requires removal of bone and usually the anterior cruciate ligament. Preserving the UKA and converting to a bicompartmental arthroplasty (BCA) by performing a second UKA is an alternative.MethodsThe results of 73 UKA-BCA patients were compared to 75 patients treated by UKA-TKA revision. Knee Society, Knee Osteoarthritis Outcome Score Joint Replacement, and patient satisfaction scores were collected by a blinded therapist. Patients were asked about their implant preference and recovery. Twenty-two UKA-BCA revision patients had a UKA (6) or TKA (16) in the contralateral knee; thus, a direct comparison of UKA-BCA to both UKA and TKA was possible.ResultsOf the UKA-BCA patients, 69 (94%) had excellent or good, 2 (3%) fair, and 2 (3%) poor outcomes with 1 patient requiring revision to TKA. Of patients with a TKA in the contralateral knee, 13 (81%) preferred the UKA-BCA replacement and 3 (19%) preferred the TKA. All patients said the UKA-BCA revision recovery was similar or easier than their initial UKA. Of UKA-TKA revisions, 59 (79%) had excellent or good, 9 (12%) fair, and 7 (9%) poor outcomes. There was 1 wound infection and 1 re-revision in the UKA-BCA group and 1 wound infection and 3 re-revisions in the UKA-TKA group. The Knee Osteoarthritis Outcome Score Joint Replacement and Knee Society Scores were better for UKA-BCA compared to UKA-TKA.ConclusionUKA-BCA is a successful treatment for disease progression following UKA.     

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution

BackgroundOutpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD.MethodsFive hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients.ResultsOne hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001).ConclusionAn option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.     

The two-stage standard: Res ipsa loquitur

Periprosthetic joint infection is a morbid and costly complication of total knee arthroplasty. Treatment options vary depending on chronicity of the infection, causative organism, and host factors. Some authors advocate single-stage exchange arthroplasty to decrease patient morbidity and healthcare utilization costs. Due to its proven efficacy for infection eradication and soft tissue healing, however, two-stage exchange arthroplasty remains the gold standard for treatment of periprosthetic joint infection after total knee arthroplasty. In this review, we present the technique of two-stage exchange arthroplasty and evidence supporting its use.     

Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty?

BackgroundWe sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint.MethodsWe conducted a matched cohort study using data from Kaiser Permanente’s arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models.ResultsNo difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63).ConclusionPatients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients.Level of EvidenceLevel III.     

CMC Arthroplasty of the Thumb: A Review

Arthritis of the first carpometacarpal (CMC) joint of the hand is a common and often debilitating disease. Diagnosis can be readily made with history, physical exam, and radiographic evaluation. Patients with advanced disease who have failed conservative treatment modalities have multiple surgical options including ligament reconstruction, resection arthroplasty, silicone implantation, tendon interposition, or total joint arthroplasty. This article will describe the variety of approaches to treatment as well as the author’s preferred method. The above authors have no conflicts of interest or monetary support from any institution or industry to declare.     

髋关节表面置换术的临床进展

髋关节疾病严重影响着患者的生活质量,尤其对于年轻、活动量大、预期寿命长、功能要求高的患者,由于传统的全髋关节置换术（total hip arthroplasty,THA）截除了正常的股骨颈而改变了生物力学关系,加上假体磨损相关并发症、股骨颈骨折等问题,使得THA术后可能需行多次翻修手术。     

Which do patients prefer,unicompartmental or total knee arthroplasty?

Objective

Unicompartmental knee arthroplasty (UKA) is a viable option for relieving pain and improving function in patients with isolated compartment knee osteoarthritis (OA). Certain surgeons prefer total knee arthroplasty (TKA) over UKA even when patients are candidates for UKA. Therefore, the decision to perform a UKA or a TKA when both are indicated is not straightforward. The goal of this study was to compare pre-operative and post-operative patient-reported outcome (PRO) scores for patients who underwent both a UKA and a contralateral TKA.

Postoperative Patient Falls on an Orthopedic Inpatient Unit

We are not aware of any data looking specifically at inpatient falls in an orthopedic ward. We reviewed all postoperative orthopedic patients who fell during 2003 and 2005 on a single postoperative orthopedic unit. Seventy patients (1%) fell, resulting in 2.5 falls per 1000 musculoskeletal inpatient days. Most (n = 45, 64%) were bathroom related, were unassisted (n = 54, 77%), and occurred during the evening or night shift (n = 46, 66%). Thirteen (19%) patients acquired an injury as a consequence. Female sex (odds ratio [OR] = 1.9), patient age greater than 65 years (OR = 1.7), prolonged admission (OR = 1.7), and admission for primary or revision knee arthroplasty (OR = 5.0) were all significant risk factors for a postoperative inpatient fall. This information has provided us with some insight to direct the development of a fall prevention program specific to postoperative orthopedic patients.     

Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020

BackgroundThe number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA.MethodsPatients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients.ResultsThe incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84).ConclusionsComplications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA.Level of EvidenceLevel III.     

No Difference in Outcomes 12 and 24 Months After Lower Extremity Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background

A better understanding of how patient-reported outcome measures (PROMs) change after total knee and hip arthroplasties (TKA and THA) is needed to support the minimum arbitrary follow-up of 24-months required by orthopedic journals. Therefore, our purpose was to perform a systematic review and meta-analysis of the THA and TKA literature to determine if equivalence exists between 12- and 24-month outcomes data.