Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data

BackgroundPatients awaiting total joint arthroplasty (TJA) have high rates of opioid use, and many continue to use opioid medications long term after surgery. The objective of this study is to estimate the risk factors associated with chronic opioid use after TJA in a comprehensive population-based cohort.MethodsAll patients undergoing TJA in the New Zealand public healthcare system were identified from Ministry of Health records. Dispensing of opioid medications up to 3 years postsurgery and potential risk factors, including demographic, socioeconomic, and surgery-related characteristics, pre-existing medical comorbidities, and use of other analgesic medications prior to surgery, were identified from linked population databases. Logistic regression analysis was used to identify factors associated with chronic postoperative opioid use.ResultsThe strongest risk factor for chronic postoperative opioid use was preoperative opioid use. Other significant risk factors included perioperative opioid use, history of alcohol or drug abuse, younger age, female gender, knee arthroplasty, several comorbid health conditions, and preoperative use of some analgesic medications. Protective factors included higher education levels and preoperative use of nonsteroidal anti-inflammatory drugs. Most risk factors had similar effects on chronic postoperative opioid use irrespective of the length of follow-up considered (1, 2, or 3 years).ConclusionThis study of a comprehensive nationwide population-based cohort of TJA patients with 3 years of follow-up identified several modifiable risk factors and other easily measured patient characteristics associated with higher risk of long-term postoperative opioid use.     

针刀松解联合丹参注射液关节腔注射治疗骨性关节炎模型兔

文题释义： 针刀疗法：用一个完整的语言来概括应该是一种介于手术方法和非手术疗法之间的闭合性松解术。针刀疗法是将东方中医学的基本理论和西方医学的手术解剖基本理论融为一体，针刀疗法其操作的特点是在治疗部位刺入深部到病变处进行轻松的切割、剥离等不同的刺激，以达到止痛祛病的目的。 丹参注射液：其化学成分主要是水溶性酚酸类化合物，通过多种靶标起到促进血液循环和祛瘀的作用。动物研究表明，丹参注射液可通过抑制IκBα磷酸化来抑制NF-κB信号通路的激活。保护软骨下骨及软骨细胞，有效防治骨关节炎。 背景：丹参注射液与针刀松解术都是临床中治疗骨关节炎很常用的技术，目前缺乏对2种治疗方法联合使用的研究。 目的：对比单独使用针刀松解术、单独使用丹参注射液与两种方法联合使用治疗兔模型骨关节炎的效果。 方法：实验方案经黑龙江中医药大学动物实验伦理委员会批准。50只新西兰白兔分为5组：空白对照组；模型组；丹参注射液组；针刀组；针刀联合丹参注射液组。除空白对照组外，其他4组兔均制备膝关节骨关节炎模型。造模成功后，对针刀组兔内外侧支持带、内外侧膝眼，膝关节上方髌上囊、股四头肌各肌肌腹，膝关节内侧股薄肌肌腹及止点、收肌肌群肌腹及止点和胫骨平台附近部位进行针刀松解；空白对照组及模型组兔关节腔注射生理盐水0.3 mL；丹参注射液组兔关节腔每次注射0.3 mL丹参注射液；针刀联合丹参注射液组：每周进行1次针刀治疗同针刀组，每次针刀干预之后，关节腔注0.3 mL丹参注射液。上述干预每周1次，持续5周。对各组兔膝关节软骨进行大体观察及病理切片组织学观察，ELISA 检测关节液白细胞介素1、肿瘤坏死因子α水平。 结果与结论：①大体观察：模型组膝关节磨损较为严重，针刀组、丹参注射液组、针刀联合丹参注射液组膝关节轻度磨损；②病理切片评分：丹参注射液组评分略高于针刀组和针刀联合丹参注射液组差异无显著性意义；③ELISA 检测结果：针刀联合丹参注射液组白细胞介素1、肿瘤坏死因子α水平显著低于或针刀组或丹参注射液组(P < 0.05)；④结果说明，在兔膝关节骨关节炎模型中降低白细胞介素1、肿瘤坏死因子α水平方面，针刀松解术结合丹参注射液关节腔注射治优于单独使用针刀或单独使用丹参注射液关节腔注射。ORCID: 0000-0003-4119-633X(刘广宇) 中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程     

全膝关节置换后双下肢长度及相关功能变化

文题释义： 膝关节置换：一种治疗膝关节终末期病变的手术方式，可明显减轻患者膝关节疼痛，改善膝关节功能，但尚有约20%患者存在术后不满意情况，需进一步研究加以改善。 下肢全长片：完整呈现全部下肢解剖结构的影像记录方法，可用于评估下肢总体力线(髋膝踝角)及下肢功能长度，为膝关节置换提供术前参考及术后功能评价。 背景：膝关节置换后功能不佳的原因有许多，下肢不等长作为其中的一种，对膝关节置换后功能的影响程度尚未被充分研究。 目的：分析全膝关节置换后患者下肢不等长的变化程度、可能影响因素及功能变化。 方法：收集徐州医科大学附属医院骨科自2016年10月至2018年9月行全膝关节置换患者107例(124膝)，男23例，女84例。单侧全膝关节置换90例(90膝)，双侧全膝关节置换17例(34膝)，其中分次双侧全膝关节置换且间隔时间超过6个月的3例(6膝)并入单膝组；因此单膝组共93例(96膝)，双膝组14例(28膝)。患者对治疗及试验方案知情同意，且得到医院伦理委员会批准。分别于术前、术后10 d及术后6个月拍摄患者站立位下肢全长正位片并测量记录下肢长度及髋膝踝角，大体测量膝关节屈曲挛缩角并记录美国特种外科医院膝关节评分。 结果与结论：①全膝关节置换后患者下肢长度随着畸形矫正而增长，术后6个月下肢长度长于术后10 d，术后10 d 时70.2%的患者下肢增长，术后6个月79.0%的患者肢体增长；②术后10 d及术后6个月时，术后屈曲挛缩角矫正量与术后下肢长度变化量呈正相关；③术侧肢体延长程度与术后美国特种外科医院膝关节评分增量呈正相关；④术前与术后下肢不等长发生率接近，术前为45.1%，术后10 d为 55.3%，术后6个月为46.0%；⑤术前及术后6个月下肢不等长受双下肢畸形差值影响，术前的影响因素为双下肢髋膝踝角差值及双下肢屈曲挛缩角差值；术后6个月时影响下肢不等长的因素是双下肢屈曲挛缩角差值；术前及术后6个月时下肢不等长影响双下肢美国特种外科医院膝关节评分差值。 ORCID: 0000-0002-9642-4136(唐金龙) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程     

Can I Ski Doc?: Return to Skiing Following Total Joint Arthroplasty

BackgroundCurrently, there are little data on performance, safety, or return to downhill skiing after total joint arthroplasty (TJA). This leaves surgeons with little information for patient counseling regarding skiing.MethodsAn online survey was sent to 4360 patients who had undergone at least 1 primary TJA at a single academic center over the past 10 years (4 surgeons). The survey asked patients about their prior and current skiing activity including ability level, limitations, and reoperations. Demographics, patient-reported outcomes, and reoperations were also captured through chart review. Chi-squared, analysis of variance, and t-tests were used to compare demographics and outcomes. Paired t-tests were used to compare preoperative and postoperative skiing levels.ResultsOf the 763 survey respondents, the average follow-up was 4.4 years (range 0.5-10.3). In total, 35.6% had never skied, 26.5% had not skied in the 5 years prior to surgery (remote), and 37.9% had skied in the 5 years prior to surgery (recent). Seventy percent of recent skiers returned to skiing after surgery, compared to 11.9% of remote skiers. The majority of skiers, mostly advanced, returned to their prior level. There was no difference in return rates in those with a single total hip arthroplasty vs total knee arthroplasty vs multiple TJAs. Rates of reoperation were not significantly different between patients who did and did not return to skiing.ConclusionThe majority of recent skiers were able to return to skiing after TJA at their same level without an increase in reoperation rate. Further studies are needed to determine long-term consequences of skiing after TJA.     

全膝关节置换术两种股骨假体定位的比较

[目的]探讨应用陀螺仪股骨髓外定位截骨行全膝关节置换的可行性及临床疗效。[方法]回顾性分析2019年3月一2020年1月行初次全膝关节置换的53例患者(61膝)的临床资料,其中27例使用陀螺仪髓外定位股骨侧截骨行全膝关节置换术(髓外组),34例行传统髓内导向杆定位股骨侧截骨全膝关节置换术(髓内组),比较两组临床疗效。[结果]所有患者均顺利完成手术,髓外组的手术时间、股骨截骨时间均少于髓内组(P<0.05);髓外组的术中失血量、术后引流量均少于髓内组(P<0.05)。两组患者术后3个月膝关节KSS评分差异无统计学意义(P>0.05)。两组患者术前、术后的髋膝踝角及术前、术后股胫角差异均无统计学意义(P>0.05)。[结论]全膝关节置换陀螺仪股骨髓外定位截骨疗效较好,能减少手术时间,降低术中失血量和术后引流量。     

Percutaneous surgery of the forefoot compared with open technique — Functional results,complications and patient satisfaction

BackgroundThe use of percutaneous surgery is currently very common in foot and ankle surgery. The following prospective open-label patient-preference based study compares the traditional open technique versus the percutaneous surgery technique.MethodsThe current study describes the results of 287 patients operated due to forefoot deformities either by open surgery or percutaneously. 96 of them underwent hallux valgus corrective surgery. The rest had lesser toe deformities. They were followed for a period of up to 24 months, to assess the surgery related pain, complications, and patient satisfaction. 112 patients were operated using a conventional open technique were compared to 175 patients treated using a percutaneous technique. Technique choice was left to the patient preference, though older patients with disturbed blood flow, were advised to undergo percutaneous surgery.ResultsThere is less pain using the percutaneous techniques relative to the open technique during the first 6 post-operative weeks. The 6, and 24 months FAOS score is similar in both groups. Complications are rare in any of the groups, with a significantly higher ASEPSIS score in the open surgery group.CondclusionsPercutaneous forefoot surgery appears safe and efficacious, demonstrating equal radiographic (in a 96 strong cohort of hallux valgus patients) and clinical results at six and 24 months. Due to less post-operative pain, and less infection risk it appears that percutaneous techniques are superior to open technique in some respects of treatment and indeed the PGIC of patients was significantly higher in this group.     

Modifiable,Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

BackgroundWe sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events.MethodsData from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days.ResultsThe average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63).ConclusionThis study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.     

What Factors Predict Patient Dissatisfaction After Contemporary Medial Opening-Wedge High Tibial Osteotomy?

BackgroundAlthough current advances in surgical techniques have improved outcomes of the medial opening-wedge high tibial osteotomy (MOWHTO), the factors associated with patient dissatisfaction remain unclear. Thus, the purpose of this study is to identify risk factors for patient dissatisfaction following contemporary MOWHTO.MethodsWe retrospectively reviewed prospectively collected data on 140 consecutive MOWHTO patients using an anatomical locking plate with a minimum follow-up of 2 years. Patient demographics, pain Visual Analogue Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Kellgren-Lawrence (K-L) grade, activity level, articular cartilage and meniscal status, hip-knee-ankle angle, change in alignment, and postoperative weight-bearing line ratio were recorded. Patients were categorized using the New Knee Society Score into satisfied (satisfaction score ≥20) or dissatisfied (satisfaction score <20) groups. Patient and surgical factors were compared between the groups by the identified predictors. Multiple logistic regression analysis was used to analyze risk factors, including K-L grade IV medial osteoarthritis (OA), preoperative pain Visual Analogue Scale, total Western Ontario and McMaster Universities Osteoarthritis Index score, postoperative hip-knee-ankle angle, change in alignment, and partial meniscectomy.ResultsOf the 140 patients, 24 (17.1%) were dissatisfied with their results. Multiple logistic regression analysis showed that only K-L grade IV medial OA was statistically associated with patient dissatisfaction following MOWHTO (odds ratio 4.911, 95% confidence interval 1.820-13.256, P < .01).ConclusionSevere medial OA was an independent risk factor for dissatisfaction following contemporary MOWHTO using a rigid locking plate. Surgeons should take this into consideration when counseling and choosing surgical options in MOWHTO candidates with severe medial OA.Level of EvidenceLevel III.     

Clinical Pharmacist Service Associated With Improved Outcomes and Cost Savings in Total Joint Arthroplasty

BackgroundInstitutions providing total joint arthroplasty (TJA) procedures are subject to substantial outcomes reporting, including those influencing payment for services. Although clinical pharmacists are well-poised to add value, a comprehensive approach to optimizing pharmacotherapy across the care continuum for TJA patients has not been described.MethodsThis prospective, interventional, sequential cohort study was approved by our Institutional Review Board. The objective was to assess the impact of an Orthopedic Clinical Pharmacist service on institutional TJA complication rates and costs. Outcomes were compared for a Baseline period of July 2015 to February 2016 and a Post-implementation period of September 2016 to February 2017, allowing for a 6-month run-in period. Additionally, we pursued a post-discharge, RN-administered patient survey and an exploratory economic assessment.ResultsA total of 1715 TJA procedures were performed at the institution during the 20-month study timeframe. Postoperative readmission rate (1.3% vs 4.8%, P = .002) and complication rate (1.8% vs 3.4%, P = .760) were lower in the Post-implementation period. Postoperative VTE rate decreased to zero in the Post-implementation period (0.0% vs 0.6%, P = .13) and average hospital length of stay was unchanged (2.8 vs 2.9 days). Patient self-rated understanding of discharge medications was improved and satisfaction with pharmacist interaction was very high. The service conferred an estimated $73,410 net annual cost savings to the institution.ConclusionIntegration of a clinical pharmacist service for TJA patients was associated with clinically meaningful improvements in institutional outcomes, likely conferring substantial cost-benefit.