INTRODUCTION
Pulsed lavage during a total knee replacement usually leaves a pool of fluid on the surgical drapes. It is common practice to suck away this fluid using the same suction device used intra-operatively. This could be a cause of direct wound contamination. We hypothesised that bacteria contaminate fluid that collects around the foot in total knee replacement surgery and that suction equipment could be a portal of contamination. We also hypothesised that bacterial count in the fluid is lower if chlorhexidine, rather than saline, is used in the pulsed lavage.PATIENTS AND METHODS
Forty patients undergoing primary total knee replacement were divided into two groups. The first group had pulsed lavage with normal saline and the second with 0.05% chlorhexidine.RESULTS
At the end of the operation, 20 ml of fluid, pooled on the surgical drapes was aspirated and cultured for bacterial growth. None of the fluid samples showed bacterial growth.CONCLUSIONS
Suction device used peri-operatively during knee replacement is unlikely to be a cause of wound contamination. Pulsed lavage with normal saline is as effective as lavage with chlorhexidine. 相似文献Background
Despite potential concerns regarding their validity, physician-rating websites continue to grow in number and utilization and feature prominently on major search engines, potentially affecting patient decision-making regarding physician selection.Questions/Purposes
We sought to determine whether patient ratings on public physician-rating websites correlate with surgeon-specific outcomes for high-volume total knee replacement (TKR) surgeons in New York State (NYS) from 2010 to 2012.Methods
Online patient ratings were compared to surgeon-specific outcomes from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health. For each surgeon, we determined the infection rate, re-admission rate, and revision surgery rate within the study period, as well as the mean inpatient length of stay, for TKR from the SPARCS database. Online ratings were collected from two physician-rating websites (Vitals.com and HealthGrades.com).Results
One hundred seventy-four high-volume TKR surgeons were identified in NYS from 2010 to 2012. The mean rates of in-hospital infection, 90-day infection, 30-day re-admission, 90-day re-admission, and revision surgery were 0.25, 1.00, 4.89, 8.43, and 1.31%, respectively. The mean number of ratings for individual surgeons on HealthGrades.com and Vitals.com were 24.0 (range: 0 to 109) and 19.3 (range: 0 to 114), respectively, and mean overall ratings were 4.2 and 4.1 (out of 5) stars, respectively. As with online patient ratings of individual surgeons, variability was observed in the total adverse event rate distribution for individual surgeons. Despite sufficient variability in both online patient rating and surgeon-specific outcomes for high-volume TKR surgeons in NYS, no correlation was observed.Conclusion
There was no correlation between surgeon-specific TKR outcome measures and online patient ratings. We therefore advise that patients exert caution when interpreting ratings on these websites.Background
One of the goals of a TKA is to approximate the function of a normal knee. Preserving the natural ligaments might provide a method of restoring close to normal function. Sacrifice of the ACL is common and practical during a TKA. However, this ligament is functional in more than 60% of patients undergoing a TKA and kinematic studies support the concept of bicruciate-retaining (that is, ACL-preserving) TKA; however, relatively few studies have evaluated patients treated with bicruciate-retaining TKA implants.Questions/purposes
I asked: (1) what is the long-term (minimum 20-year) survivorship, (2) what are the functional results, and (3) what are the reasons for revision of bicruciate-retaining knee arthroplasty prostheses?Methods
From January 1989 to September 1992, I performed 639 total knee replacements in 537 patients. Of these, 489 were performed in 390 patients using a bicruciate-retaining, minimally constrained device. During the period in question, this knee prosthesis was used for all patients observed intraoperatively to have an intact, functional ACL with between 15° varus and 15° valgus joint deformity. There were 234 women and 156 men with a mean age at surgery of 65 years (range, 42–84 years) and a primary diagnosis of osteoarthritis in 89%. The patella was resurfaced in all knees. The mean followup was 23 years (range, 20–24 years). At the time of this review, 199 (51%) patients had died and 31 (8%) patients were lost to followup, leaving 160 (41%) patients (214 knees) available for review. Component survivorship was determined by competing-risks analysis and Kaplan Meier survivorship analysis with revision for any reason as the primary endpoint. Patients were evaluated every 2 years to assess ROM, joint laxity, knee stability, and to determine American Knee Society scores.Results
The Kaplan-Meier survivorship was 89% (95% CI, 82%–93%) at 23 years with revision for any reason as the endpoint. Competing-risks survivorship was 94% (95% CI, 91%%–96 %) at 23 years. At followup, the mean age of the patients was 84 years (range, 63–101 years), the mean flexion was 117° (range, 90°–130°), the mean American Knee Society score improved from a preoperative mean of 42 (range, 26–49) to 91 (range, 61–100; p < .001). Twenty-two knees in 21 patients (5.6%) were revised, most commonly because of polyethylene wear.Conclusions
ACL sacrifice may be an unnecessary concession during TKA. This study found satisfactory survivorship and function after more than 20 years of use for patients receiving a bicruciate-retaining TKA implant. A TKA that preserves cruciate ligaments provides a stable, well-functioning knee with a low likelihood of revision at long-term followup. Retaining both cruciate ligaments during knee arthroplasty is an attractive concept that is worth considering.Level of Evidence
Level IV, therapeutic study. 相似文献Background
Whether a previous high tibial osteotomy (HTO) influences the long-term function or survival of a total knee arthroplasty (TKA) is controversial. 相似文献Background
Rapid recovery programs are now aimed to reduce costs of hip and knee arthroplasties by discharging patients directly home, shortening hospital length of stay (LOS), and reducing readmission rates. Although patients aged 80 years and older are included in the Medicare bundle, little work has been performed to determine if older patients can safely participate in rapid recovery programs.Methods
We retrospectively reviewed 2482 patients undergoing primary and revision total hip and knee arthroplasties (THA and TKA) who all participated in a multifaceted rapid recovery program. The goals of this program were next day discharge to home without the use of home services or post-acute care admission. We examined the hospital LOS and the percentage of patients discharged home as well as 90-day readmission rates to determine efficacy and safety of this program in the patients aged 80 years and older.Results
Octogenarians receiving primary THA and TKA were discharged home >90% of the time with LOSs <2 days and low readmission rates. Revision THA and TKA patients aged 80 years and older were discharged home about 70% of the time with significantly longer LOSs than patients aged more than 80 years. The revision THA patients aged more than 80 years had the highest readmission rates.Conclusion
Patients aged more than 80 years can successfully and safely participate in rapid recovery programs. 相似文献Background
Although total knee replacement (TKR) has been proven a very successful treatment modality for the end-stage knee osteoarthritis (OA) in obese patients, the rehabilitation period often is long and painful. Minimal invasive surgery (MIS) has gained much attention in TKR promising fast and less painful recovery. However, little is known about the effectiveness of the technique in the obese adult population. 相似文献Background
Unicompartmental knee arthroplasty (UKA) has long been a treatment option for patients with disease limited primarily to one compartment with small, correctable deformities. However, some surgeons presume that normal kinematics of a lateral compartment UKA are difficult to achieve. Furthermore, it is unclear whether UKA restores normal knee kinematics and interlimb symmetry.Questions/purposes
We determined knee kinematics exhibited during stair ascent by patients with medial- (MED-UKA) or lateral-UKA (LAT-UKA) and if the knee kinematics of the operated and nonoperated limbs were symmetrical.Methods
Participants were 17 individuals with MED-UKA and nine with LAT-UKA, all with nondiseased contralateral limbs. For each limb, participants walked up four stairs for five trials while a motion-capture system obtained reflective marker locations. Temporal events were determined by force platform signals. Interlimb symmetry was classified for temporal gait and knee angular kinematics by comparing observed interlimb differences with clinically meaningful differences set at 5% of stride time for temporal variables and 5° for angular variables. The minimum postoperative followup was 6 months (median, 24 months; range, 6–53 months).Results
Neither group demonstrated clinically meaningful mean interlimb differences. However, approximately half of participants of each UKA group displayed asymmetry favoring the operative or nonoperative limb with similar frequency.Conclusions
Many patients undergoing UKA demonstrate kinematic interlimb symmetry during stair ascent. Interlimb asymmetry may be affected by a variety of factors unrelated to the UKA.Clinical Relevance
A MED- or LAT-UKA can potentially restore normal knee function for a demanding task of daily life. 相似文献Background
Dynamic knee varus angle and adduction moments have been reported to be reduced after TKA. However, it is unclear whether this reduction is maintained long term. 相似文献Background
Reduced flexion following knee arthroplasty (TKA) may compromise patient’s function and outcome. The timing of manipulation under anaesthesia (MUA) has been controversial. We present our experience in a high volume practice and analyse the impact of timing.Methods
All TKA patients requiring MUA from February 1996 to June 2015 under the care of a single surgeon were analysed. MUA was offered to patients who had ≤ 75° of flexion post-op, providing that they had 30° more flexion preoperatively. To address the impact of timing from primary surgery to MUA on flexion gain we looked at 3 groups: Group I ≤ 90 days, Group II 91-180 days and Group III > 180 days.Results
Sixty two out of 7,423 (0.84%) underwent MUA. The MUA patients were significantly younger than the overall TKA cohort 61.2 vs 70.5 years (p = < 0.01). The median duration between arthroplasty and MUA was 3.9 months (IQR 3.4, Range 1.6-72.5 months). Overall flexion gained at 6-12 Weeks and 1 year post MUA showed significant improvements of 20.9° (p = <0.01) and 25° respectively (p = < 0.01). The flexion gain in group I (≤ 90 days) was significantly better than group III ( > 180 days) both at 6 weeks and 1 year following MUA but not better than group II (90-180 days).Conclusions
MUA is an effective treatment for reduced flexion following TKA and should be the first line of management after failed physiotherapy. It can still have benefit beyond 6 months but the gains become less effective with time. 相似文献The Knee Society Score (KSS) instrument is one of the most commonly reported primary outcome measures for total knee arthroplasty (TKA). Originally developed in 1989, the KSS was expanded and updated in 2011; however, the original KSS does not directly translate into the 2011 KSS. To date, no conversion algorithm has been developed, hindering the ability of researchers to adopt the 2011 KSS while maintaining their historical/longitudinal original KSS data.
Questions/purposesThe purpose of this study is to develop regression equations to map the original KSS to the 2011 KSS, allowing original and 2011 KSS data sets to be combined.
MethodsIn this multicenter, nonrandomized study, a convenience sample of 815 patients undergoing primary TKA completed the original KSS questionnaire and the 2011 KSS questionnaire. Additionally, patient gender, patient age, and patient ethnicity were recorded. These data were then used to generate regression models to estimate the 2011 objective and function KSS from the original KSS. Of the 815 study patients, 476 (58%) were female and 339 (42%) were male at an average age of 67 years (SD 9.4). Roughly half of patients were assessed preoperatively (430 of 815 [53%]) with the remaining patients assessed postoperatively (386 of 815 [47%]). The average followup for postoperative patients was 4.4 years (SD 3.5 years).
ResultsWe have created a spreadsheet that can be used by individuals with no statistical training to crosswalk the objective and function subscores from the original KSS to the 2011 KSS [Supplemental materials are available with the online version of CORR®.]. The predictive model very accurately estimated the 2011 objective score, on average, within 0.22 points on the 100-point 2011 objective KSS at the cohort or aggregate level. The objective model accurately estimated the 2011 objective KSS within 8.83 points, on average, of the actual 2011 objective KSS at the individual patient level. However, as a result of large outliers, 37% of the estimated 2011 objective KSS were greater than 10 points from the actual 2011 objective KSS. To illustrate, if you use the model to estimate the 2011 objective KSS on a cohort of 100 patients, a patient with an original objective KSS of 88 will have an estimated objective KSS between 79 and 97 points. On the other hand, if you calculate an average original objective KSS of 88 for all 100 patients, the estimated average 2011 objective KSS will be 88 for the group. The predictive model accurately estimated the 2011 function KSS within 0.14 points on the 1000-point 2011 function KSS at the cohort level. At the patient level, the 2011 function KSS was also estimated within 8.8 points of the actual 2011 function KSS. However, 43% of the estimated function scores were greater than 10 points of the actual 2011 function KSS.
ConclusionsClinicians and researchers can input their original KSS with demographic data into these equations to estimate the 2011 KSS objective and function scores. The small prediction error of 0.22 points that we calculated indicates that these models can be used to estimate the 2011 objective and function KSS at the aggregated cohort level. Although the average error score was within 10 points at the individual patient level, there was a high percentage of large errors resulting from outliers in the data set. These outliers seemed to be related to patients with excellent range of motion who had substantial pain and limited function or patients who have poor range of motion with excellent function and little pain. This may be inherent with the KSS or with the study sample. Nevertheless, one must use caution when estimating at the patient level. Additionally, the accuracy of the prediction scores decreases if any of the demographic variables included in this study are not available.
相似文献