One-Stage Sequential Bilateral Total Knee Arthroplasty: An Effective Treatment for Advanced Bilateral Knee Osteoarthritis Providing High Patient Satisfaction

BackgroundThe mortality and risks of bilateral total knee arthroplasty (BTKA) have been reported to be far greater than in unilateral total knee arthroplasty (UTKA). This study aimed to determine whether this remains the case using contemporary anesthetic and surgical techniques for one-stage single anesthetic sequential BTKA.MethodsTwo cohorts of 394 patients were created by propensity matching for gender, age, body mass index, American Society of Anesthesiologists grade, and Veterans Rand-12 health survey scores. Primary outcome was morbidity and mortality, with satisfaction measures using patient-reported outcome measures.ResultsThe mortality rate was low with one case after BTKA. Major complications were also low; however, a pulmonary embolism rate of 2% in BTKA patients was significantly higher than 0.3% after UTKA (P < .05), and associated with an American Society of Anesthesiologists grade ≥3. The rate of minor complications between the 2 cohorts was comparable (P = .95). Blood transfusions were uncommon and not significantly different between cohorts (2.5% vs 1.3%, P = .3). BTKA patients stayed in hospital a mean 1.3 days longer with greater rehabilitation requirements. At final follow-up, patient satisfaction was high with all patient-reported outcome measures significantly improved and comparable between cohorts.ConclusionBTKA is safe and effective in the majority of patients. Transfusion rates were far lower than historically reported and major complications were rare after both UTKA and BTKA. A significant increase in the rate of pulmonary embolism after BTKA was observed, especially in high risk patients. At minimum 1-year postoperatively, cohorts had the same significant clinical improvement and high level of satisfaction.     

Should we use similar perioperative protocols in patients undergoing unilateral and bilateral one-stage total knee arthroplasty?

BACKGROUNDBilateral one-stage total knee arthroplasty (BTKA) is now in greater use as an alternative option for patients with bilateral end-stage knee arthropathy. However, postoperative pain and disablement during convalescence from BTKA, and procedure-related complications have been concerning issues for patients and surgeons. Although some studies reported that BTKA in selected patients is as safe as the staged procedure, well-defined guidelines for patient screening, and perioperative care and monitoring to avoid procedure-related complications are still controversial.AIMTo compare the perioperative outcomes including perioperative blood loss (PBL), cardiac biomarkers, pain intensity, functional recovery, and complications between unilateral total knee arthroplasty (UTKA) and BTKA performed with a similar perioperative protocol. METHODSWe conducted a retrospective study on consecutive patients undergoing UTKA and BTKA that had been performed by a single surgeon with identical perioperative protocols. The exclusion criteria of this study included patients with an American Society of Anesthesiologists score > 3, and known cardiopulmonary comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14 ng/L. Outcome measures included visual analogue scale (VAS) score of postoperative pain, morphine consumption, range of knee motion, straight leg raise (SLR), length of stay (LOS), and serum hemoglobin (Hb) and hs-TnT monitored during hospitalization. RESULTSOf 210 UTKA and 137 BTKA patients, those in the BTKA group were younger and more predominately female. The PBL of the UTKA vs BTKA group was 646.45 ± 272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), and blood transfusion rates were 10.48% and 40.88% (P < 0.01), respectively. Preoperative Hb and body mass index were predictive factors for blood transfusion in BTKA, whereas preoperative Hb was only a determinant in UTKA patients. The BTKA group had significantly higher VAS scores than the UTKA group at 48, 72, and 96 h after surgery, and also had a significantly lower degree of SLR at 72 h. The BTKA group also had a significantly longer LOS than the UTKA group. Of the patients who had undergone the procedure, 5.71% of the UTKA patients and 12.41% of the BTKA patients (P = 0.04) had hs-TnT > 14 ng/L during the first 72 h postoperatively. However, there was no difference in other outcome measures and complications. CONCLUSIONFollowing similar perioperative management, the blood transfusion rate in BTKA is 4-fold that required in UTKA. Also, BTKA is associated with higher pain intensity at 48 h postoperatively and prolonged LOS when compared to the UTKA. Hence, BTKA patients may require more extensive perioperative management for blood loss and pain, even if having no higher risk of complications than UTKA.     

Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks?

BackgroundSimultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA.MethodsA prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated.ResultsCompared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12).ConclusionStaged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.     

Same-Day Surgery Does Not Increase the Manipulation Under Anesthesia and Reoperation Rates for Stiffness Following Bilateral Total Knee Arthroplasty

BackgroundThere is a paucity of data on the incidence of stiffness and need for subsequent manipulation under anesthesia (MUA) and reoperation following same-day bilateral total knee arthroplasty (BTKA). We compared the rates of at least 1 MUA, bilateral knee involvement, single and multiple MUA rates, and stiffness-related reoperation rates between patients undergoing same-day, same-admission staged, and staged within 1 year BTKA in a tertiary institution.MethodsWe analyzed institutional data for 3175 same-day (group A), 153 same-admission staged (group B), and 1226 staged within 1 year BTKA patients (group C) from 1998 to 2009. Several variables, including patient demographics, comorbidity profile, Charlson-Deyo index, and range of motion at different time points, were tabulated. Follow-up was minimum 1 year after first MUA. Univariate analyses were performed using the Wilcoxon rank-sum or Kruskal-Wallis test, and Fisher exact or the chi-square test for continuous and categorical variables, respectively. The Cochran-Armitage trend test was used to check the bilateral knee involvement rate across groups.ResultsOverall, 2.2% (98/4554) of BTKA patients required MUA. The rate of at least 1 MUA was similar across groups but the percentage of bilateral knee involvement was higher in group A. The single MUA rate was comparable among groups. Both no revision and revision reoperation rates were similar among the manipulated groups.ConclusionSame-day BTKA was not associated with increased incidence of single or multiple MUA and stiffness-related reoperation rates. These findings may facilitate preoperative counseling in patients with symptomatic bilateral knee disease, eligible for same-day BTKA.     

Staging Bilateral Total Knee Arthroplasties Reduces Alignment Outliers

BackgroundPatients frequently present with bilateral symptomatic knee osteoarthritis and request simultaneous total knee arthroplasties (TKAs). Technical differences between simultaneous and staged TKAs could affect clinical and radiographic outcomes. We hypothesized that staged TKAs would have fewer mechanical alignment outliers than simultaneous TKAs.MethodsWe reviewed 87 simultaneous and 72 staged TKAs with at least 2 years of follow-up. Radiographic assessment was done using standing long leg and lateral radiographs of the knee. Coronal and sagittal measurements were performed by 4 blinded observers on 2 separate occasions with an intraobserver agreement of 0.95 and interobserver of 0.92.ResultsThe first simultaneous knee had no difference in the probability of establishing the mechanical axis outside 3° of neutral (45%) compared to the first staged knee (54%, P = .337). However, the second simultaneous knee (49%) was more likely to establish the axis outside mechanical neutral compared to the second staged knee (28%; odds ratio 2.54, confidence interval 1.31-4.94, P = .006). There was an increased risk of deep venous thrombosis with staged TKA (odds ratio 2.96, confidence interval 1.28-6.84, P = .011), but other perioperative complication rates were not significantly different. There were no clinically significant differences in range of motion or Knee Society Score.ConclusionThere is a significantly increased risk of establishing the second knee outside mechanical neutral during a simultaneous TKA compared to staged bilateral TKAs, possibly related to a number of surgeon-related and system-related factors. The impact on clinical outcomes and radiographic loosening may become significant in long-term follow-up.     

Patients Who Have Kellgren-Lawrence Grade 3 and 4 Osteoarthritis Benefit Equally From Total Knee Arthroplasty

BackgroundRecently, some payers have limited access to total knee arthroplasty (TKA) to patients who have Kellgren-Lawrence (KL) grade 4 osteoarthritis only. This study compared the outcomes of patients who have KL grade 3 and 4 osteoarthritis after TKA to determine if this new policy is justified.MethodsThis was a secondary analysis of a series originally established to collect outcomes for a single, cemented implant design. A total of 152 patients underwent primary, unilateral TKA at two centers from 2014 to 2016. Only patients who had KL grade 3 (n = 69) or 4 (n = 83) osteoarthritis were included. There was no difference in age, sex, American Society of Anesthesiologists score, or preoperative Knee Society Score (KSS) between the groups. Patients who had KL grade 4 disease had a higher body mass index. KSS and Forgotten Joint Score (FJS) were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Generalized linear models were used to compare outcomes.ResultsControlling for demographics, improvements in KSS were comparable between the groups at all time points. There was no difference in KSS, FJS, and the proportion that achieved the patient acceptable symptom state for FJS at 2 years.ConclusionPatients who had KL grade 3 and 4 osteoarthritis experienced similar improvement at all time points up to 2 years after primary TKA. There is no justification for payers to deny access to surgical treatment for patients who have KL grade 3 osteoarthritis and have otherwise failed nonoperative treatment.     

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BackgroundHemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology.MethodsA multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status.ResultsThere were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status.ConclusionsBoth HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores.Level of EvidenceLevel III.     

One-stage versus staged ureteroscopy and percutaneous nephrolithotomy for simultaneous ureteral and renal stones

Objectives:This study is aimed to investigate the outcome of one-stage ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for simultaneous ureteral and renal stones over 10years at a tertiary urology institute.Materials and methods:We retrospectively analyzed the data of patients who were operated on for simultaneous ureteral and renal stones from January 2011 to December 2020. Patients were divided into 2 groups: group A, who underwent one-stage URS and prone PCNL, and group B, who underwent staged procedures. The overall success, complications, operative time, and hospital stays were compared between the 2 groups.Results:Data for 190 patients were reviewed; mean age was 50 ± 13years old, and 146 (77%) were male. The one-stage (A) and staged (B) groups included 102 and 88 patients, respectively. Group A included older patients, with a high The American Society of Anesthesiologists score, while group B included more patients with multiple or staghorn stones. The one-stage group recorded shorter operative time (120 ± 12min vs. 140 ± 16min, p = 0.02) and shorter hospital stays (3days [2-6] vs. 4days [3-9], p = 0.06). Otherwise, both groups had equal outcomes in terms of success rates and complications.Conclusions:PCNL and URS can be performed in one-session for simultaneous ureteral and renal stones, except for multiple renal and staghorn stones. The results are comparable to those of the staged procedure in terms of success rate and complications, with the advantage of a shorter operative time and hospital stay.     

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BackgroundThe incidence of ankle fractures is increasing and the clinical outcome is highly variable.QuestionWhat person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?Data sourcesMedline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.Study selectionPrognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.Study appraisal/synthesis methodsRisk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.ResultsFifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.ConclusionThere was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.Systematic review registrationPROSPERO registration number CRD42020184830     

Medial Meniscus Posterior Root Tear Does Not Affect the Outcome of Medial Open-Wedge High Tibial Osteotomy

BackgroundThis study aimed to verify whether the presence of medial meniscus posterior root tear (MMPRT) affects the clinical and radiographic outcomes of medial open-wedge high tibial osteotomy (MOWHTO) compared to the patients without MMPRT for over a midterm follow-up.MethodsOne hundred fifty-six knees were retrospectively enrolled that underwent MOWHTO and second-look arthroscopy concomitantly with a minimum 5 years of follow-up. Seventy-four knees with MMPRT (MMPRT group) were identified. Eighty-two knees with intact MMPR were assigned to another group (MMPRI group). All knees with torn medial meniscus with or without MMPRT had an arthroscopic partial meniscectomy during the MOWHTO. Clinical evaluation included range of motion, American Knee Society scores, and Western Ontario and McMaster Universities Osteoarthritis Index scores. Radiologically, the Kellgren-Lawrence grade was assessed preoperatively and at the latest follow-up. Cartilage status was also compared through the 2-stage arthroscopy according to the International Cartilage Repair Society grading.ResultsAverage age at operation was 55.8 years (range 42-67), and the average follow-up period was 82.2 months (range 60-148). There were no significant differences in clinical outcomes between the groups. Postoperative changes in Kellgren-Lawrence grade and arthroscopic cartilage status showed no significant differences between the groups. Resected MMPR was remodeled in 41.9% (31/74) of the MMPRT group through the second-look arthroscopy.ConclusionMMPRT does not affect the clinical and radiologic outcomes of MOWHTO compared to those patients without MMPRT over a mid-term follow-up.     

ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs

Background contextThe Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA grade) are useful for predicting morbidity and mortality for a variety of disease processes.PurposeTo evaluate CCI and ASA grade as predictors of complications after spinal surgery and examine the correlation between these comorbidity indices and the cost of care.Study design/settingProspective observational study.Patient sampleAll patients undergoing any spine surgery at a single academic tertiary center over a 6-month period.Outcome measuresDirect health-care costs estimated from diagnosis related group and Current Procedural Terminology (CPT) codes.MethodsDemographic data, including all patient comorbidities, procedural data, and all complications, occurring within 30 days of the index procedure were prospectively recorded. Charlson Comorbidity Index was calculated from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ASA grades determined from the operative record. Diagnosis related group and CPT codes were captured for each patient. Direct costs were estimated from a societal perspective using Medicare rates of reimbursement. A multivariable analysis was performed to assess the association of the CCI and ASA grade to the rate of complication and direct health-care costs.ResultsTwo hundred twenty-six cases were analyzed. The average CCI score for the patient cohort was 0.92, and the average ASA grade was 2.65. The CCI and ASA grade were significantly correlated, with Spearman ρ of 0.458 (p<.001). Both CCI and ASA grade were associated with increasing body mass index (p<.01) and increasing patient age (p<.0001). Increasing CCI was associated with an increasing likelihood of occurrence of any complication (p=.0093) and of minor complications (p=.0032). Increasing ASA grade was significantly associated with an increasing likelihood of occurrence of a major complication (p=.0035). Increasing ASA grade showed a significant association with increasing direct costs (p=.0062).ConclusionsAmerican Society of Anesthesiologists and CCI scores are useful comorbidity indices for the spine patient population, although neither was completely predictive of complication occurrence. A spine-specific comorbidity index, based on ICD-9-CM coding that could be easily captured from patient records, and which is predictive of patient likelihood of complications and mortality, would be beneficial in patient counseling and choice of operative intervention.     

Outcomes in surgical treatment for tandem spinal stenosis: systematic literature review

BACKGROUND CONTEXTTandem spinal stenosis (TSS) refers to a narrowing of the spinal canal in distinct, noncontiguous regions. TSS most commonly occurs in the cervical and lumbar regions. Decompressive surgery is indicated for those with cervical myelopathy or persistent symptoms from lumbar stenosis despite conservative management. Surgical management typically involves staged procedures, with cervical decompression taking precedence in most cases, followed by lumbar decompression at a later time. However, several studies have shown favorable outcomes in simultaneous decompression.PURPOSEThe aim of this study is to provide a literature review and compare surgical outcomes in patients undergoing staged vs simultaneous surgery for TSS.STUDY DESIGN/SETTINGSystematic literature review.METHODSA systematic review using PRISMA guidelines to identify original research articles for tandem spinal stenosis. PubMed, Cochrane, Ovid, Scopus, and Web of Science were used for electronic literature search. Original articles from 2005 to 2021 with more than eight adult patients treated surgically for cervical and lumbar TSS in staged or simultaneous procedures were included. Articles including pediatric patients, primarily thoracic stenosis, stenosis secondary to neoplasm or infectious disease, minimally invasive surgery, and non-English language were excluded. Demographic, perioperative, complications, functional outcome, and neurologic outcome data including mJOA (modified Japanese Orthopaedic Association), Nurick grade (NG), and ODI (Oswestry disability index), were extracted and summarized.RESULTSA total of 667 articles were initially identified. After preliminary screening, 21 articles underwent full-text screening. Ten articles met our inclusion criteria. A total of 831 patients were included, 571 (68%) of them underwent staged procedures, and 260 (32%) underwent simultaneous procedures for TSS. Mean follow-ups ranged from 12 to 85 months. There was no difference in estimated blood loss (EBL) between staged and simultaneous groups (p=.639). Simultaneous surgeries had shorter surgical time than staged surgeries (p<.001). Mean changes in mJOA, NG, and ODI was comparable between staged and simultaneous groups. Complications were similar between the groups. There were more major complications reported in simultaneous operations, although this was not statistically significant (p=.301).CONCLUSIONStaged and simultaneous surgery for TSS have comparable perioperative, functional, and neurologic outcomes, as well as complication rates. Careful selection of candidates for simultaneous surgery may reduce the length of stay and consolidate rehabilitation, thereby reducing hospital-associated costs.     

Surgical Helmet Systems Are Associated With a Lower Rate of Prosthetic Joint Infection After Total Knee Arthroplasty: Combined Results From the New Zealand Joint Registry and Surgical Site Infection Improvement Programme

BackgroundThis study aimed to identify the risk factors, in particular the use of surgical helmet systems (SHSs), for prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Data recorded by the New Zealand Surgical Site Infection Improvement Programme (SSIIP) and the New Zealand Joint Registry (NZJR) were combined and analyzed.MethodsPrimary TKA procedures performed between July 2013 and June 2018 that were recorded by both the SSIIP and NZJR were analyzed. Two primary outcomes were measured: (1) PJI within 90 days as recorded by the SSIIP and (2) revision TKA for deep infection within 6 months as recorded by the NZJR. Univariate and multivariate analyses were performed to identify risk factors for both outcomes with results considered significant at P < .05.ResultsA total of 19,322 primary TKAs were recorded by both databases in which 97 patients had a PJI within 90 days as recorded by the SSIIP (0.50%), and 90 patients had a revision TKA for deep infection within 6 months (0.47%) as recorded by the NZJR. An SHS was associated with a lower rate of PJI (adjusted odds ratio [OR] = 0.50, P = .008) and revision for deep infection (adjusted OR = 0.55, P = .022) than conventional gowning. Male sex (adjusted OR = 2.6, P < .001) and an American Society of Anesthesiologists score >2 were patient risk factors for infection (OR = 2.63, P < .001 for PJI and OR = 1.75, P = .017 for revision for deep infection).ConclusionUsing contemporary data from the SSIIP and NZJR, the use of the SHS was associated with a lower rate of PJI after primary TKA than conventional surgical gowning. Male sex and a higher American Society of Anesthesiologists score continue to be risk factors for infection.     

Obesity,Comorbidities, and Prior Operations Additively Increase Failure in 2-Stage Revision Total Knee Arthroplasty for Prosthetic Joint Infection

BackgroundProsthetic joint infection (PJI) of the knee carries significant morbidity, mortality, and economic cost. We hypothesize that obese and poor medical hosts will have a significant and additive increase in failure rate undergoing 2-stage revision total knee arthroplasty for PJI.MethodsAll 2-stage revision total knee arthroplasty procedures for PJI performed at one institution were identified between 2005 and 2020. In total, 144 patients were included and defined as success or failure based on published criteria regarding infection eradication, further intervention, or mortality. The American Society of Anesthesiologists score and the Charlson Comorbidity Index were utilized to assess host grade. Patient, surgical, and microbiologic variables were investigated with univariable and multivariable analysis to explore association with risk of failure.ResultsIn the cohort, 32.4% of patients failed with mean follow-up of 5.1 years. In multivariable analysis, the number of major operations requiring arthrotomy and implantation of new material between the primary and first stage, host grade, and elevated body mass index were the major contributors to failure. Combining these factors, with body mass index >30 and 2 or more major operations, the failure rate increased to 76.5% and 71.4% respectively for American Society of Anesthesiologists score 3 (P ≤ .001) and Charlson Comorbidity Index ≥2 (P ≤ .001).ConclusionIn this cohort, multiple major operations between the primary and first stage, host grade, and obesity were the major contributors to failure. When combining these factors, patients had an additive increase in failure rate. Treatments such as amputation or less invasive options and suppression should be discussed and considered in these patients.     

Failed Debridement and Implant Retention Does Not Compromise the Success of Subsequent Staged Revision in Infected Total Knee Arthroplasty

BackgroundPeriprosthetic joint infection (PJI) is the leading cause of early revisions after total knee arthroplasty. Debridement, antibiotics, and implant retention (DAIR) procedures are often the initial treatment for PJI. However, there is concern that failed DAIR undermines the future success of revision procedures. This study aims to investigate the impact of DAIR on the success of subsequent staged revisions for PJI.MethodsA multicenter retrospective review was performed over a 15-year period. Treatment success was defined as implant retention without the use of long-term suppressive antibiotics. This was compared between patients who underwent a staged revision as the first procedure for PJI (staged-only) and patients who failed DAIR before staged revision (F-DAIR). Competing risk survival analysis was performed to compare the 2 groups and considered for patient demographics, American Society of Anesthesiologists score, organism type, body mass index, age of prosthesis, and duration of symptoms.ResultsOf 291 eligible patients, 63 underwent staged revision and 228 underwent DAIR as the first procedure for PJI. Of the 228 DAIR patients, 75 failed DAIR and underwent subsequent staged revision (F-DAIR). At mean follow-up of 6.2 years, the success rate was 72% in the F-DAIR group and 81% in the staged-only group. On survival analysis, there was no significant difference in subdistribution hazard ratio comparing the probability of failure (implant retention) in the 2 treatments groups (subdistribution hazard ratio = 0.72; 95% confidence interval 0.32-1.61; P = .42).ConclusionThis study suggested that a previously failed DAIR does not compromise the success rate of a subsequent staged revision.     

Isolated Versus Full Component Revision in Total Knee Arthroplasty for Aseptic Loosening

BackgroundRevision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear.MethodsBetween January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental).ResultsA total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P < .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (?30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (?4.2, P = .050) scores, respectively.ConclusionIsolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.Level of evidenceIII, cohort with control.     

Cost Analysis,Complications, and Discharge Disposition Associated With Simultaneous vs Staged Bilateral Total Knee Arthroplasty

Background

Simultaneous vs staged bilateral total knee arthroplasty (BTKA) has long been debated. The primary objective of this study was to compare actual hospital costs and complication rates in patients undergoing simultaneous BTKA (simBTKA) and staged BTKA (staBTKA) at a single institution.

Ten-Year Results of Unicompartmental Knee Arthroplasty in Patients With Psychological Distress

BackgroundAlthough the influence of psychological distress on the outcomes of total knee arthroplasty has been described extensively, its effect on unicompartmental knee arthroplasty (UKA) is poorly defined. Furthermore, most studies in arthroplasty literature had short follow-ups of ≤1 year. We investigated the influence of psychological distress on long-term patient-reported outcomes and analyzed the change in mental health after UKA in a cohort with minimum 10 years of follow-up.MethodsProspectively collected data of 269 patients undergoing UKA in 2004-2007 were reviewed. Patients were stratified into those with psychological distress (36-item Short-Form health survey [SF-36] Mental Component Summary [MCS] <50, n = 111) and those without (SF-36 MCS ≥50, n = 158). Clinical outcomes were obtained preoperatively, at 2 years, and 10 years. Multiple regression was used to control for age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists class, and baseline scores. The rate of expectation fulfillment and satisfaction was compared.ResultsPsychologically distressed patients had poorer Knee Society Knee Score, Function Score, Oxford Knee Score, and SF-36 Physical Component Summary preoperatively, at 2 years, and 10 years. However, an equal proportion in each group attained the minimal clinically important difference for each score. Distressed patients had a comparable rate of satisfaction (91% vs 95%, P = .136) but lower fulfillment of expectations (89% vs 95%, P = .048). The percentage of distressed patients declined from 41% to 35% at follow-up. The mean SF-36 MCS improved by 6.9 points.ConclusionAlthough psychologically distressed patients had relatively greater pain and poorer function preoperatively and up to 10 years after UKA, a similar proportion of them experienced a clinically meaningful improvement in patient-reported outcomes.