Is the Newest Fibrin Sealant an Effective Strategy to Reduce Blood Loss After Total Knee Arthroplasty? A Randomized Controlled Study

An RCT was conducted to ascertain whether, compared to control management, topical application of a novel fibrin sealant (Evicel, J&J) in patients undergoing primary TKA reduces peri-operative blood loss. Sixty-two patients were randomized to receive topical application of Evicel (N = 31) or not (N = 31). The mean total blood loss was 1.9 L(± 0.7) in the control group and 1.8 L(± 0.5) in the treatment group (P = 0.4). The transfusion rate was 32.3% in the control group and 25.8% in the treatment group (P = 0.5). The transfusion rate decreased linearly with increasing preoperative Hb levels in the treatment group (P = 0.005). The results of this study suggest that topical application of this novel fibrin sealant doesn't reduce perioperative blood loss and the need for allogeneic blood transfusion.     

Does Limb Preconditioning Reduce Pain After Total Knee Arthroplasty? A Randomized,Double-blind Study

Background

Total knee arthroplasty (TKA) can be associated with considerable postoperative pain. Ischemic preconditioning of tissue before inducing procedure-related underperfusion may reduce the postoperative inflammatory response, which further may reduce associated pain.

Questions/purposes

In this prospective, randomized study, we aimed at evaluating the impact of ischemic preconditioning on postoperative pain at rest and during exercise; use of pain medication; levels of systemic prothrombotic and local inflammatory markers; and length of stay and achievement of physical therapy milestones.

Methods

Sixty patients undergoing unilateral TKA under tourniquet were enrolled with half (N = 30) being randomized to an episode of limb preconditioning before induction of ischemia for surgery (tourniquet inflation). Pain scores, analgesic consumption, markers of inflammation (interleukin-6 [IL-6], tumor necrosis factor [TNF]-α in periarticular drainage), and periarticular circumference were measured at baseline and during 2 days postoperatively. Changes in prothrombotic markers were evaluated.

Results

Patients in the preconditioning group had significantly less pain postoperatively at rest (mean difference = −0.71, 95% confidence interval [CI] = −1.40 to −0.02, p = 0.043) and with exercise (mean difference = −1.38, 95% CI = −2.32 to −0.44, p = 0.004), but showed no differences in analgesic consumption. No differences were seen between the study and the control group in terms of muscle oxygenation and intraarticular levels of IL-6 and TNF-α as well as levels of prothrombotic markers. No differences were found between groups in regard to hospitalization length and time to various physical therapy milestones.

Conclusions

Ischemic preconditioning reduces postoperative pain after TKA, but the treatment effect size we observed with the preconditioning routine used was modest.

Clinical Relevance

Given the ease of this intervention, ischemic preconditioning may be considered as part of a multimodal analgesic strategy. However, more study into the impact of different preconditioning strategies, elucidation of mechanisms, safety profiles, and cost-effectiveness of this maneuver is needed.     

Who Is Not a Candidate for a 1-Day Hospital-Based Total Knee Arthroplasty?

Background

Short-stay total knee arthroplasty (TKA), defined as a 1-day length of stay (LOS), is feasible in many patients, yet variables identifying who are candidates for a short stay are not well described in literature. With an emphasis on cost-efficiency, we examined preoperative patient characteristics and perioperative hospital factors that correlated with a longer LOS.

Does Barbed Suture Lower Cost and Improve Outcome in Total Knee Arthroplasty? A Randomized Controlled Trial

Background

Wound closure is key to prevent infection, facilitate immediate rehabilitation, and improve efficiency of total knee arthroplasty (TKA). Continuous knotless suturing with barbed suture can potentially save time and distribute tension more evenly. However, its role in TKA in terms of cost-effectiveness and wound complications is not clear. This study aims at comparing barbed and traditional sutures' wound closure time and cost in primary TKA.

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BackgroundThe management of the patella during total knee arthroplasty (TKA) remains controversial. The aim of this study is to evaluate the evidence regarding the use of patellar resurfacing in TKA.MethodsA meta-analysis of randomized controlled trials (RCTs) was performed to compare outcomes between knees receiving patellar resurfacing vs those not receiving resurfacing during primary TKA. Outcomes of interest were the Knee Society Scores, reoperation rates, anterior knee pain, patient satisfaction, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score subscores, and range of motion.ResultsTwenty RCTs met all eligibility criteria and were included in the analysis. There were statistically significant differences favoring the resurfaced group in the knee component and functional component of Knee Society Scores that were not clinically significant. There was an increased risk of reoperation among knees that did not receive resurfacing with number needed to treat to prevent one case of reoperation of 25 knees (for reoperation for any reason) and 33 knees (for reoperation for anterior knee pain). There were no statistically significant differences in any other outcomes.ConclusionThe only clear relationship is that knees that do not receive patellar resurfacing are more likely to receive reoperation, most often for secondary resurfacing. However, the disease burden of differing complication profiles associated with resurfacing and nonresurfacing groups remains unclear. Continuing to collect data from large, well-designed RCTs would be beneficial in guiding management of the patella during TKA.     

Is Bilateral Total Knee Arthroplasty Staged at a One-Week Interval Safe? A Matched Case Control Study

Controversy surrounds the safety of bilateral total knee arthroplasty (TKA) and whether staging the procedures one week apart represents a safer option. A consecutive series of 234 patients underwent either a simultaneous (103 patients) or staged bilateral TKA (131 patients) from 2007 to 2012 and were compared to a matched control group of unilateral TKA (131 patients). Staged patients had no difference in one-year complication rate when compared to simultaneous bilateral TKA and the matched unilateral TKA control group (15% vs. 19% vs. 15%, P = 0.512). There was also no difference in perioperative complications (10% vs. 14% vs. 7%, P = 0.231) or 90-day readmissions (8% vs. 4% vs. 4%, P = 0.295). In selected patients with bilateral knee OA, TKA staged at a one-week interval is a safe alternative.     

Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Reduces Patellar Crepitus Complication: A Randomized,Controlled Trial

BackgroundPatellar crepitus (PC) is a common complication after total knee arthroplasty (TKA) using a posterior-stabilized (PS) prosthesis. While numerous factors have been associated with PC development after PS-TKA, patellar resurfacing (PR) which directly impacts the patellofemoral joint kinematics has been underinvestigated. A prospective, randomized, controlled trial was conducted to (1) compare the PC incidence in PR and non-PR PS-TKA, (2) determine the time of PC presentation in PS-TKA, (3) identify radiographic parameters associated with PC, and (4) compare clinical outcomes of patients with and without PR.MethodsA total of 84 patients who underwent unilateral TKA using the Legion PS Total Knee System were randomized into PR group or non-PR group. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3 months, 6 months, 9 months, and 1 year postoperatively.ResultsPC occurred significantly more in the non-PR group (23.1% vs 7.3%, P = .048). Time of PC presentation in both groups was not different. Anterior knee pain was found in 16.7% of crepitus patients, and none required any surgical procedure. The non-PR knees had significant decreases in patellar shift index, patellar displacement, Insall-Salvati ratio, and patellar component height and increase in change in posterior femoral offset. Oxford and patellar scores were significantly better in the PR group at 9 months and 1 year.ConclusionGiven higher PC incidence and several worse clinical outcomes in the non-PR, we recommend resurfacing during PS-TKA with this knee system to avoid PC development.     

Is Obesity a Contraindication for Minimal Invasive Total Knee Replacement? A Prospective Randomized Control Trial

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.     

Can a Single-Use and Patient-Specific Instrumentation Be Reliably Used in Primary Total Knee Arthroplasty? A Multicenter Controlled Study

Background

The aim of this controlled multicenter study is to evaluate the clinical and radiologic outcomes of primary total knee arthroplasty (TKA) using single-use fully disposable and patient-specific cutting guides (SU) and compare the results to those obtained with traditional patient-specific cutting guides (PSI) vs conventional instrumentation (CI).

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

Background

Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Knee manipulation for reduced flexion after Total Knee Arthroplasty. Is timing critical?

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.

Is There a Preferred Articulating Spacer Technique for Infected Knee Arthroplasty?: A Preliminary Study

Background  

Periprosthetic infection in TKA is a devastating and challenging problem for both patients and surgeons. Two-stage exchange arthroplasty with an interval antibiotic spacer reportedly has the highest infection control rate. Studies comparing static spacers with articulating spacers have reported varying ROM after reimplant, which could be due to differences in articulating spacer technique.     

How Accurate Is ICD-10 Coding for Revision Total Knee Arthroplasty?

BackgroundThe International Classification of Diseases-10 (ICD-10) came into effect in October 2015. The new procedural codes (ICD-10-PCS) were designed to specify granular aspects of the procedure, including laterality and revised components. This specificity could improve data collection in institutional databases, large registries, and administrative claims data. Given these possible applications, this study’s purpose was to assess the accuracy of ICD-10-PCS coding for revision total knee arthroplasty (rTKA).MethodsThis multicenter retrospective analysis utilized the rTKA databases at four academic medical centers for all aseptic rTKAs between October 1, 2015 and July 3, 2019. Operative reports were reviewed to determine laterality and revised components (tibial, femoral, liner, and patellar component), which were then compared with the ICD-10-PCS codes associated with the billing records. Proper coding required both component removal and replacement codes. The correct series of removal and replacement codes was determined using the American Joint Replacement Registry’s guidelines.ResultsIn total, 1906 rTKAs were examined, and 98.0% had at least one proper ICD-10-PCS code, indicating an rTKA had occurred. Coding for components replaced was correct in 76.3% of cases. When examining both removal and replacement codes, accuracy dropped to 57.0%.ConclusionNearly 25% of rTKA procedures were incorrectly coded for replaced components, and over 40% were incorrectly coded for removed and replaced components. ICD-10-PCS codes can accurately identify that an rTKA has occurred; however, the inaccuracy in identifying which specific components were revised should prompt further evaluation of the coding process before utilizing ICD-10-PCS codes to report granular rTKA data.Level of EvidenceIII, retrospective observational analysis.     

Is Pseudo-Patella Baja Really a Serious Complication of Total Knee Arthroplasty?

BackgroundThe available evidence on pseudo-patella baja (PPB) is limited. The purpose of this study is to investigate prospectively the occurrence of PPB after primary total knee arthroplasty and its clinical consequences in a large series of patients with a minimum follow-up of 2 years. PPB was defined as a patella distally displaced in relationship to the femoral trochlea with absence of patellar tendon shortening (Grelsamer RP. J Arthroplasty 2002;17:66-69) due to elevation of the joint line.MethodsThis study is a prospective case series of 354 patients with a mean age of 71.7 (range 52-87) years. Clinical evaluation was performed by the Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form 12-item (SF12), and range of motion. Patellar height was assessed by the Insall-Salvati and Blackburne-Peel ratios.ResultsThe mean follow-up was 3.6 (range 2.0-6.6) years. Postoperatively, 286 (80.7%) patients had a normal patellar height, 17 (4.8%) had true patella baja (TPB), and 51 (14.4%) had PPB. There were no significant differences between the 3 groups in mean KSS-function (P = .107), range of motion (P = .408), WOMAC-pain (P = .095), WOMAC-stiffness (P = .279), or SF12-mental (P = .363). Between normal and PPB groups, there were no significant differences in mean KSS-knee (P = .903), WOMAC-function (P = .294), or SF12-physical (P = .940). However, the TPB group had significantly lower mean KSS-knee (P = .031), WOMAC-function (P = .018), and SF12-physical (P = .005) as compared with either 2 other groups.ConclusionPPB was a relatively common finding, but no significant differences in terms of clinical outcomes were found as compared to patients with postoperative normal patellar height. TPB was infrequent, but these patients had significantly worse clinical outcomes than those with PPB or normal patellar height.     

Total Hip Arthroplasty: Is Small Incision Better?

Outcome data are eagerly awaited at present time to evaluate the role of minimally invasive surgery in orthopedic surgery. This matched-pair study reports the outcome of total hip arthroplasty (THA) performed through regular or small incision technique by a single surgeon. There were 120 patients in this cohort with a mean age of 66.8 years (range, 39-90 years). There was no detectable difference in outcome between the two groups with regard to blood loss, analgesia requirement, functional recovery, length of hospital stay, or disposition at discharge. One patient in the small incision group with undersized femoral component required revision of the femoral stem 8 months later. The recent extensive interest for minimally invasive THA has been attributed to market-driven and patient-driven demand for this procedure. We were not able to detect any difference in outcome parameters for THA performed through small incision compared with the conventional techniques.     

How Effective Is Multiple Needle Puncturing for Medial Soft Tissue Balancing During Total Knee Arthroplasty? A Cadaveric Study

We investigated the quantitative effect and risk factors for over-release during multiple needle puncturing (MNP) for medial gap balancing in varus total knee arthroplasty (TKA). Of the ten pairs of cadaveric knees, one knee from each pair was randomly assigned to undergo MNP in extension (E group), while the other knee underwent MNP in flexion (F group). The increased extension and 90° flexion gaps after every five needle punctures were measured until over-release occurred. The extension gap (< 4 mm) and the 90° flexion gap (< 6 mm) gradually increased in both groups. The 90° flexion gaps increased more selectively than did the extension gaps. MNP in the flexed knee, a narrow MCL, and severe osteoarthritis were associated with a smaller number of MNPs required to over-release.     

Is Limited Incision Better Than Standard Total Hip Arthroplasty? A Meta-analysis

Background

The literature comparing limited incision and standard incision THAs is confusing regarding whether limited incision THA improves short-term recovery without compromising long-term durability and survival. Further, previously published meta-analyses cannot conclude that limited incision THA is better. With new data, we seek to discover if the answers now exist.

Purpose

We used meta-analysis to compare surgical and hospitalization data, clinical outcomes, and complication rates, and thus (1) confirm whether limited incision THA is at least comparable to standard incision THA; and (2) determine whether limited incision THA is an improvement over standard incision THA.

Methods

The PubMed database was searched using the terms “minimally”, “invasive”, and “total hip”. Inclusion was limited to studies directly comparing limited incision with standard incision THA and reporting effect sizes.

Results

We identified 418 articles. Of these 11 provided background information and 30 provided data (3548 THAs) for the systematic review. Limited incision THA was better than standard incision THA in four measures: length of hospitalization (6 versus 7 days), VAS pain at discharge (2 versus 4), blood loss (421 mL versus 494 mL), and the Harris hip score at 3 months postoperation (90 versus 84). There were no outcomes for which standard incision was better. There was no major difference in the rate of complications.

Conclusions

Short-term recovery favors limited incision over standard incision THA. The lack of consistent reporting for surgical outcomes, clinical outcomes, and complications continues to create difficulties when comparing limited and standard incision THAs.