What is the Evidence for Total Knee Arthroplasty in Young Patients?: A Systematic Review of the Literature

Background  

TKA is commonly performed to treat advanced inflammatory and degenerative knee arthritis. With increasing use in younger patients, it is important to define the best practices to enhance clinical performance and implant longevity.     

What is the Ideal Degree of Extension After Primary Total Knee Arthroplasty?

Background

Few studies have examined flexion contracture at the time of primary total knee arthroplasty (TKA) or how flexion contracture changes over time. The purpose of this study was to assess the ideal degree of extension immediately after TKA and to document postoperative changes in extension and clinical outcomes over 5-year follow-up.

What is the Role of Magnetic Resonance Imaging in the Evaluation of Total Hip Arthroplasty?

MRI has been shown to be an extremely effective instrument in the management of painful hip arthroplasty. Its superior soft tissue contrast and direct multiplanar acquisition compared to computerized tomography (CT) and radiographs allows for reproducible visualization of periacetabular osteolysis, demonstrating compression of neurovascular bundles by extracapsular synovial deposits. In addition, MRI can often elucidate etiology of neuropathy in the perioperative period and is further helpful in evaluating the soft tissue envelope, including the attachment of the hip abductors, short external rotators and iliopsoas tendon. A further advantage of MRI over CT is its lack of ionizing radiation. Most importantly, MRI can disclose intracapsular synovial deposits that precede osteoclastic resorption of bone.     

What Is the Timing of General Health Adverse Events That Occur After Total Joint Arthroplasty?

Clinical Orthopaedics and Related Research® - Despite extensive research regarding risk factors for adverse events after total joint arthroplasty (TJA), there are few publications describing...     

What Is the Learning Curve for the Anterior Approach for Total Hip Arthroplasty?

Background

There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon’s individual learning curve when using this approach.

Questions/purposes

(1) What was the revision rate for all surgeons adopting the anterior approach for placement of a particular implant? (2) What was the revision rate for surgeons who performed > 100 cases in this fashion? (3) Is there a minimum number of cases required to complete a learning curve for this procedure?

Methods

The Australian Orthopaedic Association National Joint Replacement Registry prospectively collects data on all primary and revision joint arthroplasty surgery. We analyzed all conventional THAs performed up to December 31, 2013, with a primary diagnosis of osteoarthritis using a specific implant combination and secondarily those associated with surgeons performing more than 100 procedures. Ninety-five percent of these procedures were performed through the direct anterior approach. Procedures using this combination were ordered from earliest (first procedure date) to latest (last procedure date) for each individual surgeon. Using the order number for each surgeon, five operation groups were defined: one to 15 operations, 16 to 30 operations, 31 to 50 operations, 51 to 100 operations, and > 100 operations. The primary outcome measure was time to first revision using Kaplan-Meier estimates of survivorship.

Results

Sixty-eight surgeons performed 5499 THAs using the specified implant combination. The cumulative percent revision at 4 years for all 68 surgeons was 3% (95% confidence interval [CI], 2.5–3.8). For surgeons who had performed over 100 operations, the cumulative revision rate was 3% (95% CI, 2.0–3.5). It was not until surgeons had performed over 50 operations that there was no difference in the cumulative percent revision compared with over 100 operations. The cumulative percent revision for surgeons performing 51 to 100 operations at 4 years was 3% (95% CI, 1.5–5.4) and over 100 operations 2% (95% CI, 1.2–2.7; hazard ratio, 1.40 [95% CI, 0.7–2.7]; p = 0.33).

Conclusions

There is a learning curve for the anterior approach for THA even when using a prosthesis combination specifically marketed for that approach. We found that 50 or more procedures need to be performed by a surgeon before the rate of revision is no different from performing 100 or more procedures. Surgeons should be aware of this initial higher rate of revision when deciding which approach delivers the best outcome for their patients.     

Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement?

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p?<?.001), costs were 14% greater (p?<?.001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p?<?.001), with no significant difference in 90-day readmission (p?=?.957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.     

What is the Quality of Online Resources About Pain Control After Total Knee Arthroplasty?

Background

With the growing opioid crisis in the United States, there has been a push to reduce the utilization of opioids in favor of multimodal analgesia options. The purpose of this study was to evaluate the quality of online resources that patients may use to learn about pain control after total knee arthroplasty (TKA).

What is the Impact of Body Mass Index Cutoffs on Total Knee Arthroplasty Complications?

BackgroundBody mass index (BMI) cutoffs are commonly used to decide whether to offer obese patients elective total knee arthroplasty (TKA). However, weight loss goals may be unachievable for many patients who are consequentially denied complication-free surgery. The purpose of this study was to assess the impact of different BMI cutoffs on the rates of complication-free surgery after TKA.MethodsPatients undergoing elective, primary TKA from 2015 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27447. The BMI and rates of any thirty-day complication were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m² were applied to model the incidence of complications if TKA would have been allowed or denied based on the BMI.ResultsA total of 314,719 patients underwent TKA, and 46,386 (14.7%) had a BMI ≥40 kg/m². With a BMI cutoff of 40 kg/m², 268,333 (85.3%) patients would have undergone TKA. A total of 282,552 (94.8%) would experience complication-free surgery, and 17.3% of all complications would be prevented. TKA would proceed for 309,479 (98.3%) patients at a BMI cutoff of 50 kg/m². A total of 293,108 (94.7%) would not experience a complication, and 2.8% of complications would be prevented. A BMI cutoff of 35 kg/m² would prevent 36.6% of all complications while allowing 94.8% of complication-free surgeries to proceed.ConclusionLower BMI cutoffs can reduce complications, but will limit access to complication-free TKA for many patients. These data do not indicate TKA should be performed without consideration of risks from obesity; however, a holistic assessment and shared decision-making may be more valuable when deciding on appropriate goal weight reduction.     

What Are the Causes of Revision Total Knee Arthroplasty in Japan?

Background

There is limited information regarding the cause of revision TKA in Asia, especially Japan. Owing to differences in patient backgrounds and lifestyles, the modes of TKA failures in Asia may differ from those in Western countries.

Questions/purposes

We therefore determined (1) causes of revision TKA in a cohort of Japanese patients with revision TKA and (2) whether patient demographic features and underlying diagnosis of primary TKA are associated with the causes of revision TKA.

Methods

We assessed all revision TKA procedures performed at five major centers in Hokkaido from 2006 to 2011 for the causes of failures. Demographic data and underlying diagnosis for index primary TKA of the revision cases were compared to those of randomly selected primary TKAs during the same period.

Results

One hundred forty revision TKAs and 4047 primary TKAs were performed at the five centers, indicating a revision burden of 3.3%. The most common cause of revision TKA was mechanical loosening (40%) followed by infection (24%), wear/osteolysis (9%), instability (9%), implant failure (6%), periprosthetic fracture (4%), and other reasons (8%). The mean age of patients with periprosthetic fracture was older (77 versus 72 years) and the male proportion in patients with infection was higher (33% versus 19%) than those of patients in the primary TKA group. There was no difference in BMI between primary TKAs and any type of revision TKA except other causes.

Conclusions

The revision burden at the five referral centers in Hokkaido was 3.3%, and the most common cause of revision TKA was mechanical loosening followed by infection. Demographic data such as age and sex might be associated with particular causes of revision TKA.     

Pharmacogenetics of Osteoporosis: What is the Evidence?

The early genetic prediction of personal drug therapy outcome, both in terms of identification of poor responders or nonresponders, as well as of subjects at risk of developing adverse reactions, and its translation into the clinical practice are the main challenges of personalized medicine. The application of pharmacogenetic predictive tests will be very useful mostly in cases of chronic disorders, as in metabolic bone diseases, that require long-term treatments and for whom exist effective differently acting drugs to be alternatively chosen. Pharmacogenetic tests, prior to drug administration, would hypothetically grant the optimization of drug therapy, based on patient's genotype, to ensure maximum efficacy with minimal adverse effects. This review aims to offer an overview on the principal findings in the field of pharmacogenetics of osteoporosis, and it will discuss future perspectives and possible clinical applications of pharmacogenetic tests for antiresorptive drugs.     

Total Joint Arthroplasty Surgery: Does Day of Surgery Matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.     

What Are the Indications for Implant Revision in Three-component Total Ankle Arthroplasty?

BackgroundGiven the increasing usage of total ankle arthroplasty (TAA), a better understanding of the reasons leading to implant revision and the factors that might influence those indications is necessary to identify at-risk patients.Question/purposesUsing a single-design three-component ankle prosthesis, we asked: (1) What is the cumulative incidence of implant revision at 5 and 10 years? (2) What are the indications for implant revision in our population? (3) What factors are associated with an increased likelihood of implant revision during the time frame in question?MethodsBetween 2003 and 2017, primary TAA using a single-design three-component ankle implant was performed by or under the supervision of the implant designer in 1006 patients (1074 ankles) aged between 17 and 88 years to treat end-stage ankle osteoarthritis. No other TAA systems were used during the study period at the investigators’ institution. In 68 patients with bilateral surgery, only the first TAA was considered. Of the patients treated with the study implant, 2% (16 of 1006) were lost to follow-up 5 to 14 years after TAA and were not known to have died or undergone revision, and 5% (55 of 1006) were deceased due to reasons unrelated to the procedure, leaving 935 patients for evaluation in this retrospective study. The mean (range) follow-up for the included patients was 8.8 ± 4.2 (0.2 to 16.8) years. Implant revision was performed 0.5 to 13.2 years after TAA in 12% (121 of 1006) of our patients. Survivorship free from revision was calculated using cumulative incidence (competing risks) survivorship, with death as a competing risk. The reason for each revision was classified into one of six categories according to a modified version of a previously published protocol: aseptic loosening, cyst formation, instability, deep infection, technical error, and pain without another cause. Two foot and ankle surgeons reviewed the records of all patients who underwent implant revision and assigned each patient’s reason for revision to one of the six categories. The decision for assigning each patient to one of the six categories was made based on a consensus agreement. A subgroup classification of preoperative ankle alignment (neutral, mild, and major deformity) and variables of age, sex, BMI, etiology of ankle osteoarthritis, and number of preoperative and intraoperative hindfoot or midfoot procedures were used in a multinomial logistic regression and Cox regression analysis to estimate their association with reason for revision and implant survival until revision.ResultsThe cumulative incidence of implant revision at the mean (range) follow-up time of 8.8 ± 4.2 years (0.2 to 16.8) was 9.8% (95% confidence interval 7.7% to 11.8%). Five and 10 years after TAA, cumulative incidence was 4.8% (95% CI 3.4 to 6.1) and 12.1% (95% CI 9.7% to 14.5%), respectively. The most common reason for revision was instability (34% [41 of 121]), followed by aseptic loosening of one or more metallic components (28% [34 of 121]), pain without another cause (12% [14 of 121]), cyst formation (10% [12 of 121]), deep infection (9% [11 of 121]), and technical error (7% [9 of 121]). Ankles with a major hindfoot deformity before TAA were more likely to undergo revision than ankles with a minor deformity (hazard ratio 1.9 [95% CI 1.2 to 3.0]; p = 0.007) or neutral alignment (HR 2.5 [95% CI 1.5 to 4.4]; p = 0.001). A preoperative hindfoot valgus deformity increased revision probability compared with a varus deformity (HR 2.1 [95% CI 1.4 to 3.4]; p = 0.001).ConclusionInstability was a more common reason for implant revision after TAA with this three-component design than previously reported. All causes inducing either a varus or valgus hindfoot deformity must be meticulously addressed during TAA to prevent revision of this implant. Future studies from surgeons/institutions not involved in this implant design are needed to confirm these findings and to further investigate why a substantial number of patients had pain of unknown cause prompting revision.Level of EvidenceLevel III, therapeutic study.     

What Is the Impact of Advancing Age on the Outcomes of Total Hip Arthroplasty?

Background

The global demand for total hip arthroplasty (THA) is increasing, underscoring its moniker as the “operation of the century.” However, debate still exists as to whether the elderly who undergo the operation achieve the same outcomes as those younger. In this study, we sought to investigate the association between older age and the risks and benefits of THA.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

Clinical Orthopaedics and Related Research® - Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most...     

Does Symptomatic Benign Prostatic Hyperplasia Increase the Risk of Periprosthetic Joint Infection After Primary Total Joint Arthroplasty?

BackgroundPeriprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsUsing the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.ResultsAt two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.ConclusionIn primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.     

In the Era of Tranexamic Acid,are Type and Screens for Primary Total Joint Arthroplasty Obsolete?

BackgroundAdvances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion.MethodsProspectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA.ResultsA total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27.ConclusionIn our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.