Clinical outcomes of osteosynthesis of well-fixed periprosthetic proximal tibial fractures (Felix type 2A) after total knee arthroplasty

AimsThis study aimed to evaluate the clinical and radiologic outcomes of well-fixed periprosthetic tibial fractures after TKA.Patients and methodsThe medical records of patients who presented with Felix type 2A periprosthetic tibial fractures after TKA between March 2015 and February 2020 were retrospectively obtained from 5 institutions. Data on injury mechanism, fracture pattern including open fractures and Felix classification, and surgical method were recorded. Functional outcomes including range of motion (ROM) and Knee Society Score (KSS) at postoperative 1 year were reviewed. The need for reoperation was also reviewed. Radiologic findings included union time and mechanical proximal tibial angle (MPTA) at the last radiologic follow-up.ResultsEighteen patients (13 women, 5 men; average age, 73.9 years) were included. The average follow-up duration was 20.8 months. The fractures resulted from high-energy (11 cases) and low-energy (7 cases) injuries. Two cases involved open fractures. Anatomical locking plates were used in all cases: single plate (4 cases) and dual plates (14 cases). The average number of proximal screws was 7.1 (range, 4-9). All patients achieved bone union at an average of 18.6 weeks without secondary intervention. No infection occurred; however, 1 patient with skin necrosis required local flap. Implant removal was performed in 5 cases: 1 case, skin defect and 4 cases, discomfort due to plate prominence. The average ROM and KSS were 120.3° and 85.9, respectively. The mean MPTA was 87.8°; the MPTA was higher in the single-plate group (94.0° vs. 88.1°, p=0.013). Three cases involved values beyond the normal MPTA range (85–90°): 104° and 96° with a single plate and 92° with dual plates. The malalignment rate was higher in the single-plate group (p=0.043).ConclusionFelix type 2A periprosthetic tibial fractures treated with minimally invasive osteosynthesis showed excellent clinical outcomes, and tibial alignment was well maintained in the dual-plate group.     

Total Knee Arthroplasty After Intramedullary Tibial Nail: A Matched Cohort Study

BackgroundAs the use of intramedullary nails (IMNs) has become more common, there are an increasing number of patients requiring total knee arthroplasty (TKA) who have an indwelling tibial IMN. The purpose of this study is to compare implant survivorship, clinical outcomes, and complications in patients undergoing primary TKA with a history of tibial IMN to those without.MethodsWe retrospectively identified 24 TKAs performed between 2000 and 2017 after ipsilateral tibial IMN. Patients were matched 1:2 to patients undergoing primary TKA without history of tibial IMN based upon age, gender, body mass index, and year of surgery. Mean follow-up was 7 years.ResultsThe 10-year survivorship free of any revision was 100% for the tibial IMN cohort, and 96% for the control cohort, while the 10-year survivorship free of any reoperation was 91% and 89%, respectively (P = .72). Patients with a history of tibial IMN had similar Knee Society Scores to matched controls at 2 years (P = .77) and 5 years (P = .09). Acquired idiopathic stiffness trended toward being more common (17% vs 6%, P = .21) and operative time trended toward being longer (135 vs 118 min, P = .07) when the tibial IMN was removed, but there was no overall difference in complication rate between cohorts.ConclusionsTo our knowledge, this is the first report of primary TKA in patients with a history of ipsilateral tibial IMN. Compared to a matched cohort of patients without tibial IMN, these patients have similar outcomes in regards to implant survivorship, clinical outcomes, and risk of complications.Level of EvidenceTherapeutic Level III.     

Single-Stage Revision of the Infected Total Knee Arthroplasty Is Associated With Improved Functional Outcomes: A Propensity Score–Matched Cohort Study

BackgroundSingle-stage revision is an alternative to the standard 2-stage revision, potentially minimizing morbidities and improving functional outcomes. This study aimed at comparing single-stage and 2-stage revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) with regard to patient-reported outcome measures (PROMs) and complication rates.Methods:A total of 185 consecutive revision TKA patients for chronic PJI with complete preoperative and postoperative PROMs were investigated. A total of 44 patients with single-stage revision TKA were matched to 88 patients following 2-stage revision TKA using propensity score matching, yielding a total of 132 propensity score–matched patients for analysis. Patient demographics and clinical information including reinfection and readmission rates were evaluated.Results:There was no significant difference in preoperative PROMs between propensity score–matched single-stage and 2-stage revision TKA cohorts. Postoperatively, significantly higher PROMs for single-stage revision TKA were observed for Knee disability and Osteoarthritis Outcome Score physical function (62.2 vs 51.9, P < .01), physical function short form 10A (42.8 vs 38.1, P < .01), PROMIS SF Physical (44.8 vs 41.0, P = .01), and PROMIS SF Mental (50.5 vs 47.1, P = .02). There was no difference between propensity score–matched single-stage and 2-stage revision TKA cohorts for clinical outcomes including reinfection rates (25.0% vs 27.2%, P = .78) and 90-day readmission rates (22.7% vs 25.0%, P = .77).ConclusionThis study illustrated that single-stage revision TKA for chronic PJI may be associated with superior patient-reported outcomes compared to 2-stage revision for the infected TKA using a variety of PROMs. Improved PROMs were not accompanied by differences in complication rates between both cohorts, suggesting that single-stage revision TKA may provide an effective alternative to 2-stage revision in patients with chronic TKA PJI.     

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BackgroundPrior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.MethodsPatients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.ResultsAfter propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.ConclusionRelative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.     

Periprosthetic Fractures of the Distal Femur: Is Open Reduction and Internal Fixation or Distal Femoral Replacement Superior?

BackgroundThe purpose of this study is to compare open reduction and internal fixation (ORIF) to distal femoral replacement (DFR) for treatment of displaced periprosthetic distal femur fractures.MethodsWe identified 72 patients with minimum 2-year follow-up following a displaced periprosthetic distal femur fracture: 50 were treated with ORIF and 22 with DFR. Outcomes were assessed with multivariate regression analysis and include Knee Society Scores (KSS), infection rates, revision incidence, and mortality.ResultsPatients treated with DFR had a higher Charlson comorbidity index (5.2 vs 3.8; P = .006). The mean postoperative KSS were similar between groups, but the Knee Society Functional Scores were higher in the ORIF group (P = .01). Six ORIF patients (12%) and 3 DFR patients (14%) underwent a revision surgery (P = .1). In the ORIF group, 3 revisions were associated with periprosthetic infection, and 3 revisions occurred for aseptic nonunion. In the DFR group, 1 infection was treated with irrigation and debridement, and 2 cases of patellar maltracking resulted in 1 liner exchange with soft tissue release and 1 femoral revision for malrotation. More patients in the ORIF group required repeat revisions, with twice as many total revisions (P < .001). Six ORIF patients and 7 DFR patients died within 2 years (P = .26).ConclusionThe Knee Society Functional Score favored ORIF, but the total incidence of revision was higher in the ORIF cohort. Given the high mortality and the substantial risk of reoperation in both groups, additional studies are needed regarding the prevention of and optimal treatment for patients with periprosthetic distal femur fractures.     

Perioperative Outcomes in Total Knee Arthroplasty for Non-English Speakers

BackgroundMany studies have demonstrated that in patients whose primary language is not English, outcomes after an orthopaedic surgery are worse compared to primary English speakers. The goal of this study was to compare perioperative outcomes in patients undergoing total knee arthroplasty (TKA) who prefer English as their first language versus those who prefer a different language.MethodsWe retrospectively reviewed all patients who underwent primary TKA from May 2012 to July 2021. Patients were separated into two groups based on whether English was their preferred primary language (PPL). Of the 13,447 patients who underwent primary TKA, 11,290 reported English as their PPL, and 2,157 preferred a language other than English. Patients whose PPL was not English were further stratified based on whether they requested interpreter services. Multiple regression analyses were performed to determine the significance of perioperative outcomes while controlling for demographic differences.ResultsOur analysis found that non-English PPL patients had significantly lower rates of readmission (P = .040), overall revision (P = .028), and manipulation under anesthesia (MUA; P = .025) within 90 days postoperatively. Sub analyses of the non-English PPL group showed that those who requested interpreter services had significantly lower 1-year revision (P < .001) and overall MUA (P = .049) rates.ConclusionOur results demonstrate that TKA patients who communicated in English without an interpreter were significantly more likely to undergo revision, readmission, and MUA. These findings may suggest that language barriers may make it more difficult to identify postoperative problems or concerns in non-English speakers, which may limit appropriate postoperative care.Level III EvidenceRetrospective Cohort Study.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.     

Outcomes of fixation for periprosthetic tibia fractures around and below total knee arthroplasty

IntroductionThe incidence of periprosthetic fractures after total knee arthroplasty (TKA) is rising due to an increasing number of TKAs performed annually and the growing elderly population. Like periprosthetic fractures of the distal femur, periprosthetic tibia fractures are primarily treated with operative fixation; however, there is limited scientific literature that has reported outcomes of periprosthetic tibia fractures treated with modern plating techniques. To our knowledge, this is the largest series of non-intraoperative periprosthetic tibia fractures treated with open reduction internal fixation (ORIF) ever reported.MethodsRetrospective chart review of 4557 operatively treated tibia fractures with ORIF over a 16-year period at two Level 1 Trauma Centers.Results38 patients with an average follow-up of 15.3 months (range 3–24) were identified. 11 (28.9%) fractures were in the proximal tibia (four with extension into the plateau (Felix 1A) and seven adjacent to the tibial stem (Felix 2A)), six (15.8%) in the midshaft/diaphysis (Felix 3A), and 21 (55.3%) in the distal 1/3rd (metaphysis, Felix 3A). 76.3% (29/38) of fractures united by 6 months following the index procedure, leaving 9 nonunions. The overall re-operation rate was 31.6% (12/38). There were no significant differences in rates of union (p = 1.00), reoperation (p = 0.66), superficial infection (p = 0.66), or deep infection (p = 0.31) in patients treated with single versus dual plating.ConclusionPeriprosthetic tibia fractures are difficult to treat and have a high risk of nonunion and reoperation even with modern plating techniques. Most patients can be treated to union with operative fixation and do not require revision arthroplasty, if the components are stable initially. We recommend dual plating for fractures in the proximal third, and either single plating or nailing for fractures in the middle and distal thirds depending on bone quality, implant positioning, and fracture morphology.     

Prior Knee Arthroscopy Is Associated With Increased Risk of Revision After Total Knee Arthroplasty

BackgroundKnee arthroscopy (KA) is frequently performed to provide improved joint function and pain relief. However, outcomes following total knee arthroplasty (TKA) after prior KA are not fully understood. The purpose of this study is to determine the relationship between prior KA within 2 years of TKA on revision rates after TKA.MethodsData were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2006 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes to identify primary TKA. Patients were stratified into 2 groups based upon a history of prior KA. Univariate and multivariate analyses were conducted to determine association between KA and outcomes at 2-year postoperative period.ResultsIn total, 138,019 patients were included in this study, with 3357 (2.4%) patients receiving a KA before TKA and 134,662 (97.6%) patients who did not. The most common reason for KA was osteoarthritis (40.0%), followed by medial tear of the meniscus (26.0%) and chondromalacia (21%.0). After adjustment, prior KA was associated with increased revision rate (odds ratio [OR], 1.392; P = .003), postoperative stiffness (OR, 1.251; P = .012), periprosthetic joint infection (OR, 1.326; P < .001), and aseptic loosening (OR, 1.401; P = .048).ConclusionPrior KA is significantly associated with increased 2-year TKA revision rate. The most common etiology for arthroscopy was osteoarthritis. The results of the study, showing that arthroscopy before TKA substantially increases the rates of revision, PJI, aseptic loosening, and stiffness, lend further credence to the idea that patients may be better served by nonsurgical management of their degenerative pathology until they become candidates for TKA. Subjecting this population to arthroscopy appears to offer limited benefit at the cost of poorer outcomes when they require arthroplasty in the future.Level of EvidenceLevel III therapeutic study.     

Outcome of Revision Surgery for the Idiopathic Stiff Total Knee Arthroplasty

BackgroundIdiopathic stiff total knee arthroplasty (TKA) represents one of the most challenging subsets of the stiff TKA, as the etiology is unknown and there is no consensus on the most appropriate surgical treatment modality. Therefore, the aim of this study is to report on postoperative outcomes of revision surgery for idiopathic stiff TKA.MethodsWe retrospectively reviewed 189 consecutive patients (202 knees) who underwent revision TKA for stiffness: (1) 101 knees in the idiopathic stiffness cohort and (2) 88 in the non-idiopathic stiffness cohort. In the idiopathic stiffness cohort, 42 knees underwent isolated tibial insert exchange and 59 knees underwent component revision. Perioperative knee range of movement and complications were analyzed.ResultsThe overall revision surgery outcomes of the idiopathic stiffness cohort were worse than those of the non-idiopathic stiffness cohort with regard to maximum flexion (91.7° vs 100.1°, P = .02) and flexion range of motion (ROM) (87.6° vs 97.1°, P = .01). In the idiopathic stiffness cohort, isolated tibial insert exchange demonstrated greater maximum flexion (96.8° vs 88.4°, P = .06) and flexion ROM (93.2° vs 83.9°, P = .07). In terms of re-revision rates, the isolated tibial insert exchange idiopathic stiffness cohort demonstrated lower re-revision rates compared to the component revision idiopathic stiffness cohort (16.7% vs 31.0%, P = .01).ConclusionThis study demonstrates that the overall revision surgery outcome of idiopathic stiff TKA is worse than non-idiopathic TKA stiffness. In idiopathic stiffness cohorts, isolated tibial insert exchange was associated with lower re-revision rates than component revision, with similar efficacy in improving ROM, suggesting that isolated tibial insert exchange may be a preferred surgical treatment option in TKA patients with idiopathic stiffness.     

Prior Nonarthroplasty Surgery Increases Risk of Complication in Primary Total Knee Arthroplasty

BackgroundPrior ipsilateral knee surgery may increase the risk for complications after total knee arthroplasty (TKA). It remains unclear if the extent of previous surgery affects those risks disparately. The purpose of this study is to evaluate prior nonarthroplasty bony procedure (BP) and soft tissue only procedure (STP) as a potential risk factor for complications after TKA and determine the association with charges or reimbursement of the primary TKA.MethodsPatients who underwent primary TKA with previous knee surgery were identified using a national Medicare database and matched 1:5 to controls without prior knee surgery. Rates of postoperative medical and surgical complications were calculated in addition to hospital-associated charges and reimbursements. Logistic regression analysis was used to control for confounding factors.ResultsPatients who underwent BP (n = 835) had increased risk of readmission (58.6% vs 45.3%, odds ratio (OR) 1.72, 95% confidence interval (CI) 1.59-1.85, P < .001) and emergency room visits (14.5% vs 10.4%, OR 1.44, 95% CI 1.29-1.61, P = .001). Patients who underwent STP (n = 6766) had increased risk of readmission (58.1% vs 45.2%, OR 1.69, 95% CI 1.64-1.73, P < .001), emergency room visits (12.6% vs 0.7%, OR 1.33, 1.28-1.39, P < .001), revision (1.8% vs 1.4%, OR 1.33, 95% CI 1.21-1.47, P = .006), cerebrovascular accident (2.3% vs 1.7%, OR 1.33, 95% CI 1.22-1.46, P = .002), and venous thromboembolism (3.8% vs 3.2%, OR 1.21, 95% CI 1.13-1.29, P = .009). Prior surgery was associated with increased charges and reimbursements.ConclusionPrior ipsilateral knee surgery is associated with significantly increased risks of postoperative complications after primary TKA. Interestingly, previous STP but not BP increased the risk of short-term revision and venous thromboembolism.     

Clinical Outcomes in Isolated Tibial Revision With Cruciate Retaining Total Knee Arthroplasty

BackgroundTibial component loosening is one of the most common modes of failure in contemporary total knee arthroplasty (TKA). Limited literature is available on the outcomes of isolated tibial revision with retention of the cruciate retaining (CR) femoral component. The purpose of this study was to determine the results of isolated tibial revisions in CR TKA.MethodsWe identified 135 patients who underwent an isolated tibial revision after a primary CR TKA from our institutional registry between January 2007 and January 2017. The mean time between the primary and revision was 2.9 years (range 0.1-15.4). Revision with a press-fit stem was performed in 79 patients and 56 patients were revised with a fully cemented stem. Patients were evaluated at a minimum of two years using Knee Society Score, Knee Injury and Osteoarthritis Score for Joint Replacement, and radiography. Implant survivorship was determined using Kaplan-Meier survival analysis.ResultsAt a mean follow-up of 5.1 years, there were six (4.4%) repeat revisions: three for periprosthetic infection (2.2%), two for instability (1.5%), and one for a fractured tibial stem (0.7%). The mean Knee Society Score and Knee Injury and Osteoarthritis Score for Joint Replacement increased from 51.6 and 56.1 preoperatively to 90.1 and 89.7 after surgery (P < .001). Survivorship free of repeat revision for any cause was 93.3% at 5 years, and aseptic revision survivorship was 95.8% at 5 years. No implants were radiographically loose.ConclusionIn patients with isolated tibial loosening and a well-fixed and well-positioned CR femoral component, isolated tibial revision provides excellent early to midterm implant survivorship and clinical outcomes with a low risk of instability and recurrent tibial loosening.     

A Prophylactic Tibial Stem Reduces Rates of Early Aseptic Loosening in Patients with Severe Preoperative Varus Deformity in Primary Total Knee Arthroplasty

BackgroundPatients with a preoperative varus deformity >8 degrees are at increased risk of aseptic loosening after total knee arthroplasty. This study analyzes the effect of a tibial stem on the rate of aseptic loosening in patients with a severe preoperative varus deformity.MethodsPatients with a preoperative varus deformity of >8 degrees and 2-year minimum follow-up with a stemmed tibial component (n = 67) were matched 1:2 to patients with a similar preoperative varus deformity with a standard tibial component (n = 134). Radiolucent lines were measured on the tibia at 6 weeks, 1 year, and 2 years postoperatively using the Knee Society Radiographic Evaluation System. Failure was defined as revision due to aseptic loosening of the tibial component. Outcomes were evaluated using Student’s t-tests and log-rank tests.ResultsPatients with tibial stems had greater preoperative deformity (12.9 vs 11.3 degrees, P = .004). There was no difference in postoperative alignment (1.7 vs 2.1 degrees varus, P = .25) or tibial component angle (1.8 vs 2.1 degrees varus, P = .33). Patients with stems were more likely to have more constraint (44.8% vs 1.5%, P < .001). Progression of radiolucent lines >2 mm was observed in 17.6% (23/134) vs 5.97% (4/67) of patients in the stem group (P = .03). Rates of aseptic loosening were lower in the stem group (0% vs 5.15%, P = .05).ConclusionDespite worse preoperative deformity and higher utilization of constraint, tibial stem use in patients with severe preoperative varus deformity resulted in lower rates of aseptic loosening. Prophylactic use of stems in these patients may help increase implant survival.     

Modular Tibial Stem Use and Risk of Revision for Aseptic Loosening in Cemented Primary Total Knee Arthroplasty

BackgroundModular tibial stem extensions in total knee arthroplasty (TKA) are designed to reduce the risk of aseptic loosening of the tibial base plate. However, these implants add significant cost and an evaluation of their effectiveness in reducing this risk of loosening has not been studied in a large cohort. We sought to evaluate modular tibial stem utilization in primary TKA.MethodsWe conducted a cohort study using our integrated healthcare system’s Total Joint Replacement Registry. Patients who underwent cemented primary TKA were identified (2009-2019). Propensity scores were used to 1:1 match patients without to those with a stem extension. Cox proportional-hazards regression was used to evaluate the risk for revision due to aseptic loosening.ResultsTen thousand four hundred seventy six TKA with a modular tibial stem were matched to 10,476 TKA without a tibial stem. Stem utilization associated with a lower risk of revision for loosening across all postoperative follow-up (hazard ratio = 0.38, 95% confidence interval = 0.17-0.85).ConclusionIn a matched cohort study, we observed presence of a stem extension was associated with a lower risk of revision for aseptic loosening. Further study to identify specific risk factors for aseptic loosening and confirm the findings presented here are warranted.Level of EvidenceLevel III.     

Tibial periprosthetic fractures in Total Knee Arthroplasty – A scoping review

BackgroundPeriprosthetic tibial fractures in Total Knee Arthroplasty are much less commonly seen than femoral fractures, and there is a paucity of available literature and management recommendation for these fractures. We aimed to identify the relevant and up-to-date literature on this subject to analyse the incidence, risk factors, and management recommendations.MethodsA literature search was done on the databases of PubMed and SCOPUS using appropriate keywords. All the published literature in the English language was included for this review.ResultsWe included 21 studies comprising 260 tibial periprosthetic fractures (91 intra-operative (35%) and 169 (65%) post-operative or delayed fractures). Only 5.9% of these fractures were managed conservatively. Whereas 98 cases (58%) were managed with open reduction and internal fixation (ORIF) with plating, 19 (11.2%) were managed with revision TKA. Seventeen cases (10%) were managed with minimally invasive percutaneous plate osteosynthesis (MIPPO), and 8 (4.7%) were managed with intramedullary nailing. Less than 6% of cases were managed with other means, viz. megaprosthesis (n = 4), arthrodesis (n = 5), amputation (n = 1), and external fixator (n = 1).ConclusionIntraoperative fractures accounted for one-third of the fractures in our review. A majority of the delayed periprosthetic fractures were treated with surgical intervention. The most preferred surgical treatment method was ORIF of fractures using locking plates (either open or MIPPO). Revision TKA or megaprosthesis was used in cases with the loosened implants in association with the fracture.Level of evidenceIV     

Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization

BackgroundPrior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA.MethodsPrimary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a “conversion” cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue.ResultsThe conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001).ConclusionPatients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.     

Comparison of the clinical and radiological outcomes between an isolated tibial component revision and total revision knee arthroplasty in aseptic loosening of an isolated tibial component

BackgroundAn isolated tibial component revision could be a treatment option for isolated tibial side loosening; however, few studies have proved its efficacy. This study aimed to compare the clinical and radiological outcomes between isolated (tibial component) and total (femoral and tibial component) revision total knee arthroplasty (TKA).MethodsBetween January 2008 and February 2017, 31 patients underwent revision TKA for isolated tibial side loosening; 14 underwent an isolated tibial component revision (isolated group) and 17 underwent total (both femoral and tibial components) revision surgery (total group). The postoperative range of motion (ROM), Western Ontario and McMaster Universities osteoarthritis (WOMAC) index, Knee Society knee score (KSKS), Knee Society function score (KSFS), and mechanical axis (MA) were compared between the two groups. The intraoperative tourniquet time and amount of blood drainage were also compared.ResultsThe mean follow-up durations in the isolated and total groups were 40.7 and 56.1 months, respectively. Both groups had similar postoperative ROM, WOMAC index, KSKS, KSFS, and MA; however, significantly shorter tourniquet time (105.2 vs. 154.6 min, P < 0.001) and less blood drainage (417.2 vs. 968.1 ml, P < 0.001) were noted in the isolated group than in the total group.ConclusionIsolated tibial component revision TKA for tibial component loosening showed comparable clinical and radiological outcomes to those of total revision TKA. The advantages of the isolated tibial component revision surgery were short operation time and small blood loss.Study designLevel III, Retrospective comparative study.     

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment

BackgroundPeriprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.MethodsA multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.ResultsThe septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).ConclusionCompared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.     

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease

BackgroundLiterature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD.MethodsPatients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan–Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control.ResultsCompared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019).ConclusionIndependent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.     

The Importance of Oral History: Does Dental Implant Placement or Caries One Year Before or After Primary Total Knee Arthroplasty Increase Medical Complications and Periprosthetic Joint Infections?

BackgroundConsensus regarding prior dental problems on the outcomes of total knee arthroplasty (TKA) patients is lacking. Therefore, our objectives were to determine the association of dental caries or dental implant placement in TKA patients on the following: (1) medical complications; (2) health care utilization (lengths of stay and readmissions); (3) implant-related complications; and (4) expenditures.MethodsA retrospective query was performed using an administrative claims database for 3 patient cohorts undergoing primary TKA from 2010 to 2020. Patients who had a history of dental caries or implant placement 1 year prior to TKA (n = 1,466) and 1 year after TKA (n = 1,127) were case-matched to patients who did not have a dental history by age and comorbidities. Outcomes included 90-day complications, health care utilization parameters, 2-year implant complications, and expenditures. Logistic regression models computed odds ratios (OR) of complications and readmissions. P values less than 0.005 were significant.ResultsPatients who had a dental implant placement prior to TKA had higher frequency of complications (20.05 versus 14.01%; OR: 1.53, P < .0001), including myocardial infarctions (2.52 versus 1.23%; OR: 2.08, P = .0002) and pneumonia (2.52 versus 1.24%; OR: 2.06, P = .0002). Lengths of stay (3.28 versus 2.98 days; P = .255), readmission rates (4.71 versus 4.28%; P = .470), and implant-related complications including periprosthetic joint infections (3.14 versus 2.63%; OR: 1.20, P = .279) were similar between patients lacking dental history. Expenditures were higher in patients who had a postoperative and preoperative dental history ($19,252 versus $19,363 versus 17,980; P < .001).ConclusionDental caries or implant placement may reflect overall worse medical condition resulting in more complications and higher costs after TKA. Dental history screening preoperatively may assist arthroplasty surgeons in minimizing complications.