Postoperative Falls After Total Knee Arthroplasty in Patients With a Femoral Nerve Catheter: Can We Reduce the Incidence?

A femoral nerve catheter (FNC) is often used to minimize pain following total knee arthroplasty (TKA), but complications including inpatient falls, may increase as a result, despite fall prevention protocols. We evaluated the rate of falls in 707 primary TKAs performed with an FNC at a major academic center from May 2009 to September 2012. Despite a formalized fall prevention protocol, we found 19 falls (2.7%). Three patients required further operative intervention. At a rate of 2.7%, postoperative fall is one of the most common complications of TKA at our institution. While pain control may be good with the use of FNCs following primary TKA, improvements in fall prevention strategies or the use of alternative postoperative pain control modalities may need to be considered.     

Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty?

BackgroundDiabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA.MethodsWe reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM).ResultsCompared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (?1.22 points, P-value = .025) and knee ROM (?1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866).ConclusionPatients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.     

Do Glycemic Markers Predict Occurrence of Complications After Total Knee Arthroplasty in Patients With Diabetes?

Background

Patients with diabetes have increased risk of infections and wound complications after total knee arthroplasty (TKA). Glycemic markers identifying patients at risk for complications after TKA have not yet been elucidated.

Questions/purposes

We aimed to determine the correlations among four commonly used glycemic markers and to identify the glycemic markers most strongly associated with the occurrence of surgical site infections and postoperative wound complications in patients with diabetes mellitus after undergoing TKA.

Methods

Our retrospective study included 462 patients with diabetes, who underwent a total of 714 TKAs. Blood levels of glycemic markers, including preoperative fasting blood glucose (FBG), postprandial glucose (PPG2), glycated hemoglobin (HbA_1c), and levels obtained from random glucose testing on postoperative days 2, 5, and 14, were collected on all patients as part of a medical clearance program and an established clinical pathway for patients with diabetes at our center. Complete followup was available on 93% (462 of 495) of the patients. Correlations among markers were assessed. Associations between the markers and patient development of complications were analyzed using multivariate regression analyses of relevant cutoff values. We considered any of the following as complications potentially related to diabetes, and these were considered study endpoints: surgical site infection (superficial and deep) and wound complications (drainage, hemarthrosis, skin necrosis, and dehiscence). During the period of study, there were no fixed criteria applied to what levels of glycemic control patients with diabetes needed to achieve before undergoing arthroplasty, and there were wide ranges in the levels of all glycemic markers; for example, whereas the mean HbA_1c level was 7%, the range was 5% to 11.3%.

Results

There were positive correlations among the levels of the four glycemic markers; the strongest correlation was found between the preoperative HbA_1c and PPG2 levels (R = 0.502, p < 0.001). After controlling for potential confounding variables using multivariate analysis, the HbA_1c cutoff level of 8 (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.6–23.4; p = 0.008) and FBG 200 mg/dL or higher (OR, 9.2; 95% CI, 2.2–38.2; p = 0.038) were associated with superficial surgical site infection after TKA.

Conclusions

In general, there is a positive correlation among the various available glycemic markers among patients with diabetes undergoing TKA, and patients undergoing surgery with HbA_1c ≥ 8 and/or FBG ≥ 200 mg/dL were associated with superficial surgical site infection. These findings should be considered in patient selection and preoperative counseling for patients with diabetes undergoing TKA.

Level of Evidence

Level III, prognostic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-4056-1) contains supplementary material, which is available to authorized users.     

Do Medial Pivot Kinematics Correlate With Patient-Reported Outcomes After Total Knee Arthroplasty?

Background

Many total knee arthroplasty (TKA) implants are designed to facilitate a medial pivot kinematic pattern. The purpose of this study was to determine whether intraoperative medial pivot kinematic patterns are associated with improved patient outcomes.

Quantifying Surgeon Work in Total Hip and Knee Arthroplasty: Where Do We Stand Today?

BackgroundPhysician work is a critical component in determining reimbursement for total joint arthroplasty (TJA). The purpose of this study is to quantify the time spent during the different phases of TJA care relative to the benchmarks used by the Centers for Medicare and Medicaid Services.MethodsWe retrospectively reviewed all patients captured in our institutional joint database between January 1, 2014, and December 31, 2018. Four phases of care were assessed: (1) preoperative period following the decision to proceed with TJA and leading to the day before surgery, (2) immediate 24 hours preceding surgery (preservice time), (3) operative time from skin incision to dressing application (intraservice time), and (4) postoperative work including day of surgery and the following 90 days.ResultsA total of 666 procedures were analyzed (379 total hip arthroplasties and 287 total knee arthroplasties). The mean preoperative care coordination, preservice, intraservice, immediate postservice, and 91-day global period times were 21.9 ± 10, 84.1, 114 ± 24, 35, and 150 ± 37 minutes, respectively. Except for a slightly higher preoperative time associated with Medicare coverage (P = .031), there were no differences in the other phases of care by payer type. There were no temporal differences between 2014 and 2017. However, in 2018, there were significant increases in preoperative and intraservice times (6 and 20 minutes, respectively, P < .001) which were accompanied with a significant decrease in postoperative service time (34 minutes, P < .001).ConclusionEven when performing TJA under the most optimal conditions, the overall time has remained stable over the past 5 years and consistent with current benchmarks.     

Chemotherapy-Associated Hepatotoxicity: Do We Need to Be Concerned?

Curative resection of liver metastases from colorectal cancer is associated with improved overall survival rates, making complete resection the goal of therapy for many patients. The addition of newer, more active chemotherapeutic regimens has prolonged patient survival in those with advanced disease and increased the number of patients eligible for surgical therapy. However, concerns regarding chemotherapy-associated liver injury may have a negative impact on the ability to offer potentially curative therapy and may increase morbidity in some patients. Specific forms of liver injury have been associated with various chemotherapeutic regimens, including steatosis and steatohepatitis with prolonged fluorouracil and irinotecan therapy, and sinusoidal injury with oxaliplatin-based regimens. While the histologic association appears likely, the contribution of chemotherapy-associated hepatotoxicity to postoperative morbidity remains ill defined. Disclosure information: Dr. Choti has served as a consultant for sanofi-aventis and Genentech.     

Tramadol in Knee Osteoarthritis: Does Preoperative Use Affect Patient-Reported Outcomes After Total Knee Arthroplasty?

BackgroundThe 2013 American Academy of Orthopedic Surgeons evidence-based guidelines recommend against the use of preoperative narcotics in the management of symptomatic osteoarthritic knees; however, the guidelines strongly recommend tramadol in this patient population. To our knowledge, no study to date has evaluated outcomes in patients who use tramadol exclusively as compared with narcotics naive patients.MethodsThis is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty between January 2017 and March 2018. PRO scores were obtained using a novel electronic patient rehabilitation application, which pushed PRO surveys via email and mobile devices within 1 month prior to surgery and 3 months postoperatively.ResultsOne hundred and thirty-six patients were opiate naïve, while 63 had obtained narcotics before the index operation. Of those, 21 patients received tramadol. The average preoperative Knee Disability and Osteoarthritis Outcome Scores were 50.4, 49.95, and 48.01 for the naïve, tramadol, and narcotic populations, respectively, (P = .60). The tramadol cohort had the least gain in 3 months postoperative Knee Disability and Osteoarthritis Outcome Scores, improving on average 12.5 points in comparison to the 19.1 and 20.1 improvements seen in the narcotic and naïve cohorts, respectively (P = .09). This difference was statistically significant when comparing the naïve and tramadol populations alone in post hoc analysis (P = .016).ConclusionsWhen comparing patients who took tramadol preoperatively to patients who were opiate naïve, patients that used tramadol trended toward significantly less improvement in functional outcomes in the short-term postoperative period.     

Neuroprotective Strategies – What Do We Really Need to Know?

While preliminary data are encouraging, definitive data are lacking to conclusively demonstrate the benefit of perioperative neurologic monitoring in improving neurodevelopmental outcomes in children who require surgery for congenital heart disease. Nonetheless, in the current era, some form of perioperative neurologic monitoring is important. Strategies include bicortical near infrared spectroscopy monitoring in the pre- and postoperative periods along with bicortical near infrared spectroscopy and transcranial Doppler intraoperatively. These monitors provide real-time information concerning cerebral oxygen delivery and blood flow. These strategies will allow us to refine treatments to optimize neurodevelopmental potential in children with congenital heart disease.     

Disease Progression After Unicompartmental Arthroplasty: Add a Compartment or Revise to Total Knee Arthroplasty?

BackgroundFive percent to 7% of unicompartmental knee arthroplasties (UKA) require revision for disease progression in untreated compartment(s), most commonly to total knee arthroplasty (TKA). TKA requires removal of bone and usually the anterior cruciate ligament. Preserving the UKA and converting to a bicompartmental arthroplasty (BCA) by performing a second UKA is an alternative.MethodsThe results of 73 UKA-BCA patients were compared to 75 patients treated by UKA-TKA revision. Knee Society, Knee Osteoarthritis Outcome Score Joint Replacement, and patient satisfaction scores were collected by a blinded therapist. Patients were asked about their implant preference and recovery. Twenty-two UKA-BCA revision patients had a UKA (6) or TKA (16) in the contralateral knee; thus, a direct comparison of UKA-BCA to both UKA and TKA was possible.ResultsOf the UKA-BCA patients, 69 (94%) had excellent or good, 2 (3%) fair, and 2 (3%) poor outcomes with 1 patient requiring revision to TKA. Of patients with a TKA in the contralateral knee, 13 (81%) preferred the UKA-BCA replacement and 3 (19%) preferred the TKA. All patients said the UKA-BCA revision recovery was similar or easier than their initial UKA. Of UKA-TKA revisions, 59 (79%) had excellent or good, 9 (12%) fair, and 7 (9%) poor outcomes. There was 1 wound infection and 1 re-revision in the UKA-BCA group and 1 wound infection and 3 re-revisions in the UKA-TKA group. The Knee Osteoarthritis Outcome Score Joint Replacement and Knee Society Scores were better for UKA-BCA compared to UKA-TKA.ConclusionUKA-BCA is a successful treatment for disease progression following UKA.