The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach. The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus. In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection). Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA.
The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants.Aims
Methods
With the widespread legalization of cannabis across the United States, well-powered studies evaluating the impact of cannabis use disorder on outcomes following primary total hip arthroplasty are warranted. Therefore, the aim of this study was to determine whether cannabis use disorder has an effect on patients who undergo primary hip arthroplasty in terms of: 1) hospital lengths of stay (LOS); 2) medical complications; 3) implant-related complications; and 4) costs of care. Using an administrative database, patients who underwent primary total hip arthroplasty and had cannabis use disorder were matched to a cohort who did not in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 44,154 patients; 7,361 who had cannabis use disorder and 36,793 who did not. Variables for analysis included postoperative LOS, 90-day medical complications, 2-year implant-related complications, and 90-day costs of care. Mann-Whitney-U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. A Introduction
Methods
Social determinants of health (SDOH) may contribute markedly to the total cost of care (COC) for patients undergoing elective total knee arthroplasty (TKA). This study investigated the association between demographics, health status, and SDOH on lengths of stay (LOS) and 30-day COC. Patients who underwent TKA between January 2018 and December 2019 were identified. Those who had complete SDOH data were utilized, leaving 234 patients. Data elements were drawn from the Chesapeake Regional Information System, the Center for Disease Control social vulnerability index (SVI), the Food Access Research Atlas (FARA). The SVI identifies areas vulnerable to catastrophic events, with 4 themed scores including: (1) socioeconomic status; (2) household composition and disability; (3) minority status and language; and (4) housing and transportation. Food deserts were defined as neighborhoods located 1 or 10 miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine an association with LOS and cost, after controlling for demographics.Introduction
Methods
Component position and overall limb alignment following total knee arthroplasty (TKA) have been shown to influence prosthetic survivorship and clinical outcomes1. The objective of this study was to compare the accuracy to plan of three-dimensional modeled (3D) TKA with manual TKA for component alignment and position. An open-label prospective clinical study was conducted to compare 3D modeling with manual TKA (non-randomized) at 4 U.S. centers between July 2016 and August 2018. Men and women aged > 18 with body mass index < 40kg/m2 scheduled for unilateral primary TKA were recruited for the study. 144 3DTKA and 86 manual TKA (230 patients) were included in the analysis of accuracy outcomes. Seven high-volume, arthroplasty fellowship-trained surgeons performed the surgeries. The surgeon targeted a neutral (0°) mechanical axis for all except 9 patients (4%) for whom the target was within 0°±3°. Computed tomography (CT) scans obtained approximately 6 weeks post-operatively were analyzed using anatomical landmarks to determine femoral and tibial component varus/valgus position, femoral component internal/external rotation, and tibial component posterior slope. Absolute deviation from surgical plan was defined as the absolute value of the difference between the CT measurement and the surgeon's operative plan. Smaller absolute deviation from plan indicated greater accuracy. Mean component positions for manual and 3DTKA groups were compared using two-sample t tests for unequal variances. Differences of absolute deviations from plan were compared using stratified Wilcoxon tests, which controlled for study center and accounted for skewed distributions of the absolute values. Alpha was 0.05 two-sided. At the time of this report, CT measurements of femoral component rotation position referenced from the posterior condylar axis were not yet completed; therefore, the current analysis of femoral component rotation accuracy to plan reflects one center that exclusively used manual instruments referencing the transepicondylar axis (TEA).Introduction
Methods
Emergency department (ED) visits following primary total knee arthroplasty (TKA) can lead to poor patient satisfaction, potentially unnecessary readmissions, and greater overall healthcare costs. Reasons for post-operative ED visits are often entirely medical in nature and can be independent of the recent operation. Several strategies have been developed to help reduce ED visits. However, one major factor that can play a critical role in addressing potentially avoidable visits is provider and patient education. A major factor that can play a crucial role in addressing potentially avoidable visits is provider and patient education. It follows that a thorough understanding of which patients are visiting the ED and why can help in avoiding the visits. Therefore, the purpose of this study was to investigate: 1) causes and 2) patient-related factors (demographics and comorbidities) associated with ED visits following primary TKA. A national private payer database was queried for primary TKAs performed between 2007 and 2016 using the International Classification of Disease, ninth revision (ICD-9) procedural code 81.54. ED visits were identified using Current Procedural Terminology (CPT) codes 99281 to 99285. Patients with 90-day ED visits were in the study group (n=28,044) whereas those without 90-day ED visits served as controls (n=82,289). Causes for ED visits were divided into cardiopulmonary, gastrointestinal, renal, thromboembolic, leg pain, or wound-related. Patient demographics and risk factors assessed included age, gender, and body mass index (BMI) as well as several comorbidities (Table 1). Pearson's chi-square tests were performed to compare patient demographics and comorbidities between the cohorts. In order to adjust for potential confounders, multivariate binomial logistic regression analysis was performed to further evaluate the associations between patient factors and 90-day ED visits. A p-value less than 0.01 was considered statistically significant.Introduction
Methods
The purpose of this study was to analyze trends in the surgical management of ON in recent years. Specifically, we evaluated the annual prevalences of: 1) joint preserving procedures (osteotomies and core decompression/grafts) and 2) joint non-preserving procedures (total hip arthroplasties [THAs], revision THAs, partial THAs) for the treatment of osteonecrosis of the femoral head (ONFH) between 2009 and 2016. A total of 406,239 ONFH patients who were treated between 2009 and 2016 were identified from a nationwide database. Treatment procedures were extracted using ICD-9-CM and ICD-10-CM procedure codes. Annual rates of each of the above procedures were calculated and the trends in the procedure types were also evaluated. Chi-square tests were performed to compare the annual prevalence of each procedure. The mean annual prevalence over the 8-year study period was calculated for each procedure.Introduction
Background
The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) A total of 12 fresh-frozen pelvis-to-toe cadaver specimens were included. Four surgeons each prepared three RATKA and three MTKA specimens for cruciate-retaining TKAs. A RATKA was performed on one knee and a MTKA on the other. Postoperatively, two additional surgeons assessed and graded damage to 14 key anatomical structures in a blinded manner. Kruskal–Wallis hypothesis tests were performed to assess statistical differences in soft-tissue damage between RATKA and MTKA cases.Objectives
Methods
As the number of total knee arthroplasties (TKA) being performed continues to increase, the number of potential failures requiring revision surgery would also be expected to increase. This study analyzed the trends in revision TKA (rTKA) from 2009 to 2016. The Nationwide Inpatient Sample (NIS) database was used to identify all rTKA by International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. The diagnoses leading to revision, revision costs, patient and hospital characteristics, and major inpatient complications were compared between 2009 and 2016. Multivariate logistic regression analyses were used to calculate odds ratios (OR) for complications.Background
Methods
Antibiotic-impregnated bone cement (AIBC) has been used for decades to treat and prevent post-operative infections in joint arthroplasty. Local delivery of antibiotics may theoretically have a bactericidal effect, however evidence supporting this is controversial and literature suggests its prophylactic use in primary total knee arthroplasty (TKA) is seldom justified. With evolving standards of care, historical data is no longer relevant in addressing the efficacy of AIBC in the contemporary TKA. The purpose of this study was to evaluate outcomes following primary TKA using AIBC and regular non-AIBC by comparing rates of surgical site infection (SSI) and prosthetic joint infection (PJI). A retrospective review was conducted of all cemented primary TKA procedures from a large institutional database between January 1, 2015 and December 31st, 2016. This identified 6,073 cases, n=2,613 in which AIBC was used and n=3,460 cases using bone cement without antibiotics. Patients were stratified into low risk and high-risk groups based on age (>65 years), BMI (>40), and Charlson Comorbidity Index (CCI; >3). Medical records were reviewed for diagnoses of SSI (skin and superficial wound infections) and PJI (deep joint infections requiring surgery) over a 2-year postoperative period. Univariate analysis and multivariate regression models were used to ascertain the effects of cement type, patient factors (age, gender, BMI, CCI), operative time, and length of stay on infection rates. Additionally, mixed models (adjusted for gender, age, race, BMI, and CCI) were built to account for surgeon variability.Introduction
Methods
Much effort has been aimed at strategies for patient optimization, perioperative standards of care, and postoperative risk stratification to reduce the incidence of SSI. Examples include, newer dressing modalities, antibiotic-impregnated bone cement, intra-wound powdered antibiotics, as well as novel suture types and techniques, all of which have shown great potential. However, the question remains as to whether these changes in practice have led to lower overall infections over the past few years. Therefore, the purpose of this study was to track the annual rates and trends of: 1) overall; 2) deep; and 3) superficial SSI following total hip arthroplasty (THA) using the most recent data (2012 to 2016) from a large nationwide database. The National Surgical Quality Improvement Program database was queried for all primary THAs (CPT code 27130) between 2012 and 2016, yielding 122,451 cases. Cases with reported superficial and/or deep SSIs were combined for an overall rate, and then independently analyzed as deep and superficial SSIs. The infection incidence for each year was calculated. After an overall 5-year correlation and trends, univariate analysis was also performed to compare the most recent year, 2016, with each of the preceding 4 years. Furthermore, a comparison of overall and deep SSI incidences from this study were compared to meta-analysis of pooled data from 2001 to 2011. Pearson correlation coefficients and chi-squared tests were used to determine correlation and statistical significance which was maintained at a p-value less than 0.05.Background
Methods
Robotic assisted Total Knee Arthroplasty (rTKA), provides surgeons with preoperative planning and real-time data allowing for continuous assessment of ligamentous tension and range-of-motion. Using this technology, soft tissue protection, reduced early post-operative pain and improved patient satisfaction have been shown. These advances have the potential to enhance surgical outcomes and may also reduce episode-of-care (EOC) costs for patients, payers, and hospitals. The purpose of this study was to compare robotic assisted vs. manual total knee arthroplasty: 1) 90-day episode-of-care (EOC) costs; 2) index costs; 3) lengths-of-stay (LOS); 4) discharge disposition; and 5) readmission rates. TKA procedures were identified using the Medicare 100% Standard Analytic Files including; Inpatient, Outpatient, Skilled Nursing (SNF) and Home Health. Members included patients with rTKA or manual TKA (mTKA) between 1/1/2016-3/31/2017. To account for potential baseline differences, propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual based on age, sex, race, geographic division, and comorbidities. After PSM, 519 rTKA and 2,595 mTKA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, discharge disposition and readmission rates were assessed.Introduction
Methods
Currently, there are no generally accepted treatments for the prevention of osteonecrosis. To compound this further, despite considerable research efforts, the natural history of this disease remains poorly understood. The disease process appears to be initially asymptomatic, but after symptoms appear, the course becomes rapidly progressive. Clinical studies have shown that, if left untreated, collapse of the femoral head will occur in 80 per cent of the cases or greater within four years. As our knowledge of the etiology and pathogenesis of osteonecrosis improves, new treatments to halt, or at least impede, the progression of the disease may be possible. Achieving the best outcomes in the treatment of osteonecrosis depends on early, accurate diagnosis, and prompt treatment appropriate for the stage of the disease. In many cases, if treated early, long-term preservation of the native joint is possible. Magnetic resonance imaging allows accurate diagnosis in even the earliest asymptomatic stages of the disease. Non-surgical treatments such as pharmacological agents have shown promise in experimental studies, although further work remains before they are appropriate for widespread use. Various hip salvaging procedures such as core decompression, percutaneous drilling, non-vascularized and vascularized bone grafting, and various osteotomies have been successful in the majority of properly selected patients over follow-up times of a decade or more. Advances in arthroplasty technologies and techniques, including hip resurfacing and modern cementless total hip arthroplasty have allowed patients to return to pain-free, active lifestyles with excellent long-term prosthesis survival. Current treatments for osteonecrosis, while generally successful, focus on halting or delaying the progression of symptomatic disease. Recent discoveries concerning the relationship between genetic factors and the development of osteonecrosis, as well as the pathophysiologic effects of various indirect and direct risk factors such as corticosteroid use and sickle cell disease, continue to improve our understanding of the underlying disease process. While these discoveries are promising, we must continue to work towards the goal of being able to identify and treat the precursors of osteonecrosis before it progresses to symptomatic disease and threatens the survival of native joints.
