Common Orthopaedic Procedures Research Articles

Post-Operative Analgesic Effect of Intra-Articular Local Anesthetic Infiltration versus Adductor Canal Block after Knee Arthroscopic Surgeries

Abstract Background Knee arthroscopic surgery is one of the most common orthopaedic procedures. Postoperative pain after Knee arthroscopy is caused by irritation of free nerve endings of synovial tissue, anterior fat pad, and joint capsule during surgical excision and resection. Aim of the Work To compare between intra-articular local anaesthetic infiltration and ultrasound guided adductor canal block to achieve effective and safe postoperative analgesia after knee arthroscopic surgeries as regarding duration of postoperative analgesia, need for analgesic supplements postoperatively, patient satisfaction, time of ambulation, and presence of any associated complications or side effects. Patients and Methods A prospective randomized comparative study was conducted in Ain Shams University hospitals, on patients aged from 20 to 60 years, ASA class I-II-III assigned for knee arthroscopic surgeries. For six to eight months started after approval from ethical committee of Ain Shams University. A written informed consent had been obtained from all patients. Every patient received an explanation for the purpose of the study and research results only used for scientific purposes. Results The study showed that adductor canal group had lower Pain perception (VAS-10) at rest, but the differences were statistically significant beginning from hour-8. Also, adductor canal group had lower Pain perception (VAS-10) during movement, but the differences were statistically significant beginning from hour-8. Rescue analgesia was significantly less frequent in adductor canal group. High satisfaction (Good/excellent) grades were significantly more frequent in adductor canal group. Conclusion The findings of our study revealed that ACB Provides better postoperative analgesia after knee arthroscopic surgeries than intra-articular local anaesthetic infiltration at rest and movement. Furthermore it facilitated earlier mobility than local anaesthetic infiltration. However, in clinical practice intra-articular local anaesthetic infiltration is easier to perform than ACB which requires experienced anaesthesiologist.

A Comparison between Sub-Sartorial Canal Block and Femoral Nerve Block for Postoperative Analgesia after Arthroscopic Knee Surgery

Abstract Background Knee arthroscopy is a common orthopedic procedure worldwide, despite its minimally invasive nature compared to the traditional knee surgery, post-arthroscopic pain may be severe, and the patients generally require a significant amount of opioid-based analgesics after such procedures. Aim of the Work The aim of the study is to compare the analgesic efficacy and functional recovery of ACB and FNB in patients who have undergone knee arthroscopy. Patients and Methods In the period from April 2021 to October 2021 sixty patients who underwent Arthroscopic knee surgery were randomly allocated to one of two groups and comparative study was done. Group I (group FNB): (no. 30): Patients received Femoral Nerve Block (FNB) after spinal anaesthesia. Group II (group ACB): (no. 30): Patients received Sub-sartorial canal block (Adductor Canal Block) (ACB) after spinal anaesthesia. Results During our study, it was found that ACB is equally effective with FNB in patient satisfaction for post operative analgesia (NRS at 4 hrs, 8 hrs, 12 hrs, 16 hrs, 20 hrs and 24 hrs was non-significant as P value was 0.3, 0.29, 0.1, 0.5, 0.35, 0.87 respectively) but ACB is more effective than FNB in post operative ambulation and rehabilitation after arthroscopic knee surgery (ACB ambulated after 180.7 ± 23.6 mins in ACB and 241.2 ± 29.12 mins in FNB with pvalue <0.001). When compared to our study, it revealed that the group received FNB suffered from quadriceps weakness which interfered with postoperative rehabilitation and early ambulation although postoperative analgesia was equally effective in comparison to the group received ACB. Conclusion Our study concluded that Adductor Canal Block is more effective than Femoral Nerve Block in post operative ambulation and equally effective with femoral nerve block in patient satisfaction for post operative analgesia after arthroscopic knee surgery.

How Have Patient Out-of-pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgical Procedures Changed Over Time? A Retrospective Study From 2010 to 2020.

Out-of-pocket (OOP) costs can be substantial financial burdens for patients and may even cause patients to delay or forgo necessary medical procedures. Although overall healthcare costs are rising in the United States, recent trends in patient OOP costs for foot and ankle orthopaedic surgical procedures have not been reported. Fully understanding patient OOP costs for common orthopaedic surgical procedures, such as those performed on the foot and ankle, might help patients and professionals make informed decisions regarding treatment options and demonstrate to policymakers the growing unaffordability of these procedures. (1) How do OOP costs for common outpatient foot and ankle surgical procedures for commercially insured patients compare between elective and trauma surgical procedures? (2) How do these OOP costs compare between patients enrolled in various insurance plan types? (3) How do these OOP costs compare between surgical procedures performed in hospital-based outpatient departments and ambulatory surgical centers (ASCs)? (4) How have these OOP costs changed over time? This was a retrospective, comparative study drawn from a large, longitudinally maintained database. Data on adult patients who underwent elective or trauma outpatient foot or ankle surgical procedures between 2010 and 2020 were extracted using the MarketScan Database, which contains well-delineated cost variables for all patient claims, which are particularly advantageous for assessing OOP costs. Of the 1,031,279 patient encounters initially identified, 41% (427,879) met the inclusion criteria. Demographic, procedural, and financial data were recorded. The median patient age was 50 years (IQR 39 to 57); 65% were women, and more than half of patients were enrolled in preferred provider organization insurance plans. Approximately 75% of surgical procedures were classified as elective (rather than trauma), and 69% of procedures were performed in hospital-based outpatient departments (rather than ASCs). The primary outcome was OOP costs incurred by the patient, which were defined as the sum of the deductible, coinsurance, and copayment paid for each episode of care. Monetary data were adjusted to 2020 USD. A general linear regression, the Kruskal-Wallis test, and the Wilcoxon-Mann-Whitney test were used for analysis, as appropriate. Alpha was set at 0.05. For foot and ankle indications, trauma surgical procedures generated higher median OOP costs than elective procedures (USD 942 [IQR USD 150 to 2052] versus USD 568 [IQR USD 51 to 1426], difference of medians USD 374; p < 0.001). Of the insurance plans studied, high-deductible health plans had the highest median OOP costs. OOP costs were lower for procedures performed in ASCs than in hospital-based outpatient departments (USD 645 [IQR USD 114 to 1447] versus USD 681 [IQR USD 64 to 1683], difference of medians USD 36; p < 0.001). This trend was driven by higher coinsurance for hospital-based outpatient departments than for ASCs (USD 391 [IQR USD 0 to 1136] versus USD 337 [IQR USD 0 to 797], difference of medians USD 54; p < 0.001). The median OOP costs for common outpatient foot and ankle surgical procedures increased by 102%, from USD 450 in 2010 to USD 907 in 2020. Rapidly increasing OOP costs of common foot and ankle orthopaedic surgical procedures warrant a thorough investigation of potential cost-saving strategies and initiatives to enhance healthcare affordability for patients. In particular, measures should be taken to reduce underuse of necessary care for patients enrolled in high-deductible health plans, such as shorter-term deductible timespans and placing additional regulations on the implementation of these plans. Moreover, policymakers and physicians could consider finding ways to increase the proportion of procedures performed at ASCs for procedure types that have been shown to be equally safe and effective as in hospital-based outpatient departments. Future studies should extend this analysis to publicly insured patients and further investigate the health and financial effects of high-deductible health plans and ASCs, respectively. Level III, economic and decision analysis.

Differences in joint line level and posterior condylar offset during total knee replacement with use of gap-balancing and measured resection techniques—matched cohort study

BackgroundTotal knee replacement (TKR) is considered one of the most common elective orthopaedic procedures. The main focus of TKR is to offer patient's symptomatic relief from persistent knee pain. To achieve this it is crucial to restore joint biomechanics by performing proper bone cuts. Some surgeons favor the measured resection technique, others prefer gap balancing technique. The researchers of the presented study performed TKR using these two techniques. The aim of this study was to compare the postoperative change in joint line and posterior condylar offset after TKR with use of anatomic knee design implants between gap balancing and measured resection techniques.MethodsTwo hundred twenty-five X-rays of patients who underwent TKR performed by a single surgeon between 2020 and 2021 were analyzed. The first group of patients (101) was operated with the use of gap balancing technique and the second group (124) was operated with the use of measured resection technique. Patients included in the study were > 50 years of age, had confirmed primary knee osteoarthritis, underwent primary TKR with a PS (posterior stabilized) knee implants without patella resurfacing and had at least 15 degree flexion contracture. T-student test and U Mann–Whitney test were used in statistical analysis of results, according to the normality of distribution examined with the Shapiro–Wilk test. Post-hoc analysis was performed using the Dwass-Steel-Crichtlow-Fligner test (DSCF).ResultsThe postoperative analysis showed a significantly elevated joint line level in the gap balancing group (-2.6 ± 4.1 vs -0.7 ± 4.8, p < 0.0005). In the gap balancing group significantly more patients had joint lines elevated > 2 mm comparing to measured resection technique. The difference between pre- and postoperative PCO (posterior condylar offset) and PCOR (posterior condylar offset ratio) results had no significant differences (100.8 ± 11.8 vs 101 ± 12.5, p > 0.05) between the groups.ConclusionsThe results of the study suggest that when it comes to restoring joint line level measured resection technique seems to be superior in comparison to the gap balancing technique. What is more, results indicate measured resection is equal in terms of restoring posterior condylar offset to the gap balancing technique.Trial registrationNCT04164147, date of registration: November 14, 2019.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty.

The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA). Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics. The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

Anterior cruciate ligament reconstruction learning curve study – Comparison of the first 50 consecutive patients of five orthopaedic surgeons during a 5-year follow-up

BackgroundThe goal of all surgical and orthopaedic training is to ensure necessary education and surgical skills without compromising the quality of operations or patient safety. Anterior cruciate ligament reconstruction (ACLR) is a common multi-staged orthopaedic surgical procedure with a learning curve. Previous studies focus mainly on learning or the learning curve of one surgeon and tunnel placements. The aims of this study were to define the learning curve in arthroscopic ACLRs, define the number of procedures needed before the surgical “knifetime” plateaus, examine the effect of experience on complications, and identify possible individual differences in the surgical learning curve. MethodsThe study included the first 50 consecutive ACLR operations of five orthopaedic surgeons, thus, a total of 250 patients. For comparison and statistical analysis, patients were arranged into five groups, each comprising 50 patients (=order group). Order group 1 comprised the first 10 patients operated on by each of the five surgeons, group 2 patients 11–20, group 3 patients 21–30, group 4 patients 31–40, and group 5 the last 10 patients. The learning curve was defined with a LOESS curve. Surgical time and complications, including graft failure and postoperative knee instability, were analysed between order groups and between surgeons. ResultsMedian surgical time was 105 (interquartile range 82–124) min. The learning curve showed the first steep decline in surgical time and started to settle slowly after 20 reconstructions. Surgical time was significantly longer when order group 1 was compared with order group 2 (p = 0.031), and when order group 1 was compared separately with order groups 3, 4, and 5 (p < 0.001). Operation order alone explained only 17.1% of the alteration in surgical time. No significant difference emerged in graft failure rate between the order groups or the surgeons. Objective instability of the knee showed a significant difference when order group 1 was compared separately with order group 3 and with order group 4 (p = 0.004). Surgical time differed between surgeons (p < 0.001), and the shape of the learning curve showed great individual variability. ConclusionIn the first 10 to 20 ACLR operations, the surgical time was longer and the complication rate higher, but thereafter both started to settle down. We recommend that first 10–20 ACLR operations should be supervised.

Narrative review of influence of prosthesis lateralization on clinical outcomes in reverse shoulder arthroplasty: glenoid vs. humerus vs. combined.

Reverse shoulder arthroplasty has become a common orthopaedic procedure, with a growing number of cases annually for multiple indications, such as rotator cuff arthropathy, osteoarthritis, or fractures of the proximal humerus, to reduce pain and restore shoulder mobility. Prosthesis design and various recent improvements aim to enhance range of motion (ROM) and stability and to limit component loosening and other potential complications. Many of these well-known issues could theoretically be improved by glenoid, humeral, or combined component lateralization. The objective of this article is to provide an up-to-date literature overview, present available options, and discuss the rationale behind lateralization of certain components, as well as their combined impact on outcomes of reverse shoulder arthroplasty. PubMed and Scopus databases from 2003 to 2023 were searched and screened for studies, including systematic reviews, on the influence of glenoid, humeral, and combined component lateralization that served for narrative review of rationale behind such design. Currently, a number of computer simulations, anatomic studies, and limited clinical references aim to support the rationale behind glenoid augmentation, variable humeral neck-shaft angle (NSA), or humeral tray design. The utility of lateralization has not yet been clinically established. Randomized, long-term clinical outcome studies are still needed to reach a verdict going beyond surgeon preference and case-specific indications.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study

Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture. International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results. Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters. Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool. This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

Abnormal Thigh Swelling after Anterior Cruciate Ligament Reconstruction with Tourniquet

Background: Anterior cruciate ligament (ACL) reconstruction surgery is a common orthopedic procedure. Minimally invasive surgeries and arthroscopy are becoming more common, and tourniquets are utilized in these procedures to reduce bleeding and allow for improved tissue visualization.&#x0D; Case Report: In this paper, we report a 32-year-old man who underwent the right knee ACL reconstruction using a tourniquet following trauma. He developed thigh swelling at the tourniquet site after surgery. Right thigh ultrasound and magnetic resonance imaging (MRI) indicated extensive interstitial edema in all compartments without collection, hematoma, or hemorrhage. The patient was treated with dexamethasone and Lasix for four days. Rehabilitation activities included exercises to improve range of motion (ROM), strength exercises, and a home workout routine. Two weeks after discharge, the swelling decreased by about 80%.&#x0D; Conclusion: We believe that using a tourniquet during the reconstruction surgery may be responsible for the extensive edema in the limb. However, despite several diagnostic methods, we could not explain the reason for the edema in the limb following surgery.

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania.

Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

Random forest identifies predictors of discharge destination following total shoulder arthroplasty

Machine learning algorithms are finding increasing use in prediction of surgical outcomes in orthopedics. Random forest is one of such algorithms popular for its relative ease of application and high predictability. In the process of sample classification, algorithms also generate a list of variables most crucial in the sorting process. Total shoulder arthroplasty (TSA) is a common orthopedic procedure after which most patients are discharged home. The authors hypothesized that random forest algorithm would be able to determine most important variables in prediction of nonhome discharge. Authors filtered the National Surgical Quality iImprovement Program database for patients undergoing elective TSA (Current Procedural Terminology 23472) between 2008 and 2018. Applied exclusion criteria included avascular necrosis, trauma, rheumatoid arthritis, and other inflammatory arthropathies to only include surgeries performed for primary osteoarthritis. Using Python and the scikit-learn package, various machine learning algorithms including random forest were trained based on the sample patients to predict patients who had nonhome discharge (to facility, nursing home, etc.). List of applied variables were then organized in order of feature importance. The algorithms were evaluated based on area under the curve of the receiver operating characteristic, accuracy, recall, and the F-1 score. Application of inclusion and exclusion criteria yielded 18,883 patients undergoing elective TSA, of whom 1813 patients had nonhome discharge. Random forest outperformed other machine learning algorithms and logistic regression based on American Society of Anesthesiologists (ASA) classification. Random forest ranked age, sex, ASA classification, and functional status as the most important variables with feature importance of 0.340, 0.130, 0.126, and 0.120, respectively. Average age of patients going to facility was 76 years, while average age of patients going home was 68 years. 78.1% of patients going to facility were women, while 52.7% of patients going home were. Among patients with nonhome discharge, 80.3% had ASA scores of 3 or 4, while patients going home had 54% of patients with ASA scores 3 or 4. 10.5% of patients going to facility were considered of partially/totally dependent functional status, whereas 1.3% of patients going home were considered partially or totally dependent (P value < .05 for all). Of various algorithms, random forest best predicted discharge destination following TSA. When using random forest to predict nonhome discharge after TSA, age, gender, ASA scores, and functional status were the most important variables. Two patient groups (home discharge, nonhome discharge) were significantly different when it came to age, gender distribution, ASA scores, and functional status.

Patient factors influencing the choice of opioid versus non-opioid postoperative analgesia following common sports procedures: a prospective survey study

PurposeDespite established opioid-free protocols for postoperative analgesia after common orthopaedic sports procedures, many patients continue to request opioids postoperatively. The purpose of this study was to elucidate patient factors influencing preferences for opioid versus nonopioid postoperative analgesia. MethodsPatients (age >/ = 15) without a history of a documented chronic pain disorder who were scheduled for one of ten sports procedure types from August 2020 to May 2021 were eligible for inclusion. Patients were excluded if undergoing revision surgery, had concomitant injuries, had opioids use >3 months preoperatively, or unable to read English. Recruitment ended after 100 patients enrolled. At the patients’ preoperative visit, patients were administered a written survey assessing pain medication preferences. Participants completed the Opioid Risk Tool survey, as well as Visual Analog Scale and Patient-Reported Outcome Measurement Information System surveys. ResultsOne hundred patients participated in the study. Forty-two patients preferred opioids versus 58 patients preferring nonopioid postoperative analgesia. Patients preferring opiates were more likely to have had previous surgery (90.2% vs. 69.6%, p = 0.023) with post-operative pain managed with opiates (87.5% vs 55.4%, p = 0.003), higher preoperative Visual Analog Scale score (6±3.5 vs. 3±2, p < 0.001), reported post-operative pain as a reason for opioids preference (88.1% vs 20.0%, p < 0.001), and were less concerned about addiction (4.8% vs. 45.5%, p < 0.001) and side effects (11.9% vs. 52.7%, p < 0.001). For every unit increase in Visual Analog Scale score, the odds of preferring opioid pain control increased 1.41 times. ConclusionsPatients with a history of prior surgery utilizing opioid pain control, higher Visual Analog Scale scores preoperatively, and concern for inadequately managed postoperative pain were more likely to prefer opioid pain control following common orthopaedic sports procedures. Patients may benefit from increased preoperative education about opioid risks and the role of multimodal pain management regimens.

A Systematic Review of the Usage of Lidocaine in Hip Replacement Surgery.

Hip replacement procedures, professionally known as hip arthroplasty, are one of the most common orthopedic procedures. Due to the variation in this procedure, the use and types of anesthetics differ. One such commonly used anesthetic is lidocaine. Since there are currently no standardized or general procedures for the application of lidocaine for perioperative hip arthroplasty procedures, this review aims to delve into this topic. A literature review surrounding the key terms "hip replacement" and "lidocaine" was performed on PubMed. After reviewing 24 randomized control trials, statistical analyses between groups that had no lidocaine versus groups that did were performed. The results showed that there was no statistical significance between various age groups and the use of lidocaine. One percent (1%) and 2% injected into the lumbar region were the most commonly reported doses of lidocaine, with 2% often being the first test dose. Other conclusions were that lidocaine was used for general anesthesia for individuals that underwent hip arthroplasty due to an underlying condition (cauda equina syndrome, ankylosing spondylitis, etc.). Lidocaine was also used for postoperative pain relief, which is a potential concern from its addictive qualities. This investigation outlines the current stance and usage of lidocaine in perioperative hip arthroplasty while noting its limitations.

Peripheral cortical bone density predicts vertebral bone mineral properties in spine fusion surgery patients.

Spine fusion surgery is one of the most common orthopedic procedures, with over 400,000 performed annually to correct deformities and pain. However, complications occur in approximately one third of cases. While many of these complications may be related to poor bone quality, it is difficult to detect bone abnormalities prior to surgery. Areal BMD (aBMD) assessed by DXA may be artifactually high in patients with spine pathology, leading to missed diagnosis of deficits. In this study, we related preoperative imaging characteristics of both central and peripheral sites to direct measurements of bone quality in vertebral biopsies. We hypothesized that pre-operative imaging outcomes would relate to vertebral bone mineralization and collagen properties. Pre-operative assessments included DXA measurements of aBMD of the spine, hip, and forearm, central quantitative computed tomography (QCT) of volumetric BMD (vBMD) at the lumbar spine, and high resolution peripheral quantitative computed tomography (HRpQCT; Xtreme CT2) measurements of vBMD and microarchitecture at the distal radius and tibia. Bone samples were collected intraoperatively from the lumbar vertebrae and analyzed using Fourier-transform Infrared (FTIR) spectroscopy. Bone samples were obtained from 23 postmenopausal women (mean age 67±7years, BMI 28±8kg/m2). We found that patients with more mature bone by FTIR, measured as lower acid phosphate content and carbonate to phosphate ratio, and greater collagen maturity and mineral maturity/crystallinity (MMC), had greater cortical vBMD at the tibia and greater aBMD at the lumbar spine and one-third radius. Our data suggests that bone quality at peripheral sites may predict bone quality at the spine. As bone quality at the spine is challenging to assess prior to surgery, there is a great need for additional screening tools. Pre-operative peripheral bone imaging may provide important insight into vertebral bone quality and may foster identification of patients with bone quality deficits.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System.

Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures. (1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed? Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure. Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure. In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing. Level III, therapeutic study.

Payor Type is Associated With Increased Rates of Reoperation and Health-care Utilization Following Unicompartmental Knee Arthroplasty: A National Database Study.

Unicompartmental knee arthroplasty (UKA) is a common orthopedic procedure with overall good clinical outcomes; however, more recent literature has identified disparities in treatment access and outcomes based on sociodemographic factors. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation following a UKA. Patients with Medicare, Medicaid, or commercial payor type who underwent primary medial or lateral UKA between 2010 and 2019 were identified using a large national database. Ninety-day incidence of emergency department visit and 1-year incidence of revision, revision to arthroplasty, reimbursement, and cost of care were evaluated. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates. Medicaid insurance was associated with an increased risk of emergency room visit (odds ratio [OR] 2.77; P < .001), revision surgery (OR 1.85; P < .001), and conversion to total knee arthroplasty (OR 1.50; P= .0292) compared to commercially insured patients. Medicaid insurance was associated with an increased risk of emergency room visit (OR 3.58; P < .001), revision surgery (OR 1.97; P < .001), and conversion to total knee arthroplasty (OR 1.80; P= .003). Medicaid patients were associated with a higher overall cost of care and lower reimbursement than commercial and Medicare patients (P < .001 and P < .001, respectively). These findings demonstrate that payor type is associated with increased rates of reoperation and health-care utilization following UKA despite controlling for covariates. Additional work is required to understand the complex relationship between socioeconomic status and outcomes to ensure appropriate health-care access for all patients and pursue appropriate risk stratification. III, retrospective chart review.

Racial/Ethnic Disparities in Physical Therapy Utilization After Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities. TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses. Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each). In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately. Level III.

When and What to Consider Knee Arthroscopy Surgery in Post-COVID 19 Infected Patients

Coronavirus disease 19 (COVID-19) is the worst pandemic ever recorded in history, as of this day more than 545 million people infected and more than 6 million cumulative deaths. COVID 19 is primarily respiratory disease, however non-respiratory presentations that could be manifested are venous and arterial thromboembolic events. Both pulmonary embolism (PE) and deep vein thrombosis (DVT) are the most frequently thrombotic events in COVID-19. Knee arthroscopy surgery is the one of the most common orthopedic surgical procedures nowadays, with the most common procedures are meniscectomy, meniscal repair and cruciate ligament reconstruction. Although knee arthroscopy is known to be a safe procedure, several complications could be found with the 3 most common complications are DVT, effusion and synovitis, and PE. We reported a case series of four patients with DVT post knee arthroscopy anterior cruciate ligament reconstruction during 2021. The DVT diagnosis was retained on clinical presentation and elevated of D-dimer testing. The patient’s mean age was 35,25 years, and all of the patients had no risk factors of DVT, although they had COVID-19 infection within 3 months before surgery. The most common clinical presentation was swelling on the lower leg (around the ankle) with slightly pain and numbness. Only one patient had severe pain around the thigh. All of the patients had elevated D-dimer testing result with mean of D-dimer 1250 (normal value &lt; 500). Only one patient had sonography testing and found proximal DVT. One of the patients had DVT at post operative day (POD) 3, one at POD 4 and the other two at POD 5. Three of the patients improved with oral anticoagulant therapy using rivaroxaban (XARELTO). In one patient the symptom was not improved after two days oral anticoagulant therapy and underwent thrombectomy by vascular surgeon. DVT is the most common complication of knee arthroscopy and also the most common non-respiratory events of COVID-19 infection. Routinely administration of thromboprophylaxis agent was not recommended, pre-operative risk assessment of DVT should be used, especially in post-COVID 19 patients.

Maximum surgical blood ordering schedule for common Orthopaedic surgical procedures at Birrd hospital (Tertiary orthopaedic hospital)

Maximum surgical blood ordering schedule for common Orthopaedic surgical procedures at Birrd hospital (Tertiary orthopaedic hospital)

Advancement in total hip implant: a comprehensive review of mechanics and performance parameters across diverse novelties.

The UK's National Joint Registry (NJR) and the American Joint Replacement Registry (AJRR) of 2022 revealed that total hip replacement (THR) is the most common orthopaedic joint procedure. The NJR also noted that 10-20% of hip implants require revision within 1 to 10 years. Most of these revisions are a result of aseptic loosening, dislocation, implant wear, implant fracture, and joint incompatibility, which are all caused by implant geometry disparity. The primary purpose of this review article is to analyze and evaluate the mechanics and performance factors of advancement in hip implants with novel geometries. The existing hip implants can be categorized based on two parts: the hip stem and the joint of the implant. Insufficient stress distribution from implants to the femur can cause stress shielding, bone loss, excessive micromotion, and ultimately, implant aseptic loosening due to inflammation. Researchers are designing hip implants with a porous lattice and functionally graded material (FGM) stems, femur resurfacing, short-stem, and collared stems, all aimed at achieving uniform stress distribution and promoting adequate bone remodeling. Designing hip implants with a porous lattice FGM structure requires maintaining stiffness, strength, isotropy, and bone development potential. Mechanical stability is still an issue with hip implants, femur resurfacing, collared stems, and short stems. Hip implants are being developed with a variety of joint geometries to decrease wear, improve an angular range of motion, and strengthen mechanical stability at the joint interface. Dual mobility and reverse femoral head-liner hip implants reduce the hip joint's dislocation limits. In addition, researchers reveal that femoral headliner joints with unidirectional motion have a lower wear rate than traditional ball-and-socket joints. Based on research findings and gaps, a hypothesis is formulated by the authors proposing a hip implant with a collared stem and porous lattice FGM structure to address stress shielding and micromotion issues. A hypothesis is also formulated by the authors suggesting that the utilization of a spiral or gear-shaped thread with a matched contact point at the tapered joint of a hip implant could be a viable option for reducing wear and enhancing stability. The literature analysis underscores substantial research opportunities in developing a hip implant joint that addresses both dislocation and increased wear rates. Finally, this review explores potential solutions to existing obstacles in developing a better hip implant system.