Primary Total Knee Arthroplasty Research Articles

Comparison of total blood loss between limited tourniquet use and conventional tourniquet use in total knee arthroplasty: a randomized controlled trial.

This study examined the differences in total blood loss, the need for blood transfusions, length of hospital stay, wound grading scores, incidence of venous thromboembolism (VTE), and reoperation rates between conventional and limited tourniquet use during unilateral primary total knee arthroplasty (TKA). This double-blind, randomized controlled trial included 90 patients undergoing unilateral primary TKA. Forty-five patients were allocated to the limited tourniquet use group (LIM-TKA), and 45 to the conventional tourniquet use group (CON-TKA). The study analyzed differences in total blood loss, the need for blood transfusions, wound grading scores, incidence of VTE, length of hospital stay, and reoperation rates. The mean total blood loss in the LIM-TKA group was 589.55 ± 238.2ml, significantly lower than the 692.31 ± 276.15ml observed in the CON-TKA group (P = 0.031). Significantly poorer wound grades were seen in the CON-TKA group compared to the LIM-TKA group, with 23 vs. 34, 15 vs. 11, 5 vs. 0, 1 vs. 0 and 1 vs. 0 patients, respectively, having grade 1, 2A, 2B, 2C and 3A wounds according to the Southampton Scoring System (P = 0.032). Patients in the LIM-TKA group also had a shorter hospital stay versus the CON-TKA group (5.6 ± 1.28 vs. 7.2 ± 4.06 days, P = 0.006). The rates of blood transfusion, VTE complications, and reoperation were similar between both groups. LIM-TKA results in significantly lower total blood loss and improved wound grading scores, as well as a decreased length of hospital stay compared to CON-TKA. LIM-TKA could be a suitable option for surgeons aiming to minimize tourniquet-related adverse outcomes while maintaining a dry bone surface during TKA cementation. This study was retrospectively registered at Thai Clinical Trials Registry (thaiclinicaltrials.org) on July 28, 2024. TCTR20240728002.

Reoperations After Operatively and Non-Operatively Treated Periprosthetic Knee Fractures: A Nationwide Study on 1,931 Fractures After Primary Total Knee Arthroplasty.

Periprosthetic knee fracture (PPKF) following total knee arthroplasty (TKA) can be difficult to treat. A PPKF can be treated both operatively and non-operatively, and the treatment varies between fracture sites. This study aimed to assess the risk of reoperation according to the fracture site and treatment of the PPKF. This study is a nationwide cohort study using register data from 1997 to 2022. Cruciate-retaining or posterior-stabilized primary TKA were identified from the Danish Knee Arthroplasty Register (DKR). Subsequent PPKFs, fracture treatments, and later reoperations were identified through the International Classification of Diseases (ICD-10) diagnosis and procedure codes in the Danish National Patient Register. Additionally, indications for revision TKA (rTKA) in the DKR were used to identify PPKFs and the reason for reoperation. We included 1,931 PPKFs (1,494 femoral, 207 patellae, and 230 tibial) with an overall two-year reoperation risk of 20% (95% CI [confidence interval]: 18 to 23). Femoral PPKFs had a two-year reoperation risk of 16% (12 to 22) after non-operative treatment and 21% (18 to 24) after operative treatment. Patellar PPKFs had a two-year reoperation risk in five to 17 after non-operative treatment and 46% (30 to 69) after operative treatment. Tibial PPKFs had a two-year reoperation risk of 17% (11 to 27) after non-operative treatment, and 36% (25 to 53) after operative treatment. The overall two-year reoperation risk was 20% (18 to 23). Operative-treated PPKFs had a higher risk of reoperation across all fracture locations. The highest reoperation risk was found after operatively treated patella and tibial PPKFs (46 and 36%, respectively), and the lowest reoperation risk was found after non-operative treated patella PPKFs.

Early insights from the routine use of patient reported outcome measures in elective hip and knee arthroplasty at a public teaching hospital in South Australia.

For advanced osteoarthritis of the knee and hip, the most clinically effective treatment remains total-knee arthroplasty (TKA) and total-hip arthroplasty (THA). Success of these surgeries have traditionally been appraised by economic and volume-based measures. There has been a shift towards the use of patient reported outcome measures (PROMs) to quantify success and guide treatment. The present study provides analysis of three PROMS which have been validated for use in orthopaedic settings; the Oxford Knee Score (OKS), Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and the EuroQol-Visual Analogue Scale (EQ-VAS) - a non-disease specific measure of health. PROMs were completed pre-operatively, 6-weeks, and 1-year after elective TKA and THA undertaken in 2018 in a public teaching hospital in South Australia. Post-operative satisfaction/dissatisfaction was measured using a 5-point Likert scale and was collected at the same 6-week and 1-year points. PROMs were collected from 285 eligible elective knee-arthroplasty, and 205 elective hip-arthroplasty patients. There was significant average improvement, greater than minimal clinical important differences between pre-operative and 1-year post-operative scores for all three PROMs tools. Inter-PROM correlation was strongest between FJS and OKS at 1-year post TKA (rs = 0.722), and between FJS and OHS in post-THA at the same interval (rs = 0.609). TKA patients with higher pre-surgical 10-year mortality were weakly associated with lower pre-operative OKS score (rs = 0.169). BMI was weakly negatively associated with pre-operative and 6-week post-operative EQ-VAS scores (rs = -0.291 and rs = -0.149 respectively). Post-TKA satisfaction was 77.2% at 1-year, and THA 88.5% at the same interval. This study provides an early insight from the use of the OKS, OHS, the EQ-VAS and the FJS as PROMs in primary TKA and THA at our centre. All PROMs demonstrate significant increase (improvement) at both 6-week and 1-year post-operative intervals, relative to pre-operative scores. The FJS demonstrated good sensitivity. Pre-existing co-morbidities do not appear to have any significant relation with post-operative PROMs collected in this study.

Can KOOS-PS be replaced with a simple anchor question in patients after total knee arthroplasty?: an agreement study of 2,478 primary surgeries.

Physical function and pain are the most important outcomes following total knee arthroplasty (TKA). These can be evaluated by patient-reported outcome measures (PROMs), or by an anchor question. The primary aim of the study was to evaluate whether a simple anchor question can replace KOOS-PS in assessing postoperative knee function until 1-year follow-up, evaluated by analyzing the agreement between the 2 methods using the diagnostic odds ratio (DOR). Secondary aims were pain (NRS) at rest and during mobilization. This is a diagnostic accuracy study with primary TKAs performed between 2010 and 2022. The surgeries were categorized as improved (I) or worsened (W) based on a dichotomized anchor question related to self-perceived change in physical function, and the dichotomized change in KOOS-PS until 1-year follow-up. This led to 4 groups: (II, IW, WI, and WW). Agreement was found with a DOR of 11.3 (CI 7.9-16.2). 2,335 (94%) reported improved function on the anchor question and 143 (6%) worsened function. Among those with improved anchor 2,132 (91%) had improved KOOS-PS, but among those with worsened anchor only 74 (52%) had worsened KOOS-PS. Pain at 1-year follow-up was lower in the groups reporting improved anchor. The KOOS-PS can be replaced with an anchor question to assess change in function until 1 year. However, the KOOS-PS might be a valuable supplement in patients reporting worsened anchor as only half of those had worsened KOOS-PS.

The incidence and risk factors of intraoperative bacterial contamination in primary total knee arthroplasty

BackgroundInfection is a devasting complication after arthroplasty. Identifying potential sources contributing to intraoperative bacterial transmission can help to reduce surgical-site infections.ObjectiveThe aim of this study was to identify the incidence and risk factors of intraoperative bacterial contamination (IBC) in primary total knee arthroplasty (TKA) procedures.MethodsActive surveillance cultures were used to detect IBC from 125 consecutive unilateral primary TKAs. The cultures were taken from different sites (surgical instruments, gloves of surgeons and surgical incisions) at different time points (before surgery, 30 min and at the end of the surgery) during arthroplasty procedures. Patient characteristics, including age, height, body weight, body mass index, comorbidity of diabetes mellitus, operative duration, intraoperative blood loss, types of prophylactic antibiotics were recorded. The white blood cell level before, the 3rd and 7th day after surgery were measured and recorded. In addition, patients were also followed for fever and surgical-site infections within 14 days after surgery.ResultsIn total, 1,000 cultures were taken. 91 (9.1%) of them showed an IBC. None of bacterial cultures of gloves and instruments before surgery were positive. At 30 min from the beginning of the procedure, 29 cultures (7.7%) from 16 patients (12.8%) showed a contamination. At the end of the surgery, 62 cultures (16.5%) from 32 patients (25.6%) showed a contamination. There were 15 cases (12.0%) of fever within 14 days after surgery, of which 11 cases with IBC, and 4 cases without IBC. No postoperative surgical-site infection occurred in all consecutive unilateral primary TKAs. The binomial logistic regression analyses confirmed that operative duration was the risk factor of IBC [OR 1.137 (95% CI 1.023 to 1.322), p = 0.014]. Moreover, compared to control group, the patients with IBC had a greater change of white blood cell level in the 3rd day after surgery (p = 0.022), and a higher risk of fever within 14 days after surgery (p < 0.001).ConclusionThe bacterial contamination rate during primary TKA is relatively high, despite the practice of standard preventive measures. Intraoperative bacterial contamination increases with long operating time, which may be one of the factors contributing to fever and leukocytosis after surgery.

Multicenter Randomized Clinical Trial of Highly Cross-Linked Polyethylene Versus Conventional Polyethylene in 518 Primary TKAs at 10 Years

Background: Second-generation highly cross-linked polyethylene (HXLPE) has revolutionized total hip arthroplasty. However, the long-term risks and benefits of HXLPE in primary total knee arthroplasty (TKA) remain unknown. This randomized clinical trial evaluated implant survivorship, complications, radiographic results, and clinical outcomes of HXLPE and conventional ultra-high molecular weight polyethylene (UHMWPE) inserts in primary TKAs. Methods: We enrolled 518 patients (518 knees) who underwent primary TKA in 3 centers within 1 tertiary referral network. The mean age was 67 years, the mean body mass index was 32 kg/m2, and 58% of the patients were women. All of the patients underwent primary TKA with a cemented posterior-stabilized tibial insert and patellar resurfacing. Randomization proceeded via stratified dynamic allocation. The patients were blinded to their study group allocation: those in the control group (254 knees) underwent TKA with an UHMWPE insert (N2Vac; Stryker); those in the treatment group (264 knees) received an HXLPE insert (X3; Stryker). Kaplan-Meier survivorship, radiographic results, and clinical outcomes were assessed. This trial was registered with ClinicalTrials.gov. The mean follow-up was 11 years. Results: The 10-year overall survivorship free from any revision and from any reoperation was 96% and 94%, respectively. There were no differences in the risk of revision or reoperation between the groups (p > 0.05). There were a total of 19 revisions. Revision indications included periprosthetic joint infection (14 knees), instability (4 knees), and open reduction and internal fixation (ORIF) for a patellar fracture due to osteolysis around a UHMWPE insert (1 knee). There were no revisions due to polyethylene wear, osteolysis, or fracture of the post in the HXLPE group. The radiographic results and clinical outcomes were otherwise similar. Conclusions: Notably, no wear-related failures were identified in the HXLPE group, but there was 1 case of osteolysis in the UHMWPE group. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Are asymmetric designs of tibial components superior to their symmetric counterparts for constrained condylar total knee arthroplasty using metal block augmentation?

PurposeIn total knee arthroplasty (TKA), asymmetric tibial components have been developed alongside symmetric tibial components to enhance bony coverage at the tibia. In primary TKA and revision TKA for patients with significant bone defects, augmentation is employed to fill the bone defect. However, there have been no reports on bony coverage of the tibial component of the revision system in the cases of bone defects. Therefore, we simulated bone defects using CT and compared the bony coverage of asymmetric and symmetric tibial components in the revision TKA system.MethodsThis study included 45 patients (50 knees involved) with medial osteoarthritis. Preoperative CT scans were used to simulate placement using ZedKnee. Three models were evaluated: Persona Revision PCCK (Zimmer) for the asymmetric component, NexGen LCCK (Zimmer) for the symmetric component, and the ATTUNE revision system (Depuy-Synthes). A 130-mm stem extension was utilized. Augmentations of each thickness were placed to simulate bone defects of 5, 10, and 15 mm. The coverage, overhang, and underhang rates were measured for each slice and compared among the models.ResultsIn terms of coverage, the rate was greater for PCCK at 0 mm, and only ATTUNE exhibited a significantly lower coverage at 5 and 10 mm. There was no significant difference in coverage at 15 mm. At 0 mm, PCCK demonstrated less posterior underhangs. At 5 and 10 mm, PCCK showed less anterior overhang but more anterior underhang. At 15 mm, PCCK had a less anterior overhang, with an overhang in the posterior region but less underhang. When overhang and underhang were combined and compared, the asymmetric component generally yielded superior results.ConclusionIn the cases of bone defects, asymmetric components demonstrated reduced anterior overhang and decreased posterior underhang, resulting in greater bone coverage. This may contribute to improved long-term outcomes in the revision TKA system.

Midterm Survival of Cementless Total Knee Arthroplasty with a Three-Dimensional Printed Metal-Backed Patellar Component from the American Joint Replacement Registry

IntroductionHistorically, metal-backed patellar components have shown high early failure rates due to fracture, lack of osseous integration, and polyethylene wear and dissociation. We aimed to describe the survival outcomes of cementless total knee arthroplasty (TKA) utilizing the first widely used additively manufactured 3-dimensionally printed metal-backed patellar component (AM-MBP) to compare these to other cementless as well as cemented TKA cohorts. MethodsThere were 35,087 primary cementless TKA procedures in patients ≥ 65 years of age that utilized the AM-MBP component during the calendar years 2012 to 2020 that were identified from the American Joint Replacement Registry (AJRR). This AM-MBP cohort was benchmarked against age-similar (≥65 years) cohorts representing all other cementless primary TKA with a patellar component (aggregate cementless, n = 10,755) and all cemented TKA with a patellar component (aggregate cemented, n = 550,908). Cumulative percent revision curves and hazard ratios for all-cause revision were estimated using Cox proportional hazards models that adjusted for age and sex. ResultsThe cumulative percent all-cause revision (95% confidence interval (CI)) at 7-year follow-up was 1.9% (1.7%, 2.1%; 1,051 at risk) for the AM-MBP and 2.5% (2.1%, 2.8%; 1,281 at risk) for other aggregated cementless. and 2.1% (2.1%, 2.1%; 105641 at risk) for the aggregate cemented group. The adjusted hazard ratio for revision comparing AM-MBP with aggregate cementless was 0.77 (0.64, 0.93; P = 0.007), indicating a 23% decreased risk of revision for the AM-MBP group compared with all other cementless TKAs with a patellar component in the AJRR, controlling for age and sex. ConclusionsThe improved survivability of primary cementless TKA with AM-MBP versus other cementless TKA suggests that the AM-MBP construct is durable in real-world use in the Medicare-eligible population (age ≥ 65 years) appears to be comparable to the average durability of other cementless constructs captured by the AJRR.

No Increased Risk of Patella Related Revisions When Comparing Ultra-Congruent Versus Cruciate-Retaining Polyethylene Liners in Primary Total Knee Arthroplasties with an Unresurfaced Patella: An Australian Registry Study of 42,105 Knee Arthroplasties

No Increased Risk of Patella Related Revisions When Comparing Ultra-Congruent Versus Cruciate-Retaining Polyethylene Liners in Primary Total Knee Arthroplasties with an Unresurfaced Patella: An Australian Registry Study of 42,105 Knee Arthroplasties

Bisphosphonate Use in Patients Who Have Osteoporosis Does Not Increase the Risk of Periprosthetic Fracture Following Total Knee Arthroplasty

The purpose of this study was to evaluate the effect of preoperative bisphosphonate use in patients who have osteoporosis on the risk of complications following primary total knee arthroplasty (TKA). An administrative claims database was queried for patients who have osteoporosis undergoing primary TKA between 2010 and 2019 with a minimum of 2-year follow-up. Bisphosphonate naïve patients and bisphosphonate users, defined as patients who had a continuous prescription for bisphosphonates for a minimum of six months preoperatively, were matched 1:1 based on age, sex, and comorbidity burden. Patients undergoing non-elective TKA on chronic glucocorticoid therapy or receiving any other pharmacologic treatment for osteoporosis were excluded. The final cohort included 21,058 matched pairs of patients. The incidence of postoperative complications was identified via International Classification of Disease (ICD) coding and compared between matched groups. A subgroup analysis was performed to examine outcomes amongst patients who underwent cemented and cementless TKA. There was no difference in the incidence of periprosthetic fracture on univariate (0.7 versus 0.8%, P = 0.068) or multivariate testing (OR [odds ratio]: 1.24, 95% CI [confidence interval] [0.99 to 1.56]; P = 0.060). Bisphosphonate users were statistically less likely to undergo all-cause revision TKA at 2 years (OR: 0.84 [0.72 to 0.97]; P = 0.021). Patients who had osteoporosis were found to have an increased risk of periprosthetic fracture when TKA was performed with cementless implants (1.6 versus 0.4%; P = 0.033). However, when treated with bisphosphonates, patients who have osteoporosis demonstrated equivalent fracture rates regardless of implant type (1.3 versus 1.0%; P = 1.000). While bisphosphonate use in patients who have osteoporosis did not decrease the risk of periprosthetic fracture, it did significantly lower the incidence of all-cause revision at 2 years although the difference identified was small. Consideration should be given to performing cemented TKA in patients who have untreated osteoporosis, given the higher rate of periprosthetic fracture when cementless implants were utilized.

Rates of Extended Oral Antibiotic Prophylaxis After Primary Total Knee Arthroplasty Among High-Risk and Standard-Risk Patients: 2009 to 2022

Rates of Extended Oral Antibiotic Prophylaxis After Primary Total Knee Arthroplasty Among High-Risk and Standard-Risk Patients: 2009 to 2022

Is there a difference between posterior-stabilized, cruciate-retaining, or medial-pivot implants used during primary TKA?

Is there a difference between posterior-stabilized, cruciate-retaining, or medial-pivot implants used during primary TKA?

Low-Volume Surgeons Operating at High-Volume Hospitals Have Low Rates of Periprosthetic Joint Infection after Hip and Knee Arthroplasty

IntroductionThe relationship between surgeon and hospital case volumes and postoperative risk following total hip and total knee arthroplasty (THA and TKA) has been described independently. This study aimed to assess the risk of periprosthetic joint infection (PJI) following primary TKA and THA to determine if lower volume surgeons operating at higher volume centers would have lower rates of complications compared to lower volume surgeons operating at lower volume hospitals. MethodsA healthcare database was used to retrospectively identify all primary, and elective total joint arthroplasties (TJAs) from October 2015 to December 2021. Using restricted cubic splines, high-volume hospitals were defined using Markov chain Monte Carlo simulation, which identified a volume beyond which PJI rates no longer decreased significantly with increasing hospital volume. A similar methodology was used to identify low-volume surgeons operating in high- and low-volume hospitals. There were 605,254 patients who underwent TJA (total hip arthroplasty [THA]: 37.71%; total knee arthroplasty [TKA]: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high-volume and low-volume hospital cohorts. High-volume hospitals were defined as > 508 THA and > 812 TKAs per year, and low-volume hospitals were defined as < 145 THAs and < 243 TKAs per year. Multivariable models accounting for potential confounding covariates were created to determine the odds of PJI between cohorts. ResultsAfter taking confounding variables into account, low-volume surgeons at high-volume hospitals had lower rates of PJI relative to their counterparts at low-volume hospitals (THA 0.67 versus 0.80%, aOR [adjusted odds ratio] = 0.69 [95% confidence interval (CI) = 0.54 to 0.88], P = 0.002; TKA 0.51 versus 0.69%, aOR = 0.73, [95%-CI = 0.61 to 0.87], P = 0.007). ConclusionIncreasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume.

Medical Malpractice Litigation Following Revision Total Hip and Knee Joint Arthroplasty: A Review of Reported Legal Claims in the U.S. in the Past 20 Years

IntroductionThe increasing incidence of primary total hip (THA) and knee (TKA) arthroplasty has been accompanied by a subsequent rise in revision surgeries. Revision total joint arthroplasty (TJA) is associated with major litigation risk, primarily due to procedural and post-surgical errors. However, the understanding of the causes and outcomes of revision TJA malpractice cases remains unstudied. This study aimed to analyze litigated malpractice claims against orthopaedic surgeons performing revision TJA using a national legal database. MethodsA database was queried for a nationwide analysis of medical malpractice litigation in revision TJA from 2000 to 2023. Data on the time, duration, and locations of the litigations, allegations of surgical negligence, the damages cited, the outcomes of the trials, and indemnities were collected. ResultsOf 110 TJA malpractice cases identified over two decades, 32 cases involving revision THA and TKA surgeries were included in the final analysis. The cases were equally divided between THA and TKA, spanning 16 states, with the highest proportions in New York, Connecticut, and Louisiana. “Procedural error” (28%; n = 9) was the most frequently cited negligence, followed by “post-surgical error” (25%; n = 8) and “failure to treat” (19%; n = 6). The most common damages were “continued pain/mobility limitations” (28%; n = 9) and “infections” (19%; n = 6). Most cases resulted in a verdict for the defense (63%; n = 20). The average indemnity was $5,713,635, with considerable variability. ConclusionThis study presents the leading causes of litigated malpractice claims over the past two decades in the United States in revision TJA as perceived procedural and post-surgical errors, with the most common damages reported being “persistent pain/mobility limitations” and “infections.” Given the rising incidence of revision TJA, orthopaedic surgeons may utilize these trends to better inform patients about the potential risks and outcomes of surgery and mitigate litigation risks.

Total knee arthroplasty combined with simultaneous open reduction and internal fixation in the treatment of knee osteoarthritis with patellar fracture: a case report and review of the literature

BackgroundPatients with severe knee osteoarthritis combined with patellar fracture are rare, and it is unclear whether single-stage surgery affects the enhanced recovery after surgery.Case presentationThis case report describes two patients of Han nationality. A 69-year-old male patient was previously diagnosed with severe knee osteoarthritis of the left knee joint and was treated conservatively with long-term oral nonsteroidal antiinflammatory drugs and intraarticular injection of sodium hyaluronate. He was hospitalized for acute left knee injury owing to a fall from a height. He was diagnosed with knee osteoarthritis of the left knee joint and patellar fracture. Another 74-year-old female patient was previously diagnosed with severe knee osteoarthritis, long-term oral nonsteroidal antiinflammatory drugs and topical Chinese medicine to relieve the pain. A month ago, she fell down the stairs and fractured the patella in her left knee, she was diagnosed with severe left knee osteoarthritis combined with an old left patella fracture. Both patients were successfully treated by single-stage primary total knee arthroplasty and fixation of the patellar fracture. They both carried out early functional exercise normally and successfully achieved enhanced recovery.ConclusionSuccessful single stage total knee replacement with patella management can not only reduce the number of operations, but also enable patients to achieve rapid postoperative recovery. However, single stage may increase the risk of local surgical complications. Therefore, for most patients, especially those with low risk of anesthesia related complications, standard of treatment remains first fixing the patellar fracture and when the fracture is healed proceed with the total knee arthroplasty.

Digital tools in primary total knee arthroplasty-Prevalence in the German-speaking region

Digital tools are being increasingly used worldwide in primary knee arthroplasty. This study aimed to analyze the utilization density of digital tools, the preferred alignment strategies, and the obstacles and benefits of implementing these technologies in German-speaking countries. An online survey with 57questions about digital tools in primary knee arthroplasty and their usage was conducted among members of the Arthroplasty Working Group (AE). The survey included questions on navigation, robotics, patient-specific instruments, individualized implants, and augmented reality. The survey revealed that 18% of hospitals use navigation and 17% use robotic systems in primary total knee arthroplasty surgery. The main reasons for not implementing supportive technologies were high acquisition and ongoing costs, as well as longer surgical duration. Patient-specific instruments and individualized implants currently play aminor role. Patient-specific alignment strategies, such as kinematic (navigation: 35%; robotics: 44%) and functional alignment (navigation: 15%; robotics: 35%), are preferred in this context. With conventional instrumentation predominantly mechanical alignment was applied (79%). The results indicate arelatively high utilization density of digital tools, which are mainly used to perform personalized alignment strategies in primary knee arthroplasty in German-speaking countries. This was particularly evident in high-volume hospitals. Economic aspects were the main reasons for not using these technologies. Future developments should aim to simplify the systems and thus achieve improved cost efficiency.

A Proposed Patient Selection Algorithm for Total Joint Arthroplasty Same-Day Discharge from an Ambulatory Surgery Center

IntroductionIdentifying appropriate patients for same-day discharge total joint arthroplasty (TJA) is critical for maintaining optimal patient safety and outcomes. This study investigated patient outcomes after same-day discharge TJA at a single ambulatory surgery center (ASC) and proposes a TJA patient-selection algorithm based on findings and existing literature. MethodsA retrospective chart review of 660 patients was performed between July 2019 and October 2021 for all patients who underwent primary TJA in a single ASC. Successful same-day discharge (SDD), length of surgery (LOS), estimated blood loss (EBL), complications, and readmission events were recorded for each patient. There were 20 total complications in 331 primary total knee arthroplasties (TKAs) (6.0%) and 15 total complications in 329 primary total hip arthroplasties (THAs) (4.6%). ResultsThere was one direct admission to the hospital in TKA patients and four direct admissions in THA patients, making the successful SDD rate 99.7% in TKAs, 98.8% in THAs, and 99.2% overall. In the TKA cohort, body mass index (BMI) was associated with total complications (r = -0.15, P = 0.006), comorbidities with wound complications (P = 0.006), and EBL was with readmissions (r = 0.30, P < 0.001), revision surgery (r = 0.12, P = 0.04), and total complications (r = 0.16, P = 0.03). In the THA cohort, BMI was weakly associated with wound complications (r = -0.12, P = 0.02), EBL was with emergency department visits (r = 0.18, P = 0.002) and total complications (r = 0.14, P = 0.01). However, there was no direct association between any of the analyzed characteristics and direct admission. ConclusionIn our ASC cohort, patients had low rates of perioperative complications and hospital admissions, supporting the safety of same-day discharge TJA using our proposed evidence-based algorithm to guide patient selection for same-day discharge.

Prehabilitation in Patients at Risk of Poorer Outcomes Following Total Knee Arthroplasty: A Systematic Review

IntroductionWhile total knee arthroplasty (TKA) is a generally successful procedure, 10 to 30% of patients still report suboptimal outcomes after surgery. Prehabilitation may offer potential benefits to improve poorer outcomes, although its effectiveness remains uncertain. Our study aimed to assess the efficacy of prehabilitation interventions on patients at risk of poor outcomes following TKA. MethodThere were six electronic databases searched up until December 2023. All randomized controlled trials (RCTs) comparing prehabilitation versus usual care in adult patients with osteoarthritis undergoing primary TKA and at risk of poorer outcomes were included. There were four reviewers who independently extracted data and assessed the risk of bias for each study. ResultsThe 13 included studies assessed prehabilitation among patients at risk of poor outcomes, identified with various factors including range of motion deficit, functional limitations, high body mass index, psychological factors, frailty, older age, central sensitization, and high risk of discharge to inpatient rehabilitation. The interventions were initiated across a wide range, from four to 277 days before surgery. The efficacy of exercise therapy and multidisciplinary rehabilitation remains inconclusive due to limited, low-quality evidence. The results failed to indicate that various forms of non-exercise therapy, including education, psychological intervention, and weight loss therapy, were effective in improving outcomes after TKA. The included studies have major limitations such as small sample size, inappropriate comparators, substantial clinical heterogeneity in intervention characteristics, inadequate blinding for providers and participants, a lack of justification for identifying patients at risk of poor recovery, and a lack of appropriate interventions for managing modifiable factors. ConclusionWhile our finding fails to show that non-exercise therapy is effective, results of exercise therapy and multidisciplinary rehabilitation remain inconclusive. Further high-quality research is warranted to establish evidence on modifiable factors predictive of poorer postoperative outcomes and investigate how they can be effectively managed.

Does robotic surgical assistant (ROSA) functionally aligned TKA lead to higher satisfaction than conventional mechanically aligned TKA: A propensity-matched pair analysis

ObjectivesTotal knee arthroplasty (TKA) is the established treatment for severe knee osteoarthritis, with robotic-assisted TKA (rTKA) proposed to enhance surgical precision and potentially improve outcomes. This study investigates whether functionally-aligned rTKA using the ROSA Knee System results in superior functional outcomes and patient satisfaction compared to conventional mechanically aligned TKA (mTKA). MethodsWe conducted a retrospective, propensity-score matched cohort study including 154 patients (46 rTKA, 108 mTKA) who underwent primary TKA by a single surgeon from October 2020 to October 2023. Functionally-aligned (FA) rTKA was performed using the ROSA Knee System. Patients were assessed using the Short-Form 36 (SF36), Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS), and Oxford Knee Score (OKS) preoperatively and at 6 months postoperatively. Immediate postoperative outcomes such as pain at rest and movement, ambulation distance, and range of motion were measured. Statistical analysis evaluated results at a 95 % confidence interval, with significance at P < 0.05. ResultsNo significant differences were observed in immediate postoperative pain at rest (P = 0.988), pain during movement (P = 0.634), ambulation distance (P = 0.243), and range of motion (P = 0.752) between the groups. At 6 months, there were no significant differences between rTKA and mTKA in achieving the minimal clinically important difference for SF36 (P = 0.996), KSKS (P = 0.150), KSFS (P = 0.091), and OKS (P = 0.949). No significant differences were noted for satisfaction levels (P = 0.315) and fulfilled expectations (P = 0.557) between both groups. ConclusionsAt 6 months postoperatively, FA rTKA demonstrated equivalent outcomes and satisfaction levels compared to mTKA. Future research should focus on examining longer-term follow-up outcomes, quantifying gap balance in MA mTKA to allow direct comparison with rTKA and studying alternative personalised alignment rTKA strategies to enhance patient outcomes.

New evidence on patella resurfacing in modern total knee arthroplasty for all inflammatory arthritis in a mixed Asian population

BackgroundTraditional teaching advocates for routine patella resurfacing (PR) during total knee arthroplasty (TKA) in patients with inflammatory arthritis. However, evidence on this topic remains limited in the Asian population. This study aims to evaluate the postoperative outcomes and complication of patella resurfacing (PR) during primary total knee arthroplasty (TKA) in Asian patients with inflammatory arthritis. MethodsA retrospective analysis was conducted using registry data from our institution. Patients with inflammatory arthritis who underwent primary TKA from August 2017 to December 2021 were included in the study. Patients were divided into two groups - patella resurfaced (PR, n = 25) and non-resurfaced patella (PNR, n = 31) groups. Demographics, operative data, patient reported outcome measures, and complications were compared. ResultsPreoperative range of motion (ROM) (PR:95.3 ± 23.6° vs PNR:105 ± 19.5°, p = 0.106), Knee Society Scoring System Knee score (KS-KS) (PR:44.6 ± 17.4 vs PNR:49.3 ± 17.7, p = 0.331) and Knee Society Function Score (KS-FS) (PR:40.9 ± 27.3 vs PNR:47.7 ± 27.0, p = 0.325) and Oxford Knee Score (OKS) (PR:25.0 ± 7.8 vs PNR:23.3 ± 10.3, p = 0.525) were similar in both groups. Outcomes between PR and PNR groups at the one-year mark in terms of ROM (PR:112.7 ± 18.1 vs PNR:114.6 ± 16.5, p = 0.455), OKS (PR:41.5 ± 3.9 vs PNR:41 ± 4.7, p = 0.954), KS-KS (PR:84.5 ± 13.2 vs PNR:89.2 ± 9.3, p = 0.095) and KS-FS (PR:73.6 ± 18.3 vs PNR:78.7 ± 19.3, p = 0.173) were also similar. Intraoperative complication (PR:0/25 vs PNR: 3/31 (9.6 %), p = 0.245) and re-operation rates (PR: 1/25 (4 %) vs PNR: 1/31 (3.2 %), p = 0.877) were also similar in both groups. ConclusionThis study conducted on a mixed Asian population with inflammatory arthritis demonstrated that the one-year postoperative ROM and functional outcomes, complication, and re-operation rates between PR and PNR groups were similar. Hence, routine patella resurfacing on all Asian patients with inflammatory arthritis undergoing TKA may not be necessary.